A Systematic Approach to Opioid Prescribing

Kelly Bossenbroek Fedoriw, MD; Amy Prentice, MSW, LCSW; Sue Slatkoff, MD; Linda Myerholtz, PhD


J Am Board Fam Med. 2020;33(6):992-997. 

In This Article

Abstract and Introduction


Background and Objectives: Opioid misuse has become a national crisis. In response to the need for improved standards of opioid prescribing within medical practices, a university-based academic family medicine practice developed, implemented, and evaluated a series of initiatives to ensure appropriate opioid prescribing and support clinicians in the practice in providing optimal care.

Methods: In 2015–2018, the University of North Carolina Family Medicine Center developed and implemented a practice-wide opioid prescribing policy, created a controlled medication advisory board (CMAB), provided regular feedback to clinicians on opioid prescribing, and trained selected providers in management of opioid use disorder. The impact of these opioid stewardship initiatives on prescribing patterns, utilization of the CMAB, and provision of medications for opioid use disorder was evaluated using electronic health record data from 2015 to 2018 and chart audits.

Results: Between 2014 and 2018 the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of concomitant use of benzodiazepines and opioids decreased by 56%. The CMAB received 117 referrals between 2015 and 2018, 60% of which resulted in recommended revision in the treatment plan.

Conclusions: Safe opioid prescribing is essential to mitigate the opioid crisis. An evidence-based standardized protocol, coupled with support for providers and patients, can reduce prescribing and improve patient safety, thereby enhancing the comprehensiveness and quality of patient care.


In 2017, the opioid crisis in the United States was declared a national public health emergency as fatal drug overdoses reached 70,237—nearly double the rate for car crashes or gun violence.[1,2] Overdose deaths were 9.6% higher in 2017 than 2016,[3] and opioids continue to be the leading cause of death under the age of 50 years.[4] Despite acknowledgment of this crisis and overall decreased prescribing, opioid use has not abated.

While prescribing patterns are only 1 contributing factor, national organizations have urged providers to better regulate opioid prescribing.[5–7] Recent years have seen a decline in prescribing from 81.3 prescriptions in 2012 to 58.5 prescriptions per 100 persons in 2017.[6–10] However, decreasing prescriptions alone is not sufficient to combat the crisis. Closely monitored tapering of opioid dosing and risk mitigation strategies are essential for patient safety and compliance. This need is demonstrated by evidence that rapid discontinuation of opioids increases the risk of opioid-related emergency department visits and hospitalizations.[11,12]

With the goal of following best practices for opioid prescribing, an academic family medicine practice in North Carolina developed a comprehensive opioid stewardship initiative, including practice-wide policies, ongoing prescription monitoring, and a controlled medication advisory board (CMAB). This brief report describes that initiative, its impact on practice patterns, and resources that may assist other primary care practices in addressing the opioid epidemic.