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Research ArticleOriginal Research

Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety

Nicholas Cox, Casey R. Tak, Susan E. Cochella, Eric Leishman and Karen Gunning
The Journal of the American Board of Family Medicine January 2018, 31 (1) 105-112; DOI: https://doi.org/10.3122/jabfm.2018.01.170210
Nicholas Cox
the Department of Pharmacy Services (NC, KG) and Department of Family and Preventive Medicine (SEC), University of Utah Health, Salt Lake City; the Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City (NC, CRT, EL, KG); and the Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City (SEC, KG).
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Casey R. Tak
the Department of Pharmacy Services (NC, KG) and Department of Family and Preventive Medicine (SEC), University of Utah Health, Salt Lake City; the Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City (NC, CRT, EL, KG); and the Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City (SEC, KG).
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Susan E. Cochella
the Department of Pharmacy Services (NC, KG) and Department of Family and Preventive Medicine (SEC), University of Utah Health, Salt Lake City; the Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City (NC, CRT, EL, KG); and the Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City (SEC, KG).
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Eric Leishman
the Department of Pharmacy Services (NC, KG) and Department of Family and Preventive Medicine (SEC), University of Utah Health, Salt Lake City; the Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City (NC, CRT, EL, KG); and the Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City (SEC, KG).
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Karen Gunning
the Department of Pharmacy Services (NC, KG) and Department of Family and Preventive Medicine (SEC), University of Utah Health, Salt Lake City; the Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City (NC, CRT, EL, KG); and the Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City (SEC, KG).
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  • Article
  • Figures & Data
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Article Figures & Data

Tables

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    Table 1.

    Patient Demographics

    CharacteristicsPatients (n = 45)
    Age (years), mean (SD)57 (13)
    Female sex22 (49)
    Race/ethnicity
        White40 (89)
        Hispanic3 (7)
        Other4 (9)
        Native American1 (2)
    Pain indication*
        Unspecified joint pain30 (67)
        Neuropathy17 (38)
        Unspecified back pain15 (33)
        Unspecified muscle pain11 (24)
        Unspecified pain11 (24)
        Osteoarthritis10 (22)
        Spinal disease or pain9 (20)
        Unspecified neck pain7 (16)
        Fibromyalgia3 (7)
        Migraine2 (4)
        Rheumatoid arthritis2 (4)
        Other8 (18)
    Comorbidities*
        Tobacco use28 (62)
        Anxiety27 (60)
        Depression25 (56)
        Insomnia20 (44)
        Alcohol use18 (42)
        Migraines9 (20)
        History of illicit drug use5 (11)
        Bipolar3 (7)
        Other psychiatric condition2 (4)
    • Data are n (%) unless otherwise indicated.

    • ↵* Characteristics are not mutually exclusive. Patients may have multiple documented indications and comorbidities.

    • SD, standard deviation.

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    Table 2.

    Morphine Milligram Equivalents per Day and Pain Scores

    OutcomesBefore Intervention (n = 45)After Intervention (n = 45)P Value
    MMEs/day
        Based on prescription directions151 (110)125 (114)<.001
        Based on number of pills prescribed per month135 (100)116 (106)<.001
    Pain scores*5.3 (2.6)5.5 (2.5).783
    • Data are mean (standard deviation) unless otherwise indicated.

    • ↵* Only patients with data available before and after the intervention were included in analysis of this outcome (n = 27).

    • MME, morphine milligram equivalent.

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    Table 3.

    Secondary Outcomes

    OutcomesBefore Intervention (n = 45)After Intervention (n = 45)P Value
    Patients concurrently taking high-risk medications
        Benzodiazepines21 (47)14 (31).008
        Hypnotics10 (22)7 (16).083
        Muscle relaxants8 (18)10 (22).157
    Nonopioid analgesics prescribed, mean (SD)2.1 (1.3)2.4 (1.4).002
    Opioid analgesics prescribed, mean (SD)1.6 (0.6)1.5 (0.7).219
    Offered outpatient naloxone prescription6 (13)22 (49).009
    Current urine drug screen*15 (33)27 (60)<.001
    Current review of the state's PDMP†12 (27)26 (58)<.001
    Referral to pain specialist17 (38)21 (47).046
    Referral to physical therapy33 (73)34 (76).317
    Patients prescribed a bowel regimen6 (13)22 (49)<.001
    • Data are n (%) unless otherwise indicated.

    • ↵* “Current” is defined as completed within the preceding 12 months.

    • ↵† “Current” is defined as completed and documented within the preceding 3 months.

    • PDMP, prescription drug monitoring program; SD, standard deviation.

    • View popup
    Table 4.

    Pharmacist and Provider Effort and Time

    OutcomesValue
    Pharmacist
        Total reviews provided, n80
        Reviews per patient1.8 (0.9)
        Minutes required for review33 (19)
    Pharmacist recommendations
        Total recommendations provided, n301
        Total recommendations implemented, n (% of total recommendations provided)114 (38)
        Provided per patient6.3 (1.5)
        Implemented per patient2.5 (1.3)
    Provider
        Total appointments, n118
        Appointments per patient2.6 (1.3)
    • Data are mean (standard deviation) unless otherwise indicated.

    • View popup
    Appendix 1.

    Morphine Milligram Equivalents Conversion

    OpioidEquivalent Milligram (mg)
    Codeine, oral200
    Fentanyl, transdermal12.5
    Hydrocodone, oral30
    Hydromorphone, oral7.5
    Hydromorphone, parenteral1.5
    Methadone, oral (1 to 20 mg/day)7.5
    Methadone, oral (21 to 40 mg/day)3.75
    Methadone, oral (41 to 60 mg/day)3
    Methadone, oral (61+ mg/day)2.5
    Morphine, oral30
    Morphine, parenteral10
    Oxycodone, oral20
    Oxymorphone, oral10
    Oxymorphone, parenteral1
    Tramadol, oral120
    • View popup
    Appendix 2.

    Select Recommendations Given and Implemented

    Select RecommendationsGiven to Provider, n (% of patients)Implemented, n (% of specific recommendation)
    Initiate/change non-opioid analgesic regimen45 (100)22 (49)
    Consider opioid taper43 (96)22 (51)
    Refer to pain specialist42 (93)5 (12)
    Offer outpatient naloxone prescription37 (82)20 (54)
    Review state's PDMP35 (78)15 (43)
    Obtain urine drug screen31 (69)16 (52)
    Taper/discontinue concurrent high-risk medications20 (44)8 (40)
    • PDMP, prescription drug monitoring program.

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The Journal of the American Board of Family     Medicine: 31 (1)
The Journal of the American Board of Family Medicine
Vol. 31, Issue 1
January-February 2018
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Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety
Nicholas Cox, Casey R. Tak, Susan E. Cochella, Eric Leishman, Karen Gunning
The Journal of the American Board of Family Medicine Jan 2018, 31 (1) 105-112; DOI: 10.3122/jabfm.2018.01.170210

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Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety
Nicholas Cox, Casey R. Tak, Susan E. Cochella, Eric Leishman, Karen Gunning
The Journal of the American Board of Family Medicine Jan 2018, 31 (1) 105-112; DOI: 10.3122/jabfm.2018.01.170210
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Keywords

  • Benzodiazepines
  • Chronic Pain
  • Drug Monitoring
  • Naloxone
  • Opioid Analgesics
  • Pain Management
  • Pharmacists
  • Pilot Study
  • Prescriptions
  • Primary Health Care
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