Multidisciplinary approach for standardized care and control of opioid administration for pain management patients
Mehlberg L, Totten A, Umar B, Copeland J, Varney R, Crow J, Shah V, Cook B. Multidisciplinary approach for standardized care and control of opioid administration for pain management patients. Clinical Chemistry 2018; 64:S267.
Objective: A multidisciplinary team (Anesthesiology, Behavior Health, Family Practice, Internal Medicine, Pathology, Psychiatry) developed a patient-centered approach to manage chronic noncancer patients in order to minimize the risk of opioid abuse, diversion, and addiction. A clear and concise guide was created for ordering and interpreting pain management drugs to help providers better manage cases and serve patients safely and effectively. Relevance: Abuse and addiction to opioid analgesics has become a major patient safety risk in the United States and has worsened over the past few years. According to the Michigan Department of Health and Human Services, in 1999 only 22%of the state's drug overdose deaths were attributed to opioids and heroin abuse. Recently, it was reported as up to 67 percent. Methodology: We developed a primary care policy to ensure providers and patients consider the safest and most effective treatment for non-cancer, non-palliative, chronic pain patients. Incorporated into the standard work of medical assistants was a screen for opioid risk of abuse, diversion, and overdose every 12 months. Patients that violate the medication management agreement are flagged with a banner on the medical information system splash page. A chronic pain registry was developed to track patients on the chronic pain syndrome problem list. Patients on the registry trigger health maintenance components, drug screens every 12 months, an automated prescription systems program every 12 months, pain and wellness score every 6 months, and pain treatment contract renewal. A dashboard was created to track providers' use of the pain registry and individual providers are coached for use of the registry. Pathology implemented a new directed chronic pain panel, where a negative opiates screen (and negative cocaine screen) will reflex to a confirmatory opiates (GCMS) order. A drug screen ordering tip sheet was developed to guide screen (qualitative) and confirmation (quantitative) ordering practices. Validation: In a survey of primary care providers, 92% requested a streamlined process for prescribing opioids for patients who actually need them. The extent to which providers enrolled their patients into the pain registry was monitored. To examine the effectiveness of the physician education component of our program, we assessed whether narcotics ordering volumes changed. Provider ordering practices were examined before and after focused education regarding proper drug screening and confirmatory strategies. Results and Conclusions: Of the 5927 patients being cared for chronic pain during the study period, enrollment by the provider to the registry increased from an average of 22% (median 16%) to 36% (33%). Patient enrollment varied widely by clinic site, from 0% to 73% of their patients. The program resulted in more appropriate test ordering by providers, with 56.9% before program initiation and nearly complete compliance afterward. Correct screening panel ordering increased from 75.7 to 237.9 per month and opiates confirmation testing increased from 11.4 to 19.8 per month. Patients managed by pain clinics has remained relatively constant, while prescriptions for narcotics decreased 4.3% year over year. A standardized approach has been instituted to better manage chronic noncancer patients on opioid drugs.