Intelligent Clinical Decision Support to Improve Safe Opioid Management of Chronic Noncancer Pain in Primary Care

Abstract

Background: Opioid prescription drug abuse is a major public health concern. Healthcare provider prescribing patterns, especially among non-pain management specialists, are a major factor. Practice guidelines recommend what to do for safe opioid prescribing but do not provide guidance on how to implement best practices.

Methods: We describe the implementation of electronic medical record clinical decision support (EMR CDS) for opioid management of chronic noncancer pain in an integrated delivery system. This prospective cohort study will examine relationships between primary care physician compliance with EMR CDS-guided care (vs usual care), delivery of guideline-concordant care, and changes in the morphine equivalent of prescribed opioids. We report baseline characteristics of patients receiving chronic opioid therapy and organizational prescribing trends.

Results: Between August and October 2016, we identified 2,759 primary care patients who received chronic opioid therapy. Of these patients, approximately 71% had chronic noncancer pain, and 62% had diagnoses of depression/anxiety. Six of 36 primary care clinics each had >100 patients receiving chronic opioid therapy. When the EMR CDS launched in October 2017, we identified 54,200 patients who had received opioid therapy for at least 14 days from various specialty and primary care providers during the prior 24 months. Of these patients, 36% had a benzodiazepine coprescription, and 13% had substance abuse diagnoses.

Conclusion: Health system research that examines workflow-focused strategies to improve physician knowledge and skills for safely managing opioid therapy is needed. If EMR CDS proves to be effective in increasing adherence to practice guidelines, this EMR strategy can potentially be replicated and scaled up nationwide to improve population health management.

Keywords: Analgesics–opioid; chronic pain; decision support system–clinical; electronic medical records; primary health care.

Figure 1

Opioid prescribing workflow in the electronic medical record. When providers write a prescription for opioid medications, they receive an alert to complete the Opioid Risk Tool (ORT) if not already done according the patient's age group. The ORT score stratifies patients into 3 categories of risk for opioid-aberrant behavior (low, medium, high). The rule engine for the chronic opioid registry then determines the recommended frequency of documenting best practices for safe management (eg, the annual pain contract and functional assessment). The recommended functional assessment includes at a minimum the Pain, Enjoyment, General Activity (PEG) 3-item pain scale and the 4-item Patient Health Questionnaire for Depression and Anxiety (PHQ-4). The chronic opioid health maintenance tool displays if high-risk patients have an active medication order for naloxone. This workflow does not apply to acute pain management. Benzo, benzodiazepines; MEDD, morphine equivalent daily dose; ORT, opioid risk tool; PDMP, prescription drug monitoring program; Rx, prescription; UDS, urine drug screen.

Figure 2

Chronic opioid registry health maintenance tool. The health maintenance tool displays if patients are up to date on chronic opioid management best practices (eg, documentation of pain management agreement, frequency of urine drug screening/monitoring, naloxone on active medication list) based on the Opioid Risk Tool–derived risk stratification described in Figure 1.

Figure 3

Medication dosing support in the electronic medical record prescription writer. The Opioid Risk Tool score, morphine equivalent daily dose (MEDD) of the opioid prescribed, and hyperlinks to the Louisiana Board of Pharmacy Prescription Monitoring Program and pain management agreement (if completed) are visible in the medication order composer for ease of accessing this information within the established medication order workflow.