Prescription opioid misuse is a significant public health problem as well as a patient safety concern. Primary care providers (PCPs) are the leading prescribers of opioids for chronic pain, yet few providers follow standard practice guidelines regarding assessment and monitoring. We propose a novel system change in delivery of primary care services to decrease misuse of and addiction to prescription opioids for patients with chronic pain. We will build on the Chronic Care Model, primary care system change to implement guidelines for chronic disease (e.g. diabetes, depression) and ultimately, to improve patient outcomes. Our proposed intervention includes a nurse-managed registry for planning individual patient care and conducting population- based care for a population of patients receiving opioids for chronic pain. We will refine tools within the electronic medical record to facilitate guideline adherence. These tools include validated instruments to screen for active substance use, depression and to assess pain and function, and will prompt clinicians to order urine drug tests. Finally, academic detailing to clinicians is another effective way to improve care. In these visits, trained individuals visit clinicians where they practice and provid them with information to change practice. The information given may also assist PCPs in overcoming obstacles to change. We will evaluate implementation strategies to integrate the best available evidence for managing patients receiving chronic opioid therapy for chronic pain into primary care settings. We propose a randomized controlled trial in 4 Boston federally qualified community health centers (CHCs). We chose to conduct the study at CHCs that could become a model for care at other CHCs as their roles expand to cover many millions of low-income populations under the Affordable Care Act. Further, CHCs are in the vanguard of clinical sites adopting the patient centered medical home. We will randomize 56 PCPs to one of the two following conditions: intervention (nurse care management, registry, electronic decision support tools, and academic detailing) or control condition (electronic decision support tools). We will follow patients and providers in both conditions for 12 months after the initiation of the intervention. Our primary outcomes are PCP adherence to chronic opioid therapy guidelines and opioid misuse among patients.

Public Health Relevance

Our project will implement interventions in the primary care setting to improve management of patients prescribed opioid therapy for chronic non-cancer pain. We will conduct a cluster randomized controlled trial, randomizing 56 primary care providers and their estimated 560 patients to the intervention condition (nurse care management, registry, electronic decision support tools, and academic detailing) or control condition (electronic decision support tools and educational outreach only). Our primary outcomes, measured at twelve months, are PCP adherence to chronic opioid therapy guidelines and opioid misuse.

Agency
National Institute of Health (NIH)
Institute
National Institute on Drug Abuse (NIDA)
Type
Research Project (R01)
Project #
3R01DA034252-01S1
Application #
8656893
Study Section
Special Emphasis Panel (ZDA1-GXM-A (04))
Program Officer
Ducharme, Lori
Project Start
2012-07-15
Project End
2017-06-30
Budget Start
2012-07-15
Budget End
2013-06-30
Support Year
1
Fiscal Year
2013
Total Cost
$6,699
Indirect Cost
$200
Name
Boston Medical Center
Department
Type
DUNS #
005492160
City
Boston
State
MA
Country
United States
Zip Code
02118
Khalid, Laila; Liebschutz, Jane M; Xuan, Ziming et al. (2015) Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med 16:480-7
Liebschutz, Jane; Beers, Donna; Lange, Allison (2014) Managing Chronic Pain in Patients with Opioid Dependence. Curr Treat Options Psychiatry 1:204-223