What are specific effective inpatient opioid stewardship interventions? Is there data regarding outcomes with default doses or durations for IV opioids?

Comment by InpharmD Researcher

Available evidence supports inpatient opioid stewardship interventions such as standardized prescribing practices, electronic health record (EHR)-based clinical decision support, audit and feedback, provider education, and multidisciplinary opioid stewardship programs. These interventions have been associated with reductions in opioid prescribing and opioid doses while maintaining appropriate pain management. Strategies focused on standardizing opioid orders, optimizing opioid selection and route of administration, and incorporating multimodal pain management approaches may help reduce unnecessary opioid exposure. Evidence evaluating default opioid doses or durations specifically for intravenous (IV) opioids remains limited; available default-setting studies have primarily evaluated opioid prescriptions at discharge rather than inpatient IV opioid administration. Therefore, while EHR defaults may reduce opioid prescribing and quantities, further data are needed to determine the impact of specific IV opioid dose or duration defaults on inpatient outcomes.
Background

Several review articles have evaluated opioid stewardship (OS) interventions across healthcare settings to promote appropriate opioid use and reduce opioid-related adverse events. Effective strategies include electronic health record (EHR)-based tools, dashboards with monitoring and audit feedback, provider education, academic detailing, opioid-focused committees or task forces, and multi-component interventions incorporating guideline-based prescribing practices. These approaches aim to support judicious opioid prescribing, reduce inappropriate high opioid doses, and improve adherence to recommended practices. Available evidence suggests that OS interventions may reduce opioid prescribing and opioid doses measured in morphine milligram equivalents (MMEs), although the strength of evidence varies by outcome. Components of opioid and pain stewardship programs described within the literature include executive support, an interdisciplinary stewardship committee, standardized opioid dosing strategies, multimodal pain management approaches, opioid safety metrics, and pharmacist involvement. Pharmacist-led teams may participate in multidisciplinary rounds, perform opioid-related interventions, and use reporting tools to identify patients receiving high-dose opioids, opioid infusions, patient-controlled analgesia (PCA), or other high-risk opioid regimens. Clinical decision support/EHR-based interventions and multi-component stewardship programs have been associated with reductions in opioid prescribing or doses without increases in pain, emergency department visits, or hospitalizations; however, evidence remains insufficient for several specific strategies, including opioid stewardship committees, clinical pharmacist consultation alone, opioid prescribing or ordering limits, dashboards, clinical audits, and prescriber feedback. Importantly, these review articles do not specifically evaluate the impact of default IV opioid doses or default IV opioid durations on inpatient outcomes, leaving a gap regarding these targeted interventions. [1], [2], [3]

Background References: [1] Shoemaker-Hunt SJ, Wyant BE. The Effect of Opioid Stewardship Interventions on Key Outcomes: A Systematic Review. J Patient Saf. 2020;16(3S Suppl 1):S36-S41. doi:10.1097/PTS.0000000000000710
[2] Santalo O. Before It Is Too Late: Implementation Strategies of an Efficient Opioid and Pain Stewardship Program. Hosp Pharm. 2021;56(3):159-164. doi:10.1177/0018578719882324
[3] Waldfogel JM, Rosen M, Sharma R, et al. Opioid Stewardship: Rapid Review. 2023 Dec. In: Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2023 Jul-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK598858/
Literature Review

A search of the published medical literature revealed 6 studies investigating the researchable question:

What are specific effective inpatient opioid stewardship interventions? Is there data regarding outcomes with default doses or durations for IV opioids?

Level of evidence

C - Multiple studies with limitations or conflicting results  Read more→


Please see Tables 1-6 for your response.

 

Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery

Design

Retrospective, single-institution study

N= 313

Objective

 To show that implementation of the nonopioid pain protocol would lead to a decrease in the oral and intravenous administration of opioids while maintaining acceptable levels of pain control in postoperative patients after minimally invasive lung surgery

Study Groups

Opioid-free protocol (n= 102)

Opioid protocol (n= 211)

Inclusion Criteria

All patients who underwent minimally invasive lobectomy before and after initiation of an opioid-free pain management protocol in January 2019 

Exclusion Criteria

None 

Methods

The analysis included opioid data on postoperative day 0, as well as for combined postoperative days 1 through 7 and the entire inpatient postoperative period. To standardize, all opioid medication doses were converted into morphine milligram equivalents (MME). A pain scale ranging from 0 to 10 was utilized, where 0 indicated no pain, 1 to 3 represented mild pain, 4 to 6 denoted moderate pain, 7 to 9 indicated severe pain, and 10 signified very severe pain. Pain scores were documented in the database along with vital signs, typically at 4-hour intervals. The average pain score was calculated by determining the mean of all recorded pain scores during the inpatient stay.

The opioid-free pain management approach involves preoperative patient education and medication, intraoperative nerve blocks, and a postoperative scheduled regimen. Patients receive 1,000 mg of acetaminophen and 300 mg of gabapentin before their surgeries. In the operating room, liposomal bupivacaine intercostal and serratus nerve blocks are administered. After the procedure, patients are prescribed 300 mg of gabapentin every 8 hours, 1,000 mg of acetaminophen every 8 hours, and 500 mg of methocarbamol every 6 hours. For patients with normal creatinine levels and no kidney disease history, 30 mg of ketorolac is also administered every 6 hours if other medications do not sufficiently manage pain, as determined by a provider on the thoracic surgery team. Medications are given at staggered intervals to ensure patients receive some form of pain relief approximately every 2 to 3 hours on average.

Opioids were administered at the provider's discretion when pain was not sufficiently managed with the opioid-free protocol. Opioid prescriptions were provided to patients upon discharge if they had consistently required opioid medications during their inpatient stay, with the decision made at the time of discharge. Patients who had received minimal or no oral opioids during their stay or those who initially received multiple opioid doses but later had effective pain control without opioids, usually after the removal of chest tubes, did not receive an opioid prescription upon discharge.

Prior to the introduction of the nonopioid protocol, there was no established pain management plan for minimally invasive lobectomy patients. Typically, patients were administered both oral and intravenous opioids, and patient-controlled analgesia (PCA) pumps were employed for nearly all patients. The decision to use PCA pumps in both groups depended on the provider's judgment, taking into consideration the patient's pain management needs and opioid consumption. Nerve blocks and epidurals were not employed, and gabapentin was only administered to patients who experienced typical subcostal nerve pain, often not until several weeks after the operation.

Duration

Opioid-free protocol: from January 2019 to November 2020

Postoperative opioids: from January 2016 to January 2019

Outcome Measures

Average MME, PCA opioid use, oral opioid use, home opioid prescription rate, pain control data

Baseline Characteristics

  

Opioid-free protocol (n= 102)

Opioid protocol (n= 211)

  

Age, years

 67  64   

Female

57% 48%  

Race

White

African American

Native American

Other

 

72%

28%

0

0 

 

80%

19%

0.5%

0.5% 

  

Last creatinine value, mg/dL

 1.0 ± 0.4  1.0 ± 0.5  

Comorbidities

Congestive heart failure

Coronary artery disease

Diabetes

Hypertension

Interstitial fibrosis

Pulmonary hypertension

On dialysis

Vascular disease

 

3% 

19%

19%

75%

1%

0

1%

11%

 

5% 

19%

25%

70%

1%

1%

0.5%

19%

  

Results

Endpoint

Opioid-free protocol (n= 102)

Opioid protocol (n= 211)

p-value

Mean MME, mg

POD 0

POD 1-7

Total stay

 

101

91 

195

 

309

513

1,218

 

< 0.001 

< 0.001 

0.018

PCA opioid use

POD 0

POD 1-7

Total stay

 

7.8%

8.8%

8.8%

 

78.2%

73.9%

81.0%

 

< 0.001

< 0.001

< 0.001 

Oral opioid MME, mg

POD 0

POD 1-7

Total stay

 

4.9

48

54 

 

5.2

113

131 

 

0.90 

< 0.001

< 0.001

Oral opioid use

POD 0

POD 1-7

Total stay

 

10.8%

41.2%

44.1% 

 

30.8%

94.8%

95.3%

 

< 0.001

< 0.001

< 0.001 

Home opioid prescriptions

38%

93%

< 0.001 

Pain control data

Average pain score (1-10)

Time pain score <3

Time pain score <6

 

2.9

56.5%

87.1%

 

4.0

42.0%

77.1%

 

< 0.001 

< 0.001 

< 0.001 

Abbreviations: MME, morphine milligram equivalent; PCA, patient-controlled analgesia; POD, postoperative day

Adverse Events

N/A

Study Author Conclusions

Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

InpharmD Researcher Critique

Retrospective chart reviews are subject to inaccuracies and missing data. The absence of a pre-planned nonopioid protocol during the time when most opioid group patients had surgery introduces potential bias. Randomized controlled trials would provide more robust data. Patient bias may affect pain scores due to preoperative education on the multimodal regimen. The inclusion of patients taking preoperative opioids may impact the data, but no cutoff for exclusion was established.



Table 1 References:
[4] Clark IC, Allman RD, Rogers AL, et al. Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery. Ann Thorac Surg. 2022;114(6):2008-2014. doi:10.1016/j.athoracsur.2022.03.059

 

A Health System–Wide Initiative to Decrease Opioid-Related Morbidity and Mortality

Design

Quality-improvement project 

Objective

To measure metrics related to care of patients on opioids and those with opioid use disorder (OUD) after implementation of an organizational opioid stewardship program (OSP) combatting opioid-related morbidity and mortality 

Study Groups

Pre-implementation

Post-implementation

Inclusion Criteria

Ambulatory care clinics, primary care practices, and hospitals within the Brigham Health; Dana-Farber Cancer Institute

Exclusion Criteria

Not specified 

Methods

Step-wise interventions were implemented to establish the system-wise OSP program. 

Intervention 1: Creation of an Organization-wide Opioid Program

Composition of the OSP executive committee: Program Director; Chair of the Department of Anesthesiology; Chair of the Department of Psychiatry; Chief Medical Officers of the main hospital, community-affiliated hospital, oncology center, and provider organization; Chief Medical Informatics Officer of Ambulatory Medicine; Chief Nursing Officer; Chief Physician Assistant; Chief Quality Officer; Director of Addiction Psychiatry; Director of the Division of Pain Medicine; Director of Graduate Medical Education; Director of Pharmacy; Director of Primary Care; Vice President of Community Health; Vice President of Strategy

Intervention 2: Creation of a Prescribing Task Force

The task force was responsible for creating safe prescribing guidelines for the health system’s clinicians. The group met monthly to create two guideline documents that apply to both the inpatient and outpatient settings, one for managing acute pain and one for managing chronic pain. 

Intervention 3: Creation of an Addiction Task Force

Members aimed to improve care for patients with OUD, which was cochaired by an addiction psychiatrist and a primary care physician. Additional focuses included a “bridge clinic” for OUD patients who were discharged from the hospital or emergency department and inpatients with medical problems resulting from OUD. 

Intervention 4: Education Initiatives and Creation of an Education Task Force

An “Opioid Grand Rounds” program was created and conducted every two months. Patient-oriented education was also established, with medication take-back program and easy access to naloxone. 

Intervention 5: Engage Information Technology (IT) Resources to Aid in Prescriber Decision Support

Content of Opioid "SmartForm:"

Designated opioid prescriber
Medication agreement filed
Last prescription drug monitoring program review
Opioid name & dose and instructions
Opioid #2 name & dose and instructions
Beginning date of opioid therapy
Anticipated end date of opioid therapy
Presence of high-risk features (these auto-populate from elsewhere in the record, if present)
     History of substance use disorder, no active use
     Active substance use disorder
     Methadone on active med list
     History of opioid overdose
     Benzodiazepine on active med list
     Opioid risk tool score of 8 or greater
     Buprenorphine or naltrexone on active med list
     Opioid morphine equivalent of >50 mg/day
Pain history
Current additional interventions
Current or past pain clinic/specialist care
Evaluation frequency (weekly, every 2 weeks, monthly, every 2 months, every 4 months)
Toxicology screening frequency (weekly, every 2 weeks, monthly, every 4 months, annually)
Naloxone on active med list
Additional comments

Intervention 6: Create Opioid-Related Metrics to Determine Successes and Need for Improvement (see 'Outcome Measures' below)

Duration

The project began in February 2016 and is ongoing

Outcome Measures

Opioid Stewardship Program Measures

Task Numerator  Denominator  Goal 

Overall Goals

Reduce # fatal overdoses

Reduce # nonfatal overdoses

 

# fatal overdoses

# nonfatal overdoses

 

health system “covered lives”

health system “covered lives”

 

50% reduction 

50% reduction

State Opioid Law Metrics

Pain treatment agreements for pts
taking opioids >90 days

Utilization of a screening tool for risk assessment

Review of state PDMP

 

# signed pain treatment agreements in EHR

# risk assessments documented in EHR

# documented lookups

 

# pts on opioids >90 days

# pts on opioids of any length or dose

# pts on opioids of any length or dose

 

100% performance 

100% performance 

100% performance 

Safe Prescribing Task Force Metrics

Urine toxicology screening for chronic opioid pts

Concurrent naloxone for pts on >50 MME per day

Visits every 4 months for pts on chronic opioids

 

# urine toxicology screens ordered

# naloxone prescriptions

# pts on chronic opioids with visits in the past 4 months

 

# pts on opioids >90 days

# pts on opioid doses of >50 MME per day

# pts on opioids >90 days

 

100% performance 

100% performance 

90% performance 

RADEO (Inpatient) Metrics 

Major ADEs

Minor ADEs

 

# major ADEs after first dose of opioids (e.g. death, transfer to ICU, code blue)

# minor ADEs after first dose of opioids (e.g. pruritus, delirium, excessive sedation)

 

Total # patient-days

Total # patient-days

 

50% reduction

25% reduction

Addiction Task Force Metrics

Naloxone Rx at ED discharge after overdose

Increase # of pts receiving MAT

Increase number of providers waivered to prescribe MAT

Increase proportion of providers that prescribe

# pts offered SUD evaluation within 24 hours of OD in the ED

 

# naloxone kits or prescriptions dispensed

# pts prescribed MAT

# providers waivered

# providers who have written >1 MAT Rx

# SUD evaluations offered in 24
hours

 

# pts presenting to ED with OD

# high-risk pts on opioid registry

# primary care providers

# primary care providers

# pts presenting to ED with OD

 

 

100% performance

N/A

40% of all PCPs

50% of PCPs waivered

100% performance
Abbreviations: ADEs, adverse drug events; ED, emergency department; EHR, electronic health record; MME, morphine milligram equivalents; MAT, medication-assisted substance use treatment; N/A, not applicable; OD, overdose; PCP, primary care provider; PDMP, prescription drug monitoring programs; pts, patients; RADEO, Reducing Adverse Drug Events Related to Opioids; SUD, substance use disorder

 

Baseline Characteristics

 Individual-level patient data were not provided. 

Results

Endpoint

 Pre-implementation

Post-implementation

Difference; p-value 

Overall Schedule II opioid prescribing

 8,941 (July 2015) 6,148 (April 2018) -73.5 prescriptions/month; <0.001

Mean MME per prescription

 - - -0.4 MME/month; <0.001)

Number of unique patients
receiving an opioid prescription each month

 6,863 (July 2015) 4,894 (April 2018) -52.6 patients/month; <0.001

Prescriptions containing a total of ≥ 90 MME

 - - -48.1 prescriptions/month; <0.001

Buprenorphine/naloxone for OUD

Number of prescriptions 

Number of prescribers 

 - -

 

+6.0 prescriptions/month; <0.001

+0.4 providers/month; <0.001

The number of overdoses fluctuates markedly by month, and although the overall linear trend is downward it does not reach statistical significance (-0.2 overdoses/month; p= 0.29). Other metrics, such as inpatient opioid-related adverse events, overdoses for patients covered by primary care physicians as opposed to all overdoses, characteristics of post-operative opioid prescriptions, compliance with PDMP queries, and best practices for patients on chronic opioids, are in development.

Adverse Events

See results 

Study Author Conclusions

This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.

InpharmD Researcher Critique

As the OSP is still ongoing at the time of study publications, the results of certain measurements require further investigation. Certain implemented interventions and metric measurements may be institution-specific and not readily applicable to other health systems.  



Table 2 References:
[5] Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3-13. doi:10.1016/j.jcjq.2018.07.003
Standardized electronic order sets decreases inpatient opioid use in emergency general surgery
Design

Non-randomized process improvement initiative at a single large tertiary-care academic medical center

N= 852
Objective To implement existing best practices for inpatient pain management into a protocolized electronic order set and determine its effect in reducing inpatient opioid use among EGS patients
Study Groups

Pre-protocol cohort (n= 635)

Post-protocol cohort (n= 217)
Inclusion Criteria Patients ≥18 years old admitted to an acute care setting to the EGS service under the 'General Surgery Admission' order set from January 2019–June 2023
Exclusion Criteria EGS patients admitted directly to the Surgical Intensive Care Unit (SICU)
Methods An interprofessional team created new electronic order sets for inpatient pain management, removing outdated medications and adding non-pharmacological interventions. Oral and IV morphine milligram equivalents (MME) were monitored from Jan 2019–Jun 2023. Statistical analysis was performed using SPSS version 29.0 and QI Macros for Excel.
Duration January 2019 to June 2023
Outcome Measures

Primary: Total MME and MME per opioid dose administered

Secondary: Pain score and formulation trends
Baseline Characteristics   Pre-protocol (n= 635) Post-protocol (n= 217)  
Age, years 48.2 ± 17.1 50.2 ± 18.5  
BMI, kg/m2 30.9 ± 22.2 29.6 ± 8.8  
Male 296 (46.6%) 95 (43.8%)  
Length of stay, days (IQR) 3.0 (1.7, 5.6) 3.0 (1.8, 5.7)  
Surgery 407 (64.1%) 143 (65.9%)  
Results   Pre-protocol (n= 635) Post-protocol (n= 217) p-value
Total MME per month 2,128.4 ± 1286.6 1,478.0 ± 996.5 0.07
Average monthly MME per medication dose 11.6 ± 4.9 8.4 ± 3.5 <0.001
Average total MME per patient 140.8 ± 247.5 81.7 ± 124.4 <0.001
Average MME per dose per patient 10.7 ± 3.4 7.7 ± 2.1 <0.001
Adverse Events Not specifically reported in the study
Study Author Conclusions Standardized pain management protocols decreased in-hospital opioid use in EGS patients, increased multimodal pain medications, decreased variability in formulation trends, and resulted in stable patient reported pain scores.
Critique The study effectively demonstrated a reduction in opioid use through standardized protocols, but its single-institution design may limit generalizability. The inability to differentiate types of operations and the exclusion of SICU patients are notable limitations. Additionally, the lack of detailed demographic data and exclusion of PCA pump data may affect the comprehensiveness of the findings.

 

Table 3 References:
[6] Lucy AT, Sickels AD, Dasinger EA, et al. Standardized electronic order sets decreases inpatient opioid use in emergency general surgery. Am J Surg. 2025;244:116299. doi:10.1016/j.amjsurg.2025.116299

 

Association of an Opioid Standard of Practice Intervention With Intravenous Opioid Exposure in Hospitalized Patients
Design

Pilot study conducted in an adult general medical unit in an urban academic medical center

N= 127
Objective To assess an intervention to reduce intravenous opioid use, total parenteral opioid exposure, and the rate of patients administered parenteral opioids
Study Groups

Intervention group (n= 127)

Control group (n=  287)
Inclusion Criteria All patients present for at least 1 midnight on the intervention unit
Exclusion Criteria Not specified
Methods

Adoption of a local opioid standard of practice preferring oral and subcutaneous routes over intravenous administration, with education for prescribers and nursing staff. Data were collected from electronic health records, and pain scores were measured on a standard 0- to 10-point Likert scale

The intervention combined implementation of a local opioid standard of practice with targeted education for prescribers and nursing staff. The standard prioritized oral opioid administration when patients could tolerate oral intake and recommended the subcutaneous route over the intravenous route when parenteral opioids were needed, while still allowing prescribers to use intravenous opioids at their discretion. Education included training on the new prescribing standard, subcutaneous opioid administration, equianalgesic dose conversions, and opioid pharmacokinetics through didactic sessions, emails, and reinforcement during nursing huddles. Nursing staff were also encouraged to remind prescribers to follow the new practice standard.
Duration Control period: 6 months; Intervention period: 3 months
Outcome Measures

Primary: Reduction in intravenous doses administered per patient-day

Secondary: Total parenteral and overall opioid doses per patient-day, parenteral and overall opioid exposure per patient-day, daily rate of patients receiving parenteral opioids, pain scores over the first 5 days of hospitalization
Baseline Characteristics   Control Intervention
No. of patients 287 127
Age, mean  56.1 ± 18.5 57.6 ± 18.5
Men 113 (9.4%) 59 (46.5%)
BMI 28.5 ± 8.9 28.7 ± 8.9
Results   Control Intervention p-value
Intravenous opioid doses per patient-day 0.39 0.06 <0.001
Total parenteral opioid doses per patient-day 0.39 0.18 <0.001
Daily rate of patients receiving parenteral opioids 14% 6% <0.001
Overall opioid doses per patient-day 0.95 0.73 0.02
Mean daily overall opioid exposure (MMEs) 9.11 ± 7.34 6.30 ± 4.12 -
Adverse Events Not specified
Study Author Conclusions An intervention targeting the use of intravenous opioids may be associated with reduced opioid exposure while providing effective pain control to hospitalized adults
Critique The study demonstrated a significant reduction in intravenous opioid use with maintained or improved pain control, highlighting the potential for practice changes to reduce opioid exposure. However, the study was limited by its single-center design and lack of generalizability to other settings or specialties. Further research is needed to explore the scalability and long-term effects of such interventions.
Table 4 References:
[7] Ackerman AL, O'Connor PG, Doyle DL, et al. Association of an Opioid Standard of Practice Intervention With Intravenous Opioid Exposure in Hospitalized Patients. JAMA Intern Med. 2018;178(6):759-763. doi:10.1001/jamainternmed.2018.1044
Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study
Design

Quasi-experimental retrospective pre–post analysis

N= 78,246 prescriptions
Objective To determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system
Study Groups

Pre-intervention (n= 38,976 prescriptions)

Post-intervention (n= 39,270 prescriptions)
Inclusion Criteria All opioid prescriptions prescribed at the institution for nonchronic pain
Exclusion Criteria Prescriptions for buprenorphine or methadone; patients with chronic pain; prescriptions written in the ED
Methods Modifications to the EHR included making duration of treatment mandatory, adding a quick button for 3 days' duration, and setting the default quantity to 10 tablets. Data on quantity, duration, and MME/day were compared pre and post-intervention.
Duration September 1, 2017, to August 31, 2019
Outcome Measures Reduction in median quantity of tablets dispensed, median duration of treatment, and proportion of prescriptions greater than 90 MME/day
Baseline Characteristics   Pre-intervention (n= 38,976) Post-intervention (n= 39,270)
Median quantity of tablets dispensed (IQR) 54 (40-120) 42 (18-90)
Median duration of treatment, days (IQR) 10.5 (5.0-30) 7.5 (3.0-30)
Proportion of prescriptions >90 MME/day 27.46% 22.86%
Results   Pre-intervention Post-intervention p-value
Median quantity of tablets dispensed (IQR) 54 (40-120) 42 (18-90) <0.001
Median duration of treatment, days (IQR) 10.5 (5.0-30) 7.5 (3.0-30) <0.001
Proportion of prescriptions >90 MME/day 27.46% 22.86% <0.001
Study Author Conclusions Modifications of opioid prescribing presets in the EHR can improve prescribing practice patterns. Reducing duration and quantity of opioid prescriptions could reduce the risk of dependence and overdose.
Critique The study effectively demonstrated a reduction in opioid prescribing through EHR modifications, which is a simple and scalable intervention. However, the study's quasi-experimental design limits causal inference, and the results may not be generalizable beyond the specific hospital system studied. Additionally, the exclusion of chronic pain patients and ED prescriptions may limit the applicability of findings to broader patient populations.

 

Table 5 References:
[8] Slovis BH, Riggio JM, Girondo M, et al. Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre-Post Study. J Med Internet Res. 2021;23(4):e24360. Published 2021 Apr 14. doi:10.2196/24360

 

Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed
Design

Cluster randomized clinical trial with 2 parallel arms

N= 21,331
Objective To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use
Study Groups

Intervention arm (n= 11,723)

Control arm (n= 9,608)
Inclusion Criteria Patients aged 18 years or older who received a new opioid analgesic prescription at a study site, with no other opioid prescription in the preceding 6 months, and no ICD-10-CM diagnosis code for cancer within 1 year before the new prescription
Exclusion Criteria Not explicitly stated, but implied exclusion of patients with recent opioid prescriptions or cancer diagnosis
Methods The intervention involved setting a default dispense quantity of 10 tablets for new opioid prescriptions in the EHR, which was fully modifiable. The control group had no change in EHR defaults. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation
Duration June 13, 2016, to June 13, 2018
Outcome Measures

Primary: Quantity of opioid analgesics prescribed with the new default prescription

Secondary: Opioid analgesic reorders and health service use within 30 days after the new prescription
Baseline Characteristics   Intervention arm (n= 3560) Control arm (n= 3957)
Age, median (IQR) 51.9 (38.2-63.1) 50.5 (37.4-62.5)
Women 2203 (61.9%) 2571 (65.0%)
Race/ethnicity - Black, non-Hispanic 1090 (30.6%) 1332 (33.7%)
Race/ethnicity - Hispanic/Latinx, any race 1678 (47.1%) 1636 (41.3%)
Race/ethnicity - White, non-Hispanic/Latinx 192 (5.4%) 439 (11.1%)
Pain diagnosis category - Limb or extremity pain or arthritis 1222 (34.3%) 1190 (30.1%)
Results   Intervention arm (unadjusted) Control arm (unadjusted) Adjusted DID (95% CI)
Dispense quantity ≤10 tablets, No. (%) 3337 (54.1%) 2751 (36.0%) 7.6 (6.1 to 9.2) 
Tablets prescribed, No. - Mean  25.3 ± 56.9 34.7 ± 79.0 −2.1 (−3.3 to −0.9)
MME prescribed, No. - Mean  144.9 ± 298.2 197.8 ± 406.8  −14.6 (−22.6 to −6.6)
Opioid analgesic prescription reorder, No. (%) 750 (12.2%) 938 (12.3%) 0.5 (−0.7 to 1.8)
Total tablets prescribed, No. - Mean  30.8 ± 69.8 40.9 ± 92.4 −2.7 (−4.8 to −0.6)
Total MME prescribed, No. - Mean  186.4 ± 501.6 244.7 ± 564.6 −15.8 (−33.8 to 2.2)
Adverse Events No significant differences in health service use between the intervention and control arms within 30 days after the new prescription
Study Author Conclusions 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. This suggests that modifying EHR prescribing defaults is a feasible intervention to modestly reduce prescribing.
Critique The study's strengths include its randomized design and large sample size, which enhance the reliability of the findings. However, the study is limited by its single-center setting, which may affect generalizability. Additionally, the lack of data on prescriptions and visits outside the medical center could lead to underestimation of outcomes. The study also did not capture patient-oriented outcomes such as pain or quality of life, which are important for understanding the full impact of the intervention.
Table 6 References:
[9] Bachhuber MA, Nash D, Southern WN, et al. 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(4):e217481. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.7481