Implementation of an Opioid Review Board to Address High Risk Opioid Prescribing

Introduction: Opioid prescriptions for chronic pain increased in the 1990's despite limited data on safety. Increased prescribing contributed to increases in opioid use disorder and overdose deaths during this time period. In response, federal guidelines were released that emphasized a risk-benefit approach to opioid prescribing for chronic, non-cancer pain. However, healthcare systems and clinics had little guidance on how to enact these guidelines. We describe the creation of an opioid review board (ORB) within a primary care clinic aimed towards reducing high-risk opioid prescribing and increasing use of sublingual (SL) buprenorphine-naloxone for opioid dependence.

Methods: Conducted at OHSU General Internal Medicine Clinic, an urban academic primary care practice with over 14,000 patients. We implemented an inter-professional review board to set clinic policy on opioid prescribing and review patients on high-dose opioids or opioid and benzodiazepine co-prescription. The ORB included faculty providers, a clinical pharmacist, a patient access specialist, a medical assistant, a clinical social worker and a medical resident. The board met monthly to set policy for safe opioid prescribing, disseminate policy updates and best practices to the clinic and review patient cases. Cases were selected for review prior to each monthly meeting and included patients prescribed morphine equivalent daily dose (MEDD) > 90 or co-prescribed opioids and benzodiazepines. Two members reviewed the patient's chart in detail and presented the case at our monthly meeting with the patient's PCP. The primary outcome of the ORB process was approval or disapproval by majority vote for continued prescribing. ORB decisions and specific recommendations, such as guidance for opioid or benzodiazepine tapers, were conveyed directly to the patient's PCP and documented in the patient chart.

Program Evaluation: From February 2017 - July 2020, the ORB completed 46 patient reviews. During this time period, the number of patients on chronic opioids decreased from 664 to 458 (-31.0%); the total number of patients with MEDD > 90 declined from 128 to 41 (-68.0%); and the number of patients on SL buprenorphine-naloxone increased from 34 to 117 (+344%). Out of the 46 patients reviewed, 45.6% began a taper or switched to SL buprenorphine-naloxone within 3 months of review.

Discussion: Through implementation of clear policies on opioid prescribing and with oversight of an ORB, our clinic decreased high dose opioid prescribing, reduced opioid and benzodiazepine co-prescribing, and increased the number of patients on SL buprenorphine-naloxone. Documented ORB decisions facilitated provider-patient conversations and supported our providers in safe opioid prescribing.

References
1) Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559-574.
2) Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;2010(1):Cd006605.
3) Ciccarone D. The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019.
4) Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA. 2016;315(15):1624-1645.
5) Guy GP, Jr., Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704.