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Randomized Controlled Trial
. 2017 Sep 1;177(9):1265-1272.
doi: 10.1001/jamainternmed.2017.2468.

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial

Jane M Liebschutz  1   2 , Ziming Xuan  3 , Christopher W Shanahan  1   2 , Marc LaRochelle  1   2 , Julia Keosaian  3 , Donna Beers  1 , George Guara  1 , Kristen O'Connor  1 , Daniel P Alford  1   2 , Victoria Parker  3 , Roger D Weiss  4   5 , Jeffrey H Samet  1   2   3 , Julie Crosson  1   6 , Phoebe A Cushman  1   2 , Karen E Lasser  1   2   3
Affiliations
Randomized Controlled Trial

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial

Jane M Liebschutz et al. JAMA Intern Med. .

Abstract

Importance: Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines.

Objective: To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk.

Design, setting, and participants: Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices.

Interventions: Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only.

Main outcomes and measures: Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language.

Results: Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001).

Conclusions and relevance: A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills.

Trial registration: clinicaltrials.gov Identifier: NCT01909076.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Weiss consulted to GW Pharmaceuticals, Alkermes, and Indivior. No other disclosures are reported.

Figures

Figure.
Figure.. Consolidated Standards of Reporting Trials Study Flow Diagram
PCC, primary care clinician (ie, a physician or nurse practitioner).
See this image and copyright information in PMC

Comment in

References

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