Understanding the current state of opioid use and prescribing behavior within Duke’s Health System is fundamental to designing appropriate interventions and targeting the right patients/providers. Duke's data warehouse, built on electronic health records, contains rich information about opioid prescriptions, opioid-related encounters and events, the context surrounding opioid use and patient outcomes. Through this project, clinical data will be curated and organized into meaningful and informative reports, models, and facts to construct a useful data model to answer questions regarding opioid management at Duke. These data will be used to support several projects within the Duke Endowment Opioid Harm Reduction Portfolio, including opioid-prescribing provider education, evaluation of Medication for Opioid Use Disorder (MOUD) programs and the effectiveness of alternative pain management therapies.
Previous research has highlighted the role dentists play in opioid prescribing, however little is known about how this impacts North Carolina Medicaid enrollees. Using information derived from prescription and dental claims data, we will describe the dispensing of opioids associated with dental procedures, statewide and by dentist.
Opioids are the mainstay of pain management during active cancer treatment. However, the extent to which cancer survivors continue to use opioids beyond active treatment is not well understood. Using unique data from the North Carolina Cancer Registry linked with Medicare, Medicaid, and private insurance claims, we will: 1) Quantify and identify predictors of long-term opioid use in the 5 years following diagnosis with stage I-III cancer and 2) Quantify and identify predictors of potentially high-risk co-prescribing of opioids with other drugs (e.g., benzodiazepines) after stage I-III cancer diagnosis. In addition, we will conduct interviews with cancer survivors and providers related to their experiences with and perspectives on long-term opioid therapy for chronic pain after cancer treatment. With the growing population of cancer survivors with chronic pain, efforts to improve the safety and effectiveness of pain management will become increasingly important
Health System Quality
The Safer Prescribing Nudge project uses behavioral economics to design informational and social incentives to reduce variation in opioid prescribing practices. A comparison report of peer physician’s prescribing behavior can provide a strong incentive to adhere to social norms. We are developing standardized reporting tools that provide social comparisons and feedback to physicians regarding their opioid prescribing practices at Duke Health clinics.
Drug diversion is the transfer of a legally prescribed controlled substance from the person it was intended for to another person for illicit use. To prevent drug diversion within the Duke University Health System, we are developing a surveillance system for inpatient services, establishing an effective model to identify cases of healthcare provider diversion, and in turn improving patient, provider, and community safety.
This project improves the quality of care for hospitalized patients with opioid use disorder by focusing on the initiation or continuation of medication for opioid use disorder (MOUD) and providing a safer and smoother transition to the community following discharge. They created a consult service line staffed by physicians and a social worker. The team sees inpatient consults for patients who may have opioid use disorder and the provider initiates MOUD (e.g. suboxone or methadone) when appropriate. A social worker helps transition patients to community organizations for continued treatment.
Durham Homeless Care Transitions (DHCT) is a transitional care program for homeless patients transitioning from Duke University Health System hospitals back to the community. DHCT provides case management and connections to housing for their clients. All DHCT referrals and enrollees are on the opioid use disorder spectrum. We will use program and medical record data to evaluate DHCT. We aim to characterize the patient population served and better understand how the program works and impacts health, health care utilization, and self-efficacy.
North Carolina has enacted The STOP Act, which addresses the opioid epidemic by enforcing safer opioid prescribing practices. Adhering to this new law requires rapid clinic transformation, system changes, as well as targeted education and local shifts in practice. Our team will assess, educate, and revamp the approach that providers and clinics take to become compliant. We will work with Duke-based clinics on quality improvement for patient safety and reduce harm by decreasing high-risk opioid prescriptions.
This project starts an acupuncture program in the Emergency Department (ED) as an alternative strategy for pain relief. Our goal is to mitigate opioid prescriptions for acute pain by expanding treatment options in the ED. We will conduct a pragmatic randomized controlled trial (RCT) that evaluates the feasibility and acceptability of two types of acupuncture for ED patients with acute musculoskeletal pain.
Lincoln Community Health Center (LCHC) is a Federally Qualified Health Center offering patient-centered, comprehensive and coordinated care primarily serving low-income and uninsured patients. To improve quality of care for patients with opioid use disorder, the clinic is implementing a low-barrier model of MAT aimed at increasing rates of treatment initiation and retention in care. This model establishes new pathways for expedited and same-day treatment initiation by increasing provider availability, and offering group treatment sessions and supportive services including:
- Counseling and case management
- Naloxone distribution
- Hepatitis C treatment
- Integrated behavioral health services
- Access to full spectrum primary care
We will evaluate this program to determine whether the low-barrier model expands access to buprenorphine treatment and improves patient outcomes. In addition, the pilot will serve as a model for other clinics to expand access to buprenorphine treatment through community health center and primary care settings.
To combat the opioid crisis, policymakers have employed prescription drug monitoring programs and prescribing guidelines. These efforts have resulted in lower prescription rates, but do not address the underlying problem of untreated pain. Integrated pain management models (incorporating pharmacologic, psychological/behavioral, physical, and occupational therapies) can effectively address this underlying burden of pain.
The goal of this project is to increase access to evidence-based integrated pain management that improves outcomes while reducing over-reliance on opioids. We will achieve this by better understanding the development and implementation of integrated pain management models and making recommendations for better deployment.
North Carolina law enforcement leaders, in partnership with the North Carolina Harm Reduction Coalition, have implemented Law Enforcement Assisted Diversion (LEAD) programs for individuals who are at high risk of overdose and high risk of cycling in and out of the criminal justice system. LEAD programs connect individuals with opioid and other substance use disorders to treatment and community services as an alternative to arrest. The evaluation of the LEAD programs in North Carolina will identify challenges and successes and assess effectiveness in:
- Reducing recidivism
- Improving health and quality of life for LEAD participants
- Reducing criminal justice and public health costs
In North Carolina, a recent study found that individuals recently released from incarceration are forty times more likely to die from an overdose than the general public. In response, four rural North Carolina counties are developing and implementing overdose prevention and naloxone education programs in county jails. This evaluation identifies best practices and evaluates preliminary results to optimize program implementation and reduce rates of overdose upon community re-entry.
The Durham County Detention Center is committed to implementing a medicated-assisted treatment (MAT) program that includes:
- Screening all individuals for opioid use disorder
- Continuing and initiating patients on MAT while incarcerated
- Offering Suboxone and naltrexone as MAT options (with plans to offer methadone at a later stage) as clinically appropriate
- Linking individuals to community MAT programs upon release
Evaluation of this program will identify barriers and facilitators to optimize expansion, and assess the preliminary program outcomes to determine whether the program will reduce rates of fatal opioid overdose and increase rates of MAT uptake in the community
In late 2018, the NC Division of Public Health’s Injury and Violence Prevention Branch funded 22 local health departments to develop programs that address the opioid crisis in North Carolina. Programs included:
- Developing or expanding syringe services programs
- Connecting justice-involved persons to harm reduction, treatment, and recovery services
- Establishing post-overdose response teams led by peers or emergency medical services
We will evaluate these programs at each local health department to provide evidence on barriers and facilitators and identify lessons learned. This evidence will be used to optimize programming and provide support to other counties interested in implementing similar initiatives.
Based in Durham, NC, TROSA is a multi-year residential program that provides recovery services for individuals with substance use disorders. As with many residential programs for substance use disorder, a large proportion of participants withdraw before completing the program, and while evidence exists on factors that influence withdrawal from shorter programs, the unique factors related to participants withdrawing within the first 6 months from TROSA’s 2 year program are unknown. This evaluation provides data on individual and program-level factors to effectively target supportive services for participants at risk for program withdrawal.
People who inject drugs (PWID) are at high risk for a range of adverse health outcomes including opioid use disorder and HIV infection. Although medication-assisted treatment (MAT) is immensely helpful for addressing issues related to opioid dependence, and HIV pre-exposure prophylaxis (PrEP) has been found to successfully reduce HIV infection risk, one of the biggest challenges to disseminating these life-saving treatments is accessing PWID. This program addresses this challenge by recruiting PWID who are interested in initiating paired MAT and PrEP from syringe access programs in two North Carolina cities, and using telemedicine for follow up visits. We will conduct in-depth interviews with participants to evaluate the program and determine whether combined treatment with MAT and PrEP through syringe access programs is acceptable and feasible when conducted remotely via telemedicine.