Fatal overdoses involving prescribed opioids tripled in the United States between 1999 and 2006, climbing to almost 14,000 deaths annually -- more than cocaine and heroin overdoses combined. Hospitalizations and emergency room visits related to prescription opioid pain medicines such as oxycodone (brand name Oxycontin) and hydrocodone (Vicodin) also increased dramatically in the same period.
Now a report in the August issue of Health Affairs describes a major initiative at Group Health to make opioid prescribing safer while improving care for patients with chronic pain. Health Affairs is the nation's premier health policy journal, and its August issue focuses on substance abuse.
In the Group Health initiative's first nine months, clinicians at the Seattle-based integrated health system developed and documented care plans for almost 6,000 patients -- 85 percent of those receiving long-term opioid therapy for chronic non-cancer pain.
Group Health's initiative was implemented well before the White House Office of Drug Control Policy, the Food and Drug Administration, and the Drug Enforcement Administration announced a national action plan in April 2011 to stem the epidemic of prescription drug abuse. Scientists from Group Health Research Institute are evaluating the initiative's effects on care, hoping Group Health's experience can help guide national efforts.
Use of prescription opioids has increased sharply since the 1980s. Excluding people with cancer and those in end-of-life care, about 4 percent of U.S. adults now use prescription opioids long term. Pharmaceutical industry advocacy and education have fueled increased opioid prescribing for chronic non-cancer pain -- despite limited scientific evidence supporting the drugs' long-term effectiveness for chronic non-cancer pain.
In January 2010, Group Health Research Institute Senior Investigator Michael Von Korff, ScD, and colleagues published the first-ever study on overdose risk by dose among patients receiving prescribed opioids for chronic non-cancer pain. That study, published in the Annals of Internal Medicine, linked higher risk of fatal and nonfatal overdose to higher daily dose prescribed. His research also showed that Group Health, like other health systems nationwide, had been prescribing more opioids for chronic non-cancer pain over time -- a twofold increase from 1997 to 2005.
Group Health launched a major primary care-based initiative to enhance opioid prescribing safety later in 2010. Led by Group Health Medical Director of Primary Care Claire Trescott, MD, the initiative aims to standardize use of opioids for chronic non-cancer pain, without creating undue restrictions on clinically appropriate opioid prescribing.
Using Lean management principles, Dr. Trescott worked with primary care doctors, nurses, pharmacists, pain specialists, and other clinical leaders to formulate new guidelines and related practice changes. These changes include creating standardized care plans for all patients receiving opioids long-term for chronic non-cancer pain.
"Our new opioid care plans specify one responsible prescribing physician, clarify expectations for monitoring and refills, outline treatment goals, and explain risks and side effects of long-term opioid use," said Dr. Trescott.
The individualized plans are created for each patient receiving opioids for 90 days or more. The clinician actively involves patients in the plan development and education on the risks and potential benefits of long-term opioid use. Prescription refill processes are modified to avert problems when patients seek a refill on short notice or run out of medication over a weekend. Periodic monitoring visits with their providers are scheduled, depending on dosage level and risk factors.
Recognizing the importance of provider education, Group Health's Chief of Physical Medicine and Rehabilitation Randi Beck, MD, partnered with Dr. Von Korff to develop an online clinician education course explaining the new guidelines. Funded by a Partnership for Innovation grant from the Group Health Foundation, the course aims to help primary care providers implement recommended practice changes.
By May 2011 -- just 9 months after the new guideline was implemented -- nearly 6,000 care plans were developed with patients receiving opioids for chronic non-cancer pain (85 percent of the target population).
"We see impressive changes when our delivery system, research institute, and foundation collaborate -- pooling our knowledge, skills, and resources," Dr. Von Korff said. "It's a powerful example of how a learning health care system can act quickly to address important problems in health care."
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