USE A ONE-QUESTION SCREEN FOR OPIOID MISUSE AMONG OLDER PATIENTS

Despite growing attention on the need to increase access to treatment for opioid use disorder (OUD), not enough emphasis has been placed on OUD screening among patients prescribed long-term opioids. A significant proportion of our practice's patients on chronic opioids are 65 years or older. This group may be at higher risk for opioid-related harms, given their increased likelihood for polypharmacy, mobility limitations, renal or hepatic impairment, and social isolation.

We implemented a one-question screen for potential opioid misuse among this population during rooming. Nurses ask these patients, “In the last year, have you used your opioid medication for a purpose — or at a frequency or dose — that is outside of what is prescribed?” Initially, our nursing colleagues expressed hesitation to do the screening, given lack of formal training in this area. To address this concern, we created a short, self-guided training module, which included instructional videos made in-house on motivational interviewing and perspective taking and content on OUD and opioid withdrawal. Surveyed nurses agreed the training increased their confidence in addressing opioid misuse and chronic pain with patients. Nearly 20% of our older adult patients screened positive for OUD, which prompted us to engage with addiction colleagues to create workflows for referrals and care coordination. Our experience demonstrates that involving nurses in screening older adults for potential opioid misuse is feasible with brief training and leads to improved care.

PAIR GLP-1 MEDS WITH BEHAVIORAL CHANGE GOALS

Glucagon-like peptide-1 (GLP-1) medications, known for their ability to reduce appetite and improve blood sugar control, can be powerful tools in weight management and diabetes care. However, their effectiveness is amplified when combined with specific behavioral change goals.

I counsel patients starting on GLP-1 medications to prioritize and track their protein intake each day. An excessive loss of appetite due to the anorectic effect of the GLP-1 type medication frequently means that patients do not meet the minimum U.S. recommended dietary allowance for protein of 0.8g/kg (roughly 70–120g of protein per day, depending on body size). If patients do not meet protein goals due to a lack of appetite, I recommend decreasing their GLP-1 dose. I also advise them to avoid refined carbohydrates and limit other carbohydrates.

I usually address exercise goals once the person has lost 20–30 pounds. I find that patients are more accepting of meaningful exercise counseling once appreciable physical changes have made it easier for them to move around and achieve simple activity goals that we set together.

REDUCE BURNOUT BY GIVING PHYSICIANS ADEQUATE TEAM SUPPORT

In a cross-sectional study of 10,315 family physicians from 2017 to 2023, researchers found that high team efficiency and appropriate time at home on the electronic health record (EHR) are associated with lower odds of burnout among family physicians. The presence of a registered nurse working closely with a physician was associated with the combined outcome of greater team efficiency and less EHR work at home. However, nurses working as core clinical team members in close partnership with a specific physician are not the norm in primary care practices today. Instead, medical assistants are more commonly used but are not frequently allowed to perform high-level functions, either because of state or institutional policy, resulting in large volumes of work being transferred to the physician.

To increase team efficiency, reduce EHR work at home, and reduce physician burnout, practices should include nurses not just in triage pools but in stable pairings with a physician. Nurses can be empowered to conduct initial nursing assessments, help set the agenda for the visit, review labs, perform medication reconciliation, administer immunizations, pend prescriptions for renewal, coordinate next steps of care, enter orders on behalf of the physician, and manage inbox messages.