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


During 7 years of developing an opioid management toolkit, we found that ambulatory clinics can be successful in adopting best practices in prescribing for patients with chronic pain, given an acceptable level of time and effort by the clinics. Lean is an approach for making changes that are feasible, efficient, and replicable. This toolkit assists clinics in improving opioid management.

Societal expectations include opioid management as part of primary care. An effective infrastructure, complete with workflows and support strategies to deliver high quality care, is key. Parchman et al.[22] recently described 6 building blocks to successfully manage long-term opioids in primary care. These include leadership, clinic policies, registries, previsit planning for patients with chronic pain, resources for complex patients, and measuring patient outcomes. We also found these elements helpful to primary care clinics. In particular, clinics found the use of rosters/registries to track and manage patients helpful, ensuring that patients received care consistently. In addition, it is clear from our results that a clinic champion is a critical component to redesigning opioid management.

As the primary care community moves toward managing chronic pain as they do other chronic health conditions, the methods of QI can assist clinics to support patients and reduce the chaos that may accompany complex and socially difficult care management. This will involve implementing best practice strategies in addition to clinic redesign. The toolkit represents a spectrum of best practices, allowing clinics to select those that best meet their local requirements, community needs, and providers' goals for providing high-quality care.

Toolkits to improve health care are ubiquitous but vary in development and content.[23] When Hsu et al.[24] reported on the development of a toolkit to spread Patient-Centered Medical Home redesign, they observed that the spread of innovation in health care is difficult, leading them to select a model of change that could be customized to the clinics while centered on patient-centered standardized work. They chose Lean as their method and formed their toolkit accordingly, which is also the method reported here. A review of 5 recently published toolkits on opioid use[25–29] exemplifies that toolkits often explain what a process should look like but do not necessarily explain how to re-engineer that process, especially with the patient as the central focus and the front-line team as the enabled change agents. This toolkit provides specific guidance and can be used in support of key outcomes described in other opioid management resources.

After studying the use of this toolkit over 7 years, we have seen a shift from strategies that maintain compliance with regulatory expectations to those that offer robust provider peer support. This may be because clinics in Vermont have had to conform rapidly to strict rules. Clinics in other settings, who may be developing clinical processes to support chronic pain management, may want to begin with strategies related to local requirements. As their workflow matures, they may find that reinforcing best practices moves them toward strategies related to peer consultation and support.

We think the strategies that these clinics implemented could be generalizable to other clinics. One strategy, an in-clinic chronic pain management council, provides prescriber peer support for complex patients, assists in the transition of "legacy" patients to new providers, and supports consistency by using a standardized treatment approach. A similar opioid use review panel was recently described as part of a QI project in Wisconsin.[30] These support mechanisms could include providers from a clinic or groups of clinics, pharmacists, behavioral health clinicians, chronic pain specialists, or others from the local community. In addition, in areas where clinics are more remote, using tele-health modalities such as Project ECHO may help establish peer-to-peer support.[31]

Previsit planning for patients on long-term opioids was another frequently chosen strategy. This strategy has been recommended in the literature[22] and is shown to decrease opioid morphine milligram-equivalents in a small study involving pharmacists.[32] In addition, a chronic pain management visit goes beyond previsit planning and was selected by clinics using the toolkit.[21] This approach offers a convenient way to focus on chronic pain and opioid-related management, including time for ongoing risk assessment for pain or function, PDMP checks, urine screens, set up and use of agreements, and coordinating engagement of other community resources, such as behavioral health.

There are several limitations to our toolkit. The toolkit has not been tested in a randomized trial. It is possible that the many opioid-related interventions implemented in our area were responsible for some of the improvements seen by clinics. However, given the supporting prepost data for strategies selected and implemented in trial 1, the results are unlikely to be due to chance or cointerventions. We did not collect systemic or patient-level outcome data in this report. Our focus was improving workflow and use of best practice prescribing strategies. Our toolkit has only been tested in clinics in Vermont, which may not reflect the patients or clinics in other regions. However, it is likely the toolkit could be generalized to other clinics with similar characteristics, including rural and suburban areas. Since the toolkit has undergone 3 revisions in 7 years, a relatively small number of clinics used any individual version. Barriers to implementing changes in workflow were unavoidable. Each clinic needed to implement its changes in a way that fit local systems, processes, and culture. Therefore, although the toolkit can guide implementation, clinic leadership must adapt the process to work within their communities.

The toolkit continues to support QI projects on opioid management after 7 years of field testing, modification, and additions of new practical resources. A Lean methodology for clinic redesign can standardize processes and ensure opioid best practices are provided to all patients with chronic pain.