Response to commentary on “A Randomized Matched-Pairs Study Of Feasibility, Acceptability, And Effectiveness Of Systems Consultation: A Novel Implementation Strategy For Adopting Clinical Guidelines For Opioid Prescribing In Primary Care” by Chris Akiba

In his commentary, Mr. Akiba raises pertinent questions related to the generalizability and scalability of the findings of Quanbeck et al.¹

To address some of Mr. Akiba’s comments about the generalizability, it can be useful to present our results in a broader context. Population-level statistics characterizing aspects of opioid prescribing patterns suggest that Dane County, WI, the geographic area of our study, is comparable to other Wisconsin counties and the nation. In the fourth quarter of 2017, 53 opioid prescriptions were dispensed per 100 Dane County residents, compared to the national rate of 66.5 opioid prescriptions per 100 residents.²  The morphine equivalent dose (MED) dispensed per capita in Dane County in 2015 was 611.9 mg; nationally, this figure was 642.1 mg. The number of a 30-day supply of opioids per Medicare Part D enrollee in Wisconsin was 2.1, mirroring the national rate.³ The state of Wisconsin overall showed a statistically significant increase in the rate of overdose death between 2015 and 2016,⁴ with Dane County ranking among the worst quintile of Wisconsin counties for drug overdose deaths involving prescription opioids.⁵

The extent to which some of the differences in prescribing patterns between Wisconsin, Dane County, and other US states and counties are meaningful and statistically significant is unclear. While Wisconsin has not been the hardest-hit state in the US, harm related to prescription opioids is certainly a significant and growing public health concern, representing a state-wide crisis.  Follow-up study broadening the sampling frame for systems consultation will be an important step in examining the strategy’s potential, and in determining what modifications might be needed in different primary care settings, health systems, and counties to maximize its impact. Future research plans will extend the approach to rural primary care clinics in Northeastern Wisconsin, a region of the state that has been particularly affected by the opioid crisis.

With respect to the applicability of systems consultation to prescribing practices in other settings beyond primary care: the nature of practice in different clinical milieus will likely require implementation strategies that are specifically tailored to each setting. Long-term opioid therapy for chronically painful conditions is more commonly undertaken in primary care settings, whereas the duration and scope of opioid prescribing by other specialties are typically more limited. We agree with Mr. Akiba that specific recommendations for practice with respect to monitoring and associated workflows will require a careful consideration and tailoring to each care setting.

¹Quanbeck, A. et al. A randomized matched-pairs study of feasibility, acceptability, and effectiveness of systems consultation: a novel implementation strategy for adopting clinical guidelines for Opioid prescribing in primary care. Sci. 13, 21 (2018).

²U.S. Prescribing Rate Maps. (Centers for Disease Control and Prevention, 2017). Available at https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Accessed 2/24/18.

³Opioid and Health Indicator Database. (The Foundation for AIDS Research). Available at http://opioid.amfar.org/WI/2. Accessed 2/24/18.

⁴Centers for Disease Control and Prevention. Opioid overdose: drug overdose death data. Atlanta, GA: U.S. Department of Health & Health Services. Dec 19, 2017. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html.30. Accessed on: Mar 4, 2018.

⁵Wisconsin Department of Health Services. Select opioid-related morbidity and mortality data for Wisconsin November 2016. Jan 2017. Available at: https://www.dhs.wisconsin.gov/publications/p01690.pdf. Accessed on: Mar 4, 2018.