Dataset Information

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial.

ABSTRACT:

Importance

Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing.

Objective

To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain.

Design setting and participants

We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache.

Interventions

Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription.

Main outcomes and measures

Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up.

Results

Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18; P = .20) for opioid justification and 0.60 (95% CI, 0.38-0.96; P = .03) for clinician comparison. Compared with control, clinician comparison was associated with decreased odds of opioid therapy of more than 3 months (aOR, 0.79; 95% CI, 0.69-0.91; P = .001) and concurrent opioid/benzodiazepine prescription (aOR, 0.85; 95% CI, 0.72-1.00; P = .04), whereas opioid justification did not have a significant effect.

Conclusions and relevance

In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing.

Trial registration

ClinicalTrials.gov Identifier: NCT03537573.

SUBMITTER: Kraemer KL

PROVIDER: S-EPMC9338412 | biostudies-literature | 2022 Jul

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial.

Kraemer Kevin L KL Althouse Andrew D AD Salay Melessa M Gordon Adam J AJ Wright Eric E Anisman David D Cochran Gerald G Fischer Gary G Gellad Walid F WF Hamm Megan M Kern Melissa M Wasan Ajay D AD

JAMA health forum 20220729 7

<h4>Importance</h4>Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing.<h4>Objective</h4>To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain.<h4>Design setting and participants</h4>We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practi ...[more]

PMID: 35983579

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Project description:IntroductionThe aim of this study was to investigate trends in the prevalence of potentially inappropriate opioid prescribing (PIOP) and identify potential risk factors among Korean noncancer patients.MethodsWe conducted a cross-sectional study of annual national patient sample data from the Korean Health Insurance Review and Assessment Service (HIRA-NPS) for the period 2012-2018. Noncancer patients who were prescribed non-injectable opioid analgesics (NIOAs) at least once were included. The proportion of patients with at least one PIOP in terms of concurrent use of benzodiazepines or gabapentinoids, substance use disorder, treatment duration, and dosage was evaluated. Multivariable logistic regression was performed to identify the risk factors associated with PIOP.ResultsOf the 9,772,503 noncancer patients, 1,583,444 (16.2%) were prescribed NIOAs at least once. Among them, 15.7% were exposed to PIOP, and the prevalence was much higher (31.6%) in the elderly group (age: ⩾65 years). The prevalence of PIOP increased 1.1-fold over 7 years (14.8-16.8%) among the total NIOA users and was more pronounced in non-tramadol NIOA users (a 1.5-fold increase, from 13.2% to 19.4%). Multivariable logistic regression indicated that older age, beneficiaries of medical aid or national meritorious service, exposure to polypharmacy, psychological disorder, chronic pain indication, and concomitant sedative use were independently associated with higher odds of PIOP.Discussion and conclusionWe found that the prevalence of PIOP was 15.7% among Korean noncancer patients, and it increased over the 7-year study period. This increasing trend is alarming because it was more drastic with non-tramadol NIOAs compared with that with tramadol. Several patient-level risk factors associated with PIOP would be useful in targeted management strategies for the safe use of opioids.Plain language summaryPotentially inappropriate opioid prescribing and related risk factors among noncancer patients prescribed non-injectable opioids in Korea In Korea, the prevalence of non-injectable opioid analgesic (NIOA) use in noncancer patients steadily increased from 15.3% in 2012 to 17.1% in 2018.Also, the prevalence of potentially inappropriate opioid prescribing (PIOP) increased from 14.8% in 2012 to 16.8% in 2018.The following factors were associated with a markedly increased risk of PIOP: age, beneficiaries of medical aid or national meritorious service, polypharmacy, psychological disorder, chronic pain, and concomitant medications.

Project description:BACKGROUND:New persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3-6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients. OBJECTIVE:To identify specialties prescribing opioids to surgical patients who develop new persistent opioid use. DESIGN, SETTING, AND PARTICIPANTS:Using a national dataset of insurance claims, we identified opioid-naïve patients aged 18-64 years undergoing surgical procedures (2008-2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes. MAIN MEASURES:Percentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery. KEY RESULTS:We identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%. CONCLUSIONS:Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence.

Project description:ObjectiveIt has been established that most patients prescribed opioids after minor surgery have tablets left over, better understanding the variation in opioid prescribing and variation in dosage of the prescription could guide efforts to reduce prescribing. This study describes the state-level variation in opioid prescribing after a knee arthroscopy among opioid-naïve patients.DesignRetrospective cohort study.SettingCommercial insurance claims data.Participants98 623 individual across the USA with commercial insurance who were opioid-naïve and had a knee arthroscopy between 2015 and 2019.ExposurePatients who filled an opioid prescription within 3 days of a knee arthroscopy.Outcome measuresOpioid prescriptions were measured as a pharmacy claim for filling an opioid within 3 days of a knee arthroscopy. We measured the patient and state-level opioid prescribing rate, tablet count, morphine milligram equivalent dose per prescription and risk-adjusted predicted opioid quantity.ResultsOverall, 72% of patients filled an opioid prescription with a median tablet count of 40 and median morphine milligram equivalent of 250. Patients with an invasive procedure (27.9% vs 22.4%; p<0.001), higher education level (p<0.001) and fewer comorbidities (0.9 vs 1.2, p<0.001) had higher rates of opioid prescribing. The prescribing rate in the highest state, Nebraska (85%), was double the prescribing rate in the lowest state, South Dakota (40%). Comparing the casemix adjusted expected prescribing rate to the observed prescribing rate displayed that 18 states had observed prescribing rates that were higher than their expected prescribing rates.ConclusionWide variation in the likelihood of receiving a prescription, depending on state of residence, was observed. The dosages prescribed were high and have been associated with transition to long-term use. These findings suggest that there is substantial opportunity for the development of guidelines to reduce variability in opioid prescribing for this common ambulatory procedure.

Project description:BackgroundLong-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use.ObjectiveTo examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients.DesignRetrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges.ParticipantsPatients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients.Main measuresExposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation ("initiation month").OutcomeProportion of patients with six or more opioid fills during the subsequent year ("long-term users").Key resultsThere were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received?<?120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs.ConclusionsEarly opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

Project description:BACKGROUND:Emergency physicians provide primary care to patients and often prescribe opioids for acutely painful self-limiting conditions. The objective of this study was to describe patterns of opioid prescribing by emergency physicians and family physicians and to explore the relation between setting of initiation of opioid treatment and adverse events over the subsequent 2 years. METHODS:This was a population-based cohort study using administrative data from Ontario. Opioid-naive patients aged 15-64 years who received an opioid prescription for noncancer pain from an emergency or family physician between Apr. 1, 2008, and Mar. 31, 2012 were eligible for inclusion. RESULTS:A total of 34?713 and 45?952 patients were initiated on an opioid by an emergency physicians and family physicians, respectively. Both emergency and family physicians most commonly prescribed codeine-containing products (58.9% and 79.6% of prescriptions, respectively); however, emergency physicians were twice as likely as family physicians to prescribe higher-potency opioids (morphine, oxycodone, hydromorphone, fentanyl, meperidine) (both combination and single-agent preparations) (40.6% v. 19.9%, ? = 20.7, 95% confidence interval [CI] 20.0-21.3). Compared to patients in the family physician group, those in the emergency physician group received significantly higher daily dosages, a higher proportion were initiated on a daily dosage of 100 mg of morphine equivalents (MEQs) or more, and had a hospital admission for opioid toxicity within 2 years (0.5% v. 0.3%, ? = 0.2%, 95% CI 0.1%-0.3%). A higher proportion of patients in the family physician group than in the emergency physician group had dosage escalation beyond 199 mg MEQs within 2 years (0.7% v. 0.1%, ? = 0.6%, 95% CI 0.5%-0.7%). INTERPRETATION:Codeine was the most common opioid prescribed by emergency and family physicians. Compared to patients prescribed opioids by family physicians, those prescribed opioids by emergency physicians received higher initial daily dosages and had an increased likelihood of opioid toxicity.

Dataset Information

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial.

Importance

Objective

Design setting and participants

Interventions

Main outcomes and measures

Results

Conclusions and relevance

Trial registration

Publications

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial.

Similar Datasets

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