Opioid Prescription Decision Tool May Be Feasible Option to Curb Overprescribing

A new report shows that an app designed to help clinicians make better opioid-prescribing decisions following surgery can be a useful tool, although not all clinicians said they would continue using it.

The study, published in BMJ Open, highlights one potential strategy to help curb the overprescription of opioids, which is believed to be a major factor in the current epidemic of opioid addiction in the United States.

The study investigators said persistent postsurgical opioid use is a common problem that occurs in about 6% of opioid-naive patients who are given the drugs. In about 15% of cases, patients are discharged with opioid prescriptions that are inconsistent with their opioid usage while in the hospital.

“For instance, patients who have not used opioids within 24 hours prior are frequently prescribed opiates unnecessarily on discharge,” they wrote.

Previous research suggests most patients who are given opioids end up with excess pills, and most do not dispose of them properly, the authors noted. They said the number of opioid prescriptions has been trending downward, but that the COVID-19 pandemic led to a reversal in that trend, as many providers gave out longer, more potent opioid prescriptions in response to pandemic lockdown measures.

The investigators wondered whether the use of a mobile application designed around clinical decision trees might lead to more tailored, judicious prescribing patterns among providers. They developed such an app, and then asked providers to use the app to make decisions following 2 common surgical procedures: laparoscopic cholecystectomy in adults and posterior spinal fusion in adolescents with idiopathic scoliosis.

Laparoscopic cholecystectomy was chosen because it is considered a straightforward minor surgery, and yet 94% of patients who undergo the procedure are discharged with an opioid prescription. Posterior spinal fusion was chosen because it is a complicated procedure associated with severe postoperative pain; previous studies indicate these patients are often prescribed an excessive number of pills.

The study was designed as a feasibility study; thus, its goal was to see whether providers would use the tool, rather than to gauge the tool’s effectiveness at reducing unnecessary prescriptions.

The investigators asked 27 providers in Columbia University’s Irving Medical Center Surgery Department to participate in the study; 15 consented to participate and 8 completed the study. They also reached out to 13 providers in the Pediatrics Department; 11 consented to participate and 10 completed the study. All of the participants in the general surgery cohort were physicians, and all of the participants in the pediatrics cohort were nurse practitioners.

At the start of the study, intended opioid prescription averaged 5.9 pills among the general surgery participants and 20.8 pills among the pediatrics participants. By the end of the study, 3 of the 8 general surgery participants said they intended to continue using the app and 7 of the 10 pediatrics participants said the same. The most common reason cited by those who said they would not continue using the app was lack of time.

Most participants reported that they learned from the app, although some said it was not useful over time and 2 respondents in the pediatric group said they already knew the recommendations and thus did not need the app.

The investigators said it was notable that the cohort with the higher intended opioid usage rate and the greater variability in prescribing patterns (the posterior spinal fusion cohort) also had the higher rate of participants stating that they would continue to use the app. They also said future iterations of the app could incorporate other factors, such as subjective measures of anxiety and insights from parents and caregivers.

However, they also cautioned that their findings cannot be generalized to a larger medical population, given the possibility that people who were willing to participate in the study were already predisposed toward wanting to use this type of technology.

Reference

Marziali ME, Giordano M, Gleit Z, Prigoff J, Landau R, Martins SS. Development and design of a mobile application for prescription opioid clinical decision-making: a feasibility study in New York City, USA. BMJ Open. Published online February 28, 2023. doi:10.1136/bmjopen-2022-066427