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Appl Clin Inform 2023; 14(05): 961-972
DOI: 10.1055/s-0043-1776879
Research Article

Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices

Meghan K. Wally
1   Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
2   Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
,
Michael E. Thompson
2   Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
,
Susan Odum
1   Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
2   Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
,
Donna M. Kazemi
3   School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
,
Joseph R. Hsu
1   Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
,
Rachel B. Seymour
1   Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
,
and PRIMUM Group › Institutsangaben Funding This work was supported in part by a cooperative agreement (CE14-004 Award Number CE002520) from the CDC and an internal grant from the Carolinas Trauma Network Research Center of Excellence. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.
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Abstract

Objectives This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.

We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices.

Methods We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing.

Results This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing.

Conclusion A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.

Keywords

opioids - musculoskeletal pain - chronic pain - clinical decision support - implementation - alert

Protection of Human and Animal Subjects

This project was approved by the Atrium Health IRB (12–14–04E) and the Wake Forest University School of Medicine IRB (IRB-M-21–0402).


* PRIMUM GROUP: Michael Beuhler, MD4; Michael Bosse, MD1; Michael Gibbs, MD5; Christopher Griggs, MD5; Steven Jarrett, PharmD6; Daniel Leas, MD1,7; Tamar Roomian, MS, MPH1; Michael Runyon, MD5; Animita Saha, MD8; Brad Watling, MD9; Ziqing Yu, MS.1


Supplementary Material



Publikationsverlauf

Eingereicht: 10. Mai 2023

Angenommen: 09. Oktober 2023

Artikel online veröffentlicht:
06. Dezember 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 United States Bone and Joint Decade.. The Burden of Musculoskeletal Diseases in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008
    Google Scholar
  • 2 Mokdad AH, Ballestros K, Echko M. et al; US Burden of Disease Collaborators. The State of US Health, 1990-2016: burden of diseases, injuries, and risk factors among US states. JAMA 2018; 319 (14) 1444-1472
    CrossrefPubMedGoogle Scholar
  • 3 Wilson N, Kariisa M, Seth P, Smith IV H, Davis NL. Drug and opioid-involved overdose deaths - United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020; 69 (11) 290-297
    CrossrefPubMedGoogle Scholar
  • 4 Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain 2014; 30 (07) 557-564
    CrossrefPubMedGoogle Scholar
  • 5 Zedler B, Xie L, Wang L. et al. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med 2014; 15 (11) 1911-1929
    CrossrefPubMedGoogle Scholar
  • 6 Bohnert AS, Valenstein M, Bair MJ. et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011; 305 (13) 1315-1321
    CrossrefPubMedGoogle Scholar
  • 7 Ivers N, Dhalla IA, Allan GM. Opioids for osteoarthritis pain: benefits and risks. Can Fam Physician 2012; 58 (12) e708
    PubMedGoogle Scholar
  • 8 American Academy of Orthopaedic Surgeons. AAOS releases new clinical practice guideline for osteoarthritis of the hip. 2017 . Accessed October 18, 2023 at: http://newsroom.aaos.org/media-resources/news/aaos-releases-new-clinical-practice-guideline-for-osteoarthritis-of-the-hip.htm
    PubMed
  • 9 Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg 2013; 21 (09) 571-576
    PubMedGoogle Scholar
  • 10 Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ; 2015. 350. g6380
    Google Scholar
  • 11 Petzke F, Klose P, Welsch P, Sommer C, Häuser W. Opioids for chronic low back pain: an updated systematic review and meta-analysis of efficacy, tolerability and safety in randomized placebo-controlled studies of at least 4 weeks of double-blind duration. Eur J Pain 2020; 24 (03) 497-517
    CrossrefPubMedGoogle Scholar
  • 12 Cryar KA, Hereford T, Edwards PK, Siegel E, Barnes CL, Mears SC. Preoperative smoking and narcotic, benzodiazepine, and tramadol use are risk factors for narcotic use after hip and knee arthroplasty. J Arthroplasty 2018; 33 (09) 2774-2779
    CrossrefPubMedGoogle Scholar
  • 13 Hsia HL, Takemoto S, van de Ven T. et al. Acute pain is associated with chronic opioid use after total knee arthroplasty. Reg Anesth Pain Med 2018; 43 (07) 705-711
    PubMedGoogle Scholar
  • 14 Cheah JW, Sing DC, McLaughlin D, Feeley BT, Ma CB, Zhang AL. The perioperative effects of chronic preoperative opioid use on shoulder arthroplasty outcomes. J Shoulder Elbow Surg 2017; 26 (11) 1908-1914
    CrossrefPubMedGoogle Scholar
  • 15 Bell KL, Shohat N, Goswami K, Tan TL, Kalbian I, Parvizi J. Preoperative opioids increase the risk of periprosthetic joint infection after total joint arthroplasty. J Arthroplasty 2018; 33 (10) 3246-3251.e1
    CrossrefPubMedGoogle Scholar
  • 16 Hernandez NM, Parry JA, Mabry TM, Taunton MJ. Patients at risk: preoperative opioid use affects opioid prescribing, refills, and outcomes after total knee arthroplasty. J Arthroplasty 2018; 33 (7S, 7s): S142-S146
    CrossrefPubMedGoogle Scholar
  • 17 Birthi P, Nagar VR, Nickerson R, Sloan PA. Hypogonadism associated with long-term opioid therapy: a systematic review. J Opioid Manag 2015; 11 (03) 255-278
    CrossrefPubMedGoogle Scholar
  • 18 Gudin JA, Laitman A, Nalamachu S. Opioid related endocrinopathy. Pain Med 2015; 16 (Suppl. 01) S9-S15
    CrossrefPubMedGoogle Scholar
  • 19 Webster LR. Opioid-induced constipation. Pain Med 2015; 16 (Suppl. 01) S16-S21
    CrossrefPubMedGoogle Scholar
  • 20 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016; 65 (Suppl. 01) 1-49
    CrossrefPubMedGoogle Scholar
  • 21 Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71 (Suppl. 03) 1-95
    CrossrefPubMedGoogle Scholar
  • 22 Goldstick JE, Guy GP, Losby JL, Baldwin G, Myers M, Bohnert ASB. Changes in initial opioid prescribing practices after the 2016 release of the CDC guideline for prescribing opioids for chronic pain. JAMA Netw Open 2021; 4 (07) e2116860
    CrossrefPubMedGoogle Scholar
  • 23 Bohnert ASB, Guy Jr GP, Losby JL. Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 Opioid Guideline. Ann Intern Med 2018; 169 (06) 367-375
    CrossrefPubMedGoogle Scholar
  • 24 Sutherland TN, Wunsch H, Pinto R. et al. Association of the 2016 US Centers for Disease Control and Prevention opioid prescribing guideline with changes in opioid dispensing after surgery. JAMA Netw Open 2021; 4 (06) e2111826
    CrossrefPubMedGoogle Scholar
  • 25 Salvatore PP, Guy GP, Mikosz CA. Changes in opioid dispensing by medical specialties after the release of the 2016 CDC guideline for prescribing opioids for chronic pain. Pain Med 2022; 23 (11) 1908-1914
    CrossrefPubMedGoogle Scholar
  • 26 Togun AT, Karaca-Mandic P, Wurtz R, Jeffery MM, Beebe T. Association of 3 CDC opioid prescription guidelines for chronic pain and 2 payer pharmacy coverage changes on opioid initiation practices. J Manag Care Spec Pharm 2021; 27 (10) 1352-1364
    PubMedGoogle Scholar
  • 27 Langnas E, Bishara A, Croci R. et al. Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention's 2016 opioid prescribing guideline. BMC Anesthesiol 2022; 22 (01) 141
    CrossrefPubMedGoogle Scholar
  • 28 Zgierska AE, Robinson JM, Lennon RP. et al. Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project. BMC Fam Pract 2020; 21 (01) 245
    CrossrefPubMedGoogle Scholar
  • 29 Ancker JS, Gossey JT, Nosal S. et al. Effect of an electronic health record “nudge” on opioid prescribing and electronic health record keystrokes in ambulatory care. J Gen Intern Med 2021; 36 (02) 430-437
    CrossrefPubMedGoogle Scholar
  • 30 Spithoff S, Mathieson S, Sullivan F. et al. Clinical decision support systems for opioid prescribing for chronic non-cancer pain in primary care: a scoping review. J Am Board Fam Med 2020; 33 (04) 529-540
    CrossrefPubMedGoogle Scholar
  • 31 Moride Y, Lemieux-Uresandi D, Castillon G. et al. A systematic review of interventions and programs targeting appropriate prescribing of opioids. Pain Physician 2019; 22 (03) 229-240
    CrossrefPubMedGoogle Scholar
  • 32 Crusco S, Smith E, Rajupet S. Improving intranasal naloxone prescribing through EMR modification and automation. J Addict Med 2021; 15 (03) 181-186
    CrossrefPubMedGoogle Scholar
  • 33 Heiman E, Lanh S, Moran TP, Steck A, Carpenter J. Electronic advisories increase naloxone prescribing across health care settings. J Gen Intern Med 2023; 38 (06) 1402-1409
    CrossrefPubMedGoogle Scholar
  • 34 Siff JE, Margolius D, Papp J, Boulanger B, Watts B. A healthcare system-level intervention to increase naloxone availability for patients with opioid prescriptions. Am J Addict 2021; 30 (02) 179-182
    CrossrefPubMedGoogle Scholar
  • 35 Jennings LK, Ward R, Pekar E. et al. The effectiveness of a noninterruptive alert to increase prescription of take-home naloxone in emergency departments. J Am Med Inform Assoc 2023; 30 (04) 683-691
    CrossrefPubMedGoogle Scholar
  • 36 Pierce RP, Eskridge B, Ross B, Wright M, Selva T. Impact of a vendor-developed opioid clinical decision support intervention on adherence to prescribing guidelines, opioid prescribing, and rates of opioid-related encounters. Appl Clin Inform 2022; 13 (02) 419-430
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 37 Smith LB, Golberstein E, Anderson K. et al. The association of EHR drug safety alerts and co-prescribing of opioids and benzodiazepines. J Gen Intern Med 2019; 34 (08) 1403-1405
    CrossrefPubMedGoogle Scholar
  • 38 Price-Haywood EG, Burton J, Burstain T. et al. Clinical effectiveness of decision support for prescribing opioids for chronic noncancer pain: a prospective cohort study. Value Health 2020; 23 (02) 157-163
    CrossrefPubMedGoogle Scholar
  • 39 Seymour RB, Leas D, Wally MK, Hsu JR. PRIMUM Group. Prescription reporting with immediate medication utilization mapping (PRIMUM): development of an alert to improve narcotic prescribing. BMC Med Inform Decis Mak 2016; 16 (01) 111
    CrossrefPubMedGoogle Scholar
  • 40 Gugelmann H, Shofer FS, Meisel ZF, Perrone J. Multidisciplinary intervention decreases the use of opioid medication discharge packs from 2 urban EDs. Am J Emerg Med 2013; 31 (09) 1343-1348
    CrossrefPubMedGoogle Scholar
  • 41 Rathlev N, Almomen R, Deutsch A, Smithline H, Li H, Visintainer P. Randomized controlled trial of electronic care plan alerts and resource utilization by high frequency emergency department users with opioid use disorder. West J Emerg Med 2016; 17 (01) 28-34
    CrossrefPubMedGoogle Scholar
  • 42 Foy R, Leaman B, McCrorie C. et al. Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016; 6 (05) e010276
    CrossrefPubMedGoogle Scholar
  • 43 Cron DC, Lee JS, Dupree JM. et al. Provider characteristics associated with outpatient opioid prescribing after surgery. Ann Surg 2020; 271 (04) 680-685
    CrossrefPubMedGoogle Scholar
  • 44 Lozada MJ, Raji MA, Goodwin JS, Kuo YF. Opioid prescribing by primary care providers: a cross-sectional analysis of nurse practitioner, physician assistant, and physician prescribing patterns. J Gen Intern Med 2020; 35 (09) 2584-2592
    CrossrefPubMedGoogle Scholar
  • 45 Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993; 269 (12) 1537-1539
    CrossrefPubMedGoogle Scholar
  • 46 Chen I, Kurz J, Pasanen M. et al. Racial differences in opioid use for chronic nonmalignant pain. J Gen Intern Med 2005; 20 (07) 593-598
    CrossrefPubMedGoogle Scholar
  • 47 Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med 2012; 13 (02) 150-174
    CrossrefPubMedGoogle Scholar
  • 48 Dickason RM, Chauhan V, Mor A. et al. Racial differences in opiate administration for pain relief at an academic emergency department. West J Emerg Med 2015; 16 (03) 372-380
    CrossrefPubMedGoogle Scholar
  • 49 Ringwalt C, Roberts AW, Gugelmann H, Skinner AC. Racial disparities across provider specialties in opioid prescriptions dispensed to medicaid beneficiaries with chronic noncancer pain. Pain Med 2015; 16 (04) 633-640
    CrossrefPubMedGoogle Scholar
  • 50 Morden NE, Chyn D, Wood A, Meara E. Racial inequality in prescription opioid receipt - role of individual health systems. N Engl J Med 2021; 385 (04) 342-351
    CrossrefPubMedGoogle Scholar
  • 51 Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. Ann Fam Med 2011; 9 (03) 219-225
    CrossrefPubMedGoogle Scholar
  • 52 Safranek CW, Feitzinger L, Joyner AKC. et al. Visualizing opioid-use variation in a pediatric perioperative dashboard. Appl Clin Inform 2022; 13 (02) 370-379
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 53 Allen KS, Danielson EC, Downs SM. et al. Evaluating a prototype clinical decision support tool for chronic pain treatment in primary care. Appl Clin Inform 2022; 13 (03) 602-611
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 54 Liu Y, Hao H, Sharma MM. et al. Clinician acceptance of order sets for pain management: a survey in two urban hospitals. Appl Clin Inform 2022; 13 (02) 447-455
    Artikel in Thieme ConnectPubMedGoogle Scholar