Problem Addressed

• Increased use in patients without cancer: Since the 1980s, use of prescription opioids such as oxycodone and hydrocodone has increased significantly for the management of chronic pain in patients without cancer.¹ Between 3 and 4 percent of all American adults who do not have cancer and are not receiving end-of-life care (roughly 5 to 8 million adults) use these drugs on a long-term basis to manage chronic pain.² Approximately 12 percent of American adults age 18 to 25 use prescription opioids for nonmedical reasons.³ Like many health care systems, Group Health experienced an increase in long-term opioid prescribing for chronic pain, with the percent of adults receiving long-term opioids doubling between 1997 and 2005.²
• Leading to adverse events, including death: While use of opioids to manage cancer pain is widely accepted, use in patients without cancer remains controversial because of the significant increase in drug abuse, morbidity, and mortality that has occurred in this population.⁴ Between 1999 and 2006, the number of fatal overdoses involving opioids increased by 240 percent, to 13,800 a year,⁵ while hospitalizations for prescription opioid poisoning doubled.⁶ Between 2004 and 2008, emergency department visits involving prescription opioids more than doubled, to more than 300,000 annually.⁷ Between 1999 and 2009, the annual number of admissions for drug abuse treatment related to nonheroin opioids grew by more than 400 percent, to 140,000.⁸
• Greater risks with higher doses: The risk of overdose and fatality increases as the dose increases. A Group Health Research Institute study involving nearly 10,000 patients found that those receiving higher doses were 9 times more likely to overdose than those receiving low doses. Roughly three-quarters of such overdoses were medically serious, and 12 percent resulted in death.⁹
• Failure to heed call to action: The White House National Office of Drug Control Policy announced a national action plan to address this epidemic in April 2011.¹⁰ In addition, several states, including Washington, have developed policy guidelines for chronic opioid prescribing,^11,12 but many health systems have not yet developed initiatives or policies to promote appropriate prescribing of these drugs.

Description of the Innovative Activity

• Comprehensive guideline covering care and monitoring: Group Health’s comprehensive guideline for chronic opioid therapy applies to any patient receiving opioids on a daily or near-daily basis for 90 days or longer, defined as receiving 70 days' supply of opioids or more in a 90-day period. For these patients, the guideline specifies the following:
  • Single physician oversight: One physician (usually the primary care physician, but possibly a specialist) takes responsibility for prescribing and managing chronic opioid therapy for the patient.
  • Standardized care plan: The responsible physician and the patient develop a standardized care plan using a template in the EMR. The plan documents treatment goals, medication regimen, frequency of monitoring, and drug screening requirements (see below for more details). The plan also documents informed consent discussions regarding the risks and benefits of therapy.
  • Early review of refill requests: Group Health modified its refill ordering processes to ensure that the prescribing physician has adequate time to review any patient request for a refill. For example, physicians write refills for 28 (rather than 30) days to ensure that patients do not run out of medication on a weekend (since the prescription will expire the same day of the week it is written), and patients are asked to provide 7 days' notice when requesting a refill.
  • Monitoring and drug screening: Each patient must see the prescribing physician periodically for monitoring. Such visits occur at least once a year, with the need for additional visits determined by dose level and other risk factors such as a history of substance abuse or severe mental health problems. At each visit, the physician conducts a standardized pain assessment and documents progress toward treatment goals. Patients on high-dose regimens or with risk factors for opioid abuse must undergo urine drug screening according to a schedule set forth in the guideline.
• Online provider training: All prescribing physicians were encouraged to complete a 90-minute online training program. The program provides a review of the following topics: management of chronic pain in patients without cancer, the biopsychosocial approach to pain management, realistic expectations about opioid therapy, Group Health policies and guidelines related to chronic opioid therapy, and 11 clinical scenarios that illustrate how to handle difficult situations related to such therapy.
• Peer support for prescribers: One or more physicians in each clinic serve as peer experts who can address colleagues’ questions and provide additional education to prescribers who have questions about how to implement the guideline. In addition, physicians who require assistance with the management of complex patients can request a consultation from staff in physical and rehabilitation medicine and behavioral health.
• EMR-based tools: Group Health's EMR gives physicians access to various tools that help promote appropriate prescribing, as outlined below:
  • Treatment agreement form: This form, which can be jointly reviewed by patient and physician, outlines realistic expectations related to the benefits, risks, and safe use of the therapy. Some physicians ask patients to sign the form; others simply review it with them.
  • Patient handout: Physicians can print and distribute a standardized patient education handout that addresses the side effects and potential benefits of long-term therapy.
  • Dose calculator: Physicians can use an online calculator (developed by Washington State; see the Tools section for more information) for estimating the morphine-equivalent dose of opioid therapy. Converting opioid therapy alternatives to a common metric allows physicians to compare the dose strength of different drugs, monitor dose escalation, and evaluate the strength of combination therapy (e.g., concurrent use of a long-acting and short-acting opioid). This information helps physicians with various issues related to therapeutic management, such as mitigating the development of tolerance to the drug, planning a strategy for reducing the dose and/or use over time, and determining the appropriate time frame for monitoring and screening.
• Financial incentives for care plans: The variable component of Group Health's physician compensation plan ties bonus payments to the achievement of specific clinical goals, one of which is to create individualized care plans for patients on chronic opioid therapy.

References/Related Articles

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Innovator Disclosures

Results

• More knowledgeable, confident physicians: After completing the online course, physicians reported increased confidence in managing chronic pain and chronic opioid therapy, more conservative attitudes about prescribing high-dose therapy and about prescribing any opioid therapy for high-risk patients, and a greater likelihood of endorsing a biopsychosocial approach to chronic pain management.
• Greater use of care plans and drug screening: Prior to implementation of this program, there was no standardized approach to documentation of care plans for chronic opioid therapy in the EMR. In addition, the proportion of patients on chronic opioid therapy who received urine drug screening increased from 13 percent in the year before implementation to 50 percent during the year after. The increase was even greater among those receiving a morphine-equivalent dose of at least 120 milligrams (21 to 65 percent).
• Fewer patients on high-dose therapy: Between 2007 and 2011, the percentage of group practice patients on chronic opioid therapy receiving high-dose regimens decreased by 47 percent, a much greater decline than occurred among similar patients seen by other practices in Group Health's provider network. The reduction in use of higher-dose regimens was not a specific goal of the initiative. The guideline did not provide advice on prescribing decisions for individual patients. The lower percentage of patients on higher-dose regimens was largely due to the cumulative effects over 4 years of reduced rates of dose escalation.
• No impact on access to lower-dose therapy: In both the integrated group practice and in the network as a whole, the proportion of adults receiving chronic opioid therapy increased by roughly similar amounts between 2005 and 2011. In 2011, 2.9 percent of adult patients in the group practice were on the therapy (a 71-percent increase since 2005), slightly above the 2.1 percent of adult patients in the entire network on such therapy (a 75-percent increase since 2005). These figures suggest that the program has not reduced the percent of chronic pain patients using opioids long term—only their likelihood of receiving opioids at higher dosage levels.
• Uncertain impact on costs: Reduced use of high-dose regimens saves between $1,400 and $1,800 per patient each year. However, to gauge the program's impact on costs, these savings must be compared with the added expense associated with operating the program, such as more drug screenings and followup visits; for example, Group Health performed 2,500 more urine screening tests in the year after implementation, at a cost of $35 each. Group Health has not performed this analysis to determine the net impact of the program on costs.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Development of online training and guideline: Two specialists in physical medicine who had been recommending more conservative opioid prescribing worked with Dr. Von Korff from the Group Health Research Institute and an outside consultant to develop the online training program. They adapted an existing online program developed by the Department of Veterans Affairs for use by Group Health. A group of clinicians outlined the previously described comprehensive guideline based on the Washington State standards of practice.
• Rapid process improvement workshop: Health system leaders and quality improvement staff trained in Toyota Lean improvement methodologies facilitated a rapid process improvement workshop. Held in June 2010, this 2-day workshop included representatives from primary care, nursing, pharmacy, relevant specialty services, information services and the legal department. During the session, attendees finalized the guideline and developed an implementation plan and related materials and policies.
• Training peer experts: One or more physicians in each clinic received training on options for chronic opioid therapy and the risks and benefits of such therapy. They also received a briefing on the overall program so that they could provide support to colleagues during and after implementation.
• Pilot testing of online program: The peer experts pilot-tested the training program and made recommendations for enhancements, such as more specific guidance on how to implement the various elements of the guideline and integration of techniques from the four habits of effective communication into approaches to working effectively with chronic pain patients using opioids long term. After implementing these recommendations over several months, the online training program went live in April 2011.
• In-clinic meetings after implementation: Each primary care clinic held one or two meetings with prescribers and relevant staff to discuss implementation of the various elements of the guideline and other program components after staff had completed the online training program. This training provided an opportunity for mid-course changes informed by the material presented in the online training program.
• Early monitoring by medical directors: When the program went live, Group Health medical directors gave physicians a list of all noncancer patients being treated for chronic pain with opioid therapy. Physicians were expected to develop care plans with their patients who were using chronic opioid therapy and to implement other aspects of the guidelines. During the year after implementation, and subsequently, clinic medical directors received reports on the percentage of patients with and without care plans and took appropriate supervisory steps to ensure that program goals were achieved as needed.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: Data are unavailable on the costs of the program. As noted, earlier, the reduction in use of high-dose therapy has reduced costs, but these savings must be weighed against program-related expenses.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Engage leadership: As noted, use of opioid therapy for chronic pain in patients without cancer remains controversial. Strong leadership is critical to any successful effort in this area. Leaders need to recognize the potential for addiction and related adverse events, serve as vocal advocates for a health system-focused approach to address the issue, highlight the effort as a major part of the organization's quality improvement agenda, and encourage physician support by creating clear expectations related to prescribing. Program developers note that this initiative was well received by Group Health physicians because it addressed problems that they were experiencing in patient care and clinical issues related to cross-coverage of patients.
• Involve prescribers and related staff in design and implementation: Involving health care providers, pharmacists, and other staff whose roles are relevant to opioid therapy in program design and implementation (e.g., IT staff to facilitate EMR changes) helps in surfacing and proactively addressing potential barriers and concerns. In the case of Group Health, the consensus building on standardization of care processes through the rapid process improvement workshop contributed to the initiative's success.
• Prepare for the workshop: Advance preparation of a draft guideline and supporting materials before holding the workshop helped participants focus on practical issues in implementing the guideline.
• Utilize EMR, if available: An EMR greatly enhances the ability to develop and implement this type of program successfully because tools, forms, and information designed to support providers in appropriately prescribing opioid therapy can be integrated into the EMR.
• Draw on good work done elsewhere: Investigate whether other relevant approaches, methods, and materials have been used in other settings, and leverage them if possible, modifying as needed.
• Standardize processes: Successful implementation comes from developing uniform processes across departments (e.g., primary care, pharmacy, relevant consultative specialists).

Sustaining This Innovation

• Share performance reports with physicians: Sharing data on physician adherence to various elements of the guideline can help to identify problem areas and encourage strong performance over time.
• Tie performance to compensation: Physicians will be more likely to adhere to various components of the guideline over time if their compensation depends in part on them doing so.

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