Understanding Institutional Physician Chronic Opioid Prescription Practices for the Improved Implementation of Newly Developed EMR Tools

BACKGROUND: Chronic non-cancer pain (CNCP) affects a significant portion of the United States population each year and is often treated with chronic opioids. There has been a rise in prescription opioids over the past 20 years, accompanied by a rise in overdose deaths as well. In order to improve patient safety related to opioid prescribing, several state and national policies including the 2016 "CDC Guidelines for Prescribing Opioids for Chronic Pain" have been developed recently to guide CNCP management. These recommendations include the use of pain management agreements, urine drug screening, prescription monitoring programs (PMP) and risk and pain assessments among others. LOCAL PROBLEM: In Texas, several recent policies have made CNCP practices mandatory, requiring support in order to enforce them. At the University of Texas Southwestern Medical Center (UTSW), there is no current reliable measure of CNCP policy adherence. Preliminary chart review by students at our institution showed low adherence overall, which may be secondary to poor documentation. METHODS: A set of surveys were developed to subjectively measure physician barriers to policy adherence, attitudes toward the policy components and current opioid prescribing practices. This survey was administered via electronic communication before and after the intervention to any physician at our academic medical center prescribing chronic opioids to at least one patient. Implementation science outcomes of appropriateness, adoption and acceptability were targeted by these surveys in order to inform implementation strategies for the intervention. INTERVENTIONS: A multi-faceted intervention including an electronic medical record (EMR) navigator tool, chronic opioids registry and physician education was developed by the institutional opioid task force to improve accessibility, documentation and understanding of opioid prescribing guideline recommendations. RESULTS: Physicians who had used the EMR navigator tool reported overall greater use of several guideline-concordant treatment components compared to those who had not used it (p < .05). Physicians who received opioid prescribing training were more aware and familiar with the policy (p < .0001). Those who were more familiar with the policy were more likely to use pain management agreements, urine drug screens and pain assessments. No specific barriers to policy adherence stood out as a remediable concern. Only a small percentage of respondents reported co-prescribing naloxone for high-risk CNCP individuals. CONCLUSION: An EMR navigator tool to improve accessibility of treatment components is effective in improving policy adherence at an academic medical center. Physician education is also effective in improving awareness and familiarity with the policy. Future steps include the study of patient-centered outcomes surrounding the intervention. There is also room for the support of other CNCP guidelines including co-prescription of naloxone for high-risk individuals and decreasing chronic opioid prescription strengths at our institution.