A leading health services researcher and implementation scientist on opioid prescribing and management in primary care, Abt Principal Associate Sarah J. Shoemaker-Hunt, Ph.D., Pharm.D., recently sat down with us to discuss her implementation research and evaluations on safer opioid prescribing across health care systems and primary care practices. Her team recently collaborated on the Agency for Healthcare Research and Quality's (AHRQ) Six Building Blocks of Opioid Management How-To Guide, which gives guidance to clinics that want to implement guideline-driven care. Shoemaker-Hunt also led development of the Centers for Disease Control and Prevention’s (CDC) Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain.
How is Abt helping to implement evidence-based guidance on opioids for primary care?
Abt has been working with various federal agencies, including CDC and AHRQ, for the last six years identifying, implementing, and evaluating best practices for addressing the opioid crisis in the health care system.
That work includes 16 quality improvement (QI) measures aligned to the CDC Guideline for Prescribing Opioids for Chronic Pain to help health systems measure where they are--at baseline-- and to monitor changes over time. We support quality improvement efforts with learning and QI collaboratives of health systems and primary care clinics, often employing multiple strategies to change and improve practices. Abt also led a project to implement and evaluate clinical decision support tools in electronic health records to improve prescribing and support providers at the point of care.
We also have developed several resources to support improved care of patients with pain and on opioids, as I mentioned earlier. For all of these efforts, we observe improvements over time and how to tweak support for practices and clinicians to provide better care for patients.
The premise of all of this work is that many patients are already on opioids for chronic pain. The question we address is how to provide patients what they need as safely as possible and to minimize the risks of opioids, including misuse, dependence, and overdose.
What are best practices for primary care providers to adopt to prescribe opioids more safely and care for patients with chronic pain?
There’s a range in terms of the evidence we have at present, although there is a good bit of work being done to expand what we know with forthcoming evidence reviews from AHRQ and guidelines sponsored by the Food and Drug Administration.
We do know higher dosages of opioids for an individual patient can put the patient at greater risk for overdose, so ensuring judicious and appropriate dosages to address a patient’s pain is important. Similarly, patients taking opioids who are prescribed an anti-anxiety drug, which also depresses the central nervous system, are at greater risk of fatal overdose.
Before getting to opioids, providers and patients should consider non-opioid and non-pharmacological options, such as physical therapy. Clinicians should regularly assess patients’ pain and, as importantly, their function. Clinicians also should check the urine drug screen and the state prescription drug monitoring program.
For someone with opioid use disorder (OUD), we know that several medication-assisted treatment (MAT) options are effective. With buprenorphine/naloxone, for example, you don’t have to be off opioids to take it. That contrasts with some drugs that are complete antagonists of opioids so you have to be weaned from opioids for a time before you start them. So if someone presents with an opioid overdose in the emergency room, you couldn’t initiate that MAT option.
While these are some of the recommendations, the guidelines are not meant to be “hard and fast rules.” Unfortunately, the CDC Guideline was misapplied with, for example, hard limits on dosages, abrupt tapering of patients off opioids, sudden dismissal of patients, and inappropriate application to cancer patients (Kroenke et al, 2019; Dowell et al, 2019).
An individualized approach for each patient is required. For example, a provider should discuss with individual patients a possible taper if the balance of risks outweighs the benefits, and even more so if pain and function have not meaningfully improved.
What does it take to implement opioid guidelines and policies into practice, to actually improve care?
It’s not just about the clinical evidence and what’s known, but how you actually change practice. That’s the work we do supporting health systems and quality improvement efforts and looking at improvements or changes over time.
Given the often complex nature of these improvements in health care systems and primary care practices, we use implementation science to evaluate and expand the evidence on how to implement opioid and chronic pain guidelines effectively and sustainably.
Read more of Sarah’s Issue Brief for AcademyHealth Implementation Research to Understand Effective Approaches to Opioid Management in Health Systems.