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Team-Based Opioid Management
The Six Building Blocks
This document describes the basic “building blocks” used by primary care settings to implement teambased safe opioid prescribing for patients with chronic non-cancer pain. This document gives an
overview of each building block along with examples of ‘high impact changes’ used in other primary care
settings to support the building block goals. Resources to help make the high impact changes can be
found on the Team-Based Safe Opioid Prescribing website, organized by building block. Although not
strictly sequential, some building blocks are easier to implement if preceding building blocks have been
attended to.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
Building Block 1: Leadership and consensus
Build organization-wide consensus to prioritize safe, more selective, and more cautious opioid
prescribing.
High-impact changes
 Identify leadership to spearhead COT practice change initiatives.
 Build a working consensus: Leaders/clinical champions bring all providers and clinic staff together to
discuss and agree upon COT definitions and safety thresholds, the need for changing COT practices,
and overarching organization goals that could include:
•
support for new standards of care to reduce over-reliance on opioids for managing
chronic pain;
•
reduction in opioid doses to safer levels when indicated;
•
use of safer alternatives for pain management; and
•
connection to appropriate treatment of patients addicted to prescription opioids.
 Clinical teams determine how each team member can contribute to reducing inappropriate use of
opioids and encourage alternative approaches to chronic pain management.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
Building Block 2: Use a registry to proactively manage patients
Implement pro-active population management before, during, and between clinic visits of all COT
patients to ensure that care is safe and appropriate AND to measure results of COT improvement
activities.
High-impact changes
 Develop a registry system for monitoring COT patients, including deciding upon standard fields to
monitor (e.g., COT dose, function and pain scores, date of state prescription database checks). Enter
all existing COT patients and their relevant enrollment data into the registry.
 Assign each COT patient to a single provider responsible for managing their opioid use. Give each
provider/prescriber a list with their COT patients.
 Assign a team member in each clinic responsibility and protected time for managing and updating
the registry.
 Develop registry workflows that enable timely:
•
updates of registry data when COT patients have an opioid prescribing visit;
•
monitoring of registry data;
•
review of registry reports for COT patients on the daily schedule;
•
identification of patients transitioning from short-term to long-term opioid use
according to established organization definitions; and
•
entry of these newly identified COT patients into the registry.
 Monitor agreed upon COT patient care data, such as the percent of patients receiving COT, their
dosage levels, and whether PDMP data have been recently checked to:
•
measure trends toward more selective and cautious opioid prescribing and share
this data with practice groups and organization leaders;
•
highlight assessments and other COT patient care steps that are due, such as urine
drug screens or treatment agreements;
•
highlight patients on higher doses than clinic policy.
 On a monthly basis, the COT improvement team reviews the registry report to measure progress
toward overall opioid reduction.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
Building Block 3: Revise policies and standard work
Revise and implement clinic policies and define standard work for health care team members to achieve
safer opioid prescribing and COT management in each clinical contact with COT patients.
High-impact changes
 Convene a COT improvement team with representatives from each sector of the clinic (e.g., front
office, back office) to review current clinic policies and compare them to sample clinic policies from
other primary care settings and to define standard work for COT patient care.
 Write or revise policies and define standard work for health care team members on the following
COT patient care topics:
•
PDMP: For patients using opioids long-term, check the PDMP prior to monitoring
visits, or at least once every six months.
•
Prevent unplanned transitions to long-term opioid use: Prescribe opioids more
cautiously for acute pain, with clear expectations for short-term, time-limited use.
Identify patients transitioning to long-term opioid use (3rd fill or 60+ day supply) and
discourage long-term opioid use unless clinically indicated (not because all other
options have failed).
•
Prevent co-prescribing of opioids and sedatives: Prevent or discourage concurrent
prescribing of chronic opioid therapy and chronic sedative use.
•
Encourage opioid tapering consistently over time: Consistently encourage opioid
tapering to discontinue opioids or reduce dose when benefits are limited, or risks
exceed benefits.
•
Prevent inappropriate dose escalation: Discourage dose escalation from initial low
doses.
•
Patient education: Counsel and provide written or on-line patient education
materials to every patient on opioids about how opioids only partially control pain,
long-term effectiveness is unknown, and the risks of long-term opioid use. Explain
through the written patient education materials that the treatment goals are
increased engagement in life activities (work, family, leisure) and improved quality
of life, not elimination of pain.
•
Evaluation of benefits in terms of quality of life: Base clinical assessment of longterm opioid use on improvements (or lack thereof) in engagement in life activities
and quality of life.
•
Treatment Agreement: Develop a standard treatment agreement that is discussed
with every COT patient and placed in the medical record. Some clinics may elect to
have patients sign these agreements, others may not.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
•
Care Plan Template: Develop a standard template for documenting opioid regimen
in the medical record (e.g., responsible clinician, drug, dose, frequency of
monitoring visits, and UDS), alternative treatments used, and functional
improvement goals and progress. Document this care plan for all patients using
opioids long-term, and for all who continue to receive opioids after identification as
a potential long-term opioid user.
•
Prescription and refills: Establish a standard advance notification period (e.g., 4
days) prior to receiving an opioid refill, a standard refill duration of 28 days, a
maximum opioid prescription supply of no more than 7 (or 14) for short-term opioid
patients or those without a documented care plan, and policies regarding crosscoverage for refills.
•
Urine Drug Screening: It is recommended that all patients have screening at least
once a year, and more frequently for higher risk patients including those on doses
above clinic policy. Require follow up discussions with the patient for any
inconsistent urine drug screening results before continuing opioid treatment.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
Building Block 4: Prepared, patient-centered visits
Through prepared visits, conduct pro-active population management before, during, and between clinic
visits of all patients on COT to ensure that care is safe and appropriate. Support patient-centered,
empathic communication for COT patient care.
High-impact changes
 Develop policies and workflows that integrate prepared visits into COT patient care. Outline what is
included in prepared visits, such as:
•
implement universal COT management precautions, including checking PDMP data,
COT care plan documentation, COT monitoring, and urine drug screens;
•
anticipate and address issues pertaining to refill requests and cross-coverage issues
in accord with clinic policies.
 Designate that the registry owner conducts pre-visit planning in the week prior to a COT visit and
ensures regular COT visits per clinic policy as part of their standard work.
 Offer organizational support for clinic staff and providers to scrub charts and do team huddles prior
to each clinic session to identify and prepare for any COT patients on the schedule.
 Develop organizational supports, such as training, to encourage:
•
the use of empathic communication techniques, including emphasizing the shared
goal of ensuring patient safety and acknowledging the limitations of medicines for
controlling chronic pain;
•
involving COT patients in decision making, setting goals for improvement, and
providing support for self-management; and
•
collaborative care plan development that include self-management and clinical
goals.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
Building Block 5: Caring for complex patients
Develop policies and resources to ensure that patients who become addicted to opioids, or who develop
complex opioid dependence, are identified and provided with appropriate care, either in the care setting
or by outside referral.
High-impact changes
 Foster organization-wide recognition that opioid misuse, abuse, diversion, and addiction are
common problems that sometimes arise with trusted patients.
 Create organizational supports for integrating empathic and respectful techniques into care of
complex patients, such as using simple, open-ended interviewing techniques during clinical
encounters.
 Register all providers for online access to the Prescription Drug Monitoring Program (PDMP)
database, and delegate authority to an MA or nurse to do the PDMP monitoring work.
 Include in organizational policies that patients may never be discharged from care due to addiction
(although opioids may be discontinued).
 Identify addiction referral resources and ensure they are readily available, setting-up referral
protocols or agreements as necessary.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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The Six Building Blocks
Building Block 6: Measuring success
Continuously monitor progress and improve with experience.
High-impact changes
 Identify key process and outcome measures to monitor practice change implementation. Examples
include:
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the overall number of patients on opioids;
the number of patients on doses higher than recommended clinic policy;
the number of patients tapered off opioids;
functional improvement among patients using COT;
provider satisfaction; and
patient satisfaction.
 Develop and implement an organization-wide system for monitoring progress in COT management,
evaluating what is and what is not working.
 Provide protected time and space for a COT improvement team comprising clinicians and clinic staff
members to regularly meet, monitor progress, and conduct on-going PDSA cycles of improvement to
make opioid prescribing safer for patients.
 Make adjustments based on progress monitoring to achieve goals, continuously improve, and
overcome barriers and setbacks.
Team-Based Opioid Management ǀ http://www.improvingopioidcare.org
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