Changing the underlying structure and culture of a clinic to address opioid epidemic

For the 20 percent of Americans who suffer from chronic pain, prescription opioids may bring relief, but also risks. An estimated 21 to 29 percent of patients who receive chronic opioid treatment will misuse their medications, and 8 to 12 percent will develop an opioid use disorder.

Tufts researchers believe that changing the way clinics and their staff approach opioids--upending old attitudes and systems--could improve those statistics. At a family medicine clinic in the Boston area, a team led by faculty from Tufts University School of Medicine conducted a five-year case study where they found medical facilities can help physicians to treat chronic pain in a way that will deter opioid misuse, while creating better processes to identify and treat patients who develop an opioid use disorder (OUD).

The team explains their process in a new paper published this month in the Journal of the American Board of Family Medicine.

The study was led by family medicine faculty Randi Sokol, a pain and addiction physician and educator, and Allen Shaughnessy, a clinical pharmacist and educator who conducts research on evidence-based medicine and clinical decision-making. Both practice and teach family medicine at Cambridge Health Alliance, an affiliate of Tufts School of Medicine.

Oftentimes primary care teams want to make changes around pain and addiction management, particularly with respect to safe opioid prescribing and helping patients with OUD, but they need the work culture and infrastructure support to do so. A culture shift could have a big impact on how clinicians are able to care for their patients. For ourselves and for other clinicians, we designed a case study to see what support this might be and what it might look like."

Allen Shaughnessy, senior and corresponding author

Of the 249 million opioid prescriptions written in the United States in 2013, nearly half came from primary care clinicians. But often those clinicians run into barriers to care, from having trouble communicating with other prescribers to create a treatment plan to not having training in medications that treat opioid dependence, such as buprenorphine-naloxone.

The researchers started the project by making the medical facility and its clinicians aware of the need, developing broad institutional support to address the opioid epidemic. A resident made a presentation on the community's opioid epidemic and the value of OUD treatment. Sokol then sparked conversation about the scope of the epidemic by posting a map of local overdose rates.

Next, the researchers introduced new systems, structures, and staff support at the clinic, including:

• clinic-wide guidelines for managing chronic pain, based on evidence and best practices
• routine monitoring of patients on opioids through a prescription tracking program, questionnaires and toxicology tests
• using shared electronic health records to promote collaborative care around safe prescribing, monitoring, and responding to aberrant patient behaviors
• developing quality improvement metrics and tracking measures
• helping chronic pain patients through behavioral strategies, such as stress reduction, cognitive restructuring, and routines that promote good sleep
• developing a consultation service to support primary care providers with complex pain and addiction related cases
• using a team-based approach with group visits to treat patients with OUD
• providing all staff with education and training around pain and addiction
• sponsoring a clinic-wide training on opioid overdose reversal
• certifying all primary care providers to prescribe buprenorphine-naloxone
• using staff meetings to share patient stories and promote a culture that destigmatizes addiction, viewing it as a chronic disease rather than a moral failing

Recognizing the need, the clinic readily adopted all these changes over the course of the study time, essentially changing the clinic culture around managing chronic pain and addressing opioid use disorder.

Our case study highlights the importance of addressing aspects of clinical care that are not typically considered when addressing complex patient populations. We focused on changing the underlying structure and culture of a clinic to provide collaborative, interdisciplinary, team-based, and evidence-based care that will hopefully help our patients with chronic pain and addiction. We hope other clinics will use this case series as an example for how they can support safe prescribing practices and play a role in responding to the devastating opioid epidemic."

Randi Sokol, first author on the study