August 4, 2011

A learning health care system mobilizes to improve opioid prescribing safety

Drug overdose is a well-recognized health problem that kills more than 26,000 Americans each year. While the decades-long “war on drugs” has focused attention and resources on illegal substances, the nation faces a newer, less obvious threat: prescription opioid pain medicines such as oxycodone (brand name Oxycontin) and hydrocodone (Vicodin).

Fatal overdoses involving prescribed opioids tripled from 1999 to 2006, climbing to almost 14,000 U.S. deaths annually—more than cocaine and heroin overdoses combined. Also troubling are dramatic increases in prescription opioid-related hospitalizations and emergency room visits—and in the number of adolescents abusing or selling opioids found in the family medicine cabinet.

Federal officials responded in April 2011 with an action plan to curb prescription drug abuse. As a learning health care system that aligns research and care delivery, Group Health was ahead of the curve—having already implemented and started evaluating an initiative to make opioid prescribing safer while improving care for patients with chronic pain.

The making of an epidemic

Use of prescription opioids began rising sharply in the 1980s, due in part to increasing emphasis on compassionate management of cancer pain. But excluding people with cancer and those in end-of-life care, about 4 percent of U.S. adults now use prescription opioids long term. Pharmaceutical industry advocacy and education have fueled opioid prescribing—despite limited scientific evidence supporting the drugs’ long-term effectiveness for chronic non-cancer pain.

Today, many pain experts—including Group Health Research Institute (GHRI) Senior Investigator Michael Von Korff, ScD—are bringing to light important evidence on opioid-related health risks. Dr. Von Korff and colleagues published the first-ever study on overdose risk among patients using prescribed opioids for chronic non-cancer pain—linking higher risk of fatal and nonfatal overdose to higher daily dose prescribed.

His research also showed that Group Health, like other health systems nationwide, had been prescribing more opioids for chronic non-cancer pain over time—a twofold increase from 1997 to 2005. As scientific research and monitoring of patient care showed increasing problems related to opioids, Group Health clinical leaders took action to protect patient safety.

From 0 to 6,000 in nine months

Group Health launched a major primary care-based initiative to enhance opioid prescribing safety in 2010 and was evaluating the outcomes before the national action plan for prescription drug abuse was announced in April 2011.

Led by Claire Trescott, MD, medical director of primary care, the Group Health initiative aims to standardize use of opioids for chronic non-cancer pain, without creating undue restrictions on clinically appropriate opioid prescribing. Using Lean management techniques, Dr. Trescott worked with primary care doctors, nurses, pharmacists, pain specialists, and other clinical leaders to formulate new guidelines and related practice changes—including creating standardized care plans for all patients receiving opioids long-term for chronic non-cancer pain.

“We are responsible for ensuring the medications we prescribe at Group Health are used safely and effectively,” explains Dr. Trescott. “Our new opioid care plans specify one responsible prescribing physician, clarify expectations for monitoring and refills, outline treatment goals, and explain risks and side effects of long-term opioid use.”

Recognizing the importance of provider education, Group Health Chief of Physical Medicine and Rehabilitation Randi Beck, MD, worked with Dr. Von Korff to develop an online clinician education course explaining the new guidelines. Funded by a Partnership for Innovation grant from the Group Health Foundation, the course aims to help primary care providers implement recommended practice changes.

Most of the 7,000 Group Health patients with long-term opioid prescriptions lacked documented care plans before the guidelines were implemented in September 2010. But by May 2011—just nine months later—nearly 6,000 of them (85 percent of the target population) had a standardized care plan documented in their medical record.

With Group Health Medical Director of Clinical Knowledge Development & Support Michelle Seelig, MD, MPH, Drs. Trescott, Beck, and Von Korff are sharing this pioneering work in a Health Affairs article published today. Dr. Von Korff is also seeking federal research funding to continue the evaluation.

“We tend to see impressive changes when our delivery system, research institute, and foundation collaborate—pooling our knowledge, skills, and resources,” he concludes. “This is a powerful example of how a learning health care system can act quickly to address important problems in health care.”

Read the abstract and news release for Dr. Von Korff’s study on opioid risk and prescribed dose.


by Jessica Ridpath