SCIENTIFIC
Intentional Structured Opioid Monitoring Protocol : Responsible and Viable Opioid Deprescribing
AUTHORS : Adam M . Franks , MD 1 ORCID # 0000-0002-3710-6138
Kevin S . McCann , MD 1 Kimberly Velthouse , MD , MPH , MBA 2 Rich Sutphin , MPH 3 Todd Davies , PhD 1
Stephen M . Petrany , MD 1 ORCID # 0000-0001-5752-2238
1
Department of Family and Community Health , Marshall University Joan C . Edwards School of Medicine
2
Marshall University Joan C . Edwards School of Medicine
3
WV Rural Health Association
INTRODUCTION
Opioid pain medication as a treatment of non-malignant chronic pain ( NMCP ) has been increasing in this country . The prevalence of addiction in patients treated with opioids for chronic pain ranges from 14 % to 19 % of the population . 1 Opioids compared to other pain-relieving medications are associated with a hazard ratio of 1.64 at six months and 4.16 at 30 days . Deleterious effects include overdose , opioid abuse , fractures , and myocardial infarction . 2 In addition to the devastating effect to patients and their families for those that develop opioid use disorder ( OUD ), total societal cost related to non-medical use of prescription opioids has been estimated at $ 55.7 billion in 2007 , with losses in the workplace of $ 25.6 billion , healthcare related costs at approximately $ 25 billion , and criminal justice costs nearly $ 5.1 billion . 3 Healthcare-specific related cost for those who abuse prescription pain medications are approximately double that of a matched cohort . 4 Hospitalization costs related to opioids have increased to $ 700 million annually between 2001 and 2012 . These increased costs were driven by a $ 4.1 million increase in the cost related to
ABSTRACT
INTRODUCTION Primary care providers are increasingly called to address the problem of treatment of nonmalignant chronic pain with opioids , particularly in low resource areas . An Intentional Structured Opioid Management Protocol ( ISOMP ) is a primary care-based program shown to significantly decrease opioid burden . The development of sustainable programs that improve opioid-related outcomes is especially important in these low resource areas .
METHODS A retrospective electronic health record review was conducted for financial data and billing practices for a cohort engaged in the ISOMP between 2011 and 2014 . Data was analyzed for sustainability within macroscopic practice-wide and microscopic daily scopes . Further analysis was conducted on the implications of patients maintained on ( Group A ) and weaned from ( Group B ) opioids . Data was analyzed with STATA software .
heroin overdose and a $ 46 million increase in hospitalization related to prescription opioids . 5 These exponential healthcare costs for addiction are noteworthy as most people using heroin report beginning with opioid pain medications first , 6 emphasizing the need for a deliberate approach to managing opioid use and dependence to reduce transformations to OUD .
Between 2000 and 2010 the percentage of office visits requiring an opioid escalated from 11.3 % to 19.6 %. 7 A National Institute of Health workshop noted that in these visits , chronic pain was being increasingly managed by primary care providers , who often had limited resources to address a problem that requires a multidimensional approach for patients who frequently have significant medical comorbidities and polypharmacy . 1 In order to adhere to the standard guidelines for managing patients with NMCP , an Intentional Structured Opioid Monitoring Protocol ( ISOMP ) was developed within a busy rural family medicine
RESULTS ISOMP demonstrated decreased patient encounters numbers ( -7.38 %), increased total work relative value unit ( RVU ) (+ 7.73 %), reduced no-show visits ( -12.14 %), and increased total reimbursement (+ 13.06 %). Group A had fewer encounters ( -6.41 %) and increased work RVU (+ 42.95 %). Group B had fewer encounters ( -24.04 %) but decreased work RVU ( -17.56 %). Significant decreases in encounters ( -44.99 %) and work RVUs ( -47.39 %) were seen after discontinuation of opioids .
CONCLUSIONS Besides its previously documented opioid discontinuation rate , the ISOMP model was associated with fewer visits and better visit compliance . Sustainability was proven as neither global practice nor daily productivity was negatively impacted . Time-based coding for Group A offset losses seen in Group B productivity with savings directly related to speed of opioid wean .
practice at the Joan C . Edwards School of Medicine at Marshall University ( Table 1 ). 8 There is evidence that taking an intentional approach to the management of NMCP is associated with fewer opioid prescriptions , 8 lower morphine equivalent dosages , 8 and greater compliance with guidelines . 9 The translational merit of this approach is a reduction in the potential pool of people who can overdose or develop an OUD . However , the merits of this type of approach extend beyond these clinical benefits . States are increasingly enacting legislation requiring more extensive monitoring and documentation regarding the use of controlled substances . Using a structured approach to assist the clinician can improve their compliance with their state requirements , thereby mitigating their professional risk . Regardless of the ability of the ISOMP to lower patient and professional risk , to be a viable option , this approach must not have a deleterious effect on the provider ’ s efficiency and revenue . Therefore , a retrospective economic anal-
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