1. Comparison of Opioid Prescribing Guidelines Violations by Clinical Speciality
Chia-Chen Teng1,2, Christy Porusnik3, Erin Johnson4, Robert Rolfs3, Jonathan Nebeker1, Brian C. Sauer1,2
1VA SLC IDEAS Center, Salt Lake City UT, 2University of Utah Division of Epidemiology, 3University of Utah DFPM, 4Utah Department of Health
Objectives
Describe unsafe prescribing according to the Utah Opioid Prescribing Guidelines by specialty for their patients classified as chronic opioid users.
Determine if provider participation in the intensive educational intervention changed prescribing.
Results for Specialty
Interpretation
Pain Medicine, nurses and anesthesiologists had a higher proportion of patients involved in a dual use of benzodiazepine and long-acting opioid, and dual use of long-acting opioids flag.
No clear differences in dual use of short-acting opioids were observed by specialty.
28% of chronic pain patients treated by pain medicine physicians experienced at least one flag.
24% of chronic pain patients treated by nurses and anesthesiologists experienced at least one flag.
About 25% of providers completed all three stages of the intensive educational intervention.
Providers that received any level of intensive educational intervention showed improvements in the dual long and short acting flags. They also had a significant reduction of patients that experienced any flag.
Due to the low number of providers who completed Stage B, we did not observe any statistical differences in provider measures.
We did not compare measures for providers who completed Stage C due to the small number completing this level.
Provider Count and Chronic Opioid Patients by Provider Specialty
Proportion of Flags and Outcome by Provider Specialty
Any Methadone
Dual Use of Long-acting Opioids
Specialty
Providers
Patients
Count
Pct (%)
Anesthesiology  77
0.92
3,070
2.74
Dentist 
1,189
14.2
6,243
5.57
Dermatology  39
0.47 96
0.09
Emergency Medicine 
371
4.43
7,939
7.09
Family Medicine 
1,008
12.04
25,152
22.45
Hospitalist  40
0.48
578
0.52
Internal Medicine 
854
10.2
12,427
11.09
Nurse
507
6.06
11,139
9.94
Obstetrics & Gynecology 
253
3.02
1,177
1.05
Ophthalmology  63
0.75
127
0.11
Other 87
1.04
710
0.63
Pain Medicine 28
0.33
2,601
2.32
Pediatrics 
116
1.39
313
0.28
Physical Medicine & Rehabilitation  98
1.17
3,546
3.16
Physician Assistant 
11,346
10.13
Podiatrist 
112
1.34
943
0.84
Preventive Medicine 
118
1.41 61
0.05
Psychiatry & Neurology 
289
3.45
3,661
3.27
Radiology  67
0.8
161
0.14
Surgery
629
7.51
7,461
6.66
Unknown
1,868
22.32
12,869
11.49
Urology 51
0.61
424
0.38
Methods
This study was IRB approved by the University of Utah.
Multiple data sources were used for this analysis including the Utah Controlled Substances Database (CSD), Utah ED encounter database, and the state medical examiner and death certificate databases.
This study was limited to evaluation of prescribing in chronic opioid users during the period of 04/2009 to 03/2010.
Chronic: >180 days of any opioid filled with no gaps >7 days within study period.
Process flags included the dual use of long-acting opioids, dual use of short-acting opioids, combined use of benzodiazepines and long-acting opioids, methadone titration.
Methadone titration rule:
Index methadone fill with ≤ 6m no methadone.
Rule based on daily Morphine EQ (ME) prior to index fill
If < 30mg ME/day then any methadone use is inappropriate
If < 60mg ME/day then > 15 mg/day methadone is inappropriate
If < 105 ME/day then > 23mg/day methadone is inappropriate
If > 30mg/day then methadone dose is inappropriate
Outcome flags included:
Opioid related ED visits
Opioid related deaths
The intensive educational intervention was based on a Performance Improvement Continuing Medical Education (PI-CME) and had 3 stages:
Stage A – participants access and use the DOPL CSD to produce a controlled substance report for all patients prescribed an opioid during the previous six months. (5 PRA credits)
Stage B – participants attend a presentation describing the problem of opioid related deaths in Utah, taught to implement 6-practices to prevent opioid deaths while still treating chronic pain, learn use Guidelines and tools. (5 PRA credits)
Stage C – participants assessed changes in their prescribing practices and in their office systems to support pain management and guideline recommendations. (5 PRA credits)
Specialties with <1000 patients receiving at least 1 opioid during the study period were classified as “other”.
Dual use of Benzo & Long-acting Opioid
Dual Use of Short-acting Opioids
Opioid Related ED Visit
Opioid Related Death
Impact
Participating in the educational intervention appears to have decreased the dual use of long-acting opioids, dual use of short-acting opioids.
Improvement may have occurred through better use of the DOPL controlled substance database to check patients opioid history when prescribing, and the use of tools supported by the guidelines.
Results for Educational Intervention
Count for Providers and Chronic Opioid Patients by Educational Intervention
No Educational Intervention
Stage A or Higher Intervention
Stage B or Higher Intervention
Provider Level Information
All Providers
7983
288 95
Pain Provider
78 (0.98%)
3 (1.04%)
0 (0.00%)
Nurse Provider
487 (6.10%)
20 (6.94%)
8 (8.42%)
Patient Level Information
All Patients
102,352
9,692
3,367
Any Methadone
586 (0.57%)
60 (0.62%)
25 (0.74%)
Dual Use of Long-acting Opioids
770 (0.75%)
46 (0.47%)
13 (0.39%)
Dual Use of Benzo and Long-acting Opioids
6,623 (6.47%)
591 (6.10%)
180 (5.35%)
Dual Use of Short-acting Opioids
12,168 (11.89%)
992 (10.24%)
371 (11.02%)
Any Process
18,996 (18.56%)
1,608 (16.59%)
565 (16.78%)
Opioid Related ED Visits
1,050 (1.03%)
95 (0.98%)
42 (1.25%)
Opioid Related Death
320 (0.31%)
22 (0.23%)
16 (0.48%)
Acknowledgements
CDC: 5 R21 CE
Utah Health Bill 137
VA HSR&D Career Development Award # RCD063002
Contact Information
Risk Ratio
No educational intervention vs. Stage A or higher
No educational intervention vs. Stage B or higher
Note:
Specialty adjustment only adjusts for pain medicine and nurse.
Baseline adjustment includes total chronic users in previous year and the total flags for the measure in the previous year.
CCOE