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:

• Requiring patients receiving opioids for 30 days or more to sign a pain agreement, with an annual review;
• Checking the N.C. CSRS prior to prescribing pain medication and requiring recurring three-month visits for refills; and
• Requiring urine drug screening (UDS) at least every six months.

In June 2017, we gave the rheumatology clinic staff the same information and outlined specific roles in the workflow. Staff was educated about commonly prescribed opioids, how to navigate the N.C. CSRS and how to review the EHR for pain manage­ment components and key points of the pain agreement.

That fall, we implemented several components in the clinic, including encouraging patients to follow up for opioid management with their provider, an NP, a PA, or a clinical pharmacist. The clinic also began requiring more vigilant use of urine drug screens and pain agreements.

Following the above interventions, the current workflow is:

1. Clinical staff review the patient’s chart, either prior to the appointment or during initial intake, for opioids prescribed by a provider in the rheuma­tology clinic. If a patient on opioids is identified, the staff locates an up-to-date pain contract and UDS, and reviews the patient’s record in the N.C. CSRS;
2. The staff member highlights any abnormalities in the N.C. CSRS, UDS or need for a current pain agreement for the provider;
3. If any component is out of date or incomplete, a nurse or other provider will order a UDS. For the new pain agreement, clinic staff will initiate a contract and review components with the patient. The staff review and update these contracts annually; and
4. At the visit’s completion, clinic staff schedule a three-month follow-up for the patient with the physician, advanced practice provider or
   clinical pharmacist.

The Results

These interventions led to some positive outcomes, including:

Staff

• The staff perception of how long it takes to complete the paperwork ordering a UDS improved;
• The staff perception of how long it takes to complete a report for the N.C. CSRS and a pain contract improved;
• The number of UDS tests ordered in the clinic doubled from 12 per month to 24 per month; and
• Pharmacist pain management visits have increased from zero to 10–15 per month.

Providers

• 78% of the time providers are checking the patient’s record with the N.C. CSRS prior to prescribing opioids vs. 38% previously;
• 78% of the time providers check UDS with opioid prescribing visits vs. 33% previously;
• 67% of the time providers review the pain agreement appropriately vs. 29% previously;
• 89% of the time clinic nursing staff help complete and verify reports in the N.C. CSRS vs. 40% previously;
• 67% of the time clinic nursing staff help verify UDS status vs. 27% previously;
• 78% of the time clinic nursing staff help verify the existence of a current pain agreement vs. 33% previously;
• 100% of providers feel that opioid prescribing processes have improved in the past nine months; and
• 86% of providers feel the length of time it takes to prescribe opioids has decreased in the past nine months.

Overall, this project has led to many positive effects on provider and staff workflow, which has also improved patient safety. For example, the project has increased providers’ awareness of how legislation directly affects clinical practice, as well as the required response to such changes.

As demonstrated by the survey results, the Rheumatology Division has improved how it meets some of the key targets addressed in the STOP Act. These changes have also led to better risk stratification and identification of high-risk patient groups and referral to pain management, when appropriate.

In addition, we have identified several patients who likely had opioid use disorder, and they received appropriate management, support and referrals. We also improved patient engagement by emphasizing shared responsibility in health and safety.

From 2015 through 2018, the number of opioid prescriptions decreased from 10% of all prescriptions to 3–5% of all prescriptions. These changes have led to a decline in opioid prescriptions, which likely indicates appropriate de-escalation and referral for high-risk patients.

We encountered several challenges during this process, including a lack of education regarding the process, negative patient reactions to the institution of pain agreements, staff and provider hesitancy to embrace workflow changes and ensuring patients had appointments every three months for follow-up. Concurrently, the health system infrastructure was evolving to incorporate needed modifications, such as changes in documentation practices surrounding opioid prescribing. Another factor that affected implementation was the expansion of the Rheumatology Division to an off-campus location, which has led to a need for new staff training, buy-in from administration and the evaluation of a new clinic workflow.

The Need for Replication

The new opioid prescribing recommendations and clinic workflow have resulted in a multi-disciplinary and clinic-wide participation in the safe prescribing and monitoring of opioids for rheumatology patients. Given the success of this program, these interventions need to be replicated in other primary care and specialty clinics.

Possibilities for future interventions include naloxone education, urine drug screen integration into clinic protocols and re-education of staff to reinforce consistency. Also, given the evolving role of the clinic pharmacist, continued education regarding multi-disciplinary roles would be beneficial.

The workflow changes and new approaches to opioid medication management in the Division of Rheumatology is a good first step. Although it is unclear if the decreasing number of opioid prescriptions in our rheumatology clinic will lead to better pain control, we will continue to strive for increased patient safety and better quality of care while balancing the known risks of opioid medications.

These strategies also need to be extended throughout the community and the Duke University Health System to include other specialties that prescribe and manage chronic pain conditions. 

Lisa Carnago, FNP-C, MSN, BSN, RN, is a nurse practitioner in the Division of Rheumatology & Immunology at Duke University Medical Center, N.C.

Jenelle Hall, PharmD, BCACP, CPP, is a clinical pharmacist at Duke University Medical Center.

Stephanie Puryear, RMA, is a registered medical assistant in the Division of Rheumatology & Immunology at Duke University Medical Center.

References

1. Overdose death rates. National Institute on Drug Abuse. 2019 Jan.
2. Kolodny A, Frieden TR. Ten steps the federal government should take now to reverse the opioid addiction epidemic. JAMA. 2017 Oct;318(16):1537–1538.