Reducing Opioid Overprescribing by Educating, Monitoring and Collaborating with Clinicians: A Quality Improvement Study

Nudging strategies to influence prescribers' behavior toward reducing opioid prescriptions: a systematic scoping review

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.

Opioid stewardship program implementation in rural and critical access hospitals in Arizona

OBJECTIVE

The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments.

DESIGN

Health administrator survey to identify the number and type of OSP elements that each hospital has implemented.

SETTING

Arizona critical access hospitals (CAHs).

PARTICIPANTS

ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments).

MAIN OUTCOME MEASURES

Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary).

RESULTS

The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD.

CONCLUSIONS

Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

Toward Safer Opioid Prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial

BACKGROUND

The 2016 U.S. Centers for Disease Control Opioid Prescribing Guideline (CDC Guideline) is currently being revised amid concern that it may be harmful to people with chronic pain on long-term opioid therapy (CP-LTOT). However, a methodology to faithfully implement the CDC guideline, measure prescriber adherence, and systematically test its effect on patient and public health outcomes is lacking. We developed and tested a CDC Guideline implementation strategy (termed TOWER), focusing on an outpatient HIV-focused primary care setting.

METHODS

TOWER was developed in a stakeholder-engaged, multi-step iterative process within an Information, Motivation and Behavioral Skills (IMB) framework of behavior change. TOWER consists of: 1) a patient-facing opioid management app (OM-App); 2) a progress note template (OM-Note) to guide the office visit; and 3) a primary care provider (PCP) training. TOWER was evaluated in a 9-month, randomized-controlled trial of HIV-PCPs (N = 11) and their patients with HIV and CP-LTOT (N = 40). The primary outcome was CDC Guideline adherence based on electronic health record (EHR) documentation and measured by the validated Safer Opioid Prescribing Evaluation Tool (SOPET). Qualitative data including one-on-one PCP interviews were collected. We also piloted patient-reported outcome measures (PROMs) reflective of domains identified as important by stakeholders (pain intensity and function; mood; substance use; medication use and adherence; relationship with provider; stigma and discrimination).

RESULTS

PCPs randomized to TOWER were 48% more CDC Guideline adherent (p < 0.0001) with significant improvements in use of: non-pharmacologic treatments, functional treatment goals, opioid agreements, prescription drug monitoring programs (PDMPs), opioid benefit/harm assessment, and naloxone prescribing. Qualitative data demonstrated high levels of confidence in conducting these care processes among intervention providers, and that OM-Note supported these efforts while experience with OM-App was mixed. There were no intervention-associated safety concerns (defined as worsening of any of the PROMs).

CONCLUSIONS

CDC-guideline adherence can be promoted and measured, and is not associated with worsening of outcomes for people with HIV receiving LTOT for CP. Future work would be needed to document scalability of these results and to determine whether CDC-guideline adherence results in a positive effect on public health. Trial registration https://clinicaltrials.gov/ct2/show/NCT03669939 . Registration date: 9/13/2018.