Multicomponent intervention linked to improved guideline adherence in long-term opioid therapy

1. In this cluster-randomized trial targeting primary care clinicians (PCC) treating patients with long-term opioid therapy in safety-net practices, a multicomponent intervention increased guideline concordant care and lead to opioid dose reduction or discontinuation compared to the control.

2. Frequency of early opioid prescription refills were not significantly different between the intervention and control groups.

Evidence Rating Level: 2 (Good)       

Study Rundown: Long-term opioid use has been linked to increased morbidity and mortality, and has led to increased availability for non-medical purposes. The Center for Disease Control and Prevention has published guidelines in order to minimize unsafe prescribing practices. The guidelines include: patient-clinician agreements, urine drug testing (UDT), prescription drug monitoring programs, and recommendations against use of more than 100 mg morphine equivalent daily dose (MEDD). The current study evaluated a multicomponent intervention (TOPCARE) aimed at improving guideline adherence for PCCs treating patients on long-term opioids in a safety-net setting. The study found that compared to the control, the intervention group were more likely to have guideline-concordant care, to have documented clinician-patient agreement, undergo at least one UDT, discontinue opioid therapy, or have a 10% reduction in opioid dose. There was no observed difference in the odds of early refill of opioid prescription.

The main strength of the study was the randomized controlled design allowing for more meaningful conclusions than previous observational studies. The limitations of this study included use of electronic medical records as the source of data, which were lacking information on patient outcomes such as pain control, overdose rates, and opioid misuse.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

In-Depth [randomized controlled trial]: This study was a cluster randomized trial assigning PCCs from 4 safety net primary care practices to either TOPCARE multicomponent intervention, or a control arm receiving only electronic decision tools for long-term opioid prescribing over a 1 year period. The intervention components included: 1) nurse care manager to aid in pain assessments, UDT testing, and prescription preparation, 2) electronic registry to consolidate electronic health record data into summary reports of action items, 3) 1-on-1 session between PCCs and an opioid prescribing expert, and 4) online evidence based decision tools to aid in opioid prescribing decisions. The primary outcomes were adherence to guideline-derived monitoring strategies, and early opioid refills. Secondary outcomes included proportion of patients discontinuing opioids, or having a 10% reduction in dose.

A total of 58 PCCs were included in the study, and 25 were assigned to the intervention group. In total, there were 985 patients on long-term opioids – 586 in the intervention group and 399 in the control. The patients assigned to TOPCARE PCCs were more likely to have guideline-concordant care (65.9% vs. 37.8%, p < 0.001), to have a clinician-patient agreement documented (53.8% vs. 6.0%, p < 0.001), undergo at least one UDT (74.6% vs. 57.9%, p < 0.001), discontinue opioid therapy (21.3% vs. 16.8%, p = 0.04), or have at least a 10% reduction in MEDD (32.8% vs. 22.9%, p = 0.01). There were no differences observed in early prescription refills (20.7% vs. 20.1%, AOR, 1.1; 95%CI, 0.7-1.8).

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