A Seattle-based health care system that implemented a program last year to prevent opioid misuse and overdose in patients with chronic noncancer pain is beginning to see positive results.

Claire E. Trescott, MD, Primary Care Director of Group Health, which has 450,000 patients and 26 clinics, says the initiative aims to standardize opioid prescribing, and make it safer. Managing opioids is one of the most difficult problems in primary care, she says. “We realized we needed to organize it so we could do it better. We were determined to focus on how we could become better clinicians in managing chronic noncancer pain, not on how we could become better policemen.”

The new system was developed over a year of consultations with representatives from the health system’s staff in primary care, physical and rehabilitation medicine, pharmacy, nursing, behavioral health and clinical informatics.

All patients on chronic opioid therapy for noncancer pain now have a standard chart template that includes treatment goals, medication regimens, frequency of monitoring visits and requirements for drug screening, if applicable. “We are no longer a group of different prescribers who all have different ideas of what to do,” she states.

Using electronic health records is a key component of the program, she notes. “Everyone in the system uses electronic health records, so that no matter where we are, we are all looking at the same chart. The patient can go online, too, and view their treatment plan.”
One key feature of the new program is that one physician is now designated as responsible for the management of long-term opioid therapy for each patient receiving opioids for 90 days or more.

Another feature is that some patients must undergo periodic mandatory urine drug screening. Patients are categorized as low, medium or high risk for opioid abuse, which determines whether, how often urine screening is performed and how often they must come in for monitoring visits. People under 25, patients with a history of substance abuse, or those on high doses of opioids, are among those considered at high risk and are monitored more closely.

Dr. Trescott says having mandatory drug screening for certain patients makes it easier for doctors to tell them they must undergo testing. “When you’re a clinician with a long-term relationship with a patient, it can be very difficult to tell them they have to undergo drug testing,” she says. “It helps if the organization says it’s the rule.”

Patients work together with their doctors to jointly determine their goals and expectations. “Doctors and patients are having honest, in-depth discussions about opioids before treatment starts,” she explains. “We make it clear to patients that it is not likely they will live pain-free with these drugs. We tell them they may have to take these drugs for the rest of their lives, or they may not work.”

A new pharmacy refill plan was created to avoid problems when patients sought a refill on short notice, and to keep patients from running out of medication over a weekend. The program also includes a new mandatory continuing medical education online course for the group’s physicians to teach them about chronic pain and opioid prescribing.

Dr. Trescott reported in Health Affairs that between September 2010, when the initiative was launched, and May 2011, almost 6,000 patients on long-term opioid therapy at all dosage levels met with their clinicians to develop care plans that were documented in their electronic health record. As of January, almost all of the system’s 7,000 patients in this category have care plans.

As a result of the new system, which made doctors’ prescribing practices very clear, some physicians are no longer allowed to prescribe opioids at Group Health, according to Dr. Trescott. “We know we’re prescribing lower doses of opioids overall, and we’re doing a lot more urine drug screening than we used to,” she says. The program staff will continue to evaluate data as it comes in, looking at trends in standardization of care and the rate of adverse events, including diagnosed abuse of prescription opioids and overdoses.

Dr. Trescott is pleased with the early outcomes of the program. “Now, if someone needs a refill, we aren’t treating them like a criminal anymore,” she notes. “And if someone is abusing substances, we catch it quickly and address it. The system has been fair, respectful, honest and transparent.”