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Editor's Note
September 2017

Going Beyond Guideline-Concordant Opioid Therapy to Improve Patient Safety

Author Affiliations
  • 1Division of General Internal Medicine, University of California, San Francisco
  • 2Los Angeles County Department of Health Services, Los Angeles, California
  • 3Deputy Editor, JAMA Internal Medicine
JAMA Intern Med. 2017;177(9):1272. doi:10.1001/jamainternmed.2017.3030

More than 25 000 Americans died of a prescription opioid overdose in 2015.1 Over the prior decade, rates of opioid-related emergency department visits and hospitalizations nearly doubled.2 Interventions to decrease opioid use and its associated harms, while still providing pain relief to alleviate suffering, are desperately needed.

The editors were pleased to see this study by Liebschutz and colleagues3 because the investigators used a rigorous study design to assess the effectiveness of a multimodal intervention to decrease the harms of opioid therapy in patients treated at a safety-net hospital or community health center. The intervention successfully increased guideline-concordant care. Patients whose primary care physician was randomized to have nursing care management available in the office, an electronic chronic opioid registry, and individualized prescription feedback were approximately 3 times more likely to have a patient-clinician agreement and regular urine toxicology testing compared with patients whose physician received only electronic decision tools. Unfortunately, the intervention was less successful in improving “hard” outcomes, and no pain outcomes were collected. Patients of physicians in the intervention group were prescribed slightly lower opioid doses on average, but there was no change in the rates of opioid discontinuation during the 12-month follow-up period.

Reversing the growth in opioid use for chronic pain is difficult because of the paucity of effective alternative treatments. In the meantime, this study demonstrates that it is possible to increase safe prescribing habits among primary care physicians. We are encouraged by the increasing evidence of benefit of many nonnarcotic and nonpharmacologic approaches to chronic pain, such as mindfulness training4 or cognitive behavioral therapy,5 that appear as effective as opioids without the addiction and overdose risks. We hope to see more interventions focused on decreasing the use and harms of opioids among patients with chronic pain.

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Article Information

Corresponding Author: Scott R. Bauer, MD, Division of General Internal Medicine, University of California, San Francisco, 1545 Divisadero St, San Francisco, CA 94115 (Scott.Bauer@ucsf.edu).

Conflict of Interest Disclosures: None reported.

Rudd  RA, Seth  P, David  F, Scholl  L.  Increases in drug and opioid-involved overdose deaths—United States, 2010-2015.  MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445-1452.PubMedGoogle ScholarCrossref
Weiss  AJ, Elixhauser  A, Barrett  ML, Steiner  CA, Bailey  MK, O’Malley  L.  Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014: Statistical Brief #219. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality; 2017.
Liebschutz  JM, Xuan  Z, Shanahan  CW,  et al.  Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized clinical trial.  JAMA Intern Med. doi:10.1001/jamainternmed.2017.2468Google Scholar
Morone  NE, Greco  CM, Moore  CG,  et al.  A mind-body program for older adults with chronic low back pain: a randomized clinical trial.  JAMA Intern Med. 2016;176(3):329-337.PubMedGoogle ScholarCrossref
Cherkin  DC, Sherman  KJ, Balderson  BH,  et al.  Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial.  JAMA. 2016;315(12):1240-1249.PubMedGoogle ScholarCrossref