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Bachhuber MA, Nash D, Southern WN, Heo M, Berger M, Schepis M, Sugarman OK, Cunningham CO. Reducing Opioid Analgesic Prescribing in Dentistry Through Prescribing Defaults: A Cluster-Randomized Controlled Trial. PAIN MEDICINE 2022; 24:1-10. [PMID: 35792881 PMCID: PMC9825153 DOI: 10.1093/pm/pnac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices. METHODS We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation. RESULTS Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (-3.3 tablets; CI: -5.9 to -0.7), and lower morphine milligram equivalents (MME) prescribed (-14.1 MME; CI: -27.8 to -0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9). CONCLUSIONS Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default. TRIAL REGISTRATION ClinicalTrials.org ID: NCT03030469.
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Affiliation(s)
- Marcus A Bachhuber
- Correspondence to: Marcus A. Bachhuber, MD, MSHP, Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Sciences Center-New Orleans, 533 Bolivar St., 5th Fl, New Orleans, LA 70112, USA. Tel: (504) 568-5700; Fax: (504) 568-5701; E-mail:
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York (CUNY), New York, New York,Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York
| | - William N Southern
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Moonseong Heo
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York,This author is now with the Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, South Carolina, New Orleans, Louisiana, USA
| | - Matthew Berger
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Mark Schepis
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Olivia K Sugarman
- Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Chua WJ, Groenewald CB, Varakitsomboon S, Harris J, Faino AV, Quan L, Walco GA, Sousa TC. Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing? Pediatr Emerg Care 2022; 38:e600-e604. [PMID: 35100763 PMCID: PMC9269031 DOI: 10.1097/pec.0000000000002411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization. METHODS We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses. RESULTS There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits. CONCLUSIONS Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.
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Affiliation(s)
- Wee-Jhong Chua
- Division of Emergency Medicine, Department of Pediatrics, North-western University Feinberg School of Medicine
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Cornelius B. Groenewald
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
- Department of Pediatrics, Seattle Children’s Hospital
| | - Shing Varakitsomboon
- Department of Pediatrics, Seattle Children’s Hospital
- Department of Orthopedics and Sports Medicine, University of Washington School of Medicine
| | - Jacob Harris
- Department of Pediatrics, Seattle Children’s Hospital
- Department of Orthopedics and Sports Medicine, University of Washington School of Medicine
| | - Anna V. Faino
- Department of Pediatrics, Seattle Children’s Hospital
- Children’s Core for Biomedical Statistics, Seattle Children’s Research Institute, Seattle, WA
| | - Linda Quan
- Department of Pediatrics, Seattle Children’s Hospital
- Division of Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Gary A. Walco
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
- Department of Pediatrics, Seattle Children’s Hospital
| | - Ted C. Sousa
- Department of Orthopedics, Shriners Hospitals for Children-Spokane, Spokane, WA
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Chua WJ, Klein EJ, Al-Haddad BJS, Quan L. Factors Associated With Opioid Prescribing for Distal Upper Extremity Fractures at a Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:e1093-e1097. [PMID: 31436676 DOI: 10.1097/pec.0000000000001908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aims of this study were to describe the prescribing patterns of oxycodone for patients with distal upper extremity fractures and to evaluate factors that influence the quantity of oxycodone prescribed at discharge. METHODS We retrospectively studied oxycodone prescriptions for patients with upper extremity fractures presenting to a single center tertiary pediatric emergency department (ED) from June 1, 2014, to May 31, 2016. We used logistic regression models to evaluate the association of opioid administration in the ED, fracture reduction under ketamine sedation, initial pain scores (low, medium, and high), patient demographics, and type of prescriber (residents, attendings, fellows, and advanced registered nurse practitioners) with oxycodone prescription at discharge and the number of doses prescribed (≤12 or >12 doses). RESULTS A total of 1185 patients met the inclusion criteria. Of these, 669 (56%) were prescribed oxycodone at discharge. Children with fractures requiring reduction had 13 times higher odds [95% confidence interval (CI), 9.45-20.12] of receiving an oxycodone prescription compared with children with fractures not requiring reduction. Opioid administration in the ED was associated with 7.5 times higher odds (95% CI, 5.41-10.51) of receiving an outpatient prescription. Children were more likely to have a higher quantity of oxycodone prescribed if they had a fracture reduction in the ED [odds ratio (OR), 1.73; 95% CI, 1.20-2.50], received an opioid in the ED (OR, 2.13; 95% CI, 1.43-3.20), or received their prescription from an emergency medicine resident (OR, 2.8; 95% CI, 1.44-5.74). CONCLUSIONS Opioid prescribing differs based on patient- and provider-related factors. Given the variability in prescribing patterns, changing suggested opioid prescriptions in the electronic medical record may lead to more consistent practice and therefore decrease unnecessary prescribing while still ensuring adequate outpatient analgesia.
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Bachhuber MA, Nash D, Southern WN, Heo M, Berger M, Schepis M, Thakral M, Cunningham CO. Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed: A Cluster Randomized Clinical Trial. JAMA Netw Open 2021; 4:e217481. [PMID: 33885773 PMCID: PMC8063068 DOI: 10.1001/jamanetworkopen.2021.7481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. OBJECTIVE To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. INTERVENTIONS A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. MAIN OUTCOMES AND MEASURES The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. RESULTS Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. CONCLUSIONS AND RELEVANCE In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03003832.
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Affiliation(s)
- Marcus A. Bachhuber
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
- Now with Section of Community and Population Medicine, Louisiana State University Health Sciences Center–New Orleans
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York
- Graduate School of Public Health and Health Policy, Department of Epidemiology and Biostatistics, City University of New York, New York, New York
| | - William N. Southern
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Moonseong Heo
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
- Now with College of Behavioral, Social and Health Sciences, Department of Public Health Sciences, Clemson University, Clemson, South Carolina
| | - Matthew Berger
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Mark Schepis
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Manu Thakral
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston
| | - Chinazo O. Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Donohue JM, Kennedy JN, Seymour CW, Girard TD, Lo-Ciganic WH, Kim CH, Marroquin OC, Moyo P, Chang CCH, Angus DC. Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischarge Opioid Use: A Cohort Study. Ann Intern Med 2019; 171:81-90. [PMID: 31207646 PMCID: PMC6815349 DOI: 10.7326/m18-2864] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patterns of inpatient opioid use and their associations with postdischarge opioid use are poorly understood. OBJECTIVE To measure patterns in timing, duration, and setting of opioid administration in opioid-naive hospitalized patients and to examine associations with postdischarge use. DESIGN Retrospective cohort study using electronic health record data from 2010 to 2014. SETTING 12 community and academic hospitals in Pennsylvania. PATIENTS 148 068 opioid-naive patients (191 249 admissions) with at least 1 outpatient encounter within 12 months before and after admission. MEASUREMENTS Number of days and patterns of inpatient opioid use; any outpatient use (self-report and/or prescription orders) 90 and 365 days after discharge. RESULTS Opioids were administered in 48% of admissions. Patients were given opioids for a mean of 67.9% (SD, 25.0%) of their stay. Location of administration of first opioid on admission, timing of last opioid before discharge, and receipt of nonopioid analgesics varied substantially. After adjustment for potential confounders, 5.9% of inpatients receiving opioids had outpatient use at 90 days compared with 3.0% of those without inpatient use (difference, 3.0 percentage points [95% CI, 2.8 to 3.2 percentage points]). Opioid use at 90 days was higher in inpatients receiving opioids less than 12 hours before discharge than in those with at least 24 opioid-free hours before discharge (7.5% vs. 3.9%; difference, 3.6 percentage points [CI, 3.3 to 3.9 percentage points]). Differences based on proportion of the stay with opioid use were modest (opioid use at 90 days was 6.4% and 5.4%, respectively, for patients with opioid use for ≥75% vs. ≤25% of their stay; difference, 1.0 percentage point [CI, 0.4 to 1.5 percentage points]). Associations were similar for opioid use 365 days after discharge. LIMITATION Potential unmeasured confounders related to opioid use. CONCLUSION This study found high rates of opioid administration to opioid-naive inpatients and associations between specific patterns of inpatient use and risk for long-term use after discharge. PRIMARY FUNDING SOURCE UPMC Health System and University of Pittsburgh.
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Affiliation(s)
- Julie M Donohue
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (J.M.D.)
| | - Jason N Kennedy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | - Christopher W Seymour
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | - Timothy D Girard
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | | | - Catherine H Kim
- UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania (C.H.K.)
| | - Oscar C Marroquin
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
| | - Patience Moyo
- Brown University School of Public Health, Providence, Rhode Island (P.M.)
| | - Chung-Chou H Chang
- University of Pittsburgh School of Medicine and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (C.H.C.)
| | - Derek C Angus
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (J.N.K., C.W.S., T.D.G., O.C.M., D.C.A.)
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