The Road to Safe and Appropriate Opioid Prescribing

Kaiser Permanente’s Comprehensive, Systematic Approach to Pain Management Can Effectively Reduce Opioid Reliance

By Michael Kanter, MD

In 2009, our physicians looked at the most frequently prescribed drugs for Kaiser Permanente members in Southern California. They were surprised to find that drugs for hypertension and diabetes were not at the top of that list. Instead, opioid painkillers and highly addictive narcotics were more frequently prescribed.

OxyContin® was near the top, even though Kaiser Permanente didn’t subsidize it and patients had to pay for it themselves.

Patients were getting more prescriptions at higher doses than we had previously seen. Around the same time, new literature was being published on the hazards and ineffectiveness of opioids for the management of chronic pain.

We decided this would be a great opportunity to improve the quality and safety of drug prescribing for our members. Rather than risk patients being addicted and overdosing, we needed to break the cycle and find alternatives.

Comprehensive Initiative on Treating Chronic Pain

Starting in 2010, Kaiser Permanente Southern California launched a comprehensive initiative to transform the way that chronic pain was viewed and treated. The Safe and Appropriate Opioid Prescribing program implemented several efforts to reduce opioid prescribing, including prescribing and dispensing policies, monitoring and follow-up processes, and clinical coordination through electronic health record integration.

The program is the focus of a study* I co-authored that was recently published in the Journal of Evaluation in Clinical Practice that shows a comprehensive, system-level strategy has the ability to positively affect opioid prescribing.

Reductions were observed in all of the tracked outcomes:

• 30 percent reduction in prescribing opioids in high doses
• 98 percent reduction in number of prescriptions with greater than 200 pills
• 90 percent decrease in opioid prescriptions with benzodiazepines and carisoprodol
• 72 percent reduction in prescribing of Long-Acting/Extended Release opioids
• 95 percent reduction in prescribing of brand name opioid-acetaminophen products

Our approach has always been to assure appropriate pain management. According to current clinical evidence and the Centers for Disease Control and Prevention (CDC) guidelines, opioids are not effective in treating chronic pain. Therefore, we have focused on making sure patients are treated with the most effective treatments, which may include other non-opioid medications, physical therapy, acupuncture, exercise, injections, cognitive behavioral therapy and other methods.

Often, reducing or stopping opioid use is associated with reduction in pain, and certainly reduces the risk of overdose and death. Some patients benefit from referral and treatment with our comprehensive addiction medicine services.

We measured and found a decreased rate of reported adverse events in our patients. Patients are generally positive about our new multidisciplinary approach to opioids and pain management. Many patients are, in the end, feeling better once they are off the very large doses of opioids they were on in the past.

Positive Response from Doctors

The response from our doctors at the Southern California Permanente Medical Group has been generally positive too. Many physicians never felt comfortable with the pressure to prescribe opioids to patients. Our system allows physicians to feel empowered to appropriately prescribe and taper opioids in patients, and to have the conversations with patients about this sensitive but important aspect of their health care.

As an organization, we have effectively and appropriately reduced the following:

• Prescribing of high-risk, long-acting opioids
• Quantities and daily morphine milligram equivalent
• Preferred brand vs. generic prescribing
• The combination prescribing of opioids with carisoprodol (known as Soma).

Kaiser Permanente’s focus on prescribing the lowest effective dose and supply also has helped to reduce the risk of diverting opioids onto the street. We know that unused medications in the medicine cabinet can find their way into our communities.

What is exciting about this program is that we are seeing similar results in other states where Kaiser Permanente operates. This is the culmination of a systematic and comprehensive set of strategies and tactics over several years. Results continue to demonstrate that Kaiser Permanente is reducing over-prescribing of opioids and reducing the risk of overdose and death in population of our members. We are encouraged for the long term because other systems could implement this program, too.

Michael Kanter, MD, is medical director of Quality and Clinical Analysis for the Southern California Permanente Medical Group, and serves as executive vice president and chief quality officer of The Permanente Federation, which represents the national interests of the Permanente Medical Groups.

*Other study authors include: Jan L. Losby, PhD, MSW, Centers for Disease Control and Prevention; Joel D. Hyatt, MD, emeritus assistant regional medical director, community health improvement, Southern California Permanente Medical Group; Grant Baldwin PhD, MPH, CDC; and Denis Matsuoka, PharmD, OptumRx.

Elements of the Safe and Appropriate Opioid Prescribing Program

The study published in the Journal of Evaluation in Clinical Practice demonstrates that a comprehensive, system-level strategy can significantly and positively affect opioid prescribing when there is leadership commitment, multi-stakeholder collaboration and cooperation, as well as accurate and timely data.

The basic components of the intervention are generalizable and applicable to other health care settings.

The Program’s Components

• Clinical and patient education: training physicians, nurses, pharmacists, and patients about the dangers and risks of opioids.
• Multi-specialty support: A multidisciplinary care team that includes pain management, addiction medicine, physical therapy, psychiatry, and neurology.
• Alternative pain management programs: These programs are offered along with addiction medicine services and counseling.
• Leveraging the electronic health record system: to measure and monitor data to improve quality care; alert doctors on their computer screen if a patient is already receiving an opioid, to avoid prescribing dangerous combinations of the drugs. Additionally, the doctor can see scientific articles describing the hazards.
• Integrated health system: Kaiser Permanente’s integrated care model – care under one roof – makes it easier to implement such programs; many departments collaborate and establish protocols quickly (e.g. primary care, pain management, pharmacy, psychiatry and rehab, care teams are all connected).
• Prescribing: Patients coming out of routine surgery no longer receive a month’s worth of opioid medication, but get a smaller supply designed to match the expected duration of their pain (usually just a few days). This avoids some of the post-operative complications of opioid use that can require readmission to the hospital and/or emergency room visits.
• Community safety: Switching from brand name to generic drugs reduces risk of diversion into communities.