A New Quality Improvement Toolkit to Improve Opioid Prescribing in Primary Care

Constance van Eeghen, DrPH, MHSA, MBA; Amanda G. Kennedy, PharmD, BCPS; Mark E. Pasanen, MD; Charles D. MacLean, MD


J Am Board Fam Med. 2020;33(1):17-26. 

In This Article

Abstract and Introduction


Introduction: The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing. This article summarizes the evolution of an opioid management toolkit using a quality improvement (QI) approach to improve prescribing.

Methods: The authors developed a list of opioid-prescribing best practices and offered in-office, team-based QI projects to ambulatory clinics, updated and tested over 3 trials in the form of a toolkit. Outcome measures included pre- and postproject surveys on provider and staff satisfaction, toolkit completion, and process measures. The toolkit supports workflow planning, redesign, and implementation.

Results: Ten clinics participated in trial 1, completing the QI project on average in 3 months, with a mean of 9.1 hours of team time. Provider satisfaction with prescribing increased from 42% to 96% and staff satisfaction from 54% to 81%. The most common strategies in trials 1 and 2 focused on regulatory compliance (35% to 36%), whereas in Trial 3 there was a strong move toward peer support (81%).

Discussion: Clinics responded to implementation of opioid-related best practices using QI with improved provider and staff satisfaction. Once the goals of regulatory compliance and workflow improvements were met, clinics focused on strategies supporting providers in the lead role of managing chronic pain, building on strategies that provide peer support. Using QI methods, primary care clinics can improve opioid-prescribing best practices for patients.


Opioid misuse is an important public health challenge in the United States. Despite a decrease in opioid prescribing from its peak in 2010, per capita opioid use remains high and varies by location and region without a clinical basis.[1] Drug overdose deaths increased 200% between 2000 to 2014, and opioids contributed to 33,091 deaths in 2015.[2,3] Although a higher proportion of deaths in recent years is attributable to fentanyl mixed with heroin, diverted prescription opioids remain an important contributor to the opioid epidemic.[2,4]

Although there has been considerable attention paid to opioid prescribing in acute settings, such as the emergency department,[5] dental offices,[6] and in postoperative settings,[7,8] opioids prescribed in primary care are less frequently reported and yet generate the majority of prescribing volume, usually for chronic conditions.[9] In 2016, the Centers for Disease Control and Prevention (CDC) published guidelines for the prescription of opioids for chronic pain, which emphasized the principles of avoiding opioids where possible, minimizing the dose, carefully balancing risks and benefits, and monitoring closely for potential side effects or misuse.[10]

Increasingly, states are establishing regulations that mandate the use of state-level prescription drug monitoring programs (PDMPs), specify quantity and duration limits of opioid prescriptions, or improve access to naloxone.[11] The effects of these interventions on outcomes are not yet clear,[12] although Washington state, which has implemented a wide range of policies and programs over the last decade, has demonstrated an important decrease in opioid-related deaths and hospitalizations.[13]

For busy primary care clinics, navigating the complexities of the CDC guidelines, state and local regulations, insurer requirements, and other specific policies enacted at the health care organizational level can be daunting. Beginning in 2012, our research team has been collaborating with the Vermont Department of Health to develop a pragmatic approach to opioid prescribing in ambulatory care clinics. Our initial goal was to apply a process improvement approach to improving opioid prescribing in ambulatory care clinics. The success of our first trial led to a new goal of standardizing our process improvement approach such that a trained quality improvement (QI) facilitator, sometimes available to clinics, could assist providers to improve prescribing. This second trial developed and tested the use of the Opioid Prescription Management Toolkit for Chronic Pain (first and second eds). The success of the toolkit led to a third trial: coaching clinic members not trained in QI to facilitate prescribing improvement with a clinic workbook for changing practice.

The purpose of this report is to share our experience with the evolution of improving opioid-prescribing practices in a wide variety of rural and small urban ambulatory care clinics.