This article provides the case study of the decision to integrate an opioid risk assessment tool into a large health care system, the careful planning prior to implementation, and how practice was monitored to assure seamless integration and continued adoption by practitioners.

The Screener and Opioid Assessment for Patients with Pain (SOAPP®) has been scientifically validated for use in screening chronic pain patients who are receiving or under consideration for long-term opioid therapy.³ This self-administered questionnaire is convenient for patients to complete and easy for clinicians to score. Along with other components of the comprehensive pain assessment, clinicians can use the information provided by the SOAPP to:

1. Better predict a patient's likelihood of misusing or abusing opioids
2. Document the assessment and clinical decision-making process for use of opioids
3. Help identify the appropriate level of monitoring necessary during the course of opioid therapy

There are several different versions of the SOAPP. The 5-item Screener and Opioid Assessment for Patients with Pain-Short Form (SOAPP®- V1 SF), (Butler, Budman, Jamison, et al., 2004) was chosen to help assure the safe and appropriate use of opioids in the Kaiser Permanente Medical Care Program.

Implementation

Successful use of an opioid risk assessment tool required careful planning before, during, and after implementation.

Planning the implementation included a number of important steps:
• Reiteration of the desire to improve opioid risk management
• Due diligence in selecting the appropriate tool
• Identifying primary care providers’ special considerations
• Evidence review
• Review of evidence-based opioid guidelines
  • For patients with chronic noncancer pain
  • For the long-term opioid use for the treatment of chronic pain
• Consideration of legal issues
  • Informed consent
  • Development of medication agreements
• Agreement among key stakeholders
  • Identification of department heads as key stakeholders:
    • Internal Medicine
    • Pain Management
    • Physical Medicine and Rehabilitation
    • Behavioral Medicine and Chemical Dependency

Education was a very important step in the implementation process and included a number of initiatives to disseminate information, not only about the implementation, but about the issue of opioid risk. These included:
• Pain Management Symposia
• Primary Care Conferences
• “Brown Bag” Luncheons
• Grand Rounds
• Webinars

Logistics of integration into clinical workflow were critical to the successful implementation of the tool and included:
• Identification of the appropriate tool for the clinical setting (in this case it was the SOAPP-V1 SF )
• Development of a way to consistently document the results of the opioid assessment, using existing documentation
• Assurance that the tool was able to mimic the existing processes within the electronic medical record (EMR) that was in place
• A way to monitor the use of the tool via routine reporting

In the case of the Kaiser Permanente Health System, the most important documentation challenge was how to incorporate a pencil and paper self-report tool into an electronic medical record. The goal was to mimic the workflow for a primary care provider. There were many tools in their EMR existing as an ‘order’, so the SOAPP-V1 SF needed to fall into that work flow without the need to further educate providers about how to find this tool. The more the process could be similar to other workflow process, the easier it was to incorporate. This benefits patients in pain who might be perceived by the clinician as a special challenge.


This was the algorithm developed to score SOAPP- V1 SF and translate the score into specific action steps.


If the sum of SOAPP- V1 SF score is:

1. ≥ 4 = High Risk
2. < 4 = Low Risk
Recommendations for structuring the treatment plan to the level of risk were:
1. High Risk
   1. Recommend careful and thoughtful planning
   2. Recommend consideration of other therapies or interventions prior to starting long-term opioids (e.g.: psychological treatment, consultation with pain management specialists)
   3. Recommend a strict follow-up procedure if opioids are prescribed, including:
      1. The use of a medication agreement/opioid therapy plan
      2. The regular use of urine toxicology screening at each follow-up visit
      3. Short refill intervals early in treatment (e.g.; every two weeks)
      4. Early signs of aberrant behaviors and violations of the medication agreement/opioid therapy plan should result in a re-evaluation of the treatment plan
2. Low Risk
   1. Recommend careful and thoughtful planning
   2. Recommend advising patients to use self-management strategies in conjunction with opioids, if they are not already doing so
   3. Recommend referring patients to HealthMedia Care for Pain on kp.org
   4. Recommend reassessing the efficacy of opioid therapy at least every six months
   5. Recommend urine toxicology screenings and update of the medication agreement/opioid therapy plan every 12 months

Conclusions

This case study yielded a number of learning points in addition to documenting the intended rationale for implementing an opioid risk assessment tool into clinical practice:

1. Workflow is key
2. Operational barriers are important
3. Knowledge must be shared about how information is disseminated
4. Data input must be clinically relevant
5. The decision-making process to introduce a tool into a large health care system requires significant due diligence prior to implementation

1. Provider Benefits
   Benefits to primary care health providers who are often overwhelmed by risk assessment and treatment with opioids
2. Organizational Benefits
   Benefits to the Organization from a medical and legal perspective, by creating a standard of practice for opioid risk assessment
3. Patient Benefits
   Improves the ability for patients at increased risk to have better access to appropriate pain treatment

Download the SOAPP®

References

1. Passik SD, Kirsh KL. The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Exp Clin Psychopharmacol. 2008;16(5):400-404.
2. Zacharoff KL, Bertagnolli A, Butler SF, Budman SH. Implementation of SOAPP® into a large integrated health care system.
3. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004 Nov;112(1-2):65-75.