A randomized trial looking at planning prompts to reduce opioid prescribing.
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ABSTRACT:
SUBMITTER: Doctor JN
PROVIDER: S-EPMC10786898 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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A randomized trial looking at planning prompts to reduce opioid prescribing.
Doctor Jason N JN Kelley Marcella A MA Goldstein Noah J NJ Lucas Jonathan J Knight Tara T Stewart Emily P EP
Nature communications 20240112 1
Prior work has demonstrated that personalized letters are effective at reducing opioid and benzodiazepine prescribing, but it is unclear whether If/when-then planning prompts would enhance this effect. We conducted a decedent-clustered trial which randomized 541 clinicians in Los Angeles County to receive a standard (n = 284), or comparator (n = 257) version of a letter with If/when-then prompts. We found a significant 12.85% (6.83%, 18.49%) and 8.32% (2.34%, 13.93%) decrease in the primary outc ...[more]
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Project description:BackgroundOverprescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. This study therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery.MethodsThis study included 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating 8-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on previous inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid and nonopioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial.ResultsThe total postdischarge opioid prescription was a median [quartile 1, quartile 3] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI, 0.80 to 1.13; P = 0.586). The alert was displayed in 28% (3,074 of 11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid and nonopioid combination medications or additional opioid prescriptions written after discharge.ConclusionsA decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.(Anesthesiology 2023; 139:186-96).Editor’s perspective
| S-EPMC10602614 | biostudies-literature
Project description:ObjectiveTo determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices.MethodsWe 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.ResultsOverall, 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).ConclusionsOur 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 registrationClinicalTrials.org ID: NCT03030469.
| S-EPMC9825153 | biostudies-literature
Project description:As the opioid crisis has escalated, states have enacted numerous policies targeting opioid access and monitoring possible misuse. Recently, the majority of states have passed electronic prescribing mandates for controlled substances. These mandates require that controlled substances be prescribed electronically directly to the pharmacy. The electronic system maintains a rich patient history that prescribers will observe when issuing a prescription while also reducing opportunities for fraud. The first enforced mandate was implemented in New York in March 2016; thus empirical evidence about the effects of such mandates is limited. We study how adoption of the New York e-prescribing mandate affected opioid supply and opioid-related overdoses. We estimate that the mandate reduced the rate of overdoses involving natural and semi-synthetic opioids by 22 %. We find little evidence of any corresponding changes in overdose rates involving illicit opioids.
| S-EPMC8222172 | biostudies-literature
Project description:BackgroundClinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.MethodsPrimary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.ResultsWe examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44-0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54-0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53-0.995).ConclusionsWe observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.Trial registrationClinicalTrials.gov: NCT01454960 .
| S-EPMC4975897 | biostudies-literature
Project description:ObjectiveTo determine if treatment with a 5-HT3 antagonist (ondansetron) reduces need for opioid therapy in infants at risk for neonatal opioid withdrawal syndrome (NOWS).Study designA multicenter, randomized, placebo controlled, double blind clinical trial of ninety (90) infants. The intervention arms were intravenous ondansetron or placebo during labor followed by a daily dose of ondansetron or placebo in infants for five days.ResultsTwenty-two (49%) ondansetron-treated and 26 (63%) placebo-treated infants required pharmacologic treatment (p > 0.05). The Finnegan score was lower in the ondansetron-treated group (4.6 vs. 5.6, p = 0.02). A non-significant trend was noted for the duration of hospitalization. There was no difference in need for phenobarbital or clonidine therapy, or total dose of morphine in the first 15 days of NOWS treatment.ConclusionsOndansetron treatment reduced the severity of NOWS symptoms; and there was an indication that it could reduce the length of stay.Clinical trial registrationClinicaltrials.gov NCT01965704.
| S-EPMC9968817 | biostudies-literature
Project description:ImportanceOpioid addiction or dependency is a serious crisis in the US that affects public health as well as social and economic welfare. The State of California passed Assembly Bill (AB) 2760 in 2018 that mandates the coprescription of naloxone and opioids for patients with a high overdose risk.ObjectiveTo assess whether the AB 2760-based electronic prompts were associated with increased naloxone orders for opioid users and reduced opioid prescribing when integrated into the practitioner workflow.Design, setting, and participantsThis cohort study used interrupted time series mixed models to evaluate data obtained from the regional integrated health care system Kaiser Permanente Southern California (KPSC) from January 1, 2018, to December 31, 2019. Clinician participants were continuously employed at KPSC during the study period and ordered an opioid analgesic for eligible patients in 2018. Patient participants were KPSC members aged 18 years or older who received an opioid analgesic prescription during the study period. A series of AB 2760-based electronic prompts were integrated into the KPSC electronic health record system on December 27, 2018. The prompts are triggered or activated when 1 or more opioid prescribing conditions, defined in the AB 2760, are met at outpatient visits. Data were analyzed from January 8, 2021, to September 15, 2021.ExposuresAssembly Bill 2760-based electronic prompts for outpatient opioid prescriptions in the electronic health record system.Main outcomes and measuresPrimary outcomes were changes in outpatient naloxone order rates among patients who were prescribed opioids and changes in outpatient opioid prescribing rates. Secondary outcomes were total morphine milligram equivalents (MMEs) ordered per prescriber-month, prompts-targeted objectives, and unintended consequences. Risk for opioid abuse among 3 types of patients was also assessed.ResultsThe 6515 eligible clinicians (mean [SD] age, 45.9 [9.43] years; 3604 men [55.3%]) included in the study served 500 711 unique patients in 1 903 289 outpatient encounters (mean [SD] age, 60.4 [15.67] years; 1 121 004 women [58.9%]) in which an opioid analgesic was prescribed. Naloxone order rate increased from 2.0% in December 2018 to 13.2% in January 2019 and then continued to increase to 27.1% in December 2019. Outpatient opioid prescribing rates decreased by 15.1% (rate ratio [RR], 0.85; 95% CI, 0.83-0.87) per prescriber-month when the electronic prompts were implemented. The postimplementation trend increased by 0.7% per prescriber-month (RR, 1.01; 95% CI, 1.01-1.01); the overall trend was still decreasing. The total MMEs per prescriber-month decreased by 7.8% (RR, 0.92; 95% CI, 0.89-0.96) after implementation of the prompts. The postimplementation trend tapered off. Other safe opioid prescribing measures also improved after implementation (decreases in concomitant muscle relaxants orders [RR, 0.94; 95% CI, 0.89-1.00], initial [RR, 0.86; 0.83-0.89] and renewal [RR, 0.65; 95% CI, 0.62-0.69] opioid orders, and long-term high-dose orders [RR, 0.96; 95% CI, 0.94-0.98]).Conclusions and relevanceThis study found an association between implementation of AB 2760-based prompts and increased naloxone order rate; improved opioid prescribing measures (ie, decreased concomitant muscle relaxants orders, initial and renewal opioid orders, and long-term high-dose orders), except monthly median MMEs; and reduced opioid prescribing. The findings suggest that opioid overdose risks can be mitigated by encouraging safe prescribing habits.
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Project description:ImportanceCenters for Disease Control and Prevention guidelines advocate reduced opioid prescribing for chronic pain, yet research on their implementation remains limited.ObjectiveTo compare 4 deimplementation strategies to promote guideline-concordant opioid prescribing.Design, setting, and participantsThis cluster randomized clinical trial was performed at 32 primary care clinics from 2 US health care systems from February 2020 to March 2022, using a hybrid type 3 sequential multiple-assignment design focused on patient outcomes. Clinics were recruited through volunteer sampling, including 268 clinicians and 8978 patients. Data were analyzed from September 2020 to March 2022.InterventionDeimplementation strategies were targeted at the system, clinic, and prescriber levels. All clinics received a system-level strategy consisting of quarterly educational meetings with monthly audit and feedback (EMAF) reports. At month 3, half the clinics were randomized to receive practice facilitation (PF), a clinic-level strategy that targets clinic workflows. At month 9, half the clinics were again randomized to add prescriber peer consulting (PPC), a prescriber-level strategy focused on challenging patient cases.Main outcomes and measuresThe primary outcome was change in mean morphine milligram equivalent (MME) dose in clinics receiving the least intensive bundle of deimplementation strategies (EMAF) vs the most intensive (EMAF plus PF plus PPC). Secondary outcomes included adherence to guideline metrics aimed at mitigating opioid risk.ResultsAmong the 8978 patients included in the analysis, 5142 (57.3%) were female; 42 (0.5%), American Indian or Alaska Native; 74 (0.8%), Asian or Pacific Islander; 411 (4.6%), Black; 187 (2.1%), Hispanic or Latino; 8127 (90.5%), White; and 137 (1.5%), other or unknown. Mean (SD) age was 58.3 (14.3) years. Eight clinics (including 66 prescibers and 2044 patients) assigned the most intensive strategy (EMAF plus PF plus PPC) had statistically significant effects on the primary outcome compared with 7 clinics (including 60 clinicians and 2427 patients) receiving the least intensive strategy (EMAF); clinics in the high-intensity group decreased the mean MME dose by 2.4 (95% CI, -4.3 to -0.5) mg/d more than the EMAF group (P = .02), representing a 6% reduction, and increased screening for pain severity, enjoyment of life, and general activity by 5.4% (95% CI, 0.4%-10.4% [P = .04]) more. Compared with EMAF, the most intensive strategy resulted in statistically significant decreases in urine drug screening (difference, -7.3% [95% CI, -11.5% to -3.0%]; P < .001) and use of treatment agreements (difference, -6.7% [95% CI, -11.1 to -2.3%]; P = .003), in the opposite direction of the hypothesis. There were no significant differences between groups in benzodiazepine coprescribing, mental health screening, or patients receiving an MME dose greater than or equal to 90.0 mg/d.Conclusions and relevanceIn this cluster randomized clinical trial, a high-intensity deimplementation strategy targeted at prescribers significantly decreased the MME dose and increased screening for pain intensity and pain-related interference while reducing use of treatment agreements and urine drug screening. Providing clinic- and prescriber-level deimplementation strategies may help health systems take positive steps toward reducing reliance on opioid medications for chronic pain management in primary care settings.Trial registrationClinicalTrials.gov Identifier: NCT04044521.
| S-EPMC11581553 | biostudies-literature
Project description:ObjectiveGuidance to address health literacy often focuses on health education rather than tools to facilitate action, despite action being important for self-management. This study evaluated an online intervention informed by health literate design principles and behavior change theory to reduce unhealthy snacking.Methods440 participants were recruited online and randomized to an intervention: 1) Health-literate action plan (guided implementation intention); 2) Standard action plan (self-guided implementation intention); 3) Education (healthy snacking fact-sheet). The primary outcome was self-reported unhealthy snacking. Follow-up was at 1 month.Results373 participants (84.8%) completed follow-up. Half the sample had adequate health literacy (52%), and the other half had low (24%) or possibly low (25%) health literacy, as measured by Newest Vital Sign (NVS). At follow-up, lower health literacy was associated with more unhealthy snacks and there was no overall difference between intervention groups. However, participants with lower health literacy who used the health-literate action plan reported less unhealthy snacking compared to the standard action plan; the reverse was true for those with higher health literacy scores (b = 1.7, p = 0.03). People scoring 2 points below the mean NVS (M = 3.4, SD = 2.0) using the health-literate action plan reported eating 8 fewer serves of unhealthy snacks, whereas people scoring 2 points above the mean NVS reported eating 6 more serves of unhealthy snacks using the same tool.ConclusionsThese findings suggest that the universal precautions approach currently recommended for health information may be less effective for facilitating action than tailoring to health literacy level.Trial registrationANZCTR identifier: ACTRN12617001194358.
| S-EPMC6336265 | biostudies-literature
Project description:BackgroundThe 2016 U.S. Centers for Disease Control Opioid Prescribing Guideline (CDC Guideline) is currently being revised amid concern that it may be harmful to people with chronic pain on long-term opioid therapy (CP-LTOT). However, a methodology to faithfully implement the CDC guideline, measure prescriber adherence, and systematically test its effect on patient and public health outcomes is lacking. We developed and tested a CDC Guideline implementation strategy (termed TOWER), focusing on an outpatient HIV-focused primary care setting.MethodsTOWER was developed in a stakeholder-engaged, multi-step iterative process within an Information, Motivation and Behavioral Skills (IMB) framework of behavior change. TOWER consists of: 1) a patient-facing opioid management app (OM-App); 2) a progress note template (OM-Note) to guide the office visit; and 3) a primary care provider (PCP) training. TOWER was evaluated in a 9-month, randomized-controlled trial of HIV-PCPs (N = 11) and their patients with HIV and CP-LTOT (N = 40). The primary outcome was CDC Guideline adherence based on electronic health record (EHR) documentation and measured by the validated Safer Opioid Prescribing Evaluation Tool (SOPET). Qualitative data including one-on-one PCP interviews were collected. We also piloted patient-reported outcome measures (PROMs) reflective of domains identified as important by stakeholders (pain intensity and function; mood; substance use; medication use and adherence; relationship with provider; stigma and discrimination).ResultsPCPs randomized to TOWER were 48% more CDC Guideline adherent (p < 0.0001) with significant improvements in use of: non-pharmacologic treatments, functional treatment goals, opioid agreements, prescription drug monitoring programs (PDMPs), opioid benefit/harm assessment, and naloxone prescribing. Qualitative data demonstrated high levels of confidence in conducting these care processes among intervention providers, and that OM-Note supported these efforts while experience with OM-App was mixed. There were no intervention-associated safety concerns (defined as worsening of any of the PROMs).ConclusionsCDC-guideline adherence can be promoted and measured, and is not associated with worsening of outcomes for people with HIV receiving LTOT for CP. Future work would be needed to document scalability of these results and to determine whether CDC-guideline adherence results in a positive effect on public health. Trial registration https://clinicaltrials.gov/ct2/show/NCT03669939 . Registration date: 9/13/2018.
| S-EPMC9108346 | biostudies-literature
Project description:Analgesia prescribing is fundamental to a patient's journey, affecting length of stay and patient experience. Laminated prompts are used throughout the NHS Foundation Trust to aid doctors prescribing. A baseline questionnaire was carried out to gather doctors' prescribing habits and current ability to convert opioids to their morphine equivalent. Ninety three percent of doctors said they were moderately to extremely confident when prescribing analgesia. However, when asked to carry out a simple opioid conversion only 14% answered correctly. Eighty three percent of doctors said they were prescribing laxatives alongside opioids frequently (57%) or almost all the time (25%). When actual rates were sampled only 14% of patients were prescribed a concurrent laxative. Laminated pain management guideline cards were created and distributed to doctors at sign in for weekly teaching. Doctor interviews were carried out to see if they were in possession of a prompt card and a simple opioid conversion question was asked. If they did not have a prompt card at the time of interview they were issued with one after answering the conversion question. Rates of concurrent laxative prescribing were collected from the electronic prescribing record of patients on the acute medical unit. Posters were displayed in doctors' offices and drug rooms. Laxative prescribing rates were re-collected and compared with the survey responses. Distribution of laminated prompts increased accuracy of opioid conversion by 86%. Error rates fell as prompt prevalence increased until there was 100% prevalence and 0% error. Concurrent prescribing of laxatives increased to 50% after posters were displayed around the acute medical unit. Doctors reported they were confident when prescribing analgesia. They reported that they often prescribed concurrent medications, however this did not relate to actual prescribing practices. Visual prompts improved doctors analgesia conversion knowledge and prescribing practices. Laminated prompt cards are now incorporated in new doctors' induction packs.
| S-EPMC4752706 | biostudies-literature