We began by identifying the scope of the problem, establishing criteria to search the electronic medical record (EMR) and identify appropriate patients. Chronic pain is often defined as pain lasting more than 3 months. Chronic opioid therapy (COT) has been defined as opioid use lasting longer than 3 months.8 Working with our IT colleagues, we defined COT patients as those with 3 or more prescriptions for opioids in the past year or those who received ≥ 30 pills a month (ie, patients who received 180 pills with 2 prescriptions written for the year). This definition gave us the ability to query our EMR to determine which patients were on COT, and we prepared lists of patients by primary care provider (FIGURE). Providers reviewed the lists to ensure these individuals were in fact on COT for CNTP. The number of patients identified after EMR query and provider review was 358, comprising 2.6% of 14,000 empaneled patients.
We based our interventions on the Arizona Department of Health Services 2014 opioid prescribing guidelines.3 The Arizona guidelines used existing national and state opioid prescribing guidelines along with clinical practice guidelines. Our study began prior to the 2016 CDC guidelines, so they were not used in this study. Our practice guidelines recommended that all 23 of our providers (MDs, DOs, and NPs) sign up for Arizona’s Controlled Substance Prescription Monitoring Program (AZCSPMP). We asked each patient to sign a controlled substance agreement (CSA), acknowledging their awareness of our proposed processes and the discussion of opioid therapy. Patients were expected to have face-to-face visits with providers at least quarterly and to complete a random urine drug screen at least annually. Patients were not incentivized to complete the process. We placed reminder calls for appointments just as we do for regular appointments.
Providers were asked to complete the Opioid Risk Tool9 with the patient at the initial visit, discuss the risks, benefits, and alternatives of long-term use of opioid medication, and review the 6 As (analgesia, activity, aberrant drug related behavior, adverse effects, affect, and adjunctive treatments). On the day before each patient visit, providers were reminded by a note in the EMR schedule to check AZCSPMP. Initial appointment times would be 30 minutes and follow-up appointments would be scheduled for 15 minutes if only addressing COT.
The QI project was introduced at an all-staff meeting in October 2015 that included providers, allied health staff, front desk personnel, and administrative staff, with the goal of beginning our COT process in November. We mailed letters to COT patients describing our new guidelines and asking them to call to schedule an appointment. If patients on COT came into the office for an alternate appointment and had not yet been seen for a COT visit, providers were encouraged to complete the COT process at that time.
We created a standard order set in the EMR for initial and follow-up visits and for the urine drug screen. We also added an interactive form to the EMR allowing providers to electronically complete the Opioid Risk Tool, and to confirm CSA completion and AZCSPMP review. We developed a database that would query the EMR for patient office visit frequency, CSA completion, and urine drug screen collection. We also placed paper copies of forms in exam rooms with a laminated instruction sheet reviewing the process steps and the 6 As.
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