How to Improve Opioid Prescribing in an Outpatient Clinic

• Requiring patients receiving opioids for 30 days or more to sign a pain agreement, with an annual review;
• Checking the N.C. CSRS prior to prescribing pain medication and requiring recurring three-month visits for refills; and
• Requiring urine drug screening (UDS) at least every six months.

In June 2017, we gave the rheumatology clinic staff the same information and outlined specific roles in the workflow. Staff was educated about commonly prescribed opioids, how to navigate the N.C. CSRS and how to review the EHR for pain manage­ment components and key points of the pain agreement.

That fall, we implemented several components in the clinic, including encouraging patients to follow up for opioid management with their provider, an NP, a PA, or a clinical pharmacist. The clinic also began requiring more vigilant use of urine drug screens and pain agreements.

Following the above interventions, the current workflow is:

1. Clinical staff review the patient’s chart, either prior to the appointment or during initial intake, for opioids prescribed by a provider in the rheuma­tology clinic. If a patient on opioids is identified, the staff locates an up-to-date pain contract and UDS, and reviews the patient’s record in the N.C. CSRS;
2. The staff member highlights any abnormalities in the N.C. CSRS, UDS or need for a current pain agreement for the provider;
3. If any component is out of date or incomplete, a nurse or other provider will order a UDS. For the new pain agreement, clinic staff will initiate a contract and review components with the patient. The staff review and update these contracts annually; and
4. At the visit’s completion, clinic staff schedule a three-month follow-up for the patient with the physician, advanced practice provider or
   clinical pharmacist.

The Results

These interventions led to some positive outcomes, including:

Staff

• The staff perception of how long it takes to complete the paperwork ordering a UDS improved;
• The staff perception of how long it takes to complete a report for the N.C. CSRS and a pain contract improved;
• The number of UDS tests ordered in the clinic doubled from 12 per month to 24 per month; and
• Pharmacist pain management visits have increased from zero to 10–15 per month.

Providers

• 78% of the time providers are checking the patient’s record with the N.C. CSRS prior to prescribing opioids vs. 38% previously;
• 78% of the time providers check UDS with opioid prescribing visits vs. 33% previously;
• 67% of the time providers review the pain agreement appropriately vs. 29% previously;
• 89% of the time clinic nursing staff help complete and verify reports in the N.C. CSRS vs. 40% previously;
• 67% of the time clinic nursing staff help verify UDS status vs. 27% previously;
• 78% of the time clinic nursing staff help verify the existence of a current pain agreement vs. 33% previously;
• 100% of providers feel that opioid prescribing processes have improved in the past nine months; and
• 86% of providers feel the length of time it takes to prescribe opioids has decreased in the past nine months.

Overall, this project has led to many positive effects on provider and staff workflow, which has also improved patient safety. For example, the project has increased providers’ awareness of how legislation directly affects clinical practice, as well as the required response to such changes.

As demonstrated by the survey results, the Rheumatology Division has improved how it meets some of the key targets addressed in the STOP Act. These changes have also led to better risk stratification and identification of high-risk patient groups and referral to pain management, when appropriate.

In addition, we have identified several patients who likely had opioid use disorder, and they received appropriate management, support and referrals. We also improved patient engagement by emphasizing shared responsibility in health and safety.

From 2015 through 2018, the number of opioid prescriptions decreased from 10% of all prescriptions to 3–5% of all prescriptions. These changes have led to a decline in opioid prescriptions, which likely indicates appropriate de-escalation and referral for high-risk patients.

We encountered several challenges during this process, including a lack of education regarding the process, negative patient reactions to the institution of pain agreements, staff and provider hesitancy to embrace workflow changes and ensuring patients had appointments every three months for follow-up. Concurrently, the health system infrastructure was evolving to incorporate needed modifications, such as changes in documentation practices surrounding opioid prescribing. Another factor that affected implementation was the expansion of the Rheumatology Division to an off-campus location, which has led to a need for new staff training, buy-in from administration and the evaluation of a new clinic workflow.