Pharmacology in Emergency Medicine
Changes in Provider Prescribing Patterns After Implementation of an Emergency Department Prescription Opioid Policy

https://doi.org/10.1016/j.jemermed.2016.07.120Get rights and content

Abstract

Background

Prescription opioid-associated abuse and overdose is a significant cause of morbidity and mortality in the United States. Opioid prescriptions generated from emergency departments (EDs) nationwide have increased dramatically over the past 20 years, and opioid-related overdose deaths have become an epidemic, according to the Centers for Disease Control and Prevention.

Objective

Our aim was to determine the effectiveness of implementing a prescription policy for opioids on overall opioid prescribing patterns in a hospital ED.

Methods

The ED provider group of an academic, non-university–affiliated urban hospital with 23,000 annual patient visits agreed to opioid prescribing guidelines for chronic pain with the goal of limiting prescriptions that may be used for abuse or diversion. These guidelines were instituted in the ED through collaborative staff meetings and educational and training sessions. We used the electronic medical record to analyze the number and type of opioid discharge prescriptions during the study period from 2006–2014, before and after the prescribing guidelines were instituted in the ED.

Results

The number of patients discharged with a prescription for opioids decreased 39.6% (25.7% to 15.6%; absolute decrease 10.2%; 95% confidence interval [CI] 9.6–10.7; p < 0.001) after the intervention. The improvements were sustained 2.5 years after the intervention. Decreases were seen in all major opioids (hydrocodone, oxycodone, hydromorphone, and codeine). The number of pills per prescription also decreased 14.8%, from 19.5% to 16.6% (absolute decrease 2.9; 95% CI 2.6–3.1; p < 0.001).

Conclusions

Implementation of an ED prescription opioid policy was associated with a significant reduction in total opioid prescriptions and in the number of pills per prescription.

Introduction

The Centers for Disease Control and Prevention has classified prescription drug abuse as an epidemic due to the recent dramatic increase in prescription drug overdose deaths in the past decade, with >13,000 deaths nationally since 2007 1, 2. The prescription of opioids for noncancer pain has also raised concerns for substance abuse, prescription drug diversion, increase in emergency department (ED) visits, overutilization of ED resources, and traumatic injuries caused by nonmedical use of prescription opioids. Among individuals who abused prescription opioids upon entering methadone treatment, 13% reported obtaining their opioids from EDs (3). Prescription opioid pain relievers are the leading cause of overdose deaths in the United States, accounting for 73.8% of prescription drug overdose deaths in 2008 (4). Opioid deaths surpassed motor-vehicle–related injuries as the highest cause of injury and death for the past several years (5). ED visits for prescription opioid misuse or diversion account for an estimated 950,000 ED visits each year (1).

Of particular concern, Washington State Department of Health (WADOH) data suggested higher rates of drug overdose deaths and a higher percentage of nonmedical use of prescription pain medication in Washington State compared to the rest of the nation 6, 7. Several potentially important factors in this increase include deregulation of prescription opioids in the mid-1990s, promotion of pain control initiatives as the fifth vital sign by The Joint Commission in 2001 with associated changes in provider prescribing patterns and creation of a long-acting formulation of oxycodone 6, 8, 9.

WADOH formed the ED Opioid Abuse Workgroup in 2009, a multi-stakeholder collaboration including the Washington State Hospital Association, Washington State Medical Association, and WA-ACEP (Washington State Chapter of American College of Emergency Physicians). This initiative led to the draft Opioid Prescribing Guidelines by mid-2010, designed to help curb the rapidly increasing opioid prescribing patterns and overdose rates (6).

There has been little analysis of the impact of an ED Opioid Prescribing Policy. Given the scope of this public health concern, implementing effective policies will be critical in reducing opioid prescription-related abuses and overdoses.

Our objective was to determine the effectiveness of implementing an opioid prescription policy on reducing opioid prescribing patterns at an urban, teaching, non–university-affiliated hospital.

Section snippets

Setting

This study was conducted as part of a quality-improvement project, resulting in a waiver by the Institutional Review Board. The setting is a 336-bed nonuniversity, teaching hospital serving primarily adults in the Pacific Northwest, with approximately 23,000 ED visits per year and about 16,000 ED visits per year that result in outpatient discharges.

Study Design

We performed a pre- and post-intervention time series study in which ED opioid prescription rates were compared during a 7-year period. The primary

Results

Between January 2007 and June 2014, there were 116,676 ED patient visits and 25,219 prescriptions for opioids. There were 34 providers who prescribed opioids in the ED, 11 were physician's assistants (PA) and 23 were physicians. Mean (standard deviation [SD]) patient age was 51.8 (20.2) years (range 18–106 years) and 61,693 (53%) were female. Patients after the intervention were slightly older (52.2 vs. 51.3 years; p < 0.001), and there were small differences in diagnosis categories (Table 1).

Discussion

Our study provides evidence of the effectiveness of an ED opioid prescribing policy with reductions in the rate of opioid prescribing and the number of doses per prescription in the setting of state initiatives aimed at reducing opioid prescriptions. The improvements were sustained through 2.5 years after the intervention. Prescriptions for oxycodone decreased most dramatically, with lesser decreases in hydrocodone, now the most commonly prescribed opioid and a designated Schedule III drug at

Conclusions

The prescription of opioids for patients with chronic non-cancer pain has dramatically increased during the course of the past 2 decades in the United States, resulting in a national epidemic of mortality associated with unintentional overdose, dependence, and abuse. Our study demonstrates that a formal ED policy with provider education can decrease ED opioid prescribing by nearly 40%. To help manage patient expectations, we placed the policy openly throughout the ED so that staff could review

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