Wednesday, July 18, 2018

Reducing EMR Default Settings for Opioids Prescribed After Surgery May Help Address Opioid Epidemic

Lowering the default number of opioid pills prescribed through an electronic medical record system to patients undergoing outpatient operations can significantly reduce the mean amount of opioid analgesia prescriptions, reports a study published today in JAMA Surgery. The findings point to a low-cost and potentially scalable intervention to continue to decrease the overprescribing of opioids.

On May 18, 2017, the Yale New Haven Health System, which uses a unified electronic medical record (EMR) system, lowered the default number of pills on all electronic opioid prescriptions from 30 to 12. To evaluate the impact of this change on the amount of opioid prescribed to patients, Alexander S. Chiu, M.D., of Yale School of Medicine and colleagues compared postprocedural prescribing patterns during the three months before the default change with the three months after the default change. The study specifically focused on opioid prescribing to patients aged 18 and older undergoing the 10 most common outpatient operations.

Overall, the median number of opioid pills prescribed per operation decreased from 30 before the default was changed to 20 afterward. “When evaluating the association over our entire hospital system, the decrease in the amount of opioid prescribed during three months was the equivalent of almost 25,000 fewer pills of 5 mg of oxycodone distributed,” Chiu and colleagues wrote.

To address concerns that reducing default opioid prescriptions might have negatively impacted patients with pain, the authors examined whether additional opioid prescriptions were written for pain-related reasons within 30 days of the operation. There was no statistical difference in opioid refill rates before and after the default change.

“The success of this intervention is a prime example of a ‘nudge,’ a concept in behavioral sciences that describes an intervention that ‘alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives,’ ” David D. Q. Zhang, M.D., C.M., and colleagues of University of Toronto wrote in an accompanying editorial.

“The usual ‘default’ postoperative prescription of 30 pills is in most circumstances excessive. Because appropriate disposal of unused opioids is uncommon, excess prescribing creates the potential for drug diversion and misuse,” they continued. “Although Chiu et al. do not evaluate if the change in physician prescribing practice was sustained, given the simplicity of the intervention and rapid change in practice, the potential of nudges to improve opioid prescribing needs to be harnessed.”

For information on ways to address opioid use disorder, see the Psychiatric News article “Group of Six Releases Principles for Addressing Opioid Crisis.”

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