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Interventions for Postsurgical Opioid PrescribingA Systematic Review

Educational Objective To identify which interventions are most effective in improving postsurgical opioid prescribing.
1 Credit CME
Key Points

Question  What interventions for improving stewardship in postsurgical opioid prescribing are effective?

Findings  In this systematic review, interventions operating at a physician or organizational level (eg, work flow changes) have shown positive results, while interventions at the patient level (eg, patient education) have shown mixed results. Monitoring for negative consequences was key across the studies evaluated.

Meaning  As attention on the opioid epidemic continues to rise, practices wishing to implement changes in postsurgical prescribing can refer to this review to develop an evidence-based intervention.

Abstract

Importance  Over the past 20 years, opioid misuse and opioid addiction have risen to epidemic proportions in the United States. One-third of adults receiving long-term opioid therapy report that their first opioid prescription came from a surgeon, indicating that postsurgical prescribing is an important point of intervention in the opioid epidemic. Such interventions differ from historical interventions on prescribing in that they must be closely monitored to ensure pain continues to be adequately controlled after surgical procedures. As evidence on nonopioid-based pain control grows, a key question is how to implement practice change in postsurgical discharge prescribing.

Objective  To examine interventions associated with changing opioid prescription practices on surgical discharge.

Evidence Review  Studies published after 2000 that included interventions that aimed at postsurgical opiate stewardship and evaluated outcomes were included. PubMed and Embase were searched through March 2018 for relevant articles, with additional articles retrieved based on citations in articles retrieved in the initial search. Quality was assessed by 2 independent reviewers using the Quality Assessment Tool for Quantitative Studies, and quality scores were reconciled through discussion and mutual agreement.

Findings  Eight studies met inclusion criteria, of which 3 were preintervention and postintervention comparison studies, 3 were controlled clinical studies, 1 was a time-series study, and 1 compared postintervention results with a predetermined baseline. Interventions done at the organization level, including changes to electronic health records order sets and workflow, showed clear positive results. Additionally, 2 studies that centered on developing guidelines based on actual patient opioid use and disseminating these guidelines to clinicians reported reductions up to 53% in the quantity prescribed. No increases in emergency department visits or refill requests were reported in studies measuring these outcomes. However, 1 study focused on reducing the number of children who were prescribed codeine found via check-in telephone calls that 13 of 240 patients (5.4%) had inadequately controlled pain.

Conclusions and Relevance  The studies reviewed provide evidence that clinician-mediated and organizational-level interventions are powerful tools in creating change in postsurgical opioid prescribing. This summary highlights paucity of high-quality studies that provide clear evidence on the most effective intervention at reducing postoperative opioid prescribing.

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Article Information

Corresponding Author: Mehul V. Raval, MD, MS, Emory University School of Medicine, Children’s Healthcare of Atlanta, 1405 Clifton Rd NE, Atlanta, GA 30322 (mehulvraval@gmail.com).

Accepted for Publication: May 15, 2018.

Published Online: August 15, 2018. doi:10.1001/jamasurg.2018.2730

Author Contributions: Ms Wetzel and Dr Raval had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wetzel, Raval.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wetzel.

Critical revision of the manuscript for important intellectual content: Raval, Hockenberry.

Administrative, technical, or material support: Wetzel.

Supervision: Raval.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Rollins School of Public Health Earn and Learn Program (Ms Wetzel) and the Robert Wood Johnson Foundation (Ms Wetzel and Drs Hockenberry and Raval), the Emory University Department of Surgery (Dr Raval), and the Emory and Children’s Healthcare of Atlanta Pediatric Research Alliance (Dr Raval).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Lisa D. Travis, MS, EdS, AHIP, Emory University, for her assistance with building the initial query. She was not compensated for these contributions.

References
1.
Rudd  RA, Aleshire  N, Zibbell  JE, Gladden  RM.  Increases in drug and opioid overdose deaths—United States, 2000-2014.  MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382. doi:10.15585/mmwr.mm6450a3PubMedGoogle ScholarCrossref
2.
American College of Surgeons. Statement on the opioid abuse epidemic. https://www.facs.org/about-acs/statements/100-opioid-abuse. Published 2017. Accesed June 29, 2018.
3.
Callinan  CE, Neuman  MD, Lacy  KE, Gabison  C, Ashburn  MA.  The initiation of chronic opioids: a survey of chronic pain patients.  J Pain. 2017;18(4):360-365. doi:10.1016/j.jpain.2016.11.001PubMedGoogle ScholarCrossref
4.
Voepel-Lewis  T, Wagner  D, Tait  AR.  Leftover prescription opioids after minor procedures: an unwitting source for accidental overdose in children.  JAMA Pediatr. 2015;169(5):497-498. doi:10.1001/jamapediatrics.2014.3583PubMedGoogle ScholarCrossref
5.
Bartels  K, Mayes  LM, Dingmann  C, Bullard  KJ, Hopfer  CJ, Binswanger  IA.  Opioid use and storage patterns by patients after hospital discharge following surgery.  PLoS One. 2016;11(1):e0147972. doi:10.1371/journal.pone.0147972PubMedGoogle ScholarCrossref
6.
Hill  MV, McMahon  ML, Stucke  RS, Barth  RJ  Jr.  Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.  Ann Surg. 2017;265(4):709-714. doi:10.1097/SLA.0000000000001993PubMedGoogle ScholarCrossref
7.
Bicket  MC, Long  JJ, Pronovost  PJ, Alexander  GC, Wu  CL.  Prescription opioid analgesics commonly unused after surgery: a systematic review.  JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831PubMedGoogle ScholarCrossref
8.
Haffajee  RL, Jena  AB, Weiner  SG.  Mandatory use of prescription drug monitoring programs.  JAMA. 2015;313(9):891-892. doi:10.1001/jama.2014.18514PubMedGoogle ScholarCrossref
9.
Ringwalt  C, Schiro  S, Shanahan  M,  et al.  The use of a prescription drug monitoring program to develop algorithms to identify providers with unusual prescribing practices for controlled substances.  J Prim Prev. 2015;36(5):287-299. doi:10.1007/s10935-015-0397-0PubMedGoogle ScholarCrossref
10.
Kumar  K, Kirksey  MA, Duong  S, Wu  CL.  A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively.  Anesth Analg. 2017;125(5):1749-1760. doi:10.1213/ANE.0000000000002497PubMedGoogle ScholarCrossref
11.
Tedesco  D, Gori  D, Desai  KR,  et al.  Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty: a systematic review and meta-analysis.  JAMA Surg. 2017;152(10):e172872. doi:10.1001/jamasurg.2017.2872PubMedGoogle ScholarCrossref
12.
Scully  RE, Schoenfeld  AJ, Jiang  W,  et al.  Defining optimal length of opioid pain medication prescription after common surgical procedures.  JAMA Surg. 2018;153(1):37-43. doi:10.1001/jamasurg.2017.3132PubMedGoogle ScholarCrossref
13.
Clarke  H, Poon  M, Weinrib  A, Katznelson  R, Wentlandt  K, Katz  J.  Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain.  Drugs. 2015;75(4):339-351. doi:10.1007/s40265-015-0365-2PubMedGoogle ScholarCrossref
14.
Thomas  BH, Ciliska  D, Dobbins  M, Micucci  S.  A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions.  Worldviews Evid Based Nurs. 2004;1(3):176-184. doi:10.1111/j.1524-475X.2004.04006.xPubMedGoogle ScholarCrossref
15.
Jackson  N, Waters  E.  Guidelines for systematic reviews in health promotion and public health taskforce: criteria for the systematic review of health promotion and public health interventions.  Health Promot Int. 2005;20(4):367-374. doi:10.1093/heapro/dai022PubMedGoogle ScholarCrossref
16.
Luk  LJ, Mosen  D, MacArthur  CJ, Grosz  AH.  Implementation of a pediatric posttonsillectomy pain protocol in a large group practice.  Otolaryngol Head Neck Surg. 2016;154(4):720-724. doi:10.1177/0194599815627810PubMedGoogle ScholarCrossref
17.
Stanek  JJ, Renslow  MA, Kalliainen  LK.  The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program.  J Hand Surg Am. 2015;40(2):341-346. doi:10.1016/j.jhsa.2014.10.054PubMedGoogle ScholarCrossref
18.
Hill  MV, Stucke  RS, McMahon  ML, Beeman  JL, Barth  RJ  Jr.  An educational intervention decreases opioid prescribing after general surgical operations.  Ann Surg. 2018;267(3):468-472.PubMedGoogle ScholarCrossref
19.
Holman  JE, Stoddard  GJ, Horwitz  DS, Higgins  TF.  The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: a surgeon-based comparative cohort study.  J Orthop Trauma. 2014;28(9):502-506. doi:10.1097/BOT.0000000000000085PubMedGoogle ScholarCrossref
20.
Sugai  DY, Deptula  PL, Parsa  AA, Don Parsa  F.  The importance of communication in the management of postoperative pain.  Hawaii J Med Public Health. 2013;72(6):180-184.PubMedGoogle Scholar
21.
Alter  TH, Ilyas  AM.  A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery.  J Hand Surg Am. 2017;42(10):810-815. doi:10.1016/j.jhsa.2017.07.003PubMedGoogle ScholarCrossref
22.
Howard  R, Waljee  J, Brummett  C, Englesbe  M, Lee  J.  Reduction in opioid prescribing through evidence-based prescribing guidelines.  JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436PubMedGoogle ScholarCrossref
23.
Prabhu  M, McQuaid-Hanson  E, Hopp  S,  et al.  A shared decision-making intervention to guide opioid prescribing after cesarean delivery.  Obstet Gynecol. 2017;130(1):42-46. doi:10.1097/AOG.0000000000002094PubMedGoogle ScholarCrossref
24.
Pennsylvania Orthopaedic Society. Opioid recommendations for acute pain. https://www.paorthosociety.org/resources/Documents/POS%20Opioid%20Statement%20and%20Recommendations%20Final.pdf. Accessed June 29, 2018.
25.
Raisch  DW.  A model of methods for influencing prescribing, part II: a review of educational methods, theories of human inference, and delineation of the model.  DICP. 1990;24(5):537-542. doi:10.1177/106002809002400514PubMedGoogle ScholarCrossref
26.
Raisch  DW.  A model of methods for influencing prescribing, part I: a review of prescribing models, persuasion theories, and administrative and educational methods.  DICP. 1990;24(4):417-421. doi:10.1177/106002809002400415PubMedGoogle ScholarCrossref
27.
Godin  G, Bélanger-Gravel  A, Eccles  M, Grimshaw  J.  Healthcare professionals’ intentions and behaviours: a systematic review of studies based on social cognitive theories.  Implement Sci. 2008;3:36. doi:10.1186/1748-5908-3-36PubMedGoogle ScholarCrossref
28.
Murshid  MA, Mohaidin  Z.  Models and theories of prescribing decisions: a review and suggested a new model.  Pharm Pract (Granada). 2017;15(2):990. doi:10.18549/PharmPract.2017.02.990PubMedGoogle ScholarCrossref
29.
Canadian Agency for Drugs and Technologies in Health. Rx for change. https://www.cadth.ca/rx-change. Published 2017. Accessed Oct 26, 2017.
30.
Soffin  EM, Waldman  SA, Stack  RJ, Liguori  GA.  An evidence-based approach to the prescription opioid epidemic in orthopedic surgery.  Anesth Analg. 2017;125(5):1704-1713. doi:10.1213/ANE.0000000000002433PubMedGoogle ScholarCrossref
31.
Katz  J, Weinrib  A, Fashler  SR,  et al.  The Toronto General Hospital transitional pain service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain.  J Pain Res. 2015;8:695-702. doi:10.2147/JPR.S91924PubMedGoogle ScholarCrossref
32.
Ghafoor  VL, Phelps  P, Pastor  J.  Implementation of a pain medication stewardship program.  Am J Health Syst Pharm. 2013;70(23):2070-2074-2075. doi:10.2146/ajhp120751PubMedGoogle ScholarCrossref
33.
Genord  C, Frost  T, Eid  D.  Opioid exit plan: A pharmacist’s role in managing acute postoperative pain.  J Am Pharm Assoc (2003). 2017;57(2S):S92-S98. doi:10.1016/j.japh.2017.01.016PubMedGoogle ScholarCrossref
34.
Waljee  JF, Li  L, Brummett  CM, Englesbe  MJ.  Iatrogenic opioid dependence in the United States: are surgeons the gatekeepers?  Ann Surg. 2017;265(4):728-730. doi:10.1097/SLA.0000000000001904PubMedGoogle ScholarCrossref
35.
O’Neill  DF, Webb Thomas  C.  Less is more: limiting narcotic prescription quantities for common orthopedic procedures.  Phys Sportsmed. 2014;42(4):100-105. doi:10.3810/psm.2014.11.2096PubMedGoogle ScholarCrossref
36.
Grindrod  KA, Patel  P, Martin  JE.  What interventions should pharmacists employ to impact health practitioners’ prescribing practices?  Ann Pharmacother. 2006;40(9):1546-1557. doi:10.1345/aph.1G300PubMedGoogle ScholarCrossref
37.
Otto  C, Crackau  B, Löhrmann  I,  et al.  Brief intervention in general hospital for problematic prescription drug use: 12-month outcome.  Drug Alcohol Depend. 2009;105(3):221-226. doi:10.1016/j.drugalcdep.2009.07.010PubMedGoogle ScholarCrossref
38.
Ostini  R, Hegney  D, Jackson  C,  et al.  Systematic review of interventions to improve prescribing.  Ann Pharmacother. 2009;43(3):502-513. doi:10.1345/aph.1L488PubMedGoogle ScholarCrossref
39.
Tran  T, Hardidge  A, Heland  M,  et al.  Slick scripts: impact on patient flow targets of pharmacists preparing discharge prescriptions in a hospital with an electronic prescribing system.  J Eval Clin Pract. 2017;23(2):333-339. doi:10.1111/jep.12615PubMedGoogle ScholarCrossref
40.
Brandal  D, Keller  MS, Lee  C,  et al.  Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: a historical-prospective study.  Anesth Analg. 2017;125(5):1784-1792. doi:10.1213/ANE.0000000000002510PubMedGoogle ScholarCrossref
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