Eastern Kentucky is drowning in pills.
The Bluegrass State, especially its eastern half, has been hit hard by the national opioid abuse epidemic. In 2011 , more than 15% of all 18- to 25-year-olds in the state were illegally using opioids, and hospital admissions and deaths from drug overdoses were spiking, with drug overdose death rates rivaling those for car crashes.
In 2012, attempting to address the crisis that was killing young and old alike and fracturing families, the Kentucky lawmakers passed legislation targeting opioid abuse. Among other measures, that year’s House Bill 1 took aim at “pill mills” by preventing nonphysicians from owning pain management clinics and by significantly expanding the state’s prescription drug monitoring program (PDMP), known as KASPER.
Because the regulations were written from a law enforcement – rather than a medical – perspective, the new law contained measures that proved difficult for prescribers to understand, let alone comply with. That meant a bad situation looked to be getting worse for doctors in Kentucky who wanted to make things better but weren’t always sure where to start.
So, Dr. Greg Hood , an internist in Lexington, Ky., decided to do something about it.
Already interested in health policy issues and active in his state’s chapter of the American College of Physicians, Dr. Hood worked with ACP leaders to formulate an education and implementation plan to help primary care practices shift toward rational opioid prescribing.
As an internist, he understood the realities of day-to-day medical practice in this hard-hit region, and he knew that effective change would need a multipronged approach.
Dr. Hood and his collaborators in the Kentucky ACP chapter, the national ACP, and the Johns Hopkins Bloomberg School of Public Health, Baltimore, put together a proposal , “Enhancing Effective, Safe Chronic Pain Management in PCMH-Recognized and ACO-Participating Primary Care Practices: A Kentucky ACP Chapter Quality Network Initiative.”
With partial funding from Pfizer and support from the ACP, the quality improvement (QI) project focused on achievable, practice-friendly steps.
The initiative involved eight primary care practices from two accountable care organizations (ACOs), a total of 41 providers participated, and each practice named a physician and a nonphysician “QI champion” to lead education and change efforts.
The whole health care team, from schedulers and medical assistants to nursing staff and prescribers, was involved, so all staff members would know why they were being asked to make changes.
The program had four primary objectives: to engage primary care teams, implement a QI program to enhance chronic pain management, evaluate the program’s impact, and, finally, further disseminate the program.
Before any practice improvement began, an ACP Quality Connect practice assessment tool gathered information about the state of chronic pain care in practices. At the outset, though about 60% of practices were screening for depression, nearly three-quarters of practices were not assessing and managing chronic pain effectively, and almost half were not consistently using opioid agreement forms and incorporating urine drug testing into practice.
Performance measures in the QI program included documented screening for clinical depression, documented pain assessments, and increased use of opioid agreements and urine drug testing – all evidence-based measures to ensure more appropriate opioid prescribing and reduce the risk of abuse or diversion.
Various practice improvement strategies were brought to the study sites and led by the QI champions. These included educational webinars about pain and mental health assessments, as well as opioid contracts and risk assessment. Nationally known QI experts participated in coaching calls with team members as implementation got underway. A patient brochure about opioids and controlled substance agreements was developed and brought into use.
After the holistic set of interventions was fully implemented, practices were again surveyed about how they were caring for their chronic pain patients.
What happened? As Dr. Hood suspected, things changed.
“Physicians and practices are capable of change if you design a project that gives offices what they need,” he said.
The average improvement from baseline for depression screening, for example, was 24%. Strikingly, one practice that never screened for depression before the QI initiative achieved a 92% screening rate post intervention. Urine drug testing and controlled substance agreement use jumped by 23%, with one practice going from 0% before intervention to 100% at follow-up.
Practices showed even more improvement – an average of 48% – in administering pain assessments, because six of the eight practices never administered pain assessments before the intervention. Improvements in this group ranged from 60% to 100%.
Lessons learned from the QI initiative, said Dr. Hood, included the importance of multilevel, ongoing engagement with all team members. Some financial support to help offset the time commitment came from Pfizer.
A good solution also has to work within the framework of the social and emotional context surrounding chronic pain. One important thing to confront, said Dr. Hood, was the “unspoken assumption that you need a controlled substance” for certain types of pain.
Although it’s not supported by the medical literature, there’s “still this tug from the patient that you’re holding something back from me” if a complaint of pain, especially chronic pain, doesn’t get an opioid prescription. The continued widespread use of an unproven treatment in chronic pain care stands out from other areas of medical care, where evidence-backed treatment is increasingly the norm, Dr. Hood noted.
Part of changing the conversation within a practice, and then expanding the dialogue to include the patient, is to reframe the discussion.
“It’s not more care or less care, but different care,” said Dr. Hood. He spoke of a patient who had been on very high opioid doses – equivalent to 200 mg morphine daily – for neuropathic pain. Within the framework of the physician-patient relationship and with a lot of talking, Dr. Hood was able to transition the patient to a regimen appropriate for his pain. Within 6 weeks, the patient’s opioid dose was equivalent to less than 80 mg morphine daily, his pain was better managed, and his quality of life was greatly improved.
The significant side-effect burden of opioids often includes a degree of constipation, which many patients won’t talk about, but which is a very real and daily struggle for those who are on high doses. This was the case for Dr. Hood’s patient with neuropathic pain, and the improvement in that symptom alone helped the patient’s willingness to stick with the transition away from an opioid-based regimen.
Keeping the patient at the center of chronic pain care, while still using available tools and knowledge to provide high-quality rational care, is an achievable goal, he said.
“We’ve proved we can make the change, and we’ve proved we can achieve adherence to the regulations,” he said. “Now, how do we further improve the care of the patient? The job’s not done.”
In development are adaptive tablet-based surveys that tailor themselves to patient responses, yielding more accurate information about patient characteristics and substance use profiles in a more user-friendly format.
Dr. Hood and his project collaborators hope to seek grant funding to disseminate the project beyond the borders of the state of Kentucky. The scalability of the QI process is a strength, he said.
In the process of developing the QI program, Dr. Hood and his collaborators met with key thought leaders in the pharmaceutical industry to build support for educational initiatives such as the ACP Quality Connect program.
As for the sometimes tainted history of the use of opioids for chronic nonmalignant pain? “That’s the past,” Dr. Hood declared. “We now have an opportunity to turn to the future. … This needs to happen to alleviate the suffering of these patients.”
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