TY - JOUR
KW - Adult
KW - Analgesics, Opioid/therapeutic use
KW - Chronic Pain/drug therapy
KW - Electronic Prescribing/standards
KW - Female
KW - Guideline Adherence/organization & administration
KW - Humans
KW - Long-Term Care/methods/organization & administration
KW - Male
KW - Massachusetts
KW - Medical Overuse/prevention & control
KW - Medication Therapy Management/organization & administration/standards
KW - Middle Aged
KW - Nursing Care/methods/standards
KW - Outcome and Process Assessment (Health Care)
KW - Practice Guidelines as Topic
KW - Primary Health Care/methods/standards
AU - Jane M. Liebschutz
AU - Ziming Xuan
AU - Christopher W. Shanahan
AU - Marc LaRochelle
AU - Julia Keosaian
AU - Donna Beers
AU - George Guara
AU - Kristen O'Connor
AU - Daniel P. Alford
AU - Victoria Parker
AU - Roger D. Weiss
AU - Jeffrey H. Samet
AU - Julie Crosson
AU - Phoebe A. Cushman
AU - Karen E. Lasser
A1 - 
AB - 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.
AD - Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Boston University School of Public Health, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Boston University School of Public Health, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Boston University School of Public Health, Boston, Massachusetts.; McLean Hospital, Belmont, Massachusetts.; Harvard Medical School, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Boston University School of Public Health, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Dorchester House Community Health Center, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.; Boston University School of Medicine, Boston, Massachusetts.; Boston University School of Public Health, Boston, Massachusetts.
BT - JAMA internal medicine
C5 - Education & Workforce; Opioids & Substance Use
CP - 9
CY - United States
DO - 10.1001/jamainternmed.2017.2468
IS - 9
JF - JAMA internal medicine
LA - eng
M1 - Journal Article
N2 - 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.
PP - United States
PY - 2017
SN - 2168-6114; 2168-6106
SP - 1265
EP - 1272
EP - 
T1 - Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial
T2 - JAMA internal medicine
TI - Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial
U1 - Education & Workforce; Opioids & Substance Use
U2 - 28715535
U3 - 10.1001/jamainternmed.2017.2468
VL - 177
VO - 2168-6114; 2168-6106
Y1 - 2017
Y2 - Sep 1
ER -