Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis

Knowledge, Attitudes, and Perceived Barriers of Nurses Regarding Pain Management in Emergency Department; a KAP Study

Introduction

Adequate knowledge and positive attitude among nurses are essential for successful pain management as a fundamental aspect of patients' rights. This study aimed to assess the knowledge, attitude and perceived barriers of nurses regarding acute pain management in emergency department.

Methods

In this cross-sectional study, participating nurses were selected using a consecutive sampling technique within a medical university. Data were collected using 4 questionnaires, which consisted of demographic information checklist, Pain Management Principles Assessment Tool (PMPAT), Nurses' Attitude Survey (NAS), and Nurses' practice checklist. The correlation between knowledge, attitude, and barriers with each other and with baseline characteristics of participates were studied.

Results

400 nurses with the mean age of 38.26±10.39 years were studied (63% male). The average knowledge score of studied nurses was 7.38 ± 2.16 (range: 1 -14). All 400 (100%) nurses exhibited a low level of knowledge. The mean attitude score of participants was 58.47± 22.08 (range:26-100). 214 (53.5%) cases had low attitude, 44 (11.0 %) average attitude, and 142 (35.5%) cases exhibited a high attitude score. The mean score of barriers about pain management was 36.48 ± 23.52 (range: 0 - 80). 23 (5.8%) participants answered the perceived barriers as never, 113 (28.3%) as seldom, 71 (17.8%) as sometimes, 133 (33.3%) as often, and 60 (15.0%) as routine. There was an reverse relationship between the knowledge score and perceived barriers of pain management (r=-0.164, p<0.001). No significant relationship was found between the average knowledge score and nurses' attitudes (r = 0.092; p > 0.065).

Conclusions

The findings of this study highlight the need for ongoing training and the organization of workshops for nurses due to their low levels of knowledge and attitude. These training sessions should focus on the concept of pain, assessment methods, pain relief, as well as pharmacology and the physiology of pain.

Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews

BACKGROUND

Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters.

METHODS

We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results.

RESULTS

Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices.

CONCLUSION

De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies.

REGISTRATION

OSF Open Science Framework 5ruzw.

The Opioid Epidemic and Faith-Based Responses in Southern Appalachia, USA: An Exploration of Factors for Successful Cross-Sector Collaboration

This study aimed to identify factors for successful cross-sector collaboration with faith-based responses to the opioid epidemic in southern Appalachia. In-depth interviews were conducted with representatives from organizations responding to the opioid epidemic (N = 25) and persons who have experienced opioid dependency (N = 11). Stakeholders perceived that collaboration is hindered by stigma, poor communication, and conflicting medical and spiritual approaches to opioid dependency. Collaborations are facilitated by cultivating compassion and trust, sharing information along relational lines, and discerning shared commitments while respecting different approaches. The study concludes with theoretical and practical implications for both religious leaders and potential cross-sector collaborators.

Opioid prescribing requirements to minimize unused medications after an emergency department visit for acute pain: a prospective cohort study

BACKGROUND

Unused opioid prescriptions can be a driver of opioid misuse. Our objective was to determine the optimal quantity of opioids to prescribe to patients with acute pain at emergency department discharge, in order to meet their analgesic needs while limiting the amount of unused opioids.

METHODS

In a prospective, multicentre cohort study, we included consecutive patients aged 18 years and older with an acute pain condition present for less than 2 weeks who were discharged from emergency department with an opioid prescription. Participants completed a pain medication diary for real-time recording of quantity, doses, and names of all analgesics consumed during a 14-day follow-up period.

RESULTS

We included 2240 participants, who had a mean age of 51 years; 48% were female. Over 14 days, participants consumed a median of 5 (quartiles, 1-14) morphine 5 mg tablet equivalents, with significant variation across pain conditions (p < 0.001). Most opioid tablets prescribed (63%) were unused. To meet the opioid need of 80% of patients for 2 weeks, we found that those experiencing renal colic or abdominal pain required fewer opioid tablets (8 morphine 5 mg tablet equivalents) than patients who had fractures (24 tablets), back pain (21 tablets), neck pain (17 tablets), or other musculoskeletal pain (16 tablets).

INTERPRETATION

Two-thirds of opioid tablets prescribed at emergency department discharge for acute pain were unused, whereas opioid requirements varied significantly based on the cause of acute pain. Smaller, cause-specific opioid prescriptions could provide adequate pain management while reducing the risk of opioid misuse.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT03953534.

Pragmatic Emergency Department Intervention Reducing Default Quantity of Opioid Tablets Prescribed

Introduction

The opioid epidemic is a major cause of morbidity and mortality in the United States. Prior work has shown that emergency department (ED) opioid prescribing can increase the incidence of opioid use disorder in a dose-dependent manner, and systemic changes that decrease default quantity of discharge opioid tablets in the electronic health record (EHR) can impact prescribing practices. However, ED leadership may be interested in the impact of communication around the intervention as well as whether the intervention may differentially impact different types of clinicians (physicians, physician assistants [PA], and nurse practitioners). We implemented and evaluated a quality improvement intervention of an announced decrease in EHR default quantities of commonly prescribed opioids at a large, academic, urban, tertiary-care ED.

Methods

We gathered EHR data on all ED discharges with opioid prescriptions from January 1, 2019-December 6, 2021, including chief complaint, clinician, and opioid prescription details. Data was captured and analyzed on a monthly basis throughout this time period. On March 29, 2021, we implemented an announced decrease in EHR default dispense quantities from 20 tablets to 12 tablets for commonly prescribed opioids. We measured pre- and post-intervention quantities of opioid tablets prescribed per discharge receiving opioids, distribution by patient demographics, and inter-clinician variability in prescribing behavior.

Results

The EHR change was associated with a 14% decrease in quantity of opioid tablets per discharge receiving opioids, from 14 to 12 tablets (P = <.001). We found no statistically significant disparities in prescriptions based on self-reported patient race (P = 0.68) or gender (P = 0.65). Nurse practitioners and PAs prescribed more opioids per encounter than physicians on average and had a statistically significant decrease in opioid prescriptions associated with the EHR change. Physicians had a lesser but still significant drop in opioid prescribing in the post-intervention period.

Conclusion

Decreasing EHR defaults is a robust, simple tool for decreasing opioid prescriptions, with potential for implementation in the 42% of EDs nationwide that have defaults exceeding the recommended 12-tablet supply. Considering significant inter-clinician variability, future interventions to decrease opioid prescriptions should examine the effects of combining EHR default changes with targeted interventions for clinician groups or individual clinicians.

Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines

Background

Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported.

Methods

ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity.

Results

Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form.

Conclusion

To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs.

Protocol registration

The protocol of this study is registered at clinicaltrials.gov: NCT04880733.

Pre-emptive paracetamol reduces intra-operative opioid use in patients undergoing day-case oncologic breast surgery

Minimization of intra-operative opioid use is an area of ongoing research interest with several potential benefits to the patient. Pre-emptive analgesia, defined as the administration of an analgesic before surgery to prevent establishment of central sensitization of pain, is one avenue that has been explored to achieve this. A retrospective observational study was undertaken to examine the effect of pre-emptive paracetamol on intra-operative opioid requirements. The medical and operative data of 156 patients who underwent day-case wide local excision and sentinel lymph node biopsy with and without regional block surgery at our center between October 2019 and May 2022 was carried out. Data were collected on demographics, total intra-operative and immediate post-operative opioid consumption. 57 patients did not receive pre-emptive paracetamol while 90 did. Baseline characteristics were similar. Our results showed a statistically significant reduction in morphine (p <0.029) and remifentanil (p <0.007) consumption in patients who received a regional block and pre-emptive paracetamol. Those who did not receive a regional block and were given pre-emptive paracetamol had a decrease in OxyNorm (p <0.022) requirements. A combination of general anesthesia (GA), regional block and pre-emptive paracetamol reduced intra-operative consumption of Fentanyl, OxyNorm, diclofenac, dexketoprofen, and clonidine (P <0.001) when compared to just GA alone. Use of pre-emptive paracetamol in reduction of intra-operative opioid requirements showed promising results but larger studies may strengthen the evidence for this association. A multimodal analgesic approach that utilizes pre-emptive paracetamol can be a viable method to decrease intra-operative of analgesic requirements.

Restriction of oxycodone in the emergency department (ROXY-ED): A randomised controlled trial

Background

The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED).

Methods

An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18-75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge.

Results

There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p < .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71-2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39-0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86-1.02).

Conclusions

Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

OBJECTIVES

Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity.

METHODS

The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback.

RESULTS

Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity.

CONCLUSIONS

Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.

Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol

INTRODUCTION

Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint.

METHODS AND ANALYSIS

We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain.

ETHICS AND DISSEMINATION

This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request.

TRIAL REGISTRATION NUMBER

NCT05555576 ClinicalTrials.Gov PRS.

Changes in opioid and other analgesic prescribing following voluntary and mandatory prescription drug monitoring program implementation: A time series analysis of early outcomes

BACKGROUND

Australian prescription drug monitoring programs (PDMPs) provide information about a patient's recent medication history for controlled drugs at the point of prescribing and dispensing. Despite their increasing use, the evidence for PDMPs is mixed, and is almost exclusively from the United States. This study examined the impact of PDMP implementation on opioid prescribing among general practitioners in Victoria, Australia.

METHOD

We examined data on analgesic prescribing using electronic records of 464 medical practices in the Australian state of Victoria between 01/04/2017 and 31/12/ 2020. We used interrupted time series analyses, to examine immediate and longer-term trends in medication prescribing following voluntary (from April 2019) and mandatory PDMP implementation (from April 2020). We examined changes in three outcomes (i) 'high' opioid dose (50-100mg oral morphine equivalent daily dose (OMEDD) and over 100mg (OMEDD) prescribing (ii) prescribing of high-risk medication combinations (opioids with either benzodiazepines or pregabalin), and (iii) initiation of non-controlled pain medications (tricyclic antidepressants, pregabalin and tramadol).

RESULTS

We found no effect of voluntary or mandatory PDMP implementation on 'high-dose' opioid prescribing with reductions only seen in those prescribed <20mg OMEDD (i.e., the lowest dose category). Co-prescribing of opioids with benzodiazepines (additional 11.87 [95%CI 2.04 to 21.67] patients/10,000 and pregabalin (additional 3.54 [95% CI 0.82 to 6.26] patients/10,000 increased following mandatory PDMP implementation among those prescribed opioids. In contrast to trends of reduced initiation prior to PDMP implementation, we found increased new initiation of non-monitored medications following PDMP implementation (e.g., an immediate increase of 2.32 [95%CI 0.02 to 4.54], patients/10,000 received pregabalin and 3.06 [95%CI 0.54 to 5.5] patients/10,000 received tricyclic antidepressants after mandatory PDMP implementation), and increased tramadol initiation during the voluntary PDMP period (an increase of 11.26 [95%CI: 5.84, 16.67] patients /10,000).

CONCLUSION

PDMP implementation did not appear to reduce prescribing of high opioid doses or high-risk combinations. Increased initiation of tricyclic antidepressants, pregabalin and tramadol may indicate a possible unintended effect.

Online education for safer opioid prescribing in hospitals-lessons learnt from the Opioid Use Change (OUCh) project

BACKGROUND

Opioids are often required for acute inpatient pain relief but lack of knowledge about common and less common long-term side effects can lead to inappropriate discharge prescribing. There are few validated educational tools available for junior prescribers on hospital wards. Education around opioid prescribing and deprescribing remains limited in the undergraduate curriculum and yet almost all controlled drug prescribing in hospitals is done by junior doctors.

METHODS

A 5-minute video was developed with iterative feedback from medical students, junior prescribers, pain specialists, primary care educational leads, and a patient who had developed opioid addiction after hospital prescribing. It explained the need for clear stop dates on discharge summaries and the range of opioid side effects. It also highlighted the hospital admission as an opportunity to reduce inappropriate high-dose opioids. A short knowledge-based quiz before and after viewing the video was used to evaluate the impact on and change in knowledge and confidence around opioid prescribing. This tool was designed to be used entirely online to allow delivery within existing mandatory training.

RESULTS

Feedback was positive and showed that knowledge of side effects significantly increased but also contacts with ward pharmacists and the acute pain team increased. Junior doctors highlighted that the undergraduate curriculum did little to prepare them for prescription addiction and that pharmacy and senior support was needed to support any changes in longer-term, high-dose opioids.

CONCLUSIONS

This short educational video improved knowledge of safe opioid prescribing and could be incorporated within wider opioid education in UK healthcare.

Effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge: A systematic review

This study aims to summarize the effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge. A systematic search was conducted on 6 electronic databases by 2 independent reviewers. We included original research articles reporting on quantitative outcomes of organizational interventions targeting appropriate opioid prescribing on hospital discharge. Quality assessment was performed by 2 independent reviewers. The protocol for this review was prospectively registered on PROSPERO (ID: CRD42020156104). Out of 173 full texts assessed for eligibility, 43 were included in this review. The majority of studies had a moderate to serious risk of bias (33 out of 43). Most of the studies implemented a multifaceted organizational intervention (16 studies). Other interventions included guideline implementation, prescriber education and default opioid-prescribing quantity changes in electronic medical records. Multiple studies found that the dissemination of patient-specific and procedure-specific guidelines reduced the quantity of opioids prescribed by 44 to 57%. Prescriber education provided with feedback was implemented in 4 studies and resulted in a 33 to 44% decrease in prescribing rates. Lowering the default quantities in the electronic medical records produced a 40% decrease in opioids prescribed in 1 study. Guideline implementation, prescriber education and default opioid-prescribing quantity changes all appear effective in improving the appropriate prescribing of opioids on hospital discharge. However, the extent of reduction of opioid prescribing upon hospital discharge after the implementation of multifaceted intervention strategies appears similar to that of simpler interventions which require fewer resources.

Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta-analysis

Objective

To quantify unused opioids among adult and pediatric patients discharged from the emergency department (ED) or ambulatory care settings with a prescription for acute pain.

Methods

We searched MEDLINE, Embase, CINHAL, PsycINFO, the Cochrane Library, and the gray literature from inception to April 29, 2021. We included observational studies in which any patient with an acutely painful condition received a prescription for an opioid on discharge from an outpatient care setting, and unused opioids were quantified. Two reviewers screened records for eligibility, extracted data, and conducted the quality assessment. Where possible, we pooled data and otherwise described the results of studies narratively. Total unused prescriptions were synthesized using a weighted average. Random effects models were used, and heterogeneity was measured by the I2 statistic. Our primary outcome was the quantity of unused opioid medication available after receiving a prescription for acute pain. Secondary outcomes were the proportion of patients with unused opioids following a prescription, the proportion of patients using no opioids, morphine equivalents of unused opioids, and factors associated with leftover opioids.

Results

In this systematic review and meta-analysis of 9 studies in emergency and ambulatory care settings, 59.6% of prescribed opioids remained unused; pediatric patients had 69.3% of their prescriptions remaining, compared to 54.6% among adult patients. The highest proportion of unused opioids was found following dental extractions (82.6%).

Conclusions and Relevance

More than 50% of opioids remain unused following prescriptions for acute pain. Responsible prescribing must be accompanied by education on safer use, storage, and disposal.