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.
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.