Achieving Opioid Management

Michael Kanter MD Executive Vice President of Quality and Chief Quality Officer for the Permanente Federation https://permanente.org and Medical Director of Quality and Clinical Analysis for the Southern California Permanente Medical Group https://permanente.org, took part in a discussion on opioid management. The event sponsored by the Duke Robert J. Margolis MD Center for Health Policy was held at the National Press Club on February 15, 2018.

Dr Kanter led the development of a comprehensive initiative to transform the way that chronic pain is viewed and treated. The group in the study included Kaiser Permanente Southern California members age 18 and older excluding cancer, hospice and palliative care patients. The 3,203,880 participants were approximately 75 percent of all Southern California members.

In doing the study, all of the data from Kaiser Permanente’s pharmacy data systems and EHRs were collected on a rolling basis as interventions were implemented from January 2010 to December 2015.

Southern California results from the study showed reductions in all tracked outcomes such as:

  • 30 percent reduction in prescribing opioids in high doses
  • 98 percent reduction in number or prescriptions with greater than 200 pills
  • 90 percent decrease in opioid prescriptions with benzodiazepines and carisoprodol
  • 72 percent reduction in prescribing Long-Acting/Extended Release opioids
  • 95 percent reduction in prescribing of brand name opioid acetaminophen products
  • Methadone prescribing did not increase during this period.

 

Dr. Kanter emphasized that physician education and support is vital to achieving results. Shared decision-making tools should be used for discussion purposes, monthly prescriber levels are collected on opioid safety metrics and prescribing patterns, program ideas need to be discussed on how to effectively manage spine related pain, and lastly, there needs to be easy access to the state prescription monitoring databases.

Physician education and support also entails collaborating with chronic pain experts on possible pharmacy initiatives. This can include reviewing all high dose prescriptions, reviewing all prescriptions for short and long acting opioids exceeding a predetermined pill count, and developing drug management initiatives focused on promoting appropriate and safe opioid utilization.

Patient safety is another key issue. Some helpful suggestions are to encourage higher dose patients to lower the dose when clinically appropriate, reduce quantity and frequency of opioids in the emergency department and after surgery, and offer alternatives to opioids if possible. Some of the alternatives that are clinically appropriate can be mindfulness training, Tai Chi, acupuncture, attending pain management classes, and giving patients’ information on the benefits of using cognitive behavioral therapy.

The study’s promising results emphasizes the fact that a comprehensive system-level strategy has the ability to positively affect opioid prescribing. The basic ideas and thoughts generated from the study show that the basic components are applicable to many other healthcare settings.

The results from this study became the focus for the article “Safe and Effective Opioid Prescribing Program” published in the “Journal of Evaluation in Clinical Practice”. The article shows how a comprehensive system strategy can positively affect opioid prescribing. The original article is available at https://onlinelibrary.wiley.com/doi/io.1111/jep.12756/full.

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