Background: Clinician prescribing practices are a contributing factor to and potential mitigator of the opioid epidemic in the United States. Several studies have identified the hospital setting as an important entry point into chronic opioid use. The Society for Hospital Medicine (SHM) and the Centers for Disease Control and Prevention (CDC) have made recommendations for the treatment of acute and chronic non-cancer pain (respectively) as a means of promoting appropriate prescribing practices.

Purpose: We implemented a multi-modal intervention targeting clinicians in the inpatient medicine setting to increase adherence to current guidelines in opioid prescribing.

Description: Our 9-month intervention (February 2nd to November 1st, 2018) focused on: decreasing opioid prescription length to less that 7 days; increasing follow up appointments for patients with opioids prescribed on discharge (OPOD); and improving documentation of state Prescription Monitoring Program (PMP) registry data.
The intervention began with several interactive sessions where medical students helped the house staff sign up for the PMP registry, and provided educational material about SHM and CDC guidelines on how to improve opioid prescribing practices. Residents and attendings on service were also emailed weekly reminders about the guidelines, along with baseline data on the division’s compliance. A standardized workflow was also created for a nursing coordinator to make appointments within one week of discharge for patients with OPOD. Beginning in August 2018, weekly emails included the team’s personal compliance for the prior week. We extracted raw data via electronic medical record queries and conducted subsequent chart reviews on all patients discharged from the hospitalist medicine services.

Compared to baseline, rates of all patients with OPOD (12%) and rates of opioid-naïve patients with POD (60% of OPOD) did not change significantly. Follow-up appointments increased from 38.6% to 65.9% (p<0.001) and OPOD with greater than one-week supply decreased from 45.2% to 39.4% (p=0.041). There was also a significant increase in changes to PMP documentation from 32.5% to 39.7% (p=0.032).

Conclusions: Our multifaceted intervention was successful at improving adherence to best practice recommendations by reducing prescriptions longer than seven days, increasing scheduled post-discharge follow-up appointments, and improving documentation of PMP registry data. We believe that frequent, multi-modal engagement with providers, along with concrete action plans, was integral in changing prescription patterns and fostering a culture that encouraged more thoughtful prescribing.

IMAGE 1: Figure 1: Change in Prescribing Practices Pre- and Post-Intervention