The Power of eConsults: comparing safe long-term opioid prescribing and pain management plan characteristics amongst patients who were mandated to receive chronic pain eConsult versus those who were requested by the treating prescriber at UConn Health

From the 2023 HVPA National Conference

Mallory Kane, Bachelor of Science (University of Connecticut), Rebecca Andrews, Medical Doctor, Kevin Chamberlin, Doctor of Pharmacy, Surita Rao, Medical Doctor, Jennifer Ozimek, Medical Doctor

Background:
In 2021, over 106,000 people died from illicit and prescription opioid overdose in the United States [1]. There have been national policy changes, novel state laws, and initiatives in effort to combat the rise seen in prescription opioid deaths from 3,442 in 1999 to 16,706 in 2021 [1], [2]. At UConn Health, pain management e-consults have been implemented by an interdisciplinary team consisting of an addiction psychiatrist, pharmacist, and two primary care physicians (PCP) to enhance quality of life, reduce pain, assure safe opioid prescribing, and optimize medication regimens to mitigate risk of overdose and adverse effects. These consults are provided at PCPs’ request (referred) as well as implemented for safety for patients on high-risk medication regimens (mandated).

Objectives:
The goal of this study was to evaluate if the origin of reason for eConsult affected the uptake of recommendations and improvement in safety metrics for high-risk patients on long term opioid therapy.

Methods:
Pain eConsults conducted at UConn Health between 2019 – 2022 (n=117) for patients followed by our PCPs were reviewed and categorized as mandated (consult prompted by morphine milliequivalents (MME) > 90 or lack of follow up in the previous 6 months, n=46) or referred (consult prompted by PCP referral, n=71). Outcomes in mandated and referred patients were compared at 3-, 6-, and 12-months after initial eConsult to determine if there was a difference in MME and percentage of recommendations followed regarding opioid, controlled non-opioid, and non-controlled medications, non-pharmaceutical (imaging, lab tests, referrals), medication use agreements, urine toxicology screening, and naloxone prescriptions.

Results:
The majority of recommended care increased, and average MME fell below the high-risk threshold of 90 in both groups at 12 months. Referred eConsults showed greater MME reduction as well as increased uptake of recommendations for opioid, controlled non-opioid, and non-opioid non-controlled therapy recommendations at the 12-month mark. Mandated eConsults had greater increase in use of medication agreements and urine toxicology screening at 12 months. Naloxone prescription recommendations decreased over time in both groups.

Conclusions:
Prescribers following opioid, controlled non-opioid, and non-controlled pharmacologic recommendations increased over time indicating that eConsults are effective to communicate comprehensive pain management treatment options. Use of eConsult recommendations increased gradually over 12 months mirroring literature on behavioral change occurring over years. Medication agreement use and MME reduction were most improved in both groups. However, adherence to urine toxicology screening was more difficult to improve possibly due to patient versus provider control. The requirement for a medical prescription for naloxone was removed during the study period which may have affected physician ordering. Both mandated and referred consults had a decline in MME over time and an MME < 90 at the 12-month follow up, which is an important safety metric related to overdose risk.

Implications:
Our study suggests three findings: 1) eConsults are effective in improving chronic pain regimens, lowering MME, and increasing medication agreement use even when initiated by institutional concern; 2) adjustment in approach may be needed to increase adherence to urine toxicology screening; and 3) prescription laws likely play a role in naloxone prescribing.

References:
Drug Overdose Death Rates. National Institute on Drug Abuse: Trends and Statistics. Feb 2023. Accessed at: https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
Dowell D, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1

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