Researchers and Pharmacists Team Up to Combat Opioid Overuse
By Jill Pope
Scientists at the Center for Health Research recently partnered with KP pharmacists to test a program to curb prolonged opioid use, as part of an FDA-funded clinical trial.
Prescription opioids such as OxyContin (oxycodone) and Vicodin (hydrocodone) can be effective for treating pain. But these drugs can also be dangerously addictive, and the U.S. is now battling a full-blown opioid addiction epidemic. The number of opioid prescriptions in the U.S. has risen from around 76 million in 1991 to nearly 207 million in 2013. Deaths due to prescription opioid overdose have more than tripled in the past 20 years, rising from about 4,000 in 1999 to 16,651 deaths in 2010.1
Since pharmacists are on the front lines of this battle, leaders at Kaiser Permanente Northwest (KPNW) are looking to them to help keep patients safe and healthy. Since 2009, the KPNW health plan has deployed an outreach team—called Support Team Onsite Resource for Management of Pain (STORM) to work with health plan members to help reduce their opioid doses.
Now, scientists from CHR have joined the effort. Using electronic medical record data and input from physicians, surgeons, and pharmacists, researchers David Smith, Eric Johnson, and Jennifer Kuntz created a risk-prediction tool to identify patients at the highest risk of becoming persistent opioid users.
Focusing on Patients After Joint Replacement Surgery
This collaborative research project, which started in 2014, focused on patients who are undergoing joint replacement surgery, for whom opioids are routinely prescribed for pain control. Most patients who have joint replacement surgery will never develop a problem with opioids after their surgery. However, for some patients, opioid use can become entrenched. Use of opioids for more than 90 days post-surgery is considered persistent use, and may raise safety concerns.
The research team from CHR examined the electronic medical records of 5,635 adult KPNW members who had a knee or hip replacement surgery to identify patients who refilled an opioid prescription 91 to 180 days after surgery. They found that 35% persistently used opioids (beyond 90 days).
The researchers asked primary care physicians, surgeons, and pharmacists what they considered important predictors of persistent opioid use. They also examined patients’ electronic medical records for possible predictors, including other conditions and prescribed medications.
They found that the strongest predictors of persistent opioid use were:
- Dose of opioid a patient had previously used
- A history of smoking
- Recent use of muscle relaxants or anticonvulsants
- Diagnosis of a substance abuse disorder
The researchers used this information to create a risk prediction tool that can reliably distinguish between patients who are at high and low risk for opioid dependence.
How the Health Plan Used the Tool
The KPNW health plan used this tool to “score” knee and hip replacement patients, prior to surgery, in terms of how likely they are to become persistent opioid users. During the clinical trial, patients were ranked by their risk for persistent opioid use and a subset of the highest risk patients were randomly assigned to either a pharmacy education and outreach program, or to receive usual care.
In the outreach program, patients received tailored educational materials before and after their surgery. For patients who continued to receive opioid prescription fills, pharmacists offered additional support, pain management tools, and education about the benefits of decreasing their opioid use. Patients in the usual care group did not receive educational information or pharmacist outreach.
Because the risk prediction tool identified high-risk patients who would benefit most from the educational materials and pharmacy outreach program, it helped the researchers avoid recruiting people who were unlikely to need help, so they could conduct a shorter and more efficient study. The research team will know soon whether the program worked to reduce persistent opioid use.
Regardless of the exact findings, this program has made an important contribution toward CHR’s goal of fostering greater collaboration with clinical and operational partners in the care delivery system.
“I found working with the STORM pharmacy group to be very rewarding, and I am eager to continue that line of research,” says Senior Investigator David Smith, who led the study. “At CHR we strive to do research and evaluations that are consequential to improving the delivery of high-quality health care. I can’t think of a better way to do that than working collaboratively alongside KPNW’s clinicians to design and evaluate interventions.”
- Mack, K.A. Drug-induced deaths - United States, 1999-2010. MMWR Surveill Summ. 2013 Nov 22;62 Suppl 3:161-3.
FOR MORE INFORMATION Contact David H. Smith, PhD (David.H.Smith@kpchr.org); Eric S. Johnson, PhD (Eric.S.Johnson@kpchr.org); or Jennifer L. Kuntz, PhD (Jennifer.L.Kuntz@kpchr.org), at the Center for Health Research.