Use of Chronic Opioid Therapy (COT) for non-cancer pain doubled in the past decade, after doubling over the previous 2 decades. Fatal overdoses involving opioid analgesics increased four-fold from 1999 to 2009. Opioid overdose deaths and admissions have increased at a rate three-fold higher in rural counties compared to metropolitan counties. Team-based approaches to managing complex patients such as those on COT produce superior results, but are not commonly used in managing patients on COT. We will implement a team-based best practices approach to safe opioid prescribing for chronic non-cancer pain in rural primary care clinics based on the Group Health Chronic Opioid initiative and findings in our recent work on the national project: Primary Care Teams: Learning from Exemplar Ambulatory Practices (LEAP).
Our specific aims are to: 1) implement a team-based best practices approach to safe opioid prescribing in primary care ; 2) examine the effectiveness of the intervention; 3) assess the sustainability of the team-based best practices approach; and, 4) develop and launch a robust dissemination program. The study will be conducted in 14 remote, rural, clinics in Washington and Idaho. Key elements of the intervention are: 1) a COT improvement team in each clinic with at least one clinician champion; 2) revision of current clinic policies using examples from Project LEAP exemplar practices; 3) develop clinic workflow and tasks needed to implement policies; 4) use of a clinic registry for pre-visit planning and visit intake; and 5) use of performance reports to track and make improvements. Clinic teams will be supported for 12 months during the implementation phase by the study team with an in-person kick-off meeting, monthly coaching calls to each clinic, monthly webinars for all clinic teams as a shared learning collaborative, and registry support and technical assistance. Our evaluation is guided by the RE- AIM framework. REACH: proportion of COT patients on COT therapy who have data from 6 or more visits entered into the registry. EFFECTIVENESS: change in the monthly average daily Morphine Equivalent Dose (MED) in patients before and one year after the start of implementation. ADOPTION: proportion of the 14 rural primary care clinics that revise their clinic policies. IMPLEMENTATION: change in score on the COT-Best Practices self-assessment survey completed by clinic staff at before and after the implementation. MAINTENANCE: change in average daily MED 6-12 months after completion of the one year intervention phase. Our dissemination plan has 3 core elements: 1) a website; 2) a plan for use of social media; and 3) use of early adopters/opinion leaders.

Public Health Relevance

This research demonstration seeks to improve safe prescribing of chronic opioid medication for patients with non-cancer pain in rural primary care clinics across Washington and Idaho. We will help clinics in their clinic policies, improving team workflows, and using a registry to track and support patients. We will develop implementation guides, toolkits and resources based on this study and disseminate them nationally through websites, social media and opinion leaders.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Healthcare Patient Safety and Quality Improvement Research (HSQR)
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Perfetto, Deborah
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Group Health Cooperative
United States
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Parchman, Michael L; Von Korff, Michael; Baldwin, Laura-Mae et al. (2017) Primary Care Clinic Re-Design for Prescription Opioid Management. J Am Board Fam Med 30:44-51