An electronic intervention to improve safety for pain patients co-prescribed chronic opioids and benzodiazepines (original) (raw)
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JAMA psychiatry, 2018
Recent increases in US opioid-related deaths underscore the need to understand drivers of fatal overdose. The initial prescription of opioids represents a critical juncture because it increases the risk of future opioid use disorder and is preventable. To examine new opioid prescribing patterns in US patients at increased risk of overdose from benzodiazepine use. This study used publicly available data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from January 1, 2005, through December 31, 2015, to identify adults 20 years or older receiving new opioid prescriptions and concurrently using a benzodiazepine. Population-based rates of new opioid prescriptions stratified by use of benzodiazepines. This study analyzed 13 146 visits, representing 214 million visits nationally, with a new opioid prescription. Rates of new opioid prescriptions among adults using a benzodiazepine increased from 189 to 351 per 1000 persons between 2005 a...
Pain Medicine, 2020
Objective In response to the opioid epidemic, the Centers for Disease Control and Prevention issued guidelines (CDCG) in 2016 for the prescription of opioids for chronic pain. To facilitate research into whether CDCG implementation will lead to reductions in opioid prescribing and improved patient safety, we sought to validate a tool that quantifies CDCG adherence based on clinical documentation. Design The Safe Opioid Prescribing Evaluation Tool (SOPET) was developed in four phases as part of a study to improve the implementation of the CDCG in the clinical setting. Four raters with varying levels of clinical experience and expertise were trained to use the SOPET and then used it to evaluate 21 baseline patient encounters. Intraclass correlation coefficient (ICC) estimates and their 95% confident intervals (CIs) were calculated for the total SOPET score based on a mean-rating (k = 4), absolute-agreement, two-way random-effects model. For intrarater reliability, two-way mixed-effect...
Academic Emergency Medicine, 2009
Background: Prescriptions for controlled substances decrease when regulatory barriers are put in place. The converse has not been studied.Objectives: The objective was to determine whether a less complicated prescription writing process is associated with a change in the prescribing patterns of controlled substances in the emergency department (ED).Methods: The authors conducted a retrospective nonconcurrent cohort study of all patients seen in an adult ED between April 19, 2005, and April 18, 2007, who were discharged with a prescription. Prior to April 19, 2006, a specialized prescription form stored in a locked cabinet was obtained from the nursing staff to write a prescription for benzodiazepines or Schedule II opioids. After April 19, 2006, New York State mandated that all prescriptions, regardless of schedule classification, be generated on a specialized bar‐coded prescription form. The main outcome of the study was to compare the proportion of Schedule III–V opioids to Sch...
Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety
The Journal of the American Board of Family Medicine
Introduction: Primary care providers (PCPs) account for half of opioid prescriptions, often feel chronic pain patients are challenging to manage, and there is wide variability in practice patterns. The purpose of this pilot study was to evaluate the impact of a previsit pharmacist review of high-risk patients treated with opioids for chronic pain on compliance to guideline recommendations at a family medicine residency clinic. Methods: All adult patients with an appointment for chronic pain who were prescribed >50 morphine milligram equivalents (MMEs)/day had charts reviewed by a pharmacist before each appointment; recommendations were sent electronically to the provider before the appointment. After 4 months of implementation, each patient's chart was manually reviewed to gather outcome variables. The primary outcomes were the mean MMEs/day and pain scores. Results: Pharmacist previsit recommendations were provided for 45 patients. When comparing outcomes before and after intervention, the mean MMEs/day decreased by 14% (P < .001), with no change in pain scores (P ؍ .783). Statistically significant improvements were noted in multiple other secondary opioid safety outcomes. Conclusion: Clinical pharmacists providing previsit recommendations was associated with decreased opioid utilization with no corresponding increase in pain scores and increased compliance to guideline recommendations.
2019
The goal of this Capstone project was to provide meaningful Continuing Education (CE) to clinicians in the Midwest to reduce perceived challenges to safely treating patients coprescribed opioid analgesics and benzodiazepines Objectives Using continuing education, increase clinician knowledge of effective alternative non-opioid and non-benzodiazepine therapies for chronic conditions while increasing clinician comfort in tapering patients off opioid analgesics and benzodiazepines Methods A one-hour CE presentation was prepared with the assistance of the Nebraska Department of Health and Human Services (NeDHHS) and broadcast to clinicians in the Midwest through a live webinar in coordination with the Great Plains Quality Innovation Network (GPQIN) and the Nebraska Medical Association (NMA). Clinicians registering for the webinar included physicians, mid-level providers such as physician assistants and nurse practitioners, pharmacists, and nurses. In the process of registering for the webinar, clinicians were required to answer five questions to assess their perceived knowledge of effective alternative non-opioid and nonbenzodiazepine therapies and their comfort with tapering patients off opioid analgesics and benzodiazepines. After the webinar, providers were required to complete a post-assessment survey of identical questions to obtain their CE credit. These questions were arranged on a 5-3 point Likert scale describing their level of agreement with the statements posed. Post-webinar responses were compared to the pre-webinar responses to examine the effect of the CE presentation on provider knowledge and comfort in treating patients prescribed both opioids and benzodiazepines. The Wilcoxon signed-rank test was used to compare the pre-and postwebinar responses to determine if the CE presentation was associated with a difference in selfreported knowledge and comfort in guideline recommended practices. Project Impact This study demonstrated that continuing education was associated with a statistically significant increase in self-reported clinician knowledge of effective alternative non-opioid and non-benzodiazepine therapies for chronic conditions while also increasing self-reported clinician comfort in tapering patients off opioid analgesics and benzodiazepines. State health departments should promote the use of CE in reducing perceived challenges to safely treating patients co-prescribed opioid analgesics and benzodiazepines in their efforts to decrease the incidence of opioid-related overdose deaths.
Pain Medicine, 2009
Objective. To demonstrate that a computer-assisted survey instrument offers an efficient means of patient evaluation when initiating opioid therapy.Design. We report on our experience with the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that uses validated questionnaires to collect comprehensive clinical and behavioral information from patients with chronic pain.Setting and Patients. Over a 39-month period, 1,400 patients entered data into PODS using a computer touch screen in a Veterans Administration Pain Clinic.Measures. Indices of pain intensity, function, mental health status, addiction history, and the potential for prescription opioid abuse were formatted for immediate inclusion into the medical record.Results. The PODS system offers physicians a tool for systematic evaluation prior to prescribing opioids The system generates an opioid agreement between the patient and physician, and provides medicolegal documentation of the patient's condition.Conclusions. PODS should improve patient care, refine pain control, and reduce the incidence of opioid abuse. Research to determine how PODS affects clinical care is underway. Specially, the effectiveness and efficiency of providing care utilizing PODS will be evaluated in future studies.
Contemporary clinical trials, 2017
Thousands of people die annually from prescription opioid overdoses; however there are few strategies to ensure patients receive medication risk information at the time of prescribing. To compare the effectiveness of the Emergency Department (ED) Electronic Medication Complete Communication (EMC(2)) Opioid Strategy (with and without text messaging) to promote safe medication use and improved patient knowledge as compared to usual care. The ED EMC(2) Opioid Strategy consists of 5 automated components to promote safe medication use: 1) physician reminder to counsel, 2) inbox message sent on to the patient's primary care physician, 3) pharmacist message on the prescription to counsel, 4) MedSheet supporting prescription information, and 5) patient-centered Take-Wait-Stop wording of prescription instructions. This strategy will be assessed both with and without the addition of text messages via a three-arm randomized trial. The study will take place at an urban academic ED (annual v...
Pain Medicine, 2021
Objective Due to increased risks of overdose fatalities and injuries associated with coprescription of opioids and benzodiazepines, healthcare systems have prioritized deprescribing this combination. Although prior work has examined providers’ perspectives on deprescribing each medication separately, perspectives on deprescribing patients with combined use is unclear. We examined providers’ perspectives on coprescribed opioids and benzodiazepines and identified barriers and facilitators to deprescribing. Design Qualitative study using semistructured interviews. Setting One multisite Veterans Affairs (VA) healthcare system in the United States of America. Subjects Primary care and mental health prescribers, key clinical leaders, clinical pharmacist specialists (N = 39). Methods Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. Themes were identified iteratively, through a multidisciplinary team-based process. Results Analyses identified four themes re...
Improving opioid prescription practices and reducing patient risk in the primary care setting
Journal of Pain Research, 2014
Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting.
Value in Health, 2019
Objectives: This prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing. Methods: Data analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use. Results: Among 14 221 patients, 9% had prescriptions with an average MEDD 90mg.TherewerenosignificantchangesinMEDDafterEMRCDSimplementation.Increasingage,CharlsonComorbidityIndexscore,femalesex,blacknon−Hispanicrace,non−opioidpainmedicationco−prescriptions,andspecialtyreferralswereassociatedwithaloweroddsofMEDD90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD 90mg.TherewerenosignificantchangesinMEDDafterEMRCDSimplementation.Increasingage,CharlsonComorbidityIndexscore,femalesex,blacknon−Hispanicrace,non−opioidpainmedicationco−prescriptions,andspecialtyreferralswereassociatedwithaloweroddsofMEDD90 (highdose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P , .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change. Conclusions: EMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.