How effective are opioid guidelines in the primary care setting?
Feb. 1, 2016
January's featured paper is "A Chronic Opioid Therapy Dose Reduction Policy in Primary Care," published in the journal Substance Abuse. The paper is published by a team led by Dr. Melissa Weimer.
People suffering from chronic pain typically experience pain that persists for months to years. Chronic pain may arise from an initial acute injury, be part of an ongoing illness, or have no clear cause. A wide array of additional health problems often accompanies chronic pain, including decreased sleep and mood changes. Chronic pain may also limit movement, which can make it difficult for sufferers to engage in everyday activities.
Treatment of chronic pain aims to reduce pain and improve function, and a variety of treatment options are currently used by the medical community.
One of those options is opioids, which are used extensively for the treatment of acute pain. Use of opioids for the management of chronic pain related to advanced medical illness such as cancer is a standard of care. However, the long-term administration of opioids for the treatment of chronic pain for non-cancer pain is a controversial subject. Questions about opioid effectiveness, safety and abuse have been raised, making opioid treatment a complex medical and social concern.
"The use of opioids to treat chronic pain is a prime example of the tension between treatment and harm," said Mary Heinricher, Ph.D., associate dean for basic research in the OHSU School of Medicine. "This tension has become a social and political issue as well as a medical issue. I chose this month's featured paper because it addresses guidelines for opioid dosing with interesting outcomes."
A look at tapering
This month's article, "A Chronic Opioid Therapy Dose Reduction Policy in Primary Care," was published recently in the journal Substance Abuse.
Lead author Melissa Weimer, D.O., M.C.R, assistant professor of medicine in the OHSU School of Medicine, focuses her clinical and research activities around the safe and effective treatment of chronic pain. "I'm interested in understanding how opioid-dosing policies in primary care affect prescribing practices. I would like to better understand the characteristics of patients who respond best to opioid tapers from high-dose opioids."
Despite significant attention on the topic, there is very little data about slowly decreasing opioid levels, a process called tapering, in a primary care setting.
"Based on data from Washington State's worker's compensation program, there appears to be a reduction in mortality for patients who are tapered off of high-dose opioids," said Dr. Weimer. "Other than those studies, however, there is actually very little known about the effectiveness of opioid guidelines in the primary care setting."
Analysis and findings
To investigate the guidelines in a primary care setting, Dr. Weimer and her team implemented a combined primary care physician-focused education and opioid dosing policy intervention which limited the dose of opioids per day.
"We compared opioid prescriptions one year before and one year after the intervention," said Dr. Weimer. "We used statistical analysis to assess which patient characteristics predicted opioid dose reduction from high opioid dose."
Dr. Weimer and colleagues found that almost 40 percent of patients prescribed high dose opioids were able to achieve a set opioid dose threshold by undergoing opioid tapers over a year-long period after policy implementation.
"Chart review of a random sample of patients who did not taper below the dosing threshold showed that a majority were continuing to taper doses toward that goal," said Dr. Weimer. Clinical outcomes of subjective pain scores and quality of life scores did not appear to be affected by the opioid dose limitation policy;however, this observation was based on a limited sample.
"Interestingly, female sex was the only significant predictor of a patient not tapering her high opioid dose in univariate and multivariate analysis," added Dr. Weimer.
"Rates of opioid misuse and overdose have reached epidemic proportions in our country, and health system responses are needed to respond to the epidemic," said Dr. Weimer. "Our work supports the utility of opioid dose reduction policies in primary care. The success of the policy intervention is important given the known association between high daily doses of opioids and opioid-related mortality, aberrant drug related behavior, emergency department visits, fracture risk and other potential harms."
"I was excited to see Dr. Weimer's article because it is addressing an important topic with a positive clinical and social effect," said Dr. Heinricher.
"Further research is needed to measure the success of similar interventions and to better fully characterize patients prescribed high dose opioids who are undergoing opioid tapers," added Dr. Weimer. "We will learn and describe how to best go about opioid tapers in an effective, humane and patient-centered manner."
A Chronic Opioid Therapy Dose Reduction Policy in Primary CareSubstance Abuse. 2015 Dec 18:0. [Epub ahead of print] Melissa B. Weimer DO, MCR*, Daniel M. Hartung PharmD, MPH, Sharia Ahmed MPH and Christina Nicolaidis MD, MPH
More Published Papers
Pictured above: (left to right) Dr. Melissa Weimer, Dr. Christina Nicolaidis, Daniel Hartung.
About the OHSU School of Medicine Paper of the Month
The OHSU School of Medicine spotlights a recently published faculty research paper each month. The goals are to describe to the public the exceptional research happening at OHSU as well as inform our faculty of the innovative work underway across the school’s departments, institutes and disciplines. The monthly paper is selected by Associate Dean for Basic Research Mary Heinricher, Ph.D.