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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.


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 (

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.

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