A Systematic Approach to Opioid Prescribing

Kelly Bossenbroek Fedoriw; Amy Prentice; Sue Slatkoff; Linda Myerholtz

doi:10.3122/jabfm.2020.06.190463

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Table 1.

DSM-5 Diagnostic Criteria for Opioid Use Disorder²⁴

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

4. Craving, or a strong desire or urge to use opioids.

5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.

8. Recurrent opioid use in situations in which it is physically hazardous.

9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following:
- a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
- b. A markedly diminished effect with continued use of the same amount of an opioid.

Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.

11. Withdrawal, as manifested by either of the following:
- a. The characteristic opioid withdrawal syndrome
- b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.
4. • Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Severity: Mild, 2–3 symptoms. Moderate, 4–5 symptoms. Severe, 6 or more symptoms.

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Table 2.

Changes in Key Patient Outcomes at the University of North Carolina Family Medicine Center after Introduction of the Opioid Policy

Variable	Year
Variable	2015*	2016	2017	2018
Total annual patient visits, n	58,200	61,364	65,638	64,773
Total opioid prescriptions, n	7174	6724	6086	6032
Opioid prescribing rate per 100 patient visits	12.3	11.0	9.3	9.3
Total benzodiazepine prescriptions, n	2463	2231	1953	2145
Benzodiazepine prescribing rate per 100 patient visits	4.2	3.6	3.0	3.3
Patients chronically on opioids, n^†	856	793	718	663
Patients on both chronic opioids and chronic benzodiazepines, n^‡	125	93	67	55

↵* The departmental pain management/opioid policy was developed over a 9-month period and implemented in September 2015.
↵† Chronic opioid use defined as 3 or more opioid prescriptions during the calendar year. Of note, patients with a terminal illness could not be excluded from the data set.
↵‡ Defined as 3 opioid prescriptions and 3 benzodiazepine prescriptions during the calendar year.

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Table 3.

Activities and Outcomes of the University of North Carolina Family Medicine Center Controlled Medication Advisory Board, 2015–2018

Activities	Results
Number of referrals	117
Sources of referrals	55 providers made referrals (Range, 1–11 referrals per provider)
Opioid Risk Tool Score*	High risk (ORT > 8), 38% (n = 24) Moderate risk (ORT 4–7), 36% (n = 23) Lower risk (ORT < 4), 27% (n = 17)

Outcomes	Percent of referrals
Treatment plan revision recommended	60% (n = 70/117)
Exemptions to policy approved	3% (n = 4/117)
Recommendation to refer to behavioral health provider	39% (n = 46/117)
Opioid decrease recommended by CMAB^†	40% (39/98^‡)
Of these, recommended decrease was successfully achieved	64% (25/39)
Benzodiazepine decrease recommended by CMAB	20% (20/98^‡)
Of these, recommended decrease was successfully achieved	65% (n = 13/20)
Naloxone was prescribed following recommendation by CMAB review	79% (n = 26/33)
Urine screen was conducted within 3 months following CMAB review	71% (n = 83/117)
Patient deceased (all were non-opioid deaths due to health conditions or natural causes)	5% (n = 6/117)
Patients no longer seen at FMC (of these, 5 [22%] left because they followed their primary care physician when they relocated to a new practice)	20% (n = 23/117)

CMAB, controlled medication advisory board; FMC, Family Medicine Center; ORT, Opioid Risk Tool.
↵* Data available for 64 patients, assesses risk of opioid abuse
↵† An opioid decrease was only recommended in 39 patients. Most of the other patients fit in the following categories: opioids already appropriately low dose, opioids already in the process of being tapered, or CMAB recommended not restarting opioids.
↵‡ This denominator of 98 is less than 117 because several of our CMAB referrals did not receive full consults due to very specific questions such as urine toxicology screen interpretation or help with referral processes.