Most interventions designed to reduce opioid prescribing at emergency department (ED) discharge successfully reduced opioid prescription rates, but they did not reduce the quantity of opioids prescribed to each patient, according to findings from a systematic review and meta-analysis.
Despite a decrease in opioid prescribing in the U.S. in recent years, rates of prescription opioid-related deaths remain high, Raoul Daoust, MD, MSc, Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l’Île de-Montréal, in Montreal, Canada, and colleagues explained in JAMA Network Open. Interventions to stem the tide of prescription opioid deaths range from prescription drug monitoring programs, new laws and policies, prescriber education programs, and beyond, but it is not clear which of these approaches works best for curtailing opioid prescribing and quantities.
Daoust and colleagues set out to “review and analyze the evidence regarding interventions to reduce the opioid prescribing rate or quantity for treating pain in adults discharged from the ED.” They categorized interventions into the following five groups:
- Education, policy, or guidelines (EPG);
- Prescription drug monitoring program or state law (PDMP);
- Clinician peer comparison (CPC);
- Electronic medical record quantity changes (EMR-QC); and
- Physical therapy (PT).
Their analysis showed that certain interventions “were associated with a reduction of opioid prescription rates, but interventions in general were limited in reducing prescribed opioid quantities,” the study authors wrote. “In a subgroup analysis of the more robust [interrupted time series] ITS study designs, we showed that EPG interventions resulted in a larger prescription rate reduction compared with PDMP interventions. In addition, only EPG interventions were associated with a reduction in prescribed opioid quantities in ITS designs. Insufficient data were available on patient-centered secondary outcomes to reach any conclusion.”
In an editorial accompanying the study, Austin S. Kilaru, MD, MSHP, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues weighed in on the finding from Daoust et al that interventions were more successful in reducing prescription rates than in cutting opioid prescription amounts.
“One interpretation of this finding is that interventions made prescribers more selective, but once determining that opioids were indicated, they reverted to standard quantities of medications,” they wrote. “Evidence suggests that the length of prescriptions influences the long-term risk of persistent use. This finding reinforces the need for more evidence to determine the right quantity of medication prescribed.”
For their review and meta-analysis, Daoust and colleagues searched for all intervention studies designed to reduce the opioid prescription rate and/or the quantity of opioids per prescription among adults discharged from the ED for home pain management. Studies that only looked at pediatric patients or individuals with substance use disorder were excluded, as were studies that only evaluated opioids administered during ED stay, were performed outside of the ED, did not assess interventions, were focused on opioid use unrelated to pain, or that did not report prescribing rates or quantities.
Each included study was categorized into one of the five intervention types. The review’s primary outcome was variation in the opioid prescription rate or quantity due to the intervention. Secondary outcomes included patient pain relief, satisfaction with their prescription, and percentage of patients who needed additional opioid prescriptions.
A total of 63 studies were included in the systematic review, of which 45 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,” Daoust and colleagues wrote. “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 patient-centered outcomes such as pain relief or patients’ satisfaction.”
They were surprised to find that EMR-QC interventions, which are specifically designed to reduce the quantity of opioids permitted per prescription, did not significantly reduce prescribing quantities. While other reviews have found a similar lack of association between this intervention and prescriptions, the approach has seen some success in postoperative settings, “and in ambulatory contexts when associated with state prescribing limits.”
Furthermore, they called the almost total lack of data on patient-centered outcomes a “major knowledge gap,” adding that it is “imperative to evaluate interventions designed to reduce opioid prescribing in a prospective manner and to integrate patient-centered outcomes.”
In their editorial, Kilaru and colleagues argued that, “[t]o some extent, implementation has outstripped the evidence regarding opioid prescribing for acute pain. Most U.S. states have enacted limits for either the duration or dosage of new prescriptions. Payers, including Medicare, have also limited the duration of new prescriptions that they will reimburse. The challenge for future interventions will be to mitigate the harms of overexposure to opioids for individual patients and communities but also permit patient-centered nuanced care and judicious prescribing of opioids. Although prescribing rates have fallen for the past decade, overdose rates have accelerated, suggesting that the solution of reduced prescribing may not, by itself, resolve the overdose crisis.
“In conclusion, the meta-analysis by Daoust et al summarizes the significant progress made during the past decade to reduce opioid prescriptions for patients discharged from the ED,” they wrote. “Ensuring that opioids are prescribed appropriately should continue to be a priority for every ED. However, the goal for the next 10 years must shift. Clinicians, health systems, and policy makers should seek to optimize opioid prescribing and incorporate patient perspectives. Furthermore, all EDs should be able to prescribe buprenorphine hydrochloride, an effective treatment for opioid use disorder, and provide naloxone hydrochloride for overdose prevention. Preventing unnecessary exposure to opioids is a worthy goal, but any hope to end the opioid epidemic demands increased access to effective treatment for opioid use disorder.”
Study limitations included that the available studies were of relatively low quality; variations in intervention categories that make generalization difficult; low heterogeneity for several categories in the ITS studies; ITS studies did not cover use of EMR-QC interventions for opioid prescription rates, use of CPC interventions for opioid quantities, or use of PT interventions for either outcome; and most studies were performed in the U.S. and may not be generalizable to other health systems.
Disclosure:
This study was supported by the Fonds des Urgentistes de l’Hôpital du Sacré-Coeur de Montréal and the OPUM (Quantity of Opioids for Acute Pain and Limit Unused Medication Study) study group.
Daoust reported receiving grants from the Emergency Department fund from the Hôpital du Sacré-Coeur de Montréal and the Instituts de Recherche en Santé during the conduct of the study. Coauthor Chauny reported receiving grants from the Instituts de Recherche en Santé during the conduct of the study.
Kilaru reported no disclosures. Editorial coauthor Agarwal reported receiving grants from the US Food and Drug Administration, the Agency for Healthcare Research and Quality, and the Patient-Centered Outcomes Research Institute.
by
John McKenna, Associate Editor, BreakingMED™
Kaiser Health News
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
