Original Research

The benefits of a standardized approach to opioid prescribing

Author and Disclosure Information

This initiative increased patient acceptance of controlled substance agreements and random urine drug screening, and it led many patients to discontinue opioid therapy.




Purpose The “opioid epidemic” in the United States has received increasing attention over the past few years. Most drug overdose deaths involve an opioid, and prescription opioid deaths have quadrupled since 1999. We sought to improve patient safety and adhere to clinical guidelines by standardizing opioid prescribing in our practice.

Methods We implemented a standardized approach to opioid prescribing based on Arizona Department of Health Services guidelines. All of our providers received instruction on Arizona’s Controlled Substance Prescription Monitoring Program (AZCSPMP) database and were encouraged to use it online. Our goal was for patients to have quarterly office visits, complete random urine drug screens, and sign a controlled substance agreement (CSA). The CSA acknowledged their understanding of the risks and benefits of opioid therapy as well as our updated prescribing policies.

Results Three-hundred fifty-eight of our practice’s patients were receiving chronic opioid therapy. All providers enrolled in AZCSPMP and used it for patient care. We increased rates of signed CSAs from 4.5% to 43.6%, and urine drug screening from 0.8% to 20.1%. For 325 patients remaining in the practice after our interventions, a postintervention chart review demonstrated a statistically significant discontinuation of opioid therapy (71/325, 21.8%; 95% confidence interval, 17.4%-26.7%).

Conclusion Implementation of a standardized opioid prescribing process resulted in discontinuation of therapy for some patients. Rates increased for signed CSAs and completed random urine drug screening. Future process interventions may improve patient and provider adherence. All primary care physicians should examine their prescribing processes to enhance the safety of opioid therapy.

The US opioid epidemic has received increased attention both nationally and at the state level over the past 2 years. This attention is warranted given the significant societal burden of opioid misuse, abuse, and overdose. Most drug overdose deaths (> 6/10) involve an opioid.1 Deaths from prescription opioids have quadrupled since 1999 in the United States.2 Arizona, the state in which we practice, ranked sixth highest in the nation for drug overdose deaths and had the fifth highest opioid prescribing rate in 2011.3 In response to the growing epidemic, the Centers for Disease Control and Prevention (CDC) released guidelines in 2016 for prescribing and monitoring opioids for chronic pain.4

Chronic nonterminal pain (CNTP) remains a significant cause of human suffering and is more prevalent in the United States than cancer, diabetes, and heart disease combined.5 The increased use of opioids since 1999 to ease CNTP has not reduced Americans’ reports of pain overall.6,7 Given the growing opioid epidemic and disease burden of CNTP, we embarked on a quality improvement (QI) project to safely prescribe and refill opioid medications in the Department of Family Medicine at the Mayo Clinic Arizona.

Under our new prescription process, patient completion of controlled substance agreements rose from 4.5% at baseline to 43.6% after the intervention.


This project received an exemption from internal review board evaluation as a QI intervention. We used a team-based approach to address standardization of opioid prescribing and monitoring within our practice. The team included physicians (MD/DO), nurses (LPN/RN), and allied health staff (MA), operations and administrative personnel, and information technology (IT) support. We did not involve patients in the initial design of our project. With future quality efforts in this area, we plan to involve patients in design processes.

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