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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.
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.
We reviewed, one by one, all tasks created from November 1 to 30, 2010. One of the study’s investigators categorized each task according to the following descriptors: who created the task, who addressed the task, what day of the week the task was created, urgency of the task, whether the task required a follow-up phone call, and whether the task was related to opioid/controlled-substance issues. The task was categorized as acute if the issue was related to a condition that had been present for fewer than 3 weeks. Chronic tasks were created for conditions present for ≥3 weeks. At the time the study was completed, our EHR had no portal through which we could communicate with patients.
ANALYSIS
We conducted statistical analyses with the IBM SPSS, version 22.0 (SPSS, Inc, Chicago, Illinois). We used descriptive statistics to examine the frequency and percentage for all variables. We used a chi-squared (χ2) test to assess the differences between the 2 clinics, and used a binary multiple logistic regression model to determine possible factors related to opioid-related tasks. P values <.05 were considered statistically significant. The Colorado Multiple Institutional Review Board approved this study.
RESULTS
Clinics 1 and 2, respectively, saw 2007 and 1186 patients during the study period (TABLE 1). The additional 1028 tasks generated by phone calls were almost equally distributed among the 3 pods of Clinic 1 (290, 202, and 260) and Clinic 2 (276). For data analysis, we compared Clinic 1 with Clinic 2 and also compared the 3 pods of Clinic 1 individually with Clinic 2. Both approaches produced similar results.
Most tasks (54% for Clinic 1 and 99% for Clinic 2) were created by MAs and CTAs. At Clinic 1, tasks were also created by residents (17%), PA/NPs (8%), attending physicians (7%), and others/clinical nurses (14%). Tasks at Clinic 1 were addressed by attending physicians (49%), residents (25%), PA/NPs (25%), and others (1%). At Clinic 2, tasks were addressed by attending physicians (75%) and PA/NPs (25%). Approximately half of the tasks (51%) in both clinics were created during weekdays, compared with the day after weekends/holidays (28%), the day before weekends/holidays (17%), and during weekends/holidays (4%). Chronic patient issues, acute patient issues, and other issues accounted for 54%, 29%, and 17% of tasks, respectively. Follow-up phone calls to patients, pharmacies, or others occurred in 37% of tasks. Two hundred twenty tasks (21%) in the clinics combined were related to opioids and controlled substances.
Multiple logistic regression analysis of data from both clinics (TABLE 2) showed more opioid-related tasks in Clinic 1 compared with Clinic 2 (P<.001), and that these tasks were more often related to chronic issues than to acute issues (P<.001). Tasks created by MAs, CTAs, clinical nurses, and others were more likely to be opioid-related compared with the tasks created by attending physicians, residents, NPs, or a PA (25% vs 15%; P<.05). Compared with non-opioid-related tasks, opioid-related tasks required more follow-up phone calls (P<.001). Follow-up phone calls to pharmacies occurred more often with opioid-related tasks than with non-opioid tasks (11% vs 5%), while follow-up phone calls to patients occurred more often for non-opioid related tasks than opioid-related tasks (28% vs 18%). No correlations with task creation were found for who addressed the opioid-related task or the day the task was created.
DISCUSSION
This study demonstrated that our process of handling patient issues related to opioids accounts for a large proportion of all tasks. Dealing with tasks is time consuming, not only for attending physicians and residents but also for clinic nurses and staff. Almost a quarter of clinic tasks were opioid related. As has been shown in previous studies,5-8 chronic pain management with opioids is an unsatisfying task for staff and care providers at our clinics. We also found that tasks created by non-providers were more likely to be opioid-related than were tasks created by providers. This is most likely due to the fact that non-providers cannot write prescriptions and they have to ask providers for further reviews.
Khalid et al found that, compared with attending physicians, residents had more patients on chronic opioids who displayed concerning behaviors, including early refills and refills from multiple providers.13 The higher number of part-time providers at Clinic 1 in our study may have also caused insufficient continuity of care at that site. Nevertheless, this model of practice is used in many academic primary care institutions.4 Another possible reason for the difference could be a lack of resident training on current guidelines for managing opiates for chronic pain.3,13,14 Again, this was a pilot study and we drew no solid conclusion about the reasons for differences between these 2 clinics.
It is obvious, however, that we spend a significant amount of time and resources dealing with chronic pain management. Our institution created an opioid/controlled-substance patient registry about 3 years ago. The data for 2014 showed that 22.8% and 18% of patients seen at least once at Clinic 1 and Clinic 2, respectively, were prescribed opioids/controlled substances (TABLE 3).
Possible solutions to reduce tasks related to opioid management. For both small and large practices, one way to reduce the number of tasks related to opioid management and, therefore, the time allocated to completing those tasks, would be to have a clear protocol to follow.3,4,8,11,14,15 The protocol may include the creation of an opioid/controlled-substance registry and the development and implementation of clinical decision support programs.
We also recommend the dissemination of tools for clinical management at the point of care. These can include a controlled-substance risk assessment tool for aberrant behaviors, a controlled-substance informed consent form, a functional and quality-of-life assessment, electronic clinical-note templates in the EHR, urine drug screening, and routine use of existing state pharmacy prescription drug monitoring programs. Also essential would be the provision of routine educational programs for clinicians regarding chronic pain management based on existing evidence and guidelines. (See “Opioids for chronic pain: The CDC’s 12 recommendations.”) It has been demonstrated that an EHR opioid dashboard or an EHR-based protocol improved adherence to guidelines for prescribing opiates.16
This study has several limitations. First, this was a small pilot study completed over a short period of time, although we believe the findings are likely representative of the prescribing practices in the 2 clinics we evaluated. Second, it was a retrospective study, which was appropriate for evaluating our questions. Third, we were unable to account for other factors that could potentially confound the results, including, but not limited to, the amount of time allocated to each task, and the total number of patients at each clinic who were on opioids for management of chronic pain during the study period. However, due to our recent addition of an opioid/controlled-substance patient registry, we were able to add information for the year 2014 (TABLE 3). Multi-center large scale studies are required to evaluate this further.
ACKNOWLEDGEMENTS
We thank Dr. Corey Lyon for his editorial assistance.
CORRESPONDENCE
Morteza Khodaee, MD, AFW Family Medicine Clinic, 3055 Roslyn Street, Denver, CO 80238; [email protected].
1. Smith BH, Torrance N. Management of chronic pain in primary care. Curr Opin Support Palliat Care. 2011;5:137-142.
2. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307:1377-1378.
3. Leverence RR, Williams RL, Potter M, et al; PRIME Net Clinicians. Chronic non-cancer pain: a siren for primary care—a report from the PRImary Care MultiEthnic Network (PRIME Net). J Am Board Fam Med. 2011;24:551-561.
4. Watkins A, Wasmann S, Dodson L, et al. An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center. Fam Med. 2004;36:487-489.
5. Brown J, Setnik B, Lee K, et al. Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011;7:467-483.
6. Duensing L, Eksterowicz N, Macario A, et al. Patient and physician perceptions of treatment of moderate-to-severe chronic pain with oral opioids. Curr Med Res Opin. 2010;26:1579-1585.
7. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011;12:S26-S35.
8. Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician. 2011;57:324-332.
9. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
10. Hartrick CT, Gatchel RJ, Conroy S. Identification and management of pain medication abuse and misuse: current state and future directions. Expert Rev Neurother. 2012;12:601-610.
11. Wiedemer NL, Harden PS, Arndt IO, et al. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8:573-584.
12. Colburn JL, Jasinski DR, Rastegar DA. Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic. J Opioid Manag. 2012;8:153-160.
13. Khalid L, Liebschutz JM, Xuan Z, et al. Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med. 2015;16:480-487.
14. Canada RE, DiRocco D, Day S. A better approach to opioid prescribing in primary care. J Fam Pract. 2014;63:E1-E8.
15. Clark LG, Upshur CC. Family medicine physicians’ views of how to improve chronic pain management. J Am Board Fam Med. 2007;20:479-482.
16. Anderson D, Zlateva I, Khatri K, et al. Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clin J Pain. 2015;31:573-579.
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.
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.
We reviewed, one by one, all tasks created from November 1 to 30, 2010. One of the study’s investigators categorized each task according to the following descriptors: who created the task, who addressed the task, what day of the week the task was created, urgency of the task, whether the task required a follow-up phone call, and whether the task was related to opioid/controlled-substance issues. The task was categorized as acute if the issue was related to a condition that had been present for fewer than 3 weeks. Chronic tasks were created for conditions present for ≥3 weeks. At the time the study was completed, our EHR had no portal through which we could communicate with patients.
ANALYSIS
We conducted statistical analyses with the IBM SPSS, version 22.0 (SPSS, Inc, Chicago, Illinois). We used descriptive statistics to examine the frequency and percentage for all variables. We used a chi-squared (χ2) test to assess the differences between the 2 clinics, and used a binary multiple logistic regression model to determine possible factors related to opioid-related tasks. P values <.05 were considered statistically significant. The Colorado Multiple Institutional Review Board approved this study.
RESULTS
Clinics 1 and 2, respectively, saw 2007 and 1186 patients during the study period (TABLE 1). The additional 1028 tasks generated by phone calls were almost equally distributed among the 3 pods of Clinic 1 (290, 202, and 260) and Clinic 2 (276). For data analysis, we compared Clinic 1 with Clinic 2 and also compared the 3 pods of Clinic 1 individually with Clinic 2. Both approaches produced similar results.
Most tasks (54% for Clinic 1 and 99% for Clinic 2) were created by MAs and CTAs. At Clinic 1, tasks were also created by residents (17%), PA/NPs (8%), attending physicians (7%), and others/clinical nurses (14%). Tasks at Clinic 1 were addressed by attending physicians (49%), residents (25%), PA/NPs (25%), and others (1%). At Clinic 2, tasks were addressed by attending physicians (75%) and PA/NPs (25%). Approximately half of the tasks (51%) in both clinics were created during weekdays, compared with the day after weekends/holidays (28%), the day before weekends/holidays (17%), and during weekends/holidays (4%). Chronic patient issues, acute patient issues, and other issues accounted for 54%, 29%, and 17% of tasks, respectively. Follow-up phone calls to patients, pharmacies, or others occurred in 37% of tasks. Two hundred twenty tasks (21%) in the clinics combined were related to opioids and controlled substances.
Multiple logistic regression analysis of data from both clinics (TABLE 2) showed more opioid-related tasks in Clinic 1 compared with Clinic 2 (P<.001), and that these tasks were more often related to chronic issues than to acute issues (P<.001). Tasks created by MAs, CTAs, clinical nurses, and others were more likely to be opioid-related compared with the tasks created by attending physicians, residents, NPs, or a PA (25% vs 15%; P<.05). Compared with non-opioid-related tasks, opioid-related tasks required more follow-up phone calls (P<.001). Follow-up phone calls to pharmacies occurred more often with opioid-related tasks than with non-opioid tasks (11% vs 5%), while follow-up phone calls to patients occurred more often for non-opioid related tasks than opioid-related tasks (28% vs 18%). No correlations with task creation were found for who addressed the opioid-related task or the day the task was created.
DISCUSSION
This study demonstrated that our process of handling patient issues related to opioids accounts for a large proportion of all tasks. Dealing with tasks is time consuming, not only for attending physicians and residents but also for clinic nurses and staff. Almost a quarter of clinic tasks were opioid related. As has been shown in previous studies,5-8 chronic pain management with opioids is an unsatisfying task for staff and care providers at our clinics. We also found that tasks created by non-providers were more likely to be opioid-related than were tasks created by providers. This is most likely due to the fact that non-providers cannot write prescriptions and they have to ask providers for further reviews.
Khalid et al found that, compared with attending physicians, residents had more patients on chronic opioids who displayed concerning behaviors, including early refills and refills from multiple providers.13 The higher number of part-time providers at Clinic 1 in our study may have also caused insufficient continuity of care at that site. Nevertheless, this model of practice is used in many academic primary care institutions.4 Another possible reason for the difference could be a lack of resident training on current guidelines for managing opiates for chronic pain.3,13,14 Again, this was a pilot study and we drew no solid conclusion about the reasons for differences between these 2 clinics.
It is obvious, however, that we spend a significant amount of time and resources dealing with chronic pain management. Our institution created an opioid/controlled-substance patient registry about 3 years ago. The data for 2014 showed that 22.8% and 18% of patients seen at least once at Clinic 1 and Clinic 2, respectively, were prescribed opioids/controlled substances (TABLE 3).
Possible solutions to reduce tasks related to opioid management. For both small and large practices, one way to reduce the number of tasks related to opioid management and, therefore, the time allocated to completing those tasks, would be to have a clear protocol to follow.3,4,8,11,14,15 The protocol may include the creation of an opioid/controlled-substance registry and the development and implementation of clinical decision support programs.
We also recommend the dissemination of tools for clinical management at the point of care. These can include a controlled-substance risk assessment tool for aberrant behaviors, a controlled-substance informed consent form, a functional and quality-of-life assessment, electronic clinical-note templates in the EHR, urine drug screening, and routine use of existing state pharmacy prescription drug monitoring programs. Also essential would be the provision of routine educational programs for clinicians regarding chronic pain management based on existing evidence and guidelines. (See “Opioids for chronic pain: The CDC’s 12 recommendations.”) It has been demonstrated that an EHR opioid dashboard or an EHR-based protocol improved adherence to guidelines for prescribing opiates.16
This study has several limitations. First, this was a small pilot study completed over a short period of time, although we believe the findings are likely representative of the prescribing practices in the 2 clinics we evaluated. Second, it was a retrospective study, which was appropriate for evaluating our questions. Third, we were unable to account for other factors that could potentially confound the results, including, but not limited to, the amount of time allocated to each task, and the total number of patients at each clinic who were on opioids for management of chronic pain during the study period. However, due to our recent addition of an opioid/controlled-substance patient registry, we were able to add information for the year 2014 (TABLE 3). Multi-center large scale studies are required to evaluate this further.
ACKNOWLEDGEMENTS
We thank Dr. Corey Lyon for his editorial assistance.
CORRESPONDENCE
Morteza Khodaee, MD, AFW Family Medicine Clinic, 3055 Roslyn Street, Denver, CO 80238; [email protected].
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.
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.
We reviewed, one by one, all tasks created from November 1 to 30, 2010. One of the study’s investigators categorized each task according to the following descriptors: who created the task, who addressed the task, what day of the week the task was created, urgency of the task, whether the task required a follow-up phone call, and whether the task was related to opioid/controlled-substance issues. The task was categorized as acute if the issue was related to a condition that had been present for fewer than 3 weeks. Chronic tasks were created for conditions present for ≥3 weeks. At the time the study was completed, our EHR had no portal through which we could communicate with patients.
ANALYSIS
We conducted statistical analyses with the IBM SPSS, version 22.0 (SPSS, Inc, Chicago, Illinois). We used descriptive statistics to examine the frequency and percentage for all variables. We used a chi-squared (χ2) test to assess the differences between the 2 clinics, and used a binary multiple logistic regression model to determine possible factors related to opioid-related tasks. P values <.05 were considered statistically significant. The Colorado Multiple Institutional Review Board approved this study.
RESULTS
Clinics 1 and 2, respectively, saw 2007 and 1186 patients during the study period (TABLE 1). The additional 1028 tasks generated by phone calls were almost equally distributed among the 3 pods of Clinic 1 (290, 202, and 260) and Clinic 2 (276). For data analysis, we compared Clinic 1 with Clinic 2 and also compared the 3 pods of Clinic 1 individually with Clinic 2. Both approaches produced similar results.
Most tasks (54% for Clinic 1 and 99% for Clinic 2) were created by MAs and CTAs. At Clinic 1, tasks were also created by residents (17%), PA/NPs (8%), attending physicians (7%), and others/clinical nurses (14%). Tasks at Clinic 1 were addressed by attending physicians (49%), residents (25%), PA/NPs (25%), and others (1%). At Clinic 2, tasks were addressed by attending physicians (75%) and PA/NPs (25%). Approximately half of the tasks (51%) in both clinics were created during weekdays, compared with the day after weekends/holidays (28%), the day before weekends/holidays (17%), and during weekends/holidays (4%). Chronic patient issues, acute patient issues, and other issues accounted for 54%, 29%, and 17% of tasks, respectively. Follow-up phone calls to patients, pharmacies, or others occurred in 37% of tasks. Two hundred twenty tasks (21%) in the clinics combined were related to opioids and controlled substances.
Multiple logistic regression analysis of data from both clinics (TABLE 2) showed more opioid-related tasks in Clinic 1 compared with Clinic 2 (P<.001), and that these tasks were more often related to chronic issues than to acute issues (P<.001). Tasks created by MAs, CTAs, clinical nurses, and others were more likely to be opioid-related compared with the tasks created by attending physicians, residents, NPs, or a PA (25% vs 15%; P<.05). Compared with non-opioid-related tasks, opioid-related tasks required more follow-up phone calls (P<.001). Follow-up phone calls to pharmacies occurred more often with opioid-related tasks than with non-opioid tasks (11% vs 5%), while follow-up phone calls to patients occurred more often for non-opioid related tasks than opioid-related tasks (28% vs 18%). No correlations with task creation were found for who addressed the opioid-related task or the day the task was created.
DISCUSSION
This study demonstrated that our process of handling patient issues related to opioids accounts for a large proportion of all tasks. Dealing with tasks is time consuming, not only for attending physicians and residents but also for clinic nurses and staff. Almost a quarter of clinic tasks were opioid related. As has been shown in previous studies,5-8 chronic pain management with opioids is an unsatisfying task for staff and care providers at our clinics. We also found that tasks created by non-providers were more likely to be opioid-related than were tasks created by providers. This is most likely due to the fact that non-providers cannot write prescriptions and they have to ask providers for further reviews.
Khalid et al found that, compared with attending physicians, residents had more patients on chronic opioids who displayed concerning behaviors, including early refills and refills from multiple providers.13 The higher number of part-time providers at Clinic 1 in our study may have also caused insufficient continuity of care at that site. Nevertheless, this model of practice is used in many academic primary care institutions.4 Another possible reason for the difference could be a lack of resident training on current guidelines for managing opiates for chronic pain.3,13,14 Again, this was a pilot study and we drew no solid conclusion about the reasons for differences between these 2 clinics.
It is obvious, however, that we spend a significant amount of time and resources dealing with chronic pain management. Our institution created an opioid/controlled-substance patient registry about 3 years ago. The data for 2014 showed that 22.8% and 18% of patients seen at least once at Clinic 1 and Clinic 2, respectively, were prescribed opioids/controlled substances (TABLE 3).
Possible solutions to reduce tasks related to opioid management. For both small and large practices, one way to reduce the number of tasks related to opioid management and, therefore, the time allocated to completing those tasks, would be to have a clear protocol to follow.3,4,8,11,14,15 The protocol may include the creation of an opioid/controlled-substance registry and the development and implementation of clinical decision support programs.
We also recommend the dissemination of tools for clinical management at the point of care. These can include a controlled-substance risk assessment tool for aberrant behaviors, a controlled-substance informed consent form, a functional and quality-of-life assessment, electronic clinical-note templates in the EHR, urine drug screening, and routine use of existing state pharmacy prescription drug monitoring programs. Also essential would be the provision of routine educational programs for clinicians regarding chronic pain management based on existing evidence and guidelines. (See “Opioids for chronic pain: The CDC’s 12 recommendations.”) It has been demonstrated that an EHR opioid dashboard or an EHR-based protocol improved adherence to guidelines for prescribing opiates.16
This study has several limitations. First, this was a small pilot study completed over a short period of time, although we believe the findings are likely representative of the prescribing practices in the 2 clinics we evaluated. Second, it was a retrospective study, which was appropriate for evaluating our questions. Third, we were unable to account for other factors that could potentially confound the results, including, but not limited to, the amount of time allocated to each task, and the total number of patients at each clinic who were on opioids for management of chronic pain during the study period. However, due to our recent addition of an opioid/controlled-substance patient registry, we were able to add information for the year 2014 (TABLE 3). Multi-center large scale studies are required to evaluate this further.
ACKNOWLEDGEMENTS
We thank Dr. Corey Lyon for his editorial assistance.
CORRESPONDENCE
Morteza Khodaee, MD, AFW Family Medicine Clinic, 3055 Roslyn Street, Denver, CO 80238; [email protected].
1. Smith BH, Torrance N. Management of chronic pain in primary care. Curr Opin Support Palliat Care. 2011;5:137-142.
2. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307:1377-1378.
3. Leverence RR, Williams RL, Potter M, et al; PRIME Net Clinicians. Chronic non-cancer pain: a siren for primary care—a report from the PRImary Care MultiEthnic Network (PRIME Net). J Am Board Fam Med. 2011;24:551-561.
4. Watkins A, Wasmann S, Dodson L, et al. An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center. Fam Med. 2004;36:487-489.
5. Brown J, Setnik B, Lee K, et al. Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011;7:467-483.
6. Duensing L, Eksterowicz N, Macario A, et al. Patient and physician perceptions of treatment of moderate-to-severe chronic pain with oral opioids. Curr Med Res Opin. 2010;26:1579-1585.
7. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011;12:S26-S35.
8. Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician. 2011;57:324-332.
9. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
10. Hartrick CT, Gatchel RJ, Conroy S. Identification and management of pain medication abuse and misuse: current state and future directions. Expert Rev Neurother. 2012;12:601-610.
11. Wiedemer NL, Harden PS, Arndt IO, et al. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8:573-584.
12. Colburn JL, Jasinski DR, Rastegar DA. Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic. J Opioid Manag. 2012;8:153-160.
13. Khalid L, Liebschutz JM, Xuan Z, et al. Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med. 2015;16:480-487.
14. Canada RE, DiRocco D, Day S. A better approach to opioid prescribing in primary care. J Fam Pract. 2014;63:E1-E8.
15. Clark LG, Upshur CC. Family medicine physicians’ views of how to improve chronic pain management. J Am Board Fam Med. 2007;20:479-482.
16. Anderson D, Zlateva I, Khatri K, et al. Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clin J Pain. 2015;31:573-579.
1. Smith BH, Torrance N. Management of chronic pain in primary care. Curr Opin Support Palliat Care. 2011;5:137-142.
2. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307:1377-1378.
3. Leverence RR, Williams RL, Potter M, et al; PRIME Net Clinicians. Chronic non-cancer pain: a siren for primary care—a report from the PRImary Care MultiEthnic Network (PRIME Net). J Am Board Fam Med. 2011;24:551-561.
4. Watkins A, Wasmann S, Dodson L, et al. An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center. Fam Med. 2004;36:487-489.
5. Brown J, Setnik B, Lee K, et al. Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011;7:467-483.
6. Duensing L, Eksterowicz N, Macario A, et al. Patient and physician perceptions of treatment of moderate-to-severe chronic pain with oral opioids. Curr Med Res Opin. 2010;26:1579-1585.
7. Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011;12:S26-S35.
8. Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician. 2011;57:324-332.
9. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
10. Hartrick CT, Gatchel RJ, Conroy S. Identification and management of pain medication abuse and misuse: current state and future directions. Expert Rev Neurother. 2012;12:601-610.
11. Wiedemer NL, Harden PS, Arndt IO, et al. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8:573-584.
12. Colburn JL, Jasinski DR, Rastegar DA. Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic. J Opioid Manag. 2012;8:153-160.
13. Khalid L, Liebschutz JM, Xuan Z, et al. Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med. 2015;16:480-487.
14. Canada RE, DiRocco D, Day S. A better approach to opioid prescribing in primary care. J Fam Pract. 2014;63:E1-E8.
15. Clark LG, Upshur CC. Family medicine physicians’ views of how to improve chronic pain management. J Am Board Fam Med. 2007;20:479-482.
16. Anderson D, Zlateva I, Khatri K, et al. Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clin J Pain. 2015;31:573-579.
