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Improving Adherence to Long-Term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

This article discusses a cluster-randomized clinical trial that aims to determine if a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE), improves guideline adherence and reduces opioid misuse risk in primary care settings. The study found that the intervention increased guideline-concordant care, opioid discontinuation, and dose reduction in patients receiving long-term opioid therapy.

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Improving Adherence to Long-Term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

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  1. Journal Club Alcohol, Other Drugs, and Health: Current Evidence November-December, 2017

  2. Featured Article Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized clinical trial Liebschutz JM, et al. JAMA Intern Med. 2017;177(9):1265–1272.

  3. Study Objectives • “To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk.” www.aodhealth.org

  4. Study Design • Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients (across 4 safety-net primary care practices) receiving long-term opioid therapy for pain. • Intervention arm included for providers: electronic registry, academic detailing, nurse care management, electronic decision tools. • Control arm included electronic decision tools only. www.aodhealth.org

  5. Assessing Validity of an Article about Therapy • Are the results valid? • What are the results? • How can I apply the results to patient care? www.aodhealth.org

  6. Are the Results Valid? • Were participants randomized? • Was randomization concealed? • Were participants analyzed in the groups to which they were randomized? • Were participants in the intervention and control groups similar? www.aodhealth.org

  7. Are the Results Valid?(cont‘d) • Were participants aware of group allocation? • Were outcome assessors aware of group allocation? • Was follow-up complete? www.aodhealth.org

  8. Were participants randomized? • Yes. • Cluster randomization was performed at the provider level. www.aodhealth.org

  9. Was randomization concealed? • Yes. www.aodhealth.org

  10. Were participants analyzed in the groups to which they were randomized? • Yes. www.aodhealth.org

  11. Were the participants in the intervention and control groups similar? • Yes. • There were no differences between groups of providers in terms of demographics or practice characteristics. • Demographic characteristics of the intervention and control patients were similar at baseline. www.aodhealth.org

  12. Were participants aware of group allocation? • Yes, providers were aware of group assignment, but not the study hypothesis. • Patients in the intervention group only knew that there was a new nurse care manager or change in medication refill process. Patients in the control group were not aware of group allocation. www.aodhealth.org

  13. Were outcome assessors aware of group allocation? • No. www.aodhealth.org

  14. Was follow-up complete? • Yes. www.aodhealth.org

  15. What Are the Results? • How large was the treatment effect? • How precise was the estimate of the treatment effect? www.aodhealth.org

  16. How large and precise was the treatment effect? • Patients in the intervention group (n=586) were more likely than controls (n=399) to receive guideline-concordant care (adjusted odds ratio [aOR], 6.0), but no less likely than controls to have ≥2 early refills (aOR, 1.1). • Intervention group patients were more likely than controls to have opioid discontinuation (aOR, 1.5) or opioid dose reduction (aOR, 1.6). www.aodhealth.org 16

  17. How Can I Apply the Results to Patient Care? • Were all clinically important outcomes considered? • Are the likely treatment benefits worth the potential harm and costs? www.aodhealth.org

  18. Were all clinically important outcomes considered? • Mostly, although the authors comment that “fearful prescribing” may have contributed to the increase in opioid discontinuation among patients in the intervention group. www.aodhealth.org

  19. Are the likely treatment benefits worth the potential harm and costs? • Probably. This trial demonstrates that a primary care-based multicomponent intervention can increase guideline-concordant opioid therapy, opioid discontinuation, and dose reduction. • Further research will be required to determine whether similar interventions decrease opioid-related adverse outcomes while maintaining patient pain control and function. www.aodhealth.org

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