Comparison of Opioid Prescribing Guidelines Violations by Clinical Speciality Chia-Chen Teng1,2, Christy Porusnik3, Erin Johnson4, Robert Rolfs3, Jonathan Nebeker1, Brian C. Sauer1,2 1VA SLC IDEAS Center, Salt Lake City UT, 2University of Utah Division of Epidemiology, 3University of Utah DFPM, 4Utah Department of Health Objectives Describe unsafe prescribing according to the Utah Opioid Prescribing Guidelines by specialty for their patients classified as chronic opioid users. Determine if provider participation in the intensive educational intervention changed prescribing. Results for Specialty Interpretation Pain Medicine, nurses and anesthesiologists had a higher proportion of patients involved in a dual use of benzodiazepine and long-acting opioid, and dual use of long-acting opioids flag. No clear differences in dual use of short-acting opioids were observed by specialty. 28% of chronic pain patients treated by pain medicine physicians experienced at least one flag. 24% of chronic pain patients treated by nurses and anesthesiologists experienced at least one flag. About 25% of providers completed all three stages of the intensive educational intervention. Providers that received any level of intensive educational intervention showed improvements in the dual long and short acting flags. They also had a significant reduction of patients that experienced any flag. Due to the low number of providers who completed Stage B, we did not observe any statistical differences in provider measures. We did not compare measures for providers who completed Stage C due to the small number completing this level. Provider Count and Chronic Opioid Patients by Provider Specialty Proportion of Flags and Outcome by Provider Specialty Any Methadone Dual Use of Long-acting Opioids Specialty Providers Patients Count Pct (%) Anesthesiology  77 0.92 3,070 2.74 Dentist  1,189 14.2 6,243 5.57 Dermatology  39 0.47 96 0.09 Emergency Medicine  371 4.43 7,939 7.09 Family Medicine  1,008 12.04 25,152 22.45 Hospitalist  40 0.48 578 0.52 Internal Medicine  854 10.2 12,427 11.09 Nurse 507 6.06 11,139 9.94 Obstetrics & Gynecology  253 3.02 1,177 1.05 Ophthalmology  63 0.75 127 0.11 Other 87 1.04 710 0.63 Pain Medicine 28 0.33 2,601 2.32 Pediatrics  116 1.39 313 0.28 Physical Medicine & Rehabilitation  98 1.17 3,546 3.16 Physician Assistant  11,346 10.13 Podiatrist  112 1.34 943 0.84 Preventive Medicine  118 1.41 61 0.05 Psychiatry & Neurology  289 3.45 3,661 3.27 Radiology  67 0.8 161 0.14 Surgery 629 7.51 7,461 6.66 Unknown 1,868 22.32 12,869 11.49 Urology 51 0.61 424 0.38 Methods This study was IRB approved by the University of Utah. Multiple data sources were used for this analysis including the Utah Controlled Substances Database (CSD), Utah ED encounter database, and the state medical examiner and death certificate databases. This study was limited to evaluation of prescribing in chronic opioid users during the period of 04/2009 to 03/2010. Chronic: >180 days of any opioid filled with no gaps >7 days within study period. Process flags included the dual use of long-acting opioids, dual use of short-acting opioids, combined use of benzodiazepines and long-acting opioids, methadone titration. Methadone titration rule: Index methadone fill with ≤ 6m no methadone. Rule based on daily Morphine EQ (ME) prior to index fill If < 30mg ME/day then any methadone use is inappropriate If < 60mg ME/day then > 15 mg/day methadone is inappropriate If < 105 ME/day then > 23mg/day methadone is inappropriate If > 30mg/day then methadone dose is inappropriate Outcome flags included: Opioid related ED visits Opioid related deaths The intensive educational intervention was based on a Performance Improvement Continuing Medical Education (PI-CME) and had 3 stages: Stage A – participants access and use the DOPL CSD to produce a controlled substance report for all patients prescribed an opioid during the previous six months. (5 PRA credits) Stage B – participants attend a presentation describing the problem of opioid related deaths in Utah, taught to implement 6-practices to prevent opioid deaths while still treating chronic pain, learn use Guidelines and tools. (5 PRA credits) Stage C – participants assessed changes in their prescribing practices and in their office systems to support pain management and guideline recommendations. (5 PRA credits) Specialties with <1000 patients receiving at least 1 opioid during the study period were classified as “other”. Dual use of Benzo & Long-acting Opioid Dual Use of Short-acting Opioids Opioid Related ED Visit Opioid Related Death Impact Participating in the educational intervention appears to have decreased the dual use of long-acting opioids, dual use of short-acting opioids. Improvement may have occurred through better use of the DOPL controlled substance database to check patients opioid history when prescribing, and the use of tools supported by the guidelines. Results for Educational Intervention Count for Providers and Chronic Opioid Patients by Educational Intervention   No Educational Intervention Stage A or Higher Intervention Stage B or Higher Intervention Provider Level Information All Providers 7983 288 95 Pain Provider 78 (0.98%) 3 (1.04%) 0 (0.00%) Nurse Provider 487 (6.10%) 20 (6.94%) 8 (8.42%) Patient Level Information All Patients 102,352 9,692 3,367 Any Methadone 586 (0.57%) 60 (0.62%) 25 (0.74%) Dual Use of Long-acting Opioids 770 (0.75%) 46 (0.47%) 13 (0.39%) Dual Use of Benzo and Long-acting Opioids 6,623 (6.47%) 591 (6.10%) 180 (5.35%) Dual Use of Short-acting Opioids 12,168 (11.89%) 992 (10.24%) 371 (11.02%) Any Process 18,996 (18.56%) 1,608 (16.59%) 565 (16.78%) Opioid Related ED Visits 1,050 (1.03%) 95 (0.98%) 42 (1.25%) Opioid Related Death 320 (0.31%) 22 (0.23%) 16 (0.48%) Acknowledgements CDC: 5 R21 CE001612-02 Utah Health Bill 137 VA HSR&D Career Development Award # RCD063002 Contact Information Jenny.Teng@hsc.utah.edu; Brian.Sauer@utah.edu Risk Ratio No educational intervention vs. Stage A or higher No educational intervention vs. Stage B or higher Note: Specialty adjustment only adjusts for pain medicine and nurse. Baseline adjustment includes total chronic users in previous year and the total flags for the measure in the previous year. CCOE