Special Topics in Pain: Opioids

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Novel peer review method for improving controlled substance prescribing in primary care.

Author(s): Penti B, et al.
Journal: J Opioid Manag. 2016; 12(4):269-276. 22 references.
Reprint: Brian Penti, MD, MS, Department of Family Medicine, Boston University School of Medicine, Boston Massachusetts.
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids


Editor’s Note: “Providing feedback to physicians on controlled substance prescribing via a Chart Review tool (CRT) has the potential to improve the safety of prescribing practices in a busy urban outpatient clinic of a safety-net hospital. The CRT can offer objective feedback based on existing guidelines in a nonpunitive manner and may provide meaningful information to researchers about opioid prescribing practices. Further research is needed to assess which aspects of the CRT are most meaningful and whether these findings are generalizable to other clinical settings. 

Class: Novel peer review method for improving controlled substance prescribing in primary care.

A family medicine clinic based in a large, urban academic safety-net hospital updated its existing controlled substance prescribing policy in 2011. In 2013, a survey of 11 providers at the clinic suggested concerns for patients' safety when prescribing controlled substances.

In August 2013, the clinic initiated a quality improvement (QI) project with the aim to improve primary care physicians' (PCPs) knowledge about best management practices when prescribing controlled substances, such as opioids for chronic noncancer pain, through the use of a peer review process that featured a chart review tool (CRT).

A committee of eight volunteer physicians and a pharmacists took four months to develop a peer review process and develop a CRT focusing on assess the six-month period prior to time of chart review. The CRT was based on the existing controlled substance policy at the clinic and the American Pain Society American Academy of Pain Medicine Guidelines and included the Opioid Risk Tool, which calculates the risk for potential aberrant drug use behavior. The amount of opioid prescribed was listed in morphine equivalent dose (MED)/day.

The QI project took place from October 2013 to September 2014. Charts were identified of patients (aged 18 or above) who had primary care visits at the clinic and were prescribed a controlled substance (defined as opioid analgesic medications, BZDs, or amphetamines) monthly for at least three consecutive months during the one-year period prior to time of request. From this list, charts were randomly selected for review each month by two to four volunteer physicians and pharmacists who reviewed three charts each, specifically looking at the most recent six-month period. After completion of the review, the CRT form was returned to the patient's PCP with the intent to provide nonpunitive, constructive feedback.

There were 88 patients on an opioid analgesic and two died during the study (one from active cancer and the other unknown causes). The majority of the 86 surviving patients received opioids for low-back pain (55%), chronic pain syndrome/fibromyalgia (15%), or arthritis (13%).

The average dose of opioid at time of review was 72.6 mg MED/day (SD 89) with 20 patients (23%) receiving > 100 mg MED/day. The average duration of opioid therapy was 61 months (SD 47.9). Caucasian patients received statistically significant higher doses of opioids (112 mg/day [SD 111]) than African Americans (57.1 mg/day [SD 80.6]) and Latino patients (59.1 mg/day [SD 46]). High-risk patients, based on ORT score, were prescribed higher doses of opioids (114.3 mg/day [SD 89]) compared to low-risk (56.1 [SD 77.8]), and moderate-risk patients (78.3 mg/day [SD 106.2]). Patients with documented controlled substance treatment agreements in their charts had higher dose of opioids (91.4 mg MED) compared to those without treatment agreements documented (52 mg MED).

The dose of opioid was associated with duration of therapy with the dose increasing 0.6 mg with each additional month of treatment in the 12 months prior to the intervention, or 7.2 MED/year. Over the 12 months prior to the chart review the mean amount of opioid prescribed per day, in MED, increased 6.9 mg. In the period of time after the chart review (average 6.3 months), there was a 2.6 mg MED mean decrease in the amount of opioid prescribed. About 51% of patients had documentation of treatment agreements in their charts.  One patient had documentation of a random pill count. Less than one-third of patient charts documented any clinical improvement with controlled substance therapy, although there was wide variation in documentation practices. Documentation of symptoms consistent with known side effects were found in 23% of patients. Overall, 14 of the 88 patients (16%) prescribed opioids had their opioids discontinued after the chart review.

Important Points:
Providing feedback to physicians on controlled substance prescribing via a CRT has the potential to improve the safety of prescribing practices in a busy urban outpatient clinic of a safety-net hospital. The CRT can offer objective feedback based on existing guidelines in a nonpunitive manner and may provide meaningful information to researchers about opioid prescribing practices. Further research is needed to assess which aspects of the CRT are most meaningful and whether these findings are generalizable to other clinical settings.  

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