Coaching reduces opioid prescribing at UW Health clinics
Opioid doses dropped 11 percent at UW Health clinics that paid special attention to urine drug testing and other monitoring of patients, while doses went up 8 percent at other UW clinics, a new study found.
UW researchers hope to expand the program, which uses “systems consultation” to help primary care doctors follow opioid prescribing guidelines, to other clinics at UW and around the state.
That could help curb the opioid abuse epidemic in Wisconsin, where 827 people died from opioid overdoses in 2016, up 35 percent from the previous year and more than double the toll from a decade earlier. The fewer pills prescribed, the less chance for misuse by patients or others, experts say.
“Reducing the overall supply (of opioids) is important from the population health perspective,” said Dr. Randall Brown, an associate professor of family medicine at UW-Madison who specializes in addiction medicine.
“If we reduce ineffective or inappropriate prescribing, (opioid) dose will come down,” said Dr. Aleksandra Zgierska, an assistant professor of family medicine at UW-Madison who also specializes in addiction medicine.
Opioids include prescription painkillers such as oxycodone, hydrocodone, morphine and fentanyl, as well as illicit drugs such as heroin. As overdose deaths have soared around the country in recent years, the Centers for Disease Control and Prevention and the Wisconsin Medical Examining Board, among other groups, have issued guidelines for proper prescribing.
In 2016, Brown and Zgierska worked with Andrew Quanbeck, an industrial engineer researcher at UW, to coach teams at four UW family medicine clinics on how to adhere to the guidelines.
Over six months, they visited the clinics, conducting audits and providing feedback.
The program focused on a few recommendations for patients on opioids for non-cancer pain: mental health screening, which can identify conditions such as depression that should be treated separately; treatment agreements, which patients sign to acknowledge risks and commit to safeguards; and urine drug testing, recommended at least yearly for people on opioids.
“They can help physicians initiate conversations about dose reduction, if that’s indicated,” Quanbeck said.
Six months after the visits ended, or a year after the program started, the average morphine milligram equivalent, or MME, prescribed to patients dropped from 87.1 to 77.2 at the clinics involved, an 11 percent decrease, according to the study. It was published in January in the journal Implementation Science.
At four UW family medicine clinics that didn’t participate, the average MME went up from 62.0 to 67.1, an 8 percent increase.
MME calculates the relative potency of various opioids. The higher the dose, the greater risk of overdose. The CDC says doctors should use extra precaution if patients get more than 50 MME and avoid or carefully justify doses over 90 MME.
The program joins other efforts to combat the opioid epidemic through prescribing. In April, the state started requiring doctors to use the Prescription Drug Monitoring Program, a database of drugs previously given to patients, before they write certain prescriptions.
Many doctors have started prescribing naloxone, the overdose-reversing drug, to patients on high doses of opioids in case problems arise at home.
The UW researchers have applied for a federal grant to expand their “systems consultation” program to 38 clinics around the state.
“Clinical guidelines are often difficult to interpret for practitioners, and hard to implement,” Quanbeck said. “This is meant to be a model that potentially could be used nationwide.”