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ITHS › ITHS Impact › Translational Science Benefits Model Profiles › Six Building Blocks for Improving Opioid Medication Management in Primary Care

Six Building Blocks for Improving Opioid Medication Management in Primary Care

TRANSLATIONAL SCIENCE BENEFITS MODEL PROFILE

The Six Building Blocks team

Benefits

Summary

Fifty million Americans suffer from chronic pain, and 1 in 5 adults with chronic pain use prescription opioids.1,2 Most patients who take opioids for chronic pain are cared for by primary care providers. Long-term opioid therapy increases risk of opioid use disorder and higher dosages increase overdose risk.3 Primary care providers struggle with providing evidence-based care to their patients with chronic pain while reducing the potential for harm from long-term opioid therapy.

six cubes in different colors falling to the ground

Six Building Blocks logo

While studying effective team-based primary care for another project, a team of researchers from the University of Washington Department of Family Medicine and Kaiser Permanente Washington Health Research Institute realized that the successful clinics all had systems in place to manage opioid treatment for patients with chronic pain.4 The team identified six ‘Building Blocks’ to improve opioid prescribing that were common across the clinics: 1) leadership & consensus; 2) policies, agreements & workflows; 3) tracking and monitoring; 4) planned patient-centered visits; 5) resources for complex patients; and 6) measuring success.5

The team recruited six rural-serving organizations with 20 clinics throughout eastern Washington and central Idaho to implement the program supported by a practice facilitator, shared learning calls, and shared resources.6 Each clinic had an improvement team and a clinical champion. After 15 months, fewer patients in Six Building Blocks clinics were on long-term opioid therapy or using higher doses, compared to a control group of patients from the same areas.6 Doctors and staff were also less stressed and more confident in managing patients on long-term opioid therapy.7 Subsequently, the Six Building Blocks program has reached at least 94 clinics and clinical organizations through direct implementation in 50 primary care clinics, training of 40 practice facilitators across 16 organizations to implement the program, and development and testing of a self-service “How-To-Implement Toolkit” in 35 clinics.8

Significance

Caring for the sheer number of patients using opioids places a heavy burden on primary care providers, who already suffer from high rates of burnout.9 The Six Building Blocks program shows that educating individual providers about opioid prescribing is not enough; a team-based approach is important to successfully manage long-term opioid therapy for patients. The Six Building Blocks program offers a new model that can improve quality of care for patients on long-term opioid therapy, reduce provider stress, and result in better outcomes for these patients.6,7 By reducing the use of higher dose opioids and long-term opioid therapy, the Six Building Blocks could reduce the substantial economic cost of opioid use disorder on society (estimated at over $471 billion in 2017).10

The Six Building Blocks program is also promising for managing opioid use in rural areas, which have been among the hardest hit by opioid use. Opioids are prescribed more often in rural communities,11 and rural health care providers often lack the training and resources to adequately care for patients on long-term opioid therapy.12 The original Six Building Blocks study served a rural population, revealing both facilitators and challenges unique to rural settings. Many of the clinics reached through later efforts were either rural locations or safety net community health centers.

Benefits

  • Demonstrated benefits are those that have been observed and are verifiable.
  • Potential benefits are those logically expected with moderate to high confidence.

The Six Building Blocks program materials provide guidance on identification of opioid use disorder and co-occurring medical and mental health conditions that can impede management of chronic pain into standard care.
Demonstrated.

Clinical Benefits:
[ultimate_modal modal_title=”Diagnostic Procedures” modal_on=”text” modal_on_align=”left” read_text=”Diagnostic Procedures” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]CLINICAL & MEDICAL BENEFITS
Procedures & Guidelines

Diagnostic procedures

Definition: Methods and techniques performed to diagnose disease, disorders, or conditions. Biological samples such as blood, urine, or saliva are used to detect the presence of bacteria, fungi, or other markers to diagnose a disease, disorder, or condition.

Rationale: Diagnostic procedures that are accurate and reliable make for a more efficient health care system by streamlining treatment and recovery, enhancing the quality of patient care, and reducing health care costs.[/ultimate_modal]

The Six Building Blocks program has been included in guidance on managing patients with chronic pain using long-term opioid therapy from SAMHSA, CDC, the Providers Clinical Support System, and the Washington State Medical Association.13–16
Demonstrated.

Clinical Benefits:
[ultimate_modal modal_title=”Guidlines” modal_on=”text” modal_on_align=”left” read_text=”Guidelines” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]CLINICAL & MEDICAL BENEFITS
Procedures & Guidelines

Guidelines

Definition: Formal recommendations or principles to assist with patient care for specific clinical circumstances. Guidelines are issued by professional organizations, government agencies, and nonprofit organizations (e.g., American Academy of Pediatrics, American Medical Association, World Health Organization, U.S. Preventive Services Task Force).

Rationale: Guidelines promote quality and effectiveness of health care services and procedures. Development of guidelines is based on extensive and systematic review of the literature to provide the evidence to support recommendations. Guidelines can serve as helpful evidence of translational research efforts that translate into improved health care services and procedures.[/ultimate_modal]

The Six Building Blocks program provides guidance materials on clinical management of long-term opioid use, including patient-centered visits and patient monitoring to identify care gaps.
Demonstrated.

Clinical Benefits:
[ultimate_modal modal_title=”Therapeutic Procedures” modal_on=”text” modal_on_align=”left” read_text=”Therapeutic Procedures” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]CLINICAL & MEDICAL BENEFITS
Procedures & Guidelines

Therapeutic Procedures

Definition: Methods and techniques that pertain to interventions, treatment, or prevention of diseases, disorders, or conditions. Therapeutic procedures are performed to improve a diagnosed health concern. They encompass a variety of procedures, ranging from the administration of prescription drugs to surgical procedures to psychotherapy.

Rationale: Therapeutic procedures that improve efficiency and/or efficacy can improve the quality of health care, and reduce long-term costs.[/ultimate_modal]

The Six Building Blocks program reduced use of opioid medications by patients with chronic pain and reduced use of higher dose opioids by patients who remained on opioid therapy.6
Demonstrated.

Community Benefits:
[ultimate_modal modal_title=”Disease Prevention & Reduction” modal_on=”text” modal_on_align=”left” read_text=”Disease Prevention & Reduction” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]COMMUNITY & PUBLIC HEALTH BENEFITS
Health Promotion

Disease Prevention & Reduction

Definition: Resources that enhance health promotion and disease prevention in communities or populations. Disease prevention resources focus on reducing the development and severity of disease, such as vaccination and maternal and child health programs. Health promotion resources focus on empowering people to take control of their own health by increasing healthy behaviors, such as nutrition counseling services or support groups. Other indicators can have implications for disease prevention, including community health services, health education or policies.

Rationale: Disease prevention & reduction advances are created through clinical research, but the methods of that research are instructed by how it will be adapted into the population and practice-based evidence (translational research). Meaningful disease prevention & reduction research is informed by clinical and translational research. For example, a very expensive vaccine that has 100% efficacy rate will not translate into as effective disease prevention and reduction intervention as an inexpensive vaccine with 90% efficacy rate.[/ultimate_modal]

The Six Building Blocks program has reached at least 94 clinics and clinical organizations through direct implementation, training of practice facilitators, and testing a self-service “How-To-Implement Toolkit.”
Demonstrated.

Community Benefits:
[ultimate_modal modal_title=”Health Care Delivery” modal_on=”text” modal_on_align=”left” read_text=”Health Care Delivery” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]COMMUNITY & PUBLIC HEALTH BENEFITS
Health Care Characteristics

Health Care Delivery

Definition: Improved provision and distribution of health services to a patient population. Delivery systems typically include healthcare providers, insurers, and government regulators. Health care delivery is measured in terms of cost, method of payment, regulation, and quality of care.

Rationale: Effective and efficient mechanisms to deliver health services to a target population require transdisciplinary collaboration and widen the impact of evidence-based medicine and health practices.[/ultimate_modal]

The Six Building Blocks program increased use of evidence-based practices for managing patients with chronic pain using long-term opioid therapy, improved clinician and staff confidence, and reduced provider stress.6,7
Demonstrated.

Community Benefits:
[ultimate_modal modal_title=”Health Care Quality” modal_on=”text” modal_on_align=”left” read_text=”Health Care Quality” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]COMMUNITY & PUBLIC HEALTH BENEFITS
Health Care Characteristics

Health Care Quality

Definition: Improved general characteristics and quality of the health service or care provided based on accepted standards of quality. Health care quality is measured in terms of effectiveness of care, equity of care to patients with different characteristics, patient experience, complications, unplanned readmissions, and delays in receiving care. Data on these characteristics must be regularly collected to maintain and improve quality.

Rationale: Health care quality informs entire health care systems and is constantly being redefined based on new research and changing patient characteristics. Clinical science uses health care quality to identify strengths and weaknesses of interventions through both qualitative (patient satisfaction) and quantitative (patient remittance rates) measures. Translational science uses health care quality definitions to interpret interventions across different fields with similar health care quality standards.[/ultimate_modal]

The Six Building Blocks research team developed a How-To guide for implementation in primary care clinics.8
Demonstrated.

Community Benefits:
[ultimate_modal modal_title=”Health Education Resources” modal_on=”text” modal_on_align=”left” read_text=”Health Education Resources” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]COMMUNITY & PUBLIC HEALTH BENEFITS
Health Activities & Products

Health Education Resources

Definition: Educational resources that lead to the improvement of health of individuals, populations, or communities. These often take the form of websites, toolkits, and print materials promoting health programs and activities that individuals themselves can do to improve their health, including resources for healthy recipes & active living.

Rationale: Heath education resources serve as potential evidence of knowledge translation to patients and the community. They also serve as preventive strategies that go beyond scientific translation by informing patients and community members of health benefits and risks through audience-targeted delivery and execution.[/ultimate_modal]

The Six Building Blocks research team developed a website (www.improvingopioidcare.org) with health education resources to help providers care for patients with chronic pain, including a clinic self-assessment and patient education resources.17
Demonstrated.

Community Benefits:
[ultimate_modal modal_title=”Health Education Resources” modal_on=”text” modal_on_align=”left” read_text=”Health Education Resources” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]COMMUNITY & PUBLIC HEALTH BENEFITS
Health Activities & Products

Health Education Resources

Definition: Educational resources that lead to the improvement of health of individuals, populations, or communities. These often take the form of websites, toolkits, and print materials promoting health programs and activities that individuals themselves can do to improve their health, including resources for healthy recipes & active living.

Rationale: Heath education resources serve as potential evidence of knowledge translation to patients and the community. They also serve as preventive strategies that go beyond scientific translation by informing patients and community members of health benefits and risks through audience-targeted delivery and execution.[/ultimate_modal]

By reducing the use of higher dose opioids and long-term opioid therapy, the Six Building Blocks program could reduce the substantial economic cost of opioid use disorder on society.10
Potential.

Economic Benefits:
[ultimate_modal modal_title=”Societal & Financial Cost of Illness” modal_on=”text” modal_on_align=”left” read_text=”Societal & Financial Cost of Illness” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]ECONOMIC BENEFITS
Financial Savings & Benefits

Societal & Financial Cost of Illness

Definition: Reduced social and economic costs of acute or chronic disease or other health conditions. Examples include general productivity losses, reduced quality of life, and lowered resources.

Rationale: New procedures, interventions, policies, and other benefits from translational science hold the potential to alleviate undue societal and community burden, provide opportunities for reallocation of resources, and increase quality of life.[/ultimate_modal]

Members of the Six Building Blocks research team served as faculty on a national learning collaborative to implement the CDC Opioid Prescribing Guideline and advisory groups regarding opioid prescribing in Washington State.18,19
Demonstrated.

Policy Benefits:
[ultimate_modal modal_title=”Committee Participation” modal_on=”text” modal_on_align=”left” read_text=”Committee Participation” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]POLICAY & LEGISTLATIVE BENEFITS
Advisory Activities

Committee Participation

Definition: Participation in advisory, standards, or other governmental or nongovernmental committees. Researchers may contribute to a wide range of committees, such as advisory committees, ethics or oversight committees, or topic-specific subcommittees. Participation is often voluntary, but sometimes paid, and can be a significant time commitment in addition to regular scientific activities.

Rationale: Through participation in expert committees, researchers can contribute to recommendations for a range of levels, including operations of institutions, grant funding, device manufacture, and drug regulation.[/ultimate_modal]

The Six Building Blocks program was included in a report by the Dr. Robert Bree Collaborative, a group appointed by the Washington state Governor to provide evidence-based recommendations to improve patient care.19
Demonstrated.

Policy Benefits:
[ultimate_modal modal_title=”Scientific Research Reports” modal_on=”text” modal_on_align=”left” read_text=”Scientific Research Reports” modal_size=”medium” overlay_bg_opacity=”80″ img_size=”80″ txt_color=”#0ba7bf”]POLICAY & LEGISTLATIVE BENEFITS
Advisory Activities

Scientific Research Reports

Definition: Non-technical, evidence-based documents geared toward audiences who intend to use the information for policy/behavioral change. Target audiences include practitioners, policy makers, public health educators, and the general public. Examples include but are not limited to reports published by the National Institutes of Health, Institute of Medicine, or the Robert Wood Johnson Foundation.

Rationale: Ranging from identification of health problems to intervention evaluation summaries, these documents often provide actionable recommendations based on scientifically-derived findings.[/ultimate_modal]

This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.

Funding

The Six Building Blocks program was originally funded by a grant from the Agency for Healthcare Research & Quality (AHRQ, R18HS23750) and the National Center For Advancing Translational Sciences of the National Institutes of Health (UL1TR002319). AHRQ supported development of the 6BBs self-service toolkit through a contract with Abt & Associates (HHSP233201500013I). The National Institute on Drug Abuse funded development of the 6BBs practice facilitator training program (UG1DA013714). The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ or the National Institutes of Health.

References

  1. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. PAIN. Published online September 17, 2021. doi:10.1097/j.pain.0000000000002291
  2. National Center for Health Statistics (U.S.), Dahlhamer JM, Connor EM, Bose J, Lucas JW, Zelaya CE. Prescription Opioid Use among Adults with Chronic Pain: United States, 2019. National Center for Health Statistics; 2021. doi:10.15620/cdc:107641
  3. Von Korff M, Kolodny A, Deyo RA, Chou R. Long-Term Opioid Therapy Reconsidered. Ann Intern Med. 2011;155(5):325-328. doi:10.1059/0003-4819-155-5-201109060-00011
  4. Institute of Translational Health Sciences. Six Building Blocks for opioid management in chronic pain. University of Washington. Published October 4, 2018. Accessed September 23, 2021.
  5. Parchman ML, Von Korff M, Baldwin LM, et al. Primary Care Clinic Re-Design for Prescription Opioid Management. J Am Board Fam Med. 2017;30(1):44-51. doi:10.3122/jabfm.2017.01.160183
  6. Parchman ML, Penfold RB, Ike B, et al. Team-Based Clinic Redesign of Opioid Medication Management in Primary Care: Effect on Opioid Prescribing. Ann Fam Med. 2019;17(4):319-325. doi:10.1370/afm.2390
  7. Ike B, Baldwin LM, Sutton S, Van Borkulo N, Packer C, Parchman ML. Staff and Clinician Work Life Perceptions after Implementing System-Based Improvements to Opioid Management. J Am Board Fam Med JABFM. 2019;32(5):715-723. doi:10.3122/jabfm.2019.05.190027
  8. Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care Self-Service How-To Guide. Agency for Healthcare Research and Quality. Accessed September 14, 2021.
  9. Physician Burnout. Agency for Healthcare Research and Quality. Accessed September 23, 2021.
  10. Florence C, Luo F, Rice K. The economic burden of opioid use disorder and fatal opioid overdose in the United States, 2017. Drug Alcohol Depend. 2021;218:108350. doi:10.1016/j.drugalcdep.2020.108350
  11. García MC. Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary Care Providers Using an Electronic Health Record System — United States, 2014–2017. MMWR Morb Mortal Wkly Rep. 2019;68. doi:10.15585/mmwr.mm6802a1
  12. Opioid Use Disorder: Challenges and Opportunities in Rural Communities. Pew Charitable Trusts. Published February 7, 2019. Accessed September 23, 2021.
  13. Evidence-Based Practices Resource Center. Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care. Substance Abuse and Mental Health Services Administration. Accessed September 23, 2021.
  14. Centers for Disease Control and Prevention. Quality Improvement (QI) and Care Coordination | CDC’s Response to the Opioid Overdose Epidemic | CDC. Published August 20, 2021. Accessed September 14, 2021.
  15. Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care – PCSS. Providers Clinical Support System. Accessed September 14, 2021.
  16. Better Prescribing, Better Treatment. Washington State Medical Association. Accessed September 14, 2021.
  17. Six Building Blocks – A Team-Based Approach to Improving Opioid Management in Primary Care. Six Building Blocks. Accessed September 23, 2021.
  18. Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1er
  19. Dr. Robert Bree Collaborative. Opioid Prescribing: Long-Term Opioid Therapy Report and Recommendations. Dr. Robert Bree Collaborative; 2020. Accessed September 14, 2021.

Research Team

Michael L. Parchman, MD, MPH (primary contact), Senior Investigator
Kaiser Permanente Washington Health Research Institute

Laura-Mae Baldwin, MD, MPH; Brooke Ike, MPH; Katie Osterhage, MMS; Ashley Johnson, MPH; David Tauben, MD; Kari Stephens, PhD
Department of Family Medicine, University of Washington

Community Partners:
Washington, Wyoming, Alaska, Montana, & Idaho (WWAMI) region Practice Research Network; Washington State Department of Health; Olympic Community of Health

Learn More About the Project