Dr. Michael Von Korff discusses how Washington state guidelines also appeared to lower opioid doses, but large dose reductions followed health plan initiatives

by Michael Von Korff, ScD, a senior investigator at Group Health Research Institute

Physicians often prescribe opioids to help patients manage pain. Prescribing them at high doses for long periods of time carries serious risks, including overdose, abuse, and addiction. In 2007, Washington state created guidelines to address this issue, recommending that doctors exercise caution when prescribing opioids at high doses for long time periods. In 2010, these directives became state law. In 2006, Group Health implemented an additional initiative for our Group Practice, also designed to encourage physicians to be more cautious in prescribing opioids for chronic pain and discouraging dose escalation as well as the use of higher opioid doses in chronic opioid therapy patients. This meant that Group Health’s Group Practice physicians were subjected to both the internal Group Health guidelines as well as the regulations stipulated by state law.

But did the guidelines change behavior?

Large reductions in use of high opioid doses achieved and sustained

Our research indicates that Washington state’s guidelines did make a difference. But when we compared physicians in Group Health’s Group Practice, who had been exposed to both the state and Group Health guidelines, to a group who had been exposed only to the state guidelines, we found even bigger differences.

Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but we didn’t know how feasible it was to reduce opioid doses in community practice.  Washington state and Group Health’s group practice implemented initiatives to reduce high-dose COT prescribing. The group practice physicians were exposed to both initiatives, while Group Health’s contracted network physicians were exposed only to statewide changes. We assessed whether these initiatives reduced opioid doses among more than 16,000 COT patients in the group practice and more than 5,000 in the contracted care setting. 

From 2006 through June 2014, the percentage of COT patients receiving at least 120 or more milligrams morphine equivalent dose declined from 17 percent to 6 percent in the group practice (a 63 percent reduction) versus 20 percent to 14 percent among COT patients of contracted physicians (a 34 percent reduction). The proportion of patients receiving excess opioid days supplied declined from 24 percent to 10 percent among group practice COT patients (a 57 percent reduction) and from 20 percent to 15 percent among COT patients of contracted physicians (a 27 percent reduction).

Reductions in prescribing of high opioid dose and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared to the contracted physicians’ patients.

So the good news is twofold:

• The legislative guidelines appear to have reduced the prescribing of high opioid doses and excess opioid days supplied among chronic opioid patients.  
• Group Health’s additional efforts to make physicians aware of the risks and limited benefits of using high opioid doses reduced them even more.

I published these findings with GHRI co-authors Sascha Dublin, MD, PhD; Rod Walker, MS; Michael Parchman, MD, MPH; Susan Shortreed, PhD, and Kathleen Saunders, JD; and Ryan Hansen, PharmD, PhD, of the University of Washington School of Pharmacy: The impact of opioid risk reduction initiatives on high-dose opioid prescribing for chronic opioid therapy patients in the Journal of Pain.