Prevention of unsafe opioid prescribing is a national priority. Researchers cluster-randomized 53 clinicians in 4 primary care practices to a multicomponent intervention (electronic registry, academic detailing, nurse care management, electronic decision tools) or control (electronic decision tools only). Eligible clinicians had ≥4 patients receiving chronic opioid therapy. Over a 12-month period, the researchers assessed the primary outcomes of guideline-concordant care (e.g., signed agreement and at least 1 urine drug test) and early refills (defined as ≥2 early refills), and the secondary outcomes of opioid discontinuation and/or 10% reduction in opioid dose.
- Patients in the intervention group (n=586) were more likely than controls (n=399) to receive guideline-concordant care (adjusted odds ratio [aOR], 6.0), but no less likely than controls to have ≥2 early refills (aOR, 1.1).
- Intervention group patients were more likely than controls to have opioid discontinuation (aOR, 1.5) or opioid dose reduction (aOR, 1.6).
- All 4 primary care practices made efforts to continue the intervention once the research study ended.
Comments: This well-designed trial demonstrates that a primary care-based multicomponent intervention can increase guideline-concordant opioid therapy, opioid discontinuation, and dose reduction. It is not clear whether instances of opioid discontinuation or dose reduction were in response to opioid misuse identified via increased monitoring. Although one-fifth of patients in both groups received ≥2 early refills, the researchers cautioned that early refills do not necessarily reflect opioid misuse because actual fill date was not known and other legitimate reasons for an early refill exist. Further research will be required to determine whether similar interventions decrease opioid-related adverse outcomes while maintaining patient pain control and function.
Kevin L. Kraemer, MD, MSc
Reference: Liebschutz JM, Xuan Z, Shanahan CW, et al. Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized clinical trial. JAMA Intern Med. 2017;177(9):1265–1272.