May 1, 2012

Opioid-prescribing safety: Finding real-world solutions for a nationwide epidemic

In April 2011, federal officials called for “urgent  action” to curb a national epidemic of prescription drug abuse. The evidence  was clear: Fatal overdoses involving prescribed opioids quadrupled from 1999 to  2009, climbing to almost 16,000 U.S. deaths annually—more than cocaine and  heroin overdoses combined. What wasn’t clear was how to combat this growing  threat. But thanks to Group Health’s pioneering opioid-prescribing safety  initiative—and a corresponding evaluation led by GHRI Senior Investigator  Michael Von Korff, ScD—we’re quickly learning new ways to improve patient  safety.

Launched  in September 2010—seven months before the federal call to action—Group Health’s  initiative aims to standardize opioid use for chronic non-cancer pain without  creating undue restrictions on clinically appropriate prescribing. Claire  Trescott, MD, Group Health’s medical director of primary care, developed the  initiative with help from clinical leaders, primary care doctors, nurses,  pharmacists, and pain specialists, including Dr. Von Korff and Group Health  Chief of Physical Medicine and Rehabilitation Randi Beck, MD.

The initiative was inspired by observations from two sources: standard patient  monitoring and findings Dr. Von Korff published in 2010 that linked higher opioid doses to greater risk of fatal and nonfatal overdose, increased rates of depression, and more fractures in seniors. The initiative addresses these risks with a new clinical guideline requiring standardized care plans for all chronic pain patients who receive opioids long term (not including patients with cancer).

Drs. Von Korff and Beck also teamed up to create an online training course to help primary care providers implement the new guideline. Funded by a Partnership for Innovation grant from  the Group Health Foundation, the course explains the standardized care plans  and other key practice changes—such as designating one physician to be responsible for any opioid prescription lasting longer than 90 days and  requiring urine screening to test for other drugs in high-risk patients. A key aim is to get doctors and patients working together to clarify goals and expectations.

“We’re prescribing lower doses of opioids overall, and we’re doing much more urine drug screening,” says Dr. Trescott. “We’re also having honest, in-depth  discussions about opioids with our patients before treatment starts. The system has been fair, respectful, honest, and transparent.”

Before  the new clinical guideline launched, few of Group Health’s 7,000 patients with long-term opioid prescriptions had documented care plans. By the end of 2011, 96 percent of them did—extraordinary results that are helping answer the  nation’s call for promising solutions to the prescription drug-abuse epidemic.  But it doesn’t end there.

“When we make changes in real-world practice and study them, we not only learn ways to address a particular problem, we learn strategies that can be generalized to other important practice changes and other systems,” explains Dr. Von Korff.  “It’s learning that reaches well beyond Group Health.”

He and his research team are pursuing  federal funding to continue evaluating the initiative’s impact on  standardization of care and the rate of adverse events.

Mobilizing a learning health care system   How did Group Health’s new opioid guideline produce such stunning results so quickly—outpacing the federal call to action?

“Our  care-delivery system, research institute, and foundation collaborated—pooling our knowledge, skills, and resources,” explains Dr. Von Korff. “It’s a powerful example of a learning health care system acting quickly to address important  problems.”

Helping  Group Health harness opportunities for swift bidirectional learning—where  evidence informs practice and practice informs evidence—is integral to the work of Associate Medical Director for Research Translation Robert J. Reid, MD, PhD,  who assumed this role early in 2011. Also a GHRI associate investigator, Dr. Reid leads Group Health’s ongoing evaluation of the patient-centered medical  home rollout in primary care— while keeping his eyes peeled for other opportunities  to study care innovations in real-world practice.

A prime example: When the  organization undertook a comprehensive clinic facility redesign initiative in  2011, Dr. Reid and his research team used funds from Group Health and GHRI to  quickly develop a baseline assessment—and are now seeking external funding to  support follow-up data collection and analysis.