Strategies to Deimplement Opioid Prescribing in Primary Care: A Cluster Randomized Clinical Trial

Area of Science:

• Health Services Research
• Clinical Interventions
• Pain Management

Background:

• Centers for Disease Control and Prevention guidelines recommend reducing opioid prescribing for chronic pain.
• Implementation research on these guidelines is limited, necessitating studies on effective deimplementation strategies.

Purpose of the Study:

• To compare the effectiveness of four deimplementation strategies in promoting guideline-concordant opioid prescribing.
• To evaluate system-, clinic-, and prescriber-level interventions for reducing opioid reliance.

Main Methods:

• A cluster randomized clinical trial involving 32 primary care clinics and 8978 patients.
• Implementation of deimplementation strategies including educational meetings, audit and feedback (EMAF), practice facilitation (PF), and prescriber peer consulting (PPC).
• Comparison of a least intensive strategy (EMAF) versus a most intensive strategy (EMAF + PF + PPC) on primary and secondary outcomes.

Main Results:

• The most intensive strategy (EMAF + PF + PPC) significantly decreased mean morphine milligram equivalent (MME) dose by 2.4 mg/d (6% reduction) compared to EMAF alone (P=.02).
• This intensive strategy increased screening for pain severity and interference by 5.4% (P=.04).
• However, it also led to significant decreases in urine drug screening (-7.3%, P<.001) and use of treatment agreements (-6.7%, P=.003).

Conclusions:

• A high-intensity deimplementation strategy, incorporating clinic- and prescriber-level interventions, effectively reduced opioid MME doses and improved pain-related screening.
• The findings suggest that multi-level deimplementation strategies can support health systems in reducing opioid dependence for chronic pain.
• Further research is needed to understand the impact on other guideline metrics and patient outcomes.