Like many healthcare organizations faced with the country’s opioid epidemic, the Southern California Permanente Medical Group wanted to cut down on the opioid painkillers its doctors prescribed.
In 2010, it introduced a comprehensive initiative to reduce opioid prescribing and transform the way doctors view and treat chronic pain. The changes they made led to a 30% reduction in the prescribing of opioids in high doses.
(Southern California Permanente Medical Group)
It’s an initiative that Michel Kanter, M.D., medical director of quality and clinical analysis for the medical group, believes other physician practices can copy.
“It will look different but I think the principles are all the same,” Kanter said in an interview with FierceHealthcare. While every practice will handle various aspects differently, certain factors that made the Permanente initiative successful can work elsewhere, he says.
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Kanter led the development of the initiative and published the results in a study in the Journal of Evaluation in Clinical Practice. He also described the steps Permanente took to cut opioid prescribing during a daylong workshop on opioids presented last month by the Food and Drug Administration and Duke-Margolis Center for Health Policy.
The initiative led Permanente to reduce opioid prescribing in all the outcomes it tracked, including:
- A 98% reduction in the number of prescriptions with more than 200 pills
- A 90% decrease in the combination of opioid prescriptions with benzodiazepines and carisoprodol
- A 72% reduction in prescribing of long-acting/extended-release opioids
- A 95% reduction in prescribing of brand name opioid-acetaminophen products
Kaiser Permanente is seeing similar results in other states where it operates, beyond the effort in Southern California.
Kanter says that medical groups that want to cut opioid prescriptions can take the following approach:
1. Recognize the problem. When the medical group’s physicians looked at the most frequently prescribed drugs for Kaiser Permanente members in southern California in 2009, they were surprised to find that drugs for hypertension and diabetes were not at the top of the list, Kanter says. Opioid painkillers and highly addictive narcotics were prescribed more frequently and OxyContin was near the top, even though Kaiser Permanente didn’t subsidize it and patients had to pay out of pocket.
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Patients were getting more prescriptions at higher doses than the medical group had previously seen. Around the same time, new literature was published on the hazards and ineffectiveness of opioids for the management of chronic pain.
Its own internal data and outside evidence resulted in a change of thinking about opioid prescribing, he says. “We realized we needed a course correction.”
“I think on this one, we were ahead of the curve,” he says. “We jumped on board before it was a crisis.” To keep patients from becoming addicted and overdosing, the medical group wanted to change prescribing patterns and find alternatives to treat patients’ pain.
2. Educate yourself and your physicians. That education needs to focus on how to best treat pain and how to best use opioids, Kanter says. Permanente has taught clinicians about pain management and alternatives to opioids. Training was given to physicians, nurses, pharmacists and patients about the dangers and risks of opioids.
The medical group is able to offer patients other treatments that may include other non-opioid medications, physical therapy, acupuncture, exercise, injections, cognitive behavioral therapy and other methods, he says.
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Patient satisfaction was also a concern of doctors. Overall, the medical group has seen a minimum change in patient satisfaction scores. With primary care physicians, there has been no change in patient satisfaction levels, he says.
3. Make sure leaders set the tone and direction. “Leadership is really needed to shine a light on it,” Kanter says. When leaders buy into an initiative, they will allocate resources to it.
Leadership buy-in allowed Permanente to launched the Safe and Appropriate Opioid Prescribing (SAOP) program—a clinically driven initiative led by physicians from primary care, pain management, addiction medicine and the pharmacy department. The group was able to mobilize a large network of pharmacists and people who could offer alternative treatments of pain, such as physical therapists.
Smaller practices can virtually create a similar support system, bringing in the people they ordinarily work with, such as community pharmacists and physical therapists, he says. Permanente also offers addiction medicine services and counseling to help patients.
When it comes to actual prescribing, patients having routine surgery no longer receive a month’s worth of opioid medication but get a smaller supply of painkillers, usually just a few days, designed to match the expected duration of pain.
4. Give doctors feedback. You need to give physicians some measure of how they are doing, he says. Permanente used its own electronic medical record system to measure and monitor data to improve quality care. It allows doctors to see how they have done over time and to compare their own prescribing habits with peers. Leveraging the EHR can alert doctors on their computer screen if a patient is already receiving an opioid and allows them to see scientific articles describing hazards.
The medical record system also let leaders know if a doctor prescribed many more opioids than other physicians. In that case, pharmacists were able to meet with the doctor and talk about effective prescribing. Other practices might find other ways to track or compare prescribing. Pharmacies and insurance companies may have useful data, he says.
The National Committee for Quality Assurance has also come out with new measures to address opioid use, including one to track long-term, high-dose use, a risk factor for overdose and death, and another to track opioid prescriptions from multiple providers or pharmacies. Those can help practices benchmark or they can create their own measures, Kanter says.