How to Improve Opioid Prescribing in an Outpatient Clinic

More than 72,000 Americans died from opioid overdoses in 2017, according to the National Institutes of Health.¹ The impact of the opioid epidemic has affected many levels of patient care and, as a result, healthcare systems are responding to escalating death rates, new legislation and the possibility of compromised patient safety in a multitude of ways. Experts have proposed several steps for the federal government to consider. These include implementing prescription drug monitoring programs, management strategies for acute pain, naloxone programs within health systems and identifying high-risk patients.^1,2

Duke University Health System, Durham, N.C., has employed several strategies to address the epidemic. These include organ­izing an opioid safety committee, addressing documentation in the electronic health record (EHR) and developing educational offerings to ensure providers comply with state-level legislative changes. In January 2018, North Carolina enacted new legis­lation called the STOP Act, which mandates:

• Nurse practitioners (NPs) and physician assistants (PAs) who work in pain clinics consult with their supervising physician before prescribing Schedule II or III opioids or narcotics;
• Initial prescriptions for acute and post-surgical pain be limited to five and seven days, respectively;
• Pharmacies report prescriptions to the N.C. Controlled Substance Reporting System (N.C. CSRS) by the close of business the day after patients receive the prescriptions;
• Targeted controlled substances be prescribed electronically; and
• Prior to prescribing a Schedule II or III opioid or narcotic, providers must review a patient’s 12-month prescription history in the N.C. CSRS, and they must review the record every three months thereafter.

The Duke Division of Rheumatology & Immunology recognized the unique opportunity to implement these changes in a specialty clinic the health system labeled as a high prescriber of opioids. In anticipation of the STOP Act, the rheumatology clinic began to make changes. At the time of the act’s implementation, the clinic comprised 30 providers, including physicians, NPs and rheumatology fellows. Approximately 10 staff members would be affected by the new law, including nurses, registered/certified medical assistants and a clinical pharmacist.

Creating a Task Force

In May 2017, we formed the Rheuma­tology Opioid Task Force, comprising an NP, a clinical pharmacist, a charge nurse and a registered medical assistant. The committee goal was to create a forum to develop strategies to obtain provider and staff buy-in and educational opportunities. A secondary focus was soliciting feedback from faculty and staff. It became clear that an additional step was needed, which centered on developing and implementing prescribing recommendations within the department. We determined this would be the optimal time to implement a quality-improvement project.

The committee met approximately once each month. An important aspect of this quality improvement project was measuring perceptions as well as knowledge and utilization of key opioid targets. These targets included the review of the N.C. CSRS, urine drug screens and pain agreements. Providers and staff were given surveys pre- and post-implementation regarding their opinion of the current workflow. The providers were given an additional survey, which determined the clinic recommendations for opioid management that would be implemented in January 2018.

An important intervention was provider education, which occurred in May 2017. We educated providers about the specific aspects of the STOP Act the clinic would target for compliance. These included: