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MP35: Targeting the opioid crisis by influencing opioid prescribing in the emergency department
Abstract
Background: Liberal prescribing of opioids is a major contributing factor to the opioid crisis. Patients who take opioids for >5 consecutive days are at greater risk of long-term use. Evidence shows that significantly more opioids are prescribed for emergency department (ED) patients with acute pain compared to amounts consumed. Guidelines recommend prescribing a 3-day supply or 10-15 tablets of opioids for patients with acute pain Aim Statement: By January 2020, >70% of opioid prescriptions from our ED will be for <15 tablets of morphine 5 mg equivalents. Measures & Design: Emergency physicians were educated on best practice of prescribing opioids for discharged patients. An electronic prescription writer was built for discharged ED patients with a pop-up reminder for quantities >15 tablets (indicating a recommended quantity of 10-15 tablets) and a pop-up reminder for quantities >30 tablets (indicating a maximum quantity of 30 tablets and recommended quantity). A feature was built to auto-populate a prescription for morphine 5 mg po q4h prn x 10 tablets to facilitate adherence to guidelines. Outcome Measure % opioid prescriptions for <15 tablets of morphine 5 mg equivalents Process Measure Amount of opioids prescribed for discharged ED patients, measured as morphine 5 mg equivalents Number of opioid prescriptions for >30 tablets of morphine 5 mg equivalents Balancing Measure Number of patients that return to ED within 7 days and receive a repeat opioid prescription. Evaluation/Results: Prior to implementation of the electronic prescription writer a sample audit revealed that 50% of opioid prescriptions were written for <15 tablets of morphine 5 mg equivalents. For the first three quarters of 2019, 62%, 61% and 69% of opioid prescriptions were written for <15 tablets of morphine 5 mg equivalents. Only two prescriptions during the study period were for >30 tablets of morphine 5 mg equivalents. An average number of 7 patients per quarter were given a repeat opioid prescription during a return ED visit. Discussion/Impact: We were successful in influencing emergency physicians to prescribe fewer opioids to discharged patients. This has the potential to avoid converting ED patients with acute pain into long-term opioid users and to avoid the diversion of unused opioid tablets.
IMPORTANCE Limiting opioid overprescribing in the emergency department (ED) may be
associated with decreases in diversion and misuse.
OBJECTIVE To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED.
DATA SOURCES MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021.
STUDY SELECTION Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers.
DATA EXTRACTION AND SYNTHESIS Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values.
MAIN OUTCOMES AND MEASURES The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies.
RESULTS Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, −22.61%; 95%CI, −30.70%to −14.52%) and other (odds ratio, 0.56; 95%CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, −8.64%; 95%CI, −17.48%to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, −0.30; 95%CI, −0.51 to −0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, −33.31%; 95%CI, −39.67%to −26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, −11.18%; 95%CI, −22.34%to −0.03%). Most intervention
categories did not reduce prescribed opioid quantities. Insufficient data were available on patientcentered outcomes such as pain relief or patients’ satisfaction.
CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found that most
interventions reduced the opioid prescription rate but not the prescribed opioid quantity for
ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed.
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