New research published in the Journal of the American Board of Family Medicine investigated best practices of select primary care clinics to improve chronic opioid therapy in response to the opioid overuse epidemic.1
Clinicians in the primary care setting face a significant share of the burden in addressing opioid-related issues, as they are the specialty that most often prescribes these drugs. A 2015 study found that in 2013, family medicine and internal medicine physicians wrote approximately 15 million and 13 million opioid prescriptions, respectively, whereas pain management physicians wrote more than 1.2 million.2 The high volume “may contribute to burnout and stress in primary care settings where both prescribers and clinic support staff struggle daily to balance risks and the potential for abuse and diversion with empathy for the suffering of chronic pain patients,” wrote the authors of the current study.
To implement recommendations similar to those detailed in the Centers for Disease Control and Prevention’s 2016 guidelines pertaining to opioid prescribing for chronic noncancer pain, healthcare organizations will need to adopt system-wide changes.3 Although such efforts have been examined in large healthcare settings, it is unclear how various primary care practices are addressing this need.
As part of a program called Primary Care Teams: Learning from Exemplar Ambulatory Practices (LEAP), funded by the Robert Wood Johnson Foundation, the current study examined the efforts of 30 primary care clinics noted for innovative, team-based models of care. The resulting observations were used to create a framework to help guide smaller clinics in transitioning to similar models, based on the following 6 building blocks for improving the delivery of chronic opioid therapy:
- Providing leadership support to prioritize work objectives and build consensus among staff regarding standards of care.
- Reviewing clinic policies, patient agreements, and workflows, and revising as needed. Staff collectively decided how policy and patient agreement documents should be revised and on protocols for managing refills and monitoring safety.
- Implementing a registry for population management to track chronic opioid therapy patients and refill requests. Some clinics had a designated registry manager, and many used the data for quality improvement efforts.
- Conducting planned patient-centered visits, which may include a staff chart review the day before a patient’s visit to identify gaps in care or to rehearse anticipated difficult conversations. In addition, many sites reported moving away from use of the visual analog pain scale to the Pain, Enjoyment, General activity (PEG) scale to assess treatment efficacy.
- Identifying resources for complex patients, such as community resources that clinics could strengthen connections with or resources the clinics could integrate into their existing setting.
- Measuring progress via process and outcome measures, which teams discussed during regular staff and leadership team meetings.
“Changing systems of care is different from changing provider prescribing habits, but experience suggests that system change in primary care settings is a critical component to sustained change in provider behaviors,” according to the authors. “In addition, primary care clinics alone cannot stem the tide of opioid overuse within local communities; it will require community-wide initiatives that include all prescribers,” they concluded.
Summary and Clinical Applicability
The current study identified 6 building blocks that are common to primary care clinics with innovative, team-based approaches to reducing problems related to chronic opioid therapy.
These recommendations are not meant to be exhaustive and must be adapted for use by each clinic.
- Parchman ML, Von Korff M, Baldwin LM, et al. Primary care clinic re-design for prescription opioid management. J Am Board Fam Med. 2017;30:144-151. doi: 10.3122/jabfm.2017.01.160183
- Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of opioids by different types of Medicare prescribers. JAMA Intern Med. 2016;176:259-261. doi: 10.1001/jamainternmed.2015.6662
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65:1-49. doi: 10.15585/mmwr.rr6501e1