We base our work on input from partners from previous academic detailing interventions as well as ongoing research and evidence-based practices in the fields of clinical education and pain and addiction medicine. Below is some of the foundational literature that has shaped our response to the opioid epidemic and guided our curriculum development.
The Opioid Epidemic
The opioid epidemic has been one of the worst public health crises in the history of the United States. Between 1999 and 2016, opioid overdose deaths increased six-fold. In total, there have been over 450,000 opioid-related deaths (1). Approximately 2.1 million Americans continue to live with opioid use disorder today (2).
There have been many efforts to reduce opioid-related mortality. While some have been successful, there is still much to do to provide adequate support for clinicians and patients.
other drug-related deaths
In 2018, 70% of all drug-related deaths were related to opioids (3).
The risks associated with initiating and discontinuing opioid therapy have contributed to many of the overdoses related to both prescription and illicit opioids.
For nearly twenty years, opioids were recommended as a first-line therapy for chronic pain. However, opioid therapy can result in severe adverse events. A study of patients on long-term opioid therapy in San Francisco reported that 37% of patients experienced an opioid overdose event where they stopped breathing or required help to wake up (4). Additionally, once started on long-term opioid therapy, patients are significantly less likely to discontinue therapy. In a study of 23,419 participants, 67% of patients remained on opioid therapy two years after receiving an initial 90-day supply. Patients on average daily doses higher than 120 MME were 34% less likely to discontinue opioid therapy than patients taking lower doses (5).
Illicit opioid pain reliever use
Adjusted Odds Ratio of Increased Use After Stopping Opioids
Tapering and discontinuation:
To combat the rising death rate, many clinicians were pressured to reduce their number of patients on opioids. Between 2012 and 2017, opioid prescriptions decreased 35% per 100,000 population (6).
This resulted in many rapid tapers and often sudden cessation of opioid therapy – which have significant risks. A study for the Veterans Health Administration showed discontinuation of long-term opioid therapy significantly increased the risk of fatal overdose or suicide compared to patients who were not discontinued (6). In other studies, patients discontinued from prescription opioids were also more likely to increase use of street-purchased opioids, including heroin and illicit opioid pain relievers (7), and to have an opioid-related hospitalization (8).
Patients discontinued from prescribed opioids were over 50% more likely to use heroin and 75% more likely to use illicit opioid pain relievers more frequently compared to participants with unchanged prescriptions (7).
Safer Treatments and Practices
New scientific literature has revealed several safer methods for opioid management, including long-term treatment with medications such as buprenorphine, methadone, and extended-release naltrexone, as well as co-prescription of naloxone to reduce the risk of death from overdose.
Opioid agonist therapy:
The introduction of opioid agonist pharmacotherapy was associated with reductions in drug overdose during and after treatment for patients with OUD compared to those who only received psychological therapy (9). In addition to reducing opioid related overdoses, use of buprenorphine is associated with reduced pain and improved quality of life (10). Finally, buprenorphine alone is just as effective in reducing the number of days of illicit opioid use per week as combining buprenorphine with counseling (11).
In a study at the San Francisco Department of Public Health, patients who received a prescription for naloxone had 47% fewer opioid-related emergency department visits after receiving the prescription compared to patients who did not receive naloxone (12). Implementation of naloxone distribution and overdose education programs have been successful in reducing fatal opioid overdoses. In Massachusetts, communities where more than 100 bystanders received naloxone and overdose education had nearly half as many fatal overdoses compared to communities that did not implement the programs (13).
Chronic pain management:
There has also been an increase in evidence-based treatments for chronic pain with non-opioid therapies. Nonpharmacological treatments for chronic tension headache, chronic neck and lower back pain, fibromyalgia, and other chronic pain conditions led to significant improvements in function and pain outcomes after one month of treatment (14). In addition, patients randomized to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) had similar pain-related function and reduced pain intensity compared to those randomized to opioids (15). Critical to understanding the implications of this study, however, is that these patients all had no history of opioid use and no contraindications to treatment with acetaminophen or NSAIDs.
Informing Clinicians Through Academic Detailing
Research has improved our understanding of opioid and chronic pain management; however, these evidence-based practices must be implemented into clinical care. Despite the availability of effective treatments, less than 1% of 297 Medicaid beneficiaries in Vermont with a diagnosis of opioid use disorder were transitioned to an opioid use disorder medication after discontinuing long-term, high-dose prescription opioid pain relievers (8).
Academic detailing, an innovative form of educational outreach, has been effective in closing the gap between the latest scientific literature and clinical practice. The Veteran’s Health Administration found over a five-fold increase in naloxone prescribing rates in providers who received academic detailing compared to those who did not (16). In another study conducted by the San Francisco Department of Public Health, receiving academic detailing was associated with an eleven-fold increase in naloxone prescriptions (17). The success of academic detailing interventions on naloxone prescribing provides promising support for the impact of academic detailing in addressing opioid safety.
1. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. Available at http://wonder.cdc.gov.
2. Ahmad FB, Escobedo LA, Rossen LM, et al. Provisional drug overdose death counts. National Center for Health Statistics. 2019. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm?mod=article_inline.
3. Hedegaard H, Miniño AM, Warner M. Drug Overdose Deaths in the United States, 1999–2018.pdf icon NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.
4. Behar E, Rowe C, Santos GM, Murphy S, Coffin PO. Primary Care Patient Experience with Naloxone Prescription. Ann Fam Med. 2016;14(5):431‐436.
5. Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011;26(12):1450–1457.
6. Oliva EM, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020; 368:m283
7. Coffin PO, Rowe C, Oman N, Sinchek K, Santos GM, et al. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. 2020:15(5): e0232538.
8. Tami ML, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Sub Ab Treatment. 2019;103:58-63.
9. Pierce M, Bird SM, Hickman M, et al. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction. 2016;111(2):298–308.
10. Danielle Daitch, MD, Jonathan Daitch, MD, Daniel Novinson, MPH, Michael Frey, MD, Carol Mitnick, ARNP, Joseph Pergolizzi, Jr, MD, Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients. Pain Medicine. 2014;15(12):2087-2094.
11. Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013;126(1):74.e1174.e7.4E17.
12. Coffin PO, Behar E, Rowe C, et al. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016;165(4):245–252.
13. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346(jan30 5):f174-f174.
14. Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Winter C, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Comparative Effectiveness Review No. 209. AHRQ Publication No 18-EHC013-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
15. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872–882.
16. Bounthavong, M, Devine, EB, Christopher, MLD, Harvey, MA, Veenstra, DL, Basu, A. Implementation evaluation of academic detailing on naloxone prescribing trends at the United States Veterans Health Administration. Health Serv Res. 2019; 54: 1055– 1064.
17. Behar E, Rowe C, Santos G, Santos N, Coffin PO. Academic Detailing Pilot for Naloxone Prescribing Among Primary Care Providers in San Francisco. Fam Med 2017;49(2):122-126.