System-wide opioid prescription reduction after shoulder arthroplasty

Abstract

BackgroundThe nonmedical use of prescription opioids is currently one of the greatest public health issues. This phenomenon was largely driven by the increase in opioid prescriptions in the past few decades. Across specialties, orthopedic surgeons are among the highest prescribers of opioids for pain control. To help individual physicians within healthcare systems adopt and maintain safe prescribing habits, system-wide policies and guidance are needed. The purpose of this study was to determine if the implementation of system-wide changes in prescription practices could result in overall reductions in opioid prescriptions after shoulder arthroplasty. MethodsAn ecological study of opioid prescriptions after shoulder arthroplasty from Q1 2016 to Q3 2018 in a closed healthcare system was conducted. The number of pills and morphine milligram equivalents (MMEs) prescribed in the 28 days immediately after surgery were collected for each patient. A multipronged systemic opioid reduction strategy was adopted over this period, which included (1) an elimination of historical physician prescribing presets in the electronic medical record, (2) a new limitation to a maximum of 20 pills per preset prescription, (3) consistent education and leadership reminders of opioid stewardship using emails, and (4) overlay of a state-mandated prescribing physician review of historical use of controlled substance use in individual patients. Univariable linear regressions were used to determine the trend in average number of pills and MMEs prescribed over the study period, and independent sample Student t-tests were used to compare prescriptions in Q1 2016 to those in Q3 2018. ResultsOver the study period, there were 872 shoulder arthroplasties performed on 840 patients. Univariable linear regression demonstrated a decrease of an average of 1.96 pills (P < .001) and 2.67 MMEs (P < .001) for each progressive quarter. The number of pills prescribed in the first 28 days after surgery decreased 18.7% from an average of 86.1 pills in Q1 2016 to 67.4 pills in Q3 2018 (P < .001). MMEs decreased 24.1% from an average of 103.3 MMEs in Q1 2016 to 78.3 MMEs in Q3 2018 (P < .001). ConclusionThis study demonstrates that it is possible to systematically reduce opioid prescriptions after shoulder arthroplasty using electronic health record changes coupled with physician guidance and state-mandated review. Although opioid needs for pain control vary per patient, system-wide policies can meaningfully reduce opioid prescriptions and help to maintain safe prescribing habits. Level of evidenceLevel III, Retrospective Cohort Designm Prognostic Study