An approach to prescribing opioids that pairs clinician education with patient-centered monitoring and feedback could help primary care doctors minimize prescribing opioid medications to manage patients’ chronic pain, according to a University of Wisconsin–Madison research team.
The team’s study, published in JAMA Network Open, found that a comprehensive “de-implementation,” strategy – doing less of something that has proven harmful or ineffective – allowed doctors working in clinics to decrease opioid dosing levels and increase patient screening for pain intensity and limitations to daily activities due to pain.
The opioid crisis has hit Wisconsin particularly hard, with the state experiencing a significant rise in opioid-related deaths over the past decade. According to experts, much of this impact has been driven by illicit opioid use.
Between 2014 and 2019, opioid overdose deaths in Wisconsin rose by 46%, according to the Wisconsin Department of Health Services Opioid Data Summary Dashboard. The trend continued upward, with data showing a persistent rise in opioid-related fatalities through 2022.
While most deaths from opioid overdoses are caused by drugs obtained illegally, initial exposure may occur through a prescription for opioid pain medication, so the need to appropriately prescribe opioids is essential, according to Andrew Quanbeck, an associate professor of family medicine and community health at the University of Wisconsin School of Medicine and Public Health, who led the research team.
Quanbeck, who holds a doctorate in industrial and systems engineering and specializes in health systems engineering, emphasized the importance of patient-centered care reflecting the updated 2022 guidance from the Centers for Disease Control and Prevention (CDC) that recommends reducing opioid prescribing.
The CDC guidelines on opioid prescribing state that providers should prescribe smaller amounts of opioids and be slow to start new opioid prescriptions.
Over the past decade, primary care stakeholders have identified opioid prescribing for chronic pain as among the most difficult implementation challenges they face, which can lead to conflict with patients and burnout among staff, according to Quanbeck.
“Health systems have responded with opioid prescribing policies to support safer opioid prescribing, but the field of implementation science has repeatedly shown that policies don’t implement themselves,” he said. “We need robust and effective implementation strategies to promote practice change.”
The research by Quanbeck and his team reveals a possible path for reducing opioid prescribing in primary care settings.
The study tested different methods of training health care providers about ways to help manage chronic pain for 8,978 patients across 56 clinics while addressing risks and benefits of opioids and adhering to CDC opioid prescribing guidelines.
Pairing CDC guidelines with the trial’s de-implementation strategies in primary care settings could lead to reducing reliance on opioid medications for chronic pain management, he said. In fact, the team’s method led to a 6% decrease in daily opioid dose, highlighting a small but statistically significant way to reduce the amount of opioids prescribed.
“The 2022 CDC guideline to start with a low dosage and go slow with new prescriptions seems to be the most solid recommendation, based on what we saw in the most intensive group in this study,” Quanbeck said.
While the findings are promising, Quanbeck acknowledged that helping people effectively manage chronic pain is a problem that needs more work.
The de-implementation study offers a roadmap for primary care providers seeking to reduce opioid prescriptions and for researchers striving to discover new ways to manage chronic pain, Quanbeck said.
Patients should know that when their care occurs in health systems that adopt the approach, they can expect more emphasis on alternatives to opioids for chronic pain; lower and shorter-term opioid dosing strategies; and greater focus on assessing pain, function and quality of life with less emphasis on potentially stigmatizing opioid treatment agreements and urine drug testing, he said.
“A de-implementation strategy means doing less of something that has shown to be harmful or ineffective, and the opioid crisis precipitated one of the largest de-implementation efforts ever seen in the United States health care system,” Quanbeck said.
This work has been funded by National Institutes of Health grant R01DA047279.