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.
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
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
Washington, Wyoming, Alaska, Montana, & Idaho (WWAMI) region Practice Research Network; Washington State Department of Health; Olympic Community of Health
Learn more about the project
- Six Building Blocks website
- About AHRQ’s Six Building Blocks: A Team-Based Approach To Improving Opioid Management in Primary Care Program (Agency for Healthcare Research and Quality)
- Six ways to manage opioids in small, rural clinics (UW Medicine Newsroom, July 2019)
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.
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.
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.
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.
The Six Building Blocks research team developed a How-To guide for implementation in primary care clinics.8 Demonstrated.
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.
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.
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.
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.
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.
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.
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.
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.
Clinical: Clinics that implement the Six Buildings Blocks program improve management of long-term opioid use by engaging clinic leadership, improving clinic policies and workflows, implementing patient-centered visits, identifying or acquiring resources for complex patients, tracking and monitoring patients to identify care gaps, and establishing measures to assess improvements. The program has been included in multiple local, regional, and national guidelines on management of patients with chronic pain using long-term opioid therapy, including guidance from SAMHSA, CDC, the Providers Clinical Support System, and the Washington State Medical Association.13–16
Community: The Six Building Blocks program has reached at least 94 clinics and clinical organizations. Clinics that use the Building Blocks have improved quality of care for patients on long-term opioid therapy for chronic pain by increasing use of evidence-based practices, improving clinician and staff confidence, and reducing provider stress.6,7 As a result, patients have decreased use of opioid medications and been able to switch to lower dose opioids.6 To share support implementation of the model at more clinics, the team created a self-service “How-To-Implement Toolkit” for primary care clinics and a website (www.improvingopioidcare.org) with additional health education resources, including a clinic self-assessment and patient education.8,17
Economic: The Six Building Blocks program could lessen the economic cost of opioid use disorder by reducing the use of higher dose opioids and long-term opioid therapy.10
Policy: The Six Building Blocks program was included in a 2020 report by the Dr. Robert Bree Collaborative, a group appointed by the Washington state Governor to provide evidence-based recommendations to improve patient care in a variety of areas.19 The report recommended the model for use in primary care clinics throughout the state.
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.
- 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
- 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
- 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
- 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. https://www.iths.org/news/six-building-blocks-for-opioid-management-in-chronic-pain/
- 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
- 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
- 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
- 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. http://www.ahrq.gov/patient-safety/settings/ambulatory/improve/six-building-blocks-guide.html
- Physician Burnout. Agency for Healthcare Research and Quality. Accessed September 23, 2021. http://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html
- 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
- 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
- Opioid Use Disorder: Challenges and Opportunities in Rural Communities. Pew Charitable Trusts. Published February 7, 2019. Accessed September 23, 2021. https://pew.org/2HWn0iP
- 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. https://www.samhsa.gov/resource/ebp/six-building-blocks-team-based-approach-improving-opioid-management-primary-care
- 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. https://www.cdc.gov/opioids/healthcare-admins/qi-cc.html
- Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care – PCSS. Providers Clinical Support System. Accessed September 14, 2021. https://pcssnow.org/resource/six-building-blocks-a-team-based-approach-to-improving-opioid-management-in-primary-care/
- Better Prescribing, Better Treatment. Washington State Medical Association. Accessed September 14, 2021. https://wsma.org/better-prescribing
- Six Building Blocks – A Team-Based Approach to Improving Opioid Management in Primary Care. Six Building Blocks. Accessed September 23, 2021. https://familymedicine.uw.edu/improvingopioidcare/
- 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
- Dr. Robert Bree Collaborative. Opioid Prescribing: Long-Term Opioid Therapy Report and Recommendations. Dr. Robert Bree Collaborative; 2020. Accessed September 14, 2021. https://www.qualityhealth.org/bree/wp-content/uploads/sites/8/2020/05/Bree-Long-Term-Opioid-Use-Recommendations-FINAL-20-05.pdf