Original Research

A look at the burden of opioid management in primary care

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This pilot study identified practice variables that can increase the time and resources needed to manage opioids. The authors suggest possible corrective steps.


 

References

ABSTRACT

Purpose Pain management with opioids in primary care is challenging. The objective of this study was to identify the number of opioid-related tasks in our clinics and determine whether opioid-related tasks occur more often in a residency setting.

Methods This was a retrospective observational review of an electronic health record (EHR) system to evaluate tasks related to the use of opioids and other controlled substances. Tasks are created in the EHR when patients call the clinic; the task-box system is a means of communication within the EHR. The study setting was 2 university-based family medicine clinics. Clinic 1 has faculty and resident providers in an urban area. Clinic 2 has only faculty providers in a suburban area. We reviewed all tasks recorded in November 2010.

Results A total of 3193 patients were seen at the clinics. In addition, 1028 call-related tasks were created, 220 of which (21.4%) were opioid-related. More than half of the tasks were about chronic (ongoing) patient issues. More than one‑third of the tasks required follow-up phone calls. Multiple logistic regression analysis showed more opioid-related tasks in the residency setting (Clinic 1) compared with the nonresidency setting (Clinic 2), (23.1% vs 16.7%; P<.001). However, multiple logistic regression analysis did not show any correlations between opioid-related tasks and who addressed the tasks or the day tasks were created.

Conclusions Primary care physicians prescribe significant amounts of opioids. Due to the nature of opioid use and abuse, a well-planned protocol customized to the practice or institution is required to streamline this process and decrease the number of unnecessary phone calls and follow-ups.

Pain management with opioids in primary care is challenging,1,2 and many physicians find it unsatisfying and burdensome.3 More than 60 million patient visits for chronic pain occur annually in the United States, consuming large amounts of time and resources.4 Contributing to the challenge is the need to ensure patient safety and satisfaction, as well as staff satisfaction with pain management.5-8 Opioid-related death is a major cause of iatrogenic mortality in the United States:9,10 From 1999 to 2006, fatal opioid-involved intoxications more than tripled from 4000 to 13,800.7

At issue for many providers, as well as patients and staff, is dissatisfaction with current systems in place for managing chronic non-cancer pain with opioids.2,3,8,11 In developing this study, we decided to focus on the systems aspect of care with 2 primary outcome measures in mind. Specifically, we sought to identify the tasks related to managing opioids and other controlled substances in 2 primary care clinics in a university-based family medicine program and to determine what proportion of all routine tasks in these 2 clinics could be attributed to opioid-related issues. With our secondary outcome measures, we sought to compare the number of opioid-related tasks in the residency setting with those in a nonresidency setting, and to identify factors that might be associated with an increase in the number of opioid-related tasks.

METHODS

Setting and design

We conducted a retrospective observational pilot study reviewing our electronic health record (EHR) system (Allscripts TouchWorks) at 2 of our outpatient family medicine clinics at the University of Colorado. When patients call the clinics, or when patient-care-related concerns need to be addressed, an electronic task message is created and sent to the appropriate task box for staff or provider response. The task box system is how staff and providers communicate within the EHR. Each provider has a personal task box, and there are other task boxes in the system (eg, triage, medication refill) for urgent and non-urgent patient care issues.

Nearly a quarter of clinic tasks were opioid related.For example, when a patient calls to request a refill, a medical assistant (MA), care team assistant (CTA), or nurse will create a task for the medication refill box. If the task is urgent, it is marked with a red asterisk and a triage provider will address the task that same day. Non-urgent triage tasks will be addressed by the patient’s primary care provider within 2 to 3 days. Depending on the issue at hand, the task may or may not require phone calls to the patient, pharmacy, or insurance company.

Clinic 1, in urban Denver, has 13 physicians (many of them part-time clinical faculty), one nurse practitioner (NP), one physician assistant (PA), and 18 family medicine residents. Clinic 2, in a suburb of Denver, has 5 physicians (only one is part-time) and one nurse practitioner. Clinic 1 is divided into 3 pods, and each has the same number of attending physicians, residents, and MAs, and either a PA or NP.

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