Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit

Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon

BACKGROUND

A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies.

OBJECTIVE

To examine the effect of the policy on prescribing, health outcomes, and health service utilization.

DESIGN

Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models.

SUBJECTS

Adult Medicaid patients with back pain enrolled between 2014 and 2018.

INTERVENTION

The Oregon Medicaid back pain policy.

MAIN MEASURES

Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization.

KEY RESULTS

The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01 pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4 days [95% CI - 0.53, - 0.26] slope), receipt of more than 7 days of short-acting opioids (- 2.36 pp [95% CI - 2.76, - 1.95] level, - 0.91 pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27 pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm.

CONCLUSIONS

A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Does electronic prescribing of controlled substances deter controlled substance prescribing in emergency departments?

Objective

To examine the association between electronic prescribing of controlled substances (EPCS) and controlled substance prescription patterns in U.S. emergency departments (ED).

Materials and methods

We conducted cross-sectional analysis at both the ED level and visit level, using the 2016-2017 National Hospital Ambulatory Medical Care Surveys.

Results

The sample included 24,296 visits to 316 EDs, 45% of which utilized EPCS. Pain-related visits were associated with significantly higher odds of prescriptions for any controlled substances (OR = 1.52; 95% CI: 1.32-1.75; p < 0.001) and Schedule II substances (OR = 2.13; 95% CI: 1.80-2.52; p < 0.001). Conditional on pain-related visits, EPCS was significantly associated with higher odds of any (OR 1.31; 95% CI: 1.08-1.59; p = 0.006) and Schedule III (OR 1.38; 95% CI: 1.03-1.85; p = 0.031) controlled substance prescriptions. For non-pain related visits, EPCS was not associated with changes in controlled substance prescriptions.

Discussion

While EPCS transmits prescriptions directly to pharmacies in order to reduce drug diversion problems, the results indicated no significant association between EPCS use and prescriptions for Schedule II drugs which include opioids. As many states move towards mandating EPCS use in order to curb the opioid epidemic, future studies should examine the barriers to the effective implementation of EPCS, in the context of other systems such as Prescription Drug Monitoring Programs.

Conclusion

EPCS does not appear to deter Schedule II controlled substances prescription including opioids in an ED visit. It may facilitate any and Schedule III controlled substance prescriptions when pain was involved in an ED visit.

Impact of a Statewide Emergency Department Information Exchange on Health Care Use and Expenditures

OBJECTIVE

To assess the effects of a program mandating the statewide adoption of an emergency department information exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state.

DATA SOURCE

Medicaid claims and managed care encounters from the Washington Health Care Authority.

STUDY DESIGN

A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program.

DATA EXTRACTION

The study population included adult Medicaid enrollees with ED visits between January 2010-October 2014.

PRINCIPAL FINDINGS

There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use or expenditures in any period.

CONCLUSIONS

Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes.

Effect on Opioids Requirement of Early Administration of Intranasal Ketamine for Acute Traumatic Pain

OBJECTIVES

To evaluate the efficacy and safety of early administration of low-dose intranasal ketamine on reducing the need for opioid and nonopioid analgesic agents in emergency department (ED) patients with acute moderate to severe acute limbs' trauma pain.

PATIENTS AND METHODS

This is a double-blind, randomized, prospective, controlled study conducted in the ED. The included patients were randomly assigned to intranasal pulverization of ketamine or placebo. Protocol treatment was given at the triage. The primary outcome is the need for opioids during ED stay. Secondary outcome included the requirement of nonopioid analgesic agents and the percentage of patients discharged from the ED with a visual analog scale (VAS) <30. A combined outcome score including the 3 outcome items was constructed.

RESULTS

The authors included 1102 patients, 550 patients in the placebo group, and 552 in the intranasal ketamine group. The groups were similar regarding demographics, clinical characteristics, and baseline VAS. The need for opioids was decreased in the intranasal ketamine group compared with the placebo group (17.2% vs. 26.5%; P<0.001). The need for nonopioid analgesics was significantly lower in the intranasal ketamine group compared with the placebo group (31.1% vs. 39.6%; P=0.003). The percentage of patients discharged with a VAS score <30 was significantly higher in the intranasal ketamine group (P<0.001). The mean combined outcome score was 0.97 in the placebo group and 0.67 in the intranasal ketamine group (P<0.001).

CONCLUSION

Intranasal ketamine administered early in the triage was associated with a decrease in opioids and nonopioid analgesics need in patients with acute limb trauma-related pain.

Sex-related differences in opioid administration in the emergency department: a population-based study

BACKGROUND

Sex differences in pain experience and expression may influence ED pain management. Our objective was to evaluate the effect of sex on ED opioid administration.

METHODS

We conducted a multicentre population-based observational cohort study using administrative data from Calgary's four EDs between 2017 and 2018. Eligible patients had a presenting complaint belonging to one of nine pain categories or an arrival pain score >3. We performed multivariable analyses to identify predictors of opioid administration and stratified analyses by age, pain severity and pain category.

RESULTS

We studied 119 510 patients (mean age 47.4 years; 55.4% female). Opioid administration rates were similar for men and women. After adjusting for age, hospital site, pain category, ED length of stay and pain severity, male sex was not a predictor of opioid treatment (adjusted OR (aOR)=0.93; 95% CI 0.85 to 1.02). However, men were more likely to receive opioids in the categories of trauma (aOR=1.58, 95% CI 1.40 to 1.78), flank pain (aOR=1.24, 95% CI 1.11 to 1.38), headache (aOR=1.18, 95% CI 1.03 to 1.34) and abdominal pain (aOR=1.11, 95% CI 1.08 to 1.18). Pain category appears to be a strong determinant of opioid administration, especially back pain (aOR=6.56, 95% CI 5.99 to 7.19) and flank pain (aOR=6.04, 95% CI 5.48 to 6.65). There was significant variability in opioid provision by ED site (aOR 0.76 to 1.24).

CONCLUSIONS

This population-based study demonstrated high variability in opioid use across different settings. Overall, men and women had similar likelihood of receiving opioids; however men with trauma, flank pain, headache and abdominal pain were much more likely to receive opioids. ED physicians should self-examine their analgesic practices with respect to possible sex biases, and departments should introduce evidence-based, indication-specific analgesic protocols to reduce practice variability and optimise opioid analgesia.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Oxycodone prescribing in the emergency department during the opioid crisis

OBJECTIVE

Misuse of prescription opioids is a significant public health issue in Australia. There has been a rapid rise in prescription opioid use, with an associated increase in overdose and death. The over-prescribing of oral opioids, especially oxycodone, in the ED has been identified as a contributor to this problem overseas. It is unclear if similar practice occurs in the Australian ED. The primary aim of our study was to identify the incidence of oral oxycodone administration to patients within the ED. The secondary outcome was to identify the incidence of oxycodone prescribed to patients on discharge from the ED into the community.

METHODS

Our study was designed as an observational, retrospective data analysis of the incidence of oxycodone prescribed within the three EDs of a large Australian public health service. All immediate-release (IR) and slow-release (SR) oral oxycodone prescribed over a 4-year period (2015-2018) was included.

RESULTS

There were 890 557 presentations to the three EDs during the period, which resulted in 288 242 episodes of oxycodone administration within department, equivalent to 324 administrations per 1000 presentations. There were 39 381 prescriptions for oxycodone provided on discharge, resulting in an incidence of 44 prescriptions per 1000 discharged. The most frequently prescribed opioid medication in the ED was oxycodone IR 5 mg, 78.6% of discharge prescriptions generated provided a maximum quantity (20 for IR formulation or 28 for SR) of tablets allowable under the pharmaceutical benefits scheme.

CONCLUSIONS

There is a higher incidence of oxycodone prescribing in the Australian ED than previously recognised. An overuse of oxycodone may be contributing to adverse patient outcomes and a public health crisis. Hospitals should consider appropriate steps to reduce the incidence of opioid prescribing and the supply of these medications into the community.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015

BACKGROUND

Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing.

METHODS

The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program.

RESULTS

A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use.

CONCLUSIONS

This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits.

PRACTICAL IMPLICATIONS

Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Conversion to Persistent or High-Risk Opioid Use After a New Prescription From the Emergency Department: Evidence From Washington Medicaid Beneficiaries

STUDY OBJECTIVE

We describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription.

METHODS

A retrospective cohort study of Washington Medicaid beneficiaries was performed with linked Medicaid and prescription drug monitoring program files. We identified adults who had no record of opioid prescriptions in the previous 12 months, and who filled a new opioid prescription within 1 day of an ED discharge in 2014. We assessed the risk of persistent opioid use or high-risk prescription fills within 12 months after the index visit. Logistic regression was used to assess the association between pertinent variables and conversion to persistent or high-risk use.

RESULTS

Among 202,807 index ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months compared with 3.2% for patients who received no opioids at the index visit. Factors associated with increased likelihood of persistent opioid or high-risk prescription fills included a history of skeletal or connective-tissue disorder; neck, back, or dental pain; and a history of prescribed benzodiazepines. The highest conversion rates (37.3%) were observed among visits in which greater than or equal to 350 morphine milligram equivalents were prescribed. Conversion rates remained greater than 10% even among visits resulting in lower-dose opioid prescriptions.

CONCLUSION

Medicaid recipients are at moderate risk for conversion to persistent or high-risk opioid use after a new ED prescription. Longer or higher-dose prescriptions are associated with increased risk for conversion; however, even visits that lead to guideline-concordant prescriptions bear some risk for long-term or high-risk use.

A Quality Improvement Initiative Featuring Peer-Comparison Prescribing Feedback Reduces Emergency Department Opioid Prescribing

BACKGROUND

Opioid prescribing in the United States nearly tripled from 1999 to 2015, and opioid overdose deaths doubled in the same time frame. Emergency departments (EDs) may play a pivotal role in the opioid epidemic as a source of first-time opioid exposure; however, many prescribers are generally unaware of their prescribing behaviors relative to their peers.

METHODS

All 117 ED prescribers at an urban academic medical center were provided with regular feedback on individual rates of opioid prescribing relative to their de-identified peers. To evaluate the effect of this intervention on the departmental rate of opioid prescribing, a statistical process control (SPC) chart was created to identify special cause variation, and an interrupted time series analysis was conducted to evaluate the immediate effect of the intervention and any change in the postintervention trend due to the intervention.

RESULTS

The aggregate opioid prescribing rate in the preintervention period was 8.6% (95% confidence interval [CI]: 8.3%-8.9%), while the aggregate postintervention prescribing rate was 5.8% (95% CI: 5.5%-6.1%). The SPC chart revealed special cause variation in both the pre- and postintervention periods, with an overall downtrend of opioid prescribing rates across the evaluation period and flattening of rates in the final four blocks. Interrupted time series analysis demonstrated a significant immediate downward effect of the intervention and a nonsignificant additional decrease in postintervention trend.

CONCLUSION

Implementation of peer-comparison opioid prescribing feedback was associated with a significant immediate reduction in the rate of ED discharge opioid prescribing.

Trends in Opioid Prescribing for Adolescents and Young Adults in Ambulatory Care Settings

BACKGROUND

Adolescents and young adults are at high risk for opioid misuse after exposure from medical treatment. However, the epidemiology of opioid prescribing among outpatient adolescents and young adults remains poorly described. We aimed to characterize opioid prescribing in adolescents and young adults receiving care in emergency departments (EDs) and outpatient clinics.

METHODS

We analyzed National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data from 2005 to 2015. We included visits to EDs and outpatient clinics for adolescents (13-17 years old) and young adults (18-22 years old). Rates of opioid prescribing were calculated with 95% confidence intervals (CIs), and linear trends over time were examined with logistic regression models.

RESULTS

Nearly 57 million visits (5.7%; 95% CI 5.4% to 6.0%) by adolescents and young adults were associated with an opioid prescription. The rate of opioid prescribing was 14.9% (95% CI 14.4% to 15.6%) for ED visits and 2.8% (95% CI 2.5% to 3.1%) for outpatient clinic visits. There was a small but significant decrease in the rate of opioid prescriptions among ED visits (odds ratio 0.96; 95% CI 0.95 to 0.98); no change was seen for outpatient clinic visits. Among ED visits, opioid-prescribing rates were highest among adolescents and young adults with dental disorders (59.7% and 57.9%, respectively), followed by adolescents with clavicle (47.0%) and ankle fractures (38.1%).

CONCLUSIONS

Rates of opioid prescribing in EDs and outpatient clinics remain high for adolescents and young adults, especially for certain emergency conditions. These findings inform targeted educational campaigns aiming to ensure judicious use of opioids in this high-risk population.

Effect on Morphine Requirement of Early Administration of Oral Acetaminophen vs. Acetaminophen/Tramadol Combination in Acute Pain

OBJECTIVES

To evaluate the effect on opioid requirement of pain treatment starting at triage, and to evaluate satisfaction in emergency department (ED) patients with acute pain.

METHODS

This is a single-blind, randomized, prospective study conducted in the ED. The included patients were randomly assigned to single oral doses of placebo, acetaminophen, or a tramadol/acetaminophen combination. Protocol treatment was given at triage. The primary outcome was the need for rescue morphine during ED stay. The secondary outcome included patient satisfaction, ED length of stay, and percentage of patients discharged from the ED with a VAS score of <30.

RESULTS

We included 1,485 patients: 496 patients in the placebo group, 497 in the acetaminophen group, and 492 in the tramadol/acetaminophen combination group. The groups were similar regarding demographic and clinical characteristics and baseline VAS pain scores. Rescue morphine was significantly decreased in the tramadol/acetaminophen combination group compared to that in the placebo and acetaminophen groups (11.5%, 23.2%, and 18.9%, respectively; P = 0.03). Patient satisfaction was higher in the tramadol/acetaminophen combination group (77% vs. 69% in the acetaminophen group and 68% in the placebo group). A VAS score of <30 was observed in 84% of patients in the placebo group, 83% in the acetaminophen group, and 87% in the tramadol/acetaminophen combination group (P = 0.01 between the acetaminophen group and tramadol/acetaminophen combination group). The ED length of stay was 60 minutes for the acetaminophen group and tramadol/acetaminophen combination group and 71 minutes for the placebo group (P = 0.04).

CONCLUSION

Oral tramadol/acetaminophen combination administered early in triage was associated with a decrease in intravenous morphine requirement and increase in satisfaction among ED patients with acute pain when compared with patients taking acetaminophen. No significant increase in side effects was found. This intervention may be considered in EDs with an aim of similar benefits.

Variations in prescription drug monitoring program use by prescriber specialty

BACKGROUND

Although prescription drug monitoring programs (PDMPs) have been widely implemented to potentially reduce abuse of prescription opioids, there is limited data on variations in PDMP use by prescriber specialty. Such knowledge may guide targeted interventions to improve PDMP use.

METHODS

Using data from Washington state Medicaid program, we performed a retrospective cohort study of opioid prescribers and their PDMP queries between Nov 1, 2013 and Oct 31, 2014. PDMP registration was mandatory for emergency physicians, but not for other providers. The unit of analysis was the prescriber. The primary outcome was any prescriber queries of the PDMP. We used multivariate regression models to identify variations in PDMP queries by prescriber specialty, as well as to explore explanatory pathways for observed variations.

RESULTS

We studied 17,390 providers who prescribed opioids, including 8718 (50%) who were not registered with PDMP, 4767 (27%) who were registered but had no recorded use of the PDMP, and 3905 (23%) PDMP users (queries/user: median 18, IQR 5-64). Compared to general medicine physicians, PDMP use was higher for emergency physicians (OR 1.4, 95%CI: 1.2-1.7), and lower for surgical specialists (OR 0.1, 95%CI: 0.08-0.1), obstetrician-gynecologists (OR 0.2, 95%CI: 0.1-0.2) and dentists (OR 0.4, 95%CI: 0.4-0.5). Higher use by emergency physicians appeared to be mediated by higher registration rates, rather than by provider level predilection to use the PDMP.

CONCLUSIONS

A minority of opioid prescribers to Medicaid beneficiaries used the PDMP. We identified variations in PDMP use by prescriber specialty. Interventions to increase PDMP queries should target both PDMP registration and PDMP use after registration, as well as specialties with current low use rates.

Effect of a Data-driven Intervention on Opioid Prescribing Intensity Among Emergency Department Providers: A Randomized Controlled Trial

OBJECTIVE

Little is known about accuracy of provider self-perception of opioid prescribing. We hypothesized that an intervention asking emergency department (ED) providers to self-identify their opioid prescribing practices compared to group norms-and subsequently providing them with their actual prescribing data-would alter future prescribing compared to controls.

METHODS

This was a prospective, multicenter randomized trial in which all attending physicians, residents, and advanced practice providers at four EDs were randomly assigned either to no intervention or to a brief data-driven intervention during which providers were: 1) asked to self-identify and explicitly report to research staff their perceived opioid prescribing in comparison to their peers and 2) then given their actual data with peer group norms for comparison. Our primary outcome was the change in each provider's proportion of patients discharged with an opioid prescription at 6 and 12 months. Secondary outcomes were opioid prescriptions per hundred total prescriptions and normalized morphine milligram equivalents prescribed. Our primary comparison stratified intervention providers by those who underestimated their prescribing and those who did not underestimate their prescribing, both compared to controls.

RESULTS

Among 109 total participants, 51 were randomized to the intervention, 65% of whom underestimated their opioid prescribing. Intervention participants who underestimated their baseline prescribing had larger-magnitude decreases than controls (Hodges-Lehmann difference = -2.1 prescriptions per hundred patients at 6 months [95% confidence interval {CI} = -3.9 to -0.5] and -2.2 per hundred at 12 months [95% CI = -4.8 to -0.01]). Intervention participants who did not underestimate their prescribing had similar changes to controls.

CONCLUSIONS

Self-perception of prescribing was frequently inaccurate. Providing clinicians with their actual opioid prescribing data after querying their self-perception reduced future prescribing among providers who underestimated their baseline prescribing. Our findings suggest that guideline and policy interventions should directly address the potential barrier of inaccurate provider self-awareness.

Effect of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing

STUDY OBJECTIVE

We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities.

METHODS

We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre-post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high-risk opioid use. We performed multiple sensitivity analyses, including restriction to pain-related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high-risk indicators.

RESULTS

The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] -0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI -0.15 to 5.48). There was no evidence of selective reduction in patients with previous high-risk opioid use (1.2 per 1,000 encounters, 95% CI -9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI -3.39 to 5.82). The lack of a selective reduction in high-risk patients was robust to all sensitivity analyses.

CONCLUSION

An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.

Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines

OBJECTIVE

Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture.

METHODS

We conducted a pre-post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre- and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing.

RESULTS

There were 508,337 pre- and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR] = 0.89, 95% CI = 0.87-0.91) and a decrease in the monthly trend compared to the preintervention period (OR = 0.99, 95% CI = 0.99-0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR = 0.81, 95% CI = 0.72-0.91), whereas the fracture cohort showed no change (OR = 1.10, 95% CI = 0.97-1.25).

CONCLUSION

The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.