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Team Based Chronic Opioid Management

Keywords: Opioid, Chronic, Team


A program to improve opioid prescribing and management via practice guidelines, EMR modules, and a team-based management approach.


Julie Tishler MD

Kristin Huang MD



Selena Li


Tufts Medical Center Adult Primary Care, Boston, MA

Organizational Context

  • Tufts Medical Center Adult Primary Care Service consists of 40 Physicians (~28 FTE), 6 NPs (~4.5 clinical FTE), 2 PAs, 3 social workers, 72 residents, 8 FTE RNs, and 60 support staff
  • It sees 38,000 patients via 6,500 office visits a month. The practice gets 14,000 incoming phone calls a month
  • From 2008 to 2011, the number of Tufts primary care patients with opioids on their medication list grew from 1000 to almost 2000 patients. 
  • There was limited PCP training in pain management and poor communication with specialists about prescribing medications. Patients and providers were frustrated and documentation was unclear.  

Population Served

  • Tufts serves a diverse patient population, with ~10% of its population African American, 10% Asian, and 9% Hispanic. 25% of its patients are on Medicaid, and 32% are on Medicare

Project Leadership

  • Three MDs were central to setting up the program. 
  • Two physician assistants help to manage the program, and three social workers assist with behavioral health management. 
  • Tufts Primary Care’s IT specialist set up the EMR components supporting the program.

Project Tools and Components

The following components were developed for the intervention:

  • An electronic health record component was developed that:
    • Helps providers keep track of active medications and automatically calculates refill due dates.
    • Helps providers document monitoring activities and provides quick links to resources.
    • Prompts risk assessments, keeps a running record of prior red flags, and has a space for provider to provider comments to facilitate communication
  • Newly developed practice guidelines for initiating and managing chronic opioid prescribing, which stipulate that:
    • Minimum monitoring for all patients includes: 1) patients’ problem list including “chronic pain - opioid requiring,” 2) a controlled substances agreement signed and filled yearly, 3) quarterly office visits with a PCP, NP, or PA, 4) two urine tox screens per year, 5) a prescription monitoring program (PMP) checked at every refill, 6) a 28 day refill schedule.
    • Higher risk patients receive increased monitoring.
  • A team-based algorithm for caring for high-risk patients.
    •  Two PAs dedicated half their time to managing the chronic opioid program, including coordinating refills and managing gaps in monitoring
    • Three social workers assist with behavioral health management, including identifying community resources, contracting with detox centers, and emergency counseling. 
  • Standardized risk assessment tools were either developed (Opioid Risk Tool) or acquired (Current Opioid Misuse Measure).


  • EMR registry 

Team Members

  • Physician
  • SW
  • PA

Daily Workflow Steps

  • The program uses the Opioid Risk Tool (ORT) to assess all patients new to the practice or prior to starting chronic opiates. 
    •  A score of 0-7 is considered low to moderate risk. A score of 8 or higher is considered high risk. 
    • If patients received a score of 0 to 7 on the ORT, they received no additional intervention beyond standard care. 
    • Patients with a score of 8 or higher on the ORT or with a personal history of substance abuse or provider discretion are considered moderate to high risk. 
  • These patients are scheduled for a social work consult, at which time social workers will complete the Current Opioid Misuse Measure (COMM) and conduct a psychosocial assessment. 
    • If the patient has a COMM score less than 9, the COMM will be administered again in 6 months. 
    • If the patient has a score greater than or equal to 9, the patient will be recommended for further review and individualized planning, which can include pain management consultations, 3 months of alternative therapy, and increased monitoring in conjunction with opioid prescribing. 
  • PCPs receive monthly reports about all of their patients on chronic opioids, including who has overdue contracts, tox screens, PMPs, refills
  • PAs help PCPs coordinate refills and gaps in monitoring
  • Social workers address social needs arising from population health management or at visits
  • PCPs interact with the EMR-based opioid prescribing module for every relevant patient, facilitating medication refills, monitoring activities, and awareness of red flags.



  • The budget covers half the salaries of two PAs; notably PA revenues from the other half of their time paid for these salaries


  • The intervention is currently ongoing


  • The percentage of  patients with urine drug screening increased from 63% to 92%.
  • Patients checked using the MA Prescription Monitoring Program in the past year rose from 21% to 98%.
  • The percentage of patients on chronic opiates with a signed contract in the past year rose from 52% (n = 551) to 70% (n = 469).
  • IM residents felt more comfortable managing chronic opiates with the program in place, with average comfort increasing from 2.77 (n = 44) to 3.06 (n = 32) on a 5-point Likert scale


  • The program successfully increased provider comfort with managing chronic opioids and standardized processes.  
  • A comprehensive population health approach contributed to patient safety by more accurately assessing risk, increasing compliance with monitoring parameters, and improving counseling of patients.


  • Need for enhanced prescription of intranasal naloxone.
  • Need for increased social work capacity.
  • Need for more support for dual diagnosis patients with limited access to psychiatry/addiction services
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