CAPP’s Accountable Doctors Lead Innovation in Opioid Safety
Tragically, an average of 116 Americans die each day from opioid overdoses[1]. Recognizing this public health crisis as it was evolving, physician leaders at Council for Accountable Physician Practices (CAPP) groups have pioneered a variety of programs to combat the opioid epidemic and to provide patients with safer pain management options. Their successful programs include reducing the number of opioid prescriptions initiated, monitoring and counseling patients taking opioids, finding safer alternatives for pain management, instituting new protocols in the emergency department (ED) related to opioids, and collaborating with local, state and federal agencies to reduce the number of opioids in the communities they serve.
Two examples illustrate the success of these programs that leverage physician engagement and leadership, coordinated care teams, and connected technology.
The Permanente Medical Groups’ Safe and Effective Opioid Prescribing Program[2], [3]
The eight Permanente Medical Groups, all of which participate in CAPP, began their physician-led opioid management programs in 2010. Based on a four-pronged approach to opioid management encompassing patient education, physician education/support, patient safety, and community protection, the program has succeeded in substantially reducing opioid prescriptions.
Program results were published in a study in the Journal of Evaluation in Clinical Practice, co-authored by Michael Kanter, M.D., medical director of Quality and Clinical Analysis for the Southern California Permanente Medical Group. The study covered program data from 2010 through 2015.
Results
The report showed:
- 98 percent reduction in the number of opioid-acetaminophen combination prescriptions with greater than 200 pills
- 95 percent reduction in prescribing of brand name opioids (such as hydrocodone products including hydrocodone‐acetaminophen, oxycodone‐acetaminophen products, and codeine‐acetaminophen products)
- 90 percent decrease in opioid prescriptions with benzodiazepines and carisoprodol
- 72 percent reduction in prescribing of long-acting/extended release opioids
A presentation at the World Health Care Congress by Imelda Dacones, M.D., President and CEO of Northwest Permanente, also cited significant reductions in opioid prescriptions and in hospital admissions related to ED patients. She emphasized the importance of an integrated electronic medical record, which makes it possible to track prescribing at all points in the system, from surgery through dentistry.
The Permanente Medical Groups use online media and informational materials in multiple languages to educate patients about the dangers of opioids along with nonpharmacologic alternatives for managing their pain. Their physicians receive robust training to ensure consistency in treatment of acute and chronic pain, as well as monthly reports on opioid safety metrics and prescribing patterns. Additionally, tools related to electronic medical records and decision-support technology flag high-risk scenarios and offer evidence-based guidance on treatment options. Physicians also are encouraged to collaborate with chronic pain experts such as pharmacists, physical therapists, and case managers.
To help patients safely manage their pain without reliance on opioids, physicians support patients to taper to a lower dose when appropriate and offer alternative pain management options such as yoga, tai chi, acupuncture and cognitive behavioral therapy. Patients are also connected with specialists in physical therapy, psychiatry, neurology, addiction medicine, and pharmacy to treat their pain.
The opioid management program also focuses on community protection through education and information sharing with local emergency departments. The Permanente Medical Groups also collaborate with federal, academic and other nonprofit groups to promote best practices for opioid safety.
HealthPartners of Minnesota’s Approach to Preventing Opioid Abuse
CAPP group HealthPartners, an integrated care delivery, hospital and financing organization in Minnesota and western Wisconsin and the largest consumer-governed nonprofit health organization in the nation, addresses opioid use in its ambulatory clinics, hospitals and health plan with patient-centered approaches that emphasize education, conversation and respect, and by revamping treatment on a condition-specific basis.
For example, the health system developed a multi-disciplinary, holistic pain treatment model that addresses the multiple causes of chronic pain instead of relying on opioids which are not effective long-term and can make pain worse. Rather than relying on prescriptions drugs as do most pain clinics, the clinical team instead focuses on alternatives to pain management, including treatment by physical therapists, behavioral health therapists, the pain psychologists, sleep medicine physicians and addiction medicine physicians.
Using the EMR and other data sources, HealthPartners identifies when patients have long-term prescriptions for opioids and may be at risk of addiction. All patients taking long-acting opioids or receiving more than two opioid prescriptions within a three-month period (except for trauma, cancer, or post-operation acute pain patients), must sign an agreement stating they will only take the medications as prescribed, keep regular appointments, and must take a drug screen at least once a year. Care plans are documented in their electronic health record which can be accessed by other providers so that they are aware of recommended treatment. Patients work with their clinician to develop an action plan that helps manage pain with exercise, healthy lifestyle choices and stress reduction techniques such as yoga or healing touch.
E-prescribing and Electronic Guidelines Helps Clinicians
The use of e-prescribing and electronic guidelines also helps clinicians throughout the system better manage patients. HealthPartners lowered the default setting for opioids in the electronic medical record to 10 which is half the previous setting. E-prescribing helps not only to manage and monitor the use of opioids, but it also helps to prevent fraudulent prescriptions. Nine out of ten prescriptions for narcotics across the care systems are now sent to pharmacies electronically.
Specialized pain clinics provide a multidisciplinary, holistic approach for treating chronic pain with a comprehensive approach that addresses the fact that pain, mood, and addiction are linked. New guidelines have also been implemented in HealthPartners dental clinics to limit prescriptions for opioids after root canals, wisdom teeth removal, and other dental work that may require this type of pain medication. Programs for conditions such as back pain that are frequently associated with pain management now focus more on promoting activity, exercise, and physical therapy rather than prescribing pain medications. In seven years, the number of patients who receive opioids after being diagnosed with chronic back pain decreased 51 percent.
As a result of these efforts, HealthPartners reduced opioid use in one year by:
| HealthPartners | Reduction in Pills |
|---|---|
| Health plan | 2,150,9733 |
| Medical Clinics & Hospitals | 3,336,9671 |
| Dental Clinics | 91,5782 |
| Care Group Total | 3,428,545 |
1 Based on number of pills prescribed from August 2015 – July 2016 compared to August 2016 – July 2017
2 2017 annualized rate compared to 2014
3Based on number of pills filled from August 2015 – July 2016 compared to August 2016 – July 2017
The key to the success of these programs, and others within CAPP groups, are:
- Physician leadership and education
- Connections through technology, including the electronic medical record, to track patient and prescription activity and to obtain data to assess results and identify issues
- A multi-disciplinary team approach for improving care coordination and system processes
Throughout the CAPP medical groups, physician-led connected care, integrated electronic medical records, and alternative approaches to pain management are helping to turn back the tide on the opioid tsunami. We invite other groups to share their experience and ideas on the Accountable Docs blog.
