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Diwan S, Vilhelmsson A, Wolf A, Jildenstål P. Nudging strategies to influence prescribers' behavior toward reducing opioid prescriptions: a systematic scoping review. J Int Med Res 2024; 52:3000605241272733. [PMID: 39258400 PMCID: PMC11402103 DOI: 10.1177/03000605241272733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024] Open
Abstract
OBJECTIVE This systematic scoping review aimed to map the literature on the use of various nudging strategies to influence prescriber behavior toward reducing opioid prescriptions across diverse healthcare settings. METHODS A systematic database search was conducted using seven electronic databases. Only articles published in English were included. A total of 2234 articles were identified, 35 of which met the inclusion criteria. Two independent dimensions were used to describe nudging strategies according to user action and the timing of their implementation. RESULTS Six nudging strategies were identified. The most common strategy was default choices, followed by increasing salience of information or incentives and providing feedback. Moreover, 32 studies used the electronic health record as an implementation method, and 29 reported significant results. Most of the effective interventions were multicomponent interventions (i.e., combining nudge strategies and non-nudge components). CONCLUSIONS Most nudging strategies used a passive approach, such as defaulting prescriptions to generics and requiring no action from the prescriber. Although reported as effective, this approach often operates under the prescriber's radar. Future research should explore the ethical implications of nudging strategies.INPLASY registration number: 202420082.
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Affiliation(s)
- Salwan Diwan
- University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Andreas Vilhelmsson
- Lund University, Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Lund, Sweden
| | - Axel Wolf
- University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- University of Gothenburg, Centre for Person-Centred Care (GPCC), Gothenburg, Sweden
- Institute of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Pether Jildenstål
- University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Örebro University Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Anaesthesia, Operation and Intensive Care, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Health Sciences, Lund University, Lund, Sweden
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Guilcher SJT, Cimino SR, Tadrous M, McCarthy LM, Riad J, Tricco AC, Hagens S, Lien J, Tharmalingam S, Gomes T. Experiences and Outcomes of Using e-Prescribing for Opioids: Rapid Scoping Review. J Med Internet Res 2023; 25:e49173. [PMID: 38153776 PMCID: PMC10784986 DOI: 10.2196/49173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/31/2023] [Accepted: 11/01/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND e-Prescribing is designed to assist in facilitating safe and appropriate prescriptions for patients. Currently, it is unknown to what extent e-prescribing for opioids influences experiences and outcomes. To address this gap, a rapid scoping review was conducted. OBJECTIVE This rapid scoping review aims to (1) explore how e-prescribing has been used clinically; (2) examine the effects of e-prescribing on clinical outcomes, the patient or clinician experience, service delivery, and policy; and (3) identify current gaps in the present literature to inform future studies and recommendations. METHODS A rapid scoping review was conducted following the guidance of the JBI 2020 scoping review methodology and the World Health Organization guide to rapid reviews. A comprehensive literature search was completed by an expert librarian from inception until November 16, 2022. Three databases were electronically searched: MEDLINE (Ovid), Embase (Ovid), and Scopus (Elsevier). The search criteria were as follows: (1) e-prescribing programs targeted to the use or misuse of opioids, including those that were complemented or accompanied by clinically focused initiatives, and (2) a primary research study of experimental, quasi-experimental, observational, qualitative, or mixed methods design. An additional criterion of an ambulatory component of e-prescribing (eg, e-prescribing occurred upon discharge from acute care) was added at the full-text stage. No language limitations or filters were applied. All articles were double screened by trained reviewers. Gray literature was manually searched by a single reviewer. Data were synthesized using a descriptive approach. RESULTS Upon completing screening, 34 articles met the inclusion criteria: 32 (94%) peer-reviewed studies and 2 (6%) gray literature documents (1 thesis study and 1 report). All 33 studies had a quantitative component, with most highlighting e-prescribing from acute care settings to community settings (n=12, 36%). Only 1 (3%) of the 34 articles provided evidence on e-prescribing in a primary care setting. Minimal prescriber, pharmacist, and clinical population characteristics were reported. The main outcomes identified were related to opioid prescribing rates, alerts (eg, adverse drug events and drug-drug interactions), the quantity and duration of opioid prescriptions, the adoption of e-prescribing technology, attitudes toward e-prescribing, and potential challenges with the implementation of e-prescribing into clinical practice. e-Prescribing, including key features such as alerts and dose order sets, may reduce prescribing errors. CONCLUSIONS This rapid scoping review highlights initial promising results with e-prescribing and opioid therapy management. It is important that future work explores the experience of prescribers, pharmacists, and patients using e-prescribing for opioid therapy management with an emphasis on prescribers in the community and primary care. Developing a common set of quality indicators for e-prescribing of opioids will help build a stronger evidence base. Understanding implementation considerations will be of importance as the technology is integrated into clinical practice and health systems.
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Affiliation(s)
- Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie R Cimino
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Jessica Riad
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Andrea C Tricco
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | | | | | | | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
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Belardo ZE, Talwar D, Blumberg TJ, Nelson SE, Upasani VV, Sankar WN, Shah AS. Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial. J Bone Joint Surg Am 2023; 105:1875-1885. [PMID: 37956188 PMCID: PMC10695340 DOI: 10.2106/jbjs.23.00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures. METHODS Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort. RESULTS A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort. CONCLUSIONS Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Zoe E. Belardo
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Divya Talwar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Todd J. Blumberg
- Department of Orthopaedics and Sports Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Susan E. Nelson
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | | | - Wudbhav N. Sankar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Apurva S. Shah
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Blasier RD. It's Time to Rein in the Opioids: Commentary on an article by Zoe E. Belardo, BA, et al.: "Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures. Results from a Prospective Multicenter Trial". J Bone Joint Surg Am 2023; 105:e57. [PMID: 38063780 DOI: 10.2106/jbjs.23.00993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- R Dale Blasier
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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King'uyu DN, Edgar EL, Figueroa C, Kirkland JM, Kopec AM. Morphine exposure during adolescence induces enduring social changes dependent on adolescent stage of exposure, sex, and social test. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.21.537856. [PMID: 37131669 PMCID: PMC10153224 DOI: 10.1101/2023.04.21.537856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Drug exposure during adolescence, when the 'reward' circuitry of the brain is developing, can permanently impact reward-related behavior. Epidemiological studies show that opioid treatment during adolescence, such as pain management for a dental procedure or surgery, increases the incidence of psychiatric illness including substance use disorders. Moreover, the opioid epidemic currently in the United States is affecting younger individuals raising the impetus to understand the pathogenesis of the negative effects of opioids. One reward-related behavior that develops during adolescence is social behavior. We previously demonstrated that social development occurs in rats during sex-specific adolescent periods: early to mid-adolescence in males (postnatal day (P)30-40) and pre-early adolescence in females (P20-30). We thus hypothesized that morphine exposure during the female critical period would result in adult sociability deficits in females, but not males, and morphine administered during the male critical period would result in adult sociability deficits in males, but not females. We found that morphine exposure during the female critical period primarily resulted in deficits in sociability in females, while morphine exposure during the male critical period primarily resulted in deficits in sociability primarily in males. However, depending on the test performed and the social parameter measured, social alterations could be found in both sexes that received morphine exposure at either adolescent stage. These data indicate that when drug exposure occurs during adolescence, and how the endpoint data are measured, will play a large role in determining the effects of drug exposures on social development.
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Affiliation(s)
- David N King'uyu
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College
| | - Erin L Edgar
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College
| | - Christopher Figueroa
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College
| | - J M Kirkland
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College
| | - Ashley M Kopec
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College
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Wagner KJ, Beck JJ, Carsen S, Crepeau AE, Cruz AI, Ellis HB, Mayer SW, Niu E, Pennock AT, Stinson ZS, VandenBerg C, Ellington MD. Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction. J Pediatr Orthop 2023; 43:e278-e283. [PMID: 36728478 DOI: 10.1097/bpo.0000000000002344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. METHODS A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. RESULTS Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. CONCLUSIONS Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | - Sasha Carsen
- Children's Hospital of Eastern Ontario, ON, Canada
| | | | | | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical School, Dallas, TX
| | | | - Emily Niu
- Children's National Medical Center, Washington DC
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