Kaiser Permanente
Oakland, CA

In October 2017, as the number of opioid deaths in the U.S. continued to climb, the Department of Health and Human Services declared the opioid crisis a public health emergency. Opioids are the primary driver of overdose deaths, killing more than 70,000 people in 20171, more than any year on record. Forty percent of all opioid deaths involve a prescription opioid.2

The 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain advise that non-drug pain therapy (such as physical therapy or acupuncture) and non-opioid drugs are preferred treatments for chronic pain.3 If opioid therapy is determined to be an appropriate treatment plan, the CDC advises clinicians to use caution when prescribing opioids at any dose, to carefully assess evidence of risks and benefits when considering a dose of 50 morphine milligram equivalents (MME)/day or more, and to avoid prescribing doses in excess of 90 MME/day. This represents a new understanding about what constitutes a high opioid dose: in 2012, the CDC guidelines cautioned prescribers to avoid doses higher than 120 MME/day.

Kaiser Permanente Southern California (KPSC) and Kaiser Permanente Northern California (KPNC) began to implement safer opioid prescribing practices in 2012. The model they created has spread across Kaiser Permanente’s entire national organization, with additional innovations and customized solutions in each region.

Interdisciplinary Planning and Design

KPSC created an interdisciplinary steering committee to focus on the opioid crisis. The team included representatives from pharmacy operations, primary care, pain management, addiction medicine, psychiatry, physical medicine, IT, legal, member services, clinical and pharmacy analytic services, health education and continuing medical education.4 The group developed a strategic plan and launched the Safe and Appropriate Opioid Prescribing Program (SAOPP).

KPNC leaders emphasized collaboration and coordination at the regional, service and individual physician level. Regional leaders convened a day-long summit that began the process of designing a safe opioid prescribing framework, bringing together chiefs of adult family medicine, chronic pain, behavioral health, chemical dependency recovery programs and pharmacy, along with professionals from quality improvement, patient education, physician education and IT. Together, they identified desired outcomes, performance gaps, barriers to change and ways to address those barriers, including workflows based on guidelines, electronic health record tools that support workflows and physician-level reports to measure success.

KPNC rolled out its opioid initiative in stages, beginning with Adult and Family Medicine — the highest prescribing group — and moving on to the Emergency Department, followed by Orthopedics and ultimately all surgical and hospital-based specialties. This methodical implementation gave leaders the chance to learn and apply lessons as the program expanded.

Customized, Localized Education for Prescribers

“The response from our doctors has been generally positive. 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.”

Michael Kanter, MD,
Medical Director, Quality and Clinical Analysis, Southern California Permanente Medical Group, and Executive Vice President and Chief Quality Officer, The Permanente Federation

To educate physicians about safe opioid prescribing, KPSC organized educational presentations for all clinicians at each of the 13 medical centers in the region, and subsequently deployed clinical pharmacists to meet directly with physicians. Today, all new KPSC physicians are required to complete a three-hour online pain education program. Pharmacists are also required to undergo opioid training and education programs.

KPNC’s opioid initiative includes an education program for physicians, clinicians and pharmacists, run at the local level and customized to local needs and preferences. Training on safe opioid prescribing is available in-person at live, six-hour didactic workshops led by experienced physician instructors, and by video, or online through self-guided modules. Special attention is paid to skills and techniques for communicating effectively with patients.

Policies and Tools to Support Best Practices
With the support of primary care and specialty physicians, KPSC established a policy that only pain specialists, oncologists and palliative care physicians may write a new prescription for OxyContin or Opana.5 Since 2014, KPSC emergency and urgent care departments have been following opioid prescribing guidelines from the American Academy of Emergency Medicine, which limit prescriptions to reduce the risk of opioid misuse and overdose.

Coordinating with the regional team, KPNC opioid leaders and their implementation teams at the service area level developed facility-specific workflows and service agreements, as well as protocols for using metrics to identify high-risk patients.

KP’s electronic health records incorporate decision support tools that both help and warn physicians regarding opioid prescribing. For example, the electronic health record alerts physicians prescribing a benzodiazepine if a patient is already receiving an opioid, because the combination can be dangerous. In addition, when a physician attempts to write a prescription for OxyContin or Opana, a pop-up “alternative medication” alert provides the risks and dangers of these medications, the preferred and maximum doses, and links to evidence-based guidelines on optimal usage.

The electronic health record includes access to a chronic opioid therapy management tool that provides drug information and guides physicians through the process of ordering pain medications in ways that comply with medical board and CDC guidelines. The electronic health record also includes a tool that translates opioid dosages into morphine equivalents, to help prescribers calculate the MME/day for commonly prescribed opioids.

Physicians without privileges to write a new prescription for specific opioids receive an electronic warning if they try to do so. The system prompts the physician to enter the name of an approved prescriber who supports the prescription, and denies the prescription if such approval is not given.

Regular Feedback Through Data Sharing

Both California Permanente Medical Groups send monthly reports to physician administrators with a list of patients on doses of 50 MME or higher, as well as patients taking a high-risk combination known by pharmacists as the “trinity” or “triad”: an opioid, a benzodiazepine and the muscle relaxant carisoprodol. The reports also provide recommendations on appropriate actions for many situations including how to taper a patient to a lower dose or to a safer medication. Physician leads and department chiefs also receive comparative data on physician prescribing patterns for regular review. These leaders can provide direction to outlying physicians.

Emergency and urgent care departments receive regular reports identifying frequent visitors to who are opioid users. Reports also document the use of injectable opioids in both settings, a practice discouraged by the American Academy of Emergency Medicine for chronic opioid patients.

Results

Kaiser Permanente Northern California:

The graph below shows a nearly 50 percent reduction in the average MME per member at KP Northern California between 2013 and 2018.

In addition, KPNC has documented the following results:

Northern California results, 2017:

  • >40% reduction in total opioid prescribing across all specialties (since 2013)
  • >80% high-dose opioid patients have medication agreement letters (up from 42% in 2014)
  • Over 75% of patients on high dose opioids have had a urine drug screen in the past 12 months (52% in 2014)
  • In the Emergency Department, >40% reduction in number of encounters resulting in an opioid prescription (since 2016)

Kaiser Permanente Southern California:

The number of opioid users in KP Southern California region decreased by 31 percent between May 2013 and December 2015, as shown in this graph published by the California Health Care Foundation:6

Number of Opioid Users on >120 MME Daily Dose (per 1,000 members per month), May 2013 to December 2015
In addition, since implementing its safe opioid program in 2010, KP Southern California has documented:7

  • 30% reduction in prescribing opioids in high doses
  • 98% reduction in number of prescriptions with greater than 200 pills
  • 90% decrease in opioid prescriptions with benzodiazepines and carisoprodol
  • 72% reduction in prescribing of long-acting/extended release opioids
  • 95% reduction in prescribing of brand name opioid-acetaminophen products

 


Sources

1. Centers for Disease Control and Prevention Provisional Drug Overdose Death Counts. Oct. 2018. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

2. Centers for Disease Control and Prevention. Opioid Overdose. Oct. 2017. https://www.cdc.gov/drugoverdose/index.html

3. Centers for Disease Control and Prevention. CDC Guidelines for Prescribing Opioids for Chronic Pain. 2016. https://www.cdc.gov/drugoverdose/prescribing/guideline.html

4. Ibid.

5. Ibid.

6. Ibid.

7. Kaiser Permanente, News & Views. Safer and More Appropriate Opioid Prescribing: Kaiser Permanente’s Comprehensive Approach. July 17, 2017. https://share.kaiserpermanente.org/article/safer-appropriate-opioid-prescribing-kaiser-permanentes-comprehensive-approach/

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CASE STUDY: Foster Safer Opioid Prescribing

Download a PDF of the "Foster Safer Opioid Prescribing" case study

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INFOGRAPHIC: Safer Opioid Prescribing

By closely collaborating with physicians, Kaiser Permanente is reducing opioid prescription rates and improving patient safety

Power in partnership – A conversation with ACHP’s Ceci Connolly