In the Journals

Intervention improves guideline adherence, does not decrease opioid refills

A multicomponent primary care-based intervention tripled guideline-concordant opioid monitoring; however, it was not successful in reducing opioid misuse risk, according to a study published in JAMA Internal Medicine.

The United States is facing an opioid morbidity and mortality crisis,” Jane M. Liebschutz, MD, MPH, from the section of general internal medicine at Boston Medical Center, and colleagues wrote. “Legitimately prescribed opioid analgesics contribute to the availability of opioids, and they are then used for nonmedical purposes. To improve opioid prescribing, professional medical societies and the [CDC] have released clinical guidelines for long-term opioid therapy.”

“Despite national guidelines, educational programs and regulatory requirements, most clinicians do not follow best practices for opioid prescribing,” they added.

Between January 2014 and March 2016, Liebschutz and colleagues conducted a cluster-randomized controlled trial to determine whether Transforming Opioid Prescribing in Primary Care (TOPCARE), a multicomponent intervention, improves guideline concordant care while decreasing opioid misuse in patients with chronic pain. The researchers included 52 primary care physicians and 985 patients (519 men; mean age, 54.7 years) receiving long-term opioid therapy for pain (mean morphine-equivalent daily dose, 57.8 mg) from four safety-net primary care practices. Primary care practices in the intervention group received nurse care management, an electronic registry, one-on-one academic detailing and electronic decision tools for safe opioid prescribing, while those in the control group received electronic decision tools only. Guideline-concordant care was defined as agreement between patients and PCPs in the EHR and performing at least one urine drug test over 12 months.

Results indicated that receiving guideline-concordant care (65.9% vs. 37.8%; adjusted OR = 6; 95% CI, 3.6-10.2), having agreement between a patient and a PCP who did not have an agreement at baseline (53.8% vs. 6%; aOR = 11.9; 95% CI, 4.4-32.2), and undergoing at least one urine drug test (74.6% vs. 57.9%; aOR = 3; 95% CI, 1.8-5) were more likely in intervention patients at 1 year than controls. Odds of early refill receipt did not differ between the intervention and control groups (20.7% vs 20.1%; aOR = 1.1; 95% CI, 0.7-1.8). Patients in the intervention group had a greater likelihood of having a 10% dose reduction or opioid treatment discontinuation (aOR = 1.6; 95% CI, 1.3-2.1) than those in the control group. Adjusted analyses showed that mean morphine-equivalent daily dose was 6.8 mg lower in the intervention group than the control group.

“TOPCARE ... was successful in increasing [PCP] adherence to guidelines for monitoring patients treated with long-term opioid therapy for chronic pain but not at decreasing early opioid refills by these patients,” Liebschutz and colleagues concluded.

“Further research is needed to determine whether guideline adherence reduces opioid-related risks,” they added. – by Alaina Tedesco

Disclosure: The study was partially funded by the National Institute of Drug Abuse.

 

A multicomponent primary care-based intervention tripled guideline-concordant opioid monitoring; however, it was not successful in reducing opioid misuse risk, according to a study published in JAMA Internal Medicine.

The United States is facing an opioid morbidity and mortality crisis,” Jane M. Liebschutz, MD, MPH, from the section of general internal medicine at Boston Medical Center, and colleagues wrote. “Legitimately prescribed opioid analgesics contribute to the availability of opioids, and they are then used for nonmedical purposes. To improve opioid prescribing, professional medical societies and the [CDC] have released clinical guidelines for long-term opioid therapy.”

“Despite national guidelines, educational programs and regulatory requirements, most clinicians do not follow best practices for opioid prescribing,” they added.

Between January 2014 and March 2016, Liebschutz and colleagues conducted a cluster-randomized controlled trial to determine whether Transforming Opioid Prescribing in Primary Care (TOPCARE), a multicomponent intervention, improves guideline concordant care while decreasing opioid misuse in patients with chronic pain. The researchers included 52 primary care physicians and 985 patients (519 men; mean age, 54.7 years) receiving long-term opioid therapy for pain (mean morphine-equivalent daily dose, 57.8 mg) from four safety-net primary care practices. Primary care practices in the intervention group received nurse care management, an electronic registry, one-on-one academic detailing and electronic decision tools for safe opioid prescribing, while those in the control group received electronic decision tools only. Guideline-concordant care was defined as agreement between patients and PCPs in the EHR and performing at least one urine drug test over 12 months.

Results indicated that receiving guideline-concordant care (65.9% vs. 37.8%; adjusted OR = 6; 95% CI, 3.6-10.2), having agreement between a patient and a PCP who did not have an agreement at baseline (53.8% vs. 6%; aOR = 11.9; 95% CI, 4.4-32.2), and undergoing at least one urine drug test (74.6% vs. 57.9%; aOR = 3; 95% CI, 1.8-5) were more likely in intervention patients at 1 year than controls. Odds of early refill receipt did not differ between the intervention and control groups (20.7% vs 20.1%; aOR = 1.1; 95% CI, 0.7-1.8). Patients in the intervention group had a greater likelihood of having a 10% dose reduction or opioid treatment discontinuation (aOR = 1.6; 95% CI, 1.3-2.1) than those in the control group. Adjusted analyses showed that mean morphine-equivalent daily dose was 6.8 mg lower in the intervention group than the control group.

“TOPCARE ... was successful in increasing [PCP] adherence to guidelines for monitoring patients treated with long-term opioid therapy for chronic pain but not at decreasing early opioid refills by these patients,” Liebschutz and colleagues concluded.

“Further research is needed to determine whether guideline adherence reduces opioid-related risks,” they added. – by Alaina Tedesco

Disclosure: The study was partially funded by the National Institute of Drug Abuse.