Use of EMR Directive Tied to Reduced Opioid Prescribing After Spine Surgery

FORT LAUDERDALE, Fla. -- Use of an electronic medical record (EMR) order set to prescribe ≤30 opioid doses among patients who underwent spine surgery was linked to reduced prescribing at discharge, a quality improvement study showed.

Of the 34 patients in this intervention arm, the number of opioid pills prescribed at hospital discharge was reduced from an average of 36.8 pills to 24.7 pills, a 33% decrease, reported Antje Barreveld, MD, of Tufts University School of Medicine and Newton-Wellesley Hospital in Newton, Massachusetts, during the American Academy of Pain Medicine annual meeting.

After a staff education intervention, the mean refill opioid pill count decreased from 97.3 to 65.4 pills at 6 weeks after surgery among 12 patients, Barreveld said, noting that this resulted in fewer unused opioid pills in the community.

"Further prospective studies must investigate patients' pain and opioid requirements after spine surgery and the impact of prescribing limits/guidelines on persistent opioid use after spine surgery," she said. "At this point, we really don't know what patients really require in pain medication after spine surgery."

Session moderator Rosanne Sheinberg, MD, of the University of Washington in Seattle, said that "the reduction of refill requests was surprising to me."

"I would have expected that the refill requests would at least be neutral," she told MedPage Today. "It would be really interesting to see if this was a reproducible effect. This may just be the effect of a small study."

However, Sheinberg suggested that if the patient and doctors are aware that they have fewer pills to control pain, there may be attempts to get off the pills sooner, and by doing that, the risk of a difficult withdrawal period may be reduced, which may manifest with reduced needs for refills of the pain medication.

"So, the idea is to get the patient off the opioid before that withdrawal point is reached," she said. "I thought that was one of the key messages of the study."

Barreveld said the impetus for the study was the knowledge that spine surgery -- a common and painful procedure -- results in an estimated 13% of patients requiring opioids for more than 3 months after surgery.

During 3-month periods from July 2021 through October 2021, the average postoperative opioid prescription for patients undergoing 1-level and 2-level lumbar fusion surgery at Newton-Wellesley Hospital was 37 pills. She noted that over-prescribing may result in as many as 70% of these pills being unused, which increases the risk of misuse, as well as the pill burden in the community.

The primary outcome was opioid pills prescribed at discharge after prescribers were directed to achieve a 20% reduction in prescribing after spine surgery, and refill opioid pills prescribed at 6 weeks after staff education and data sharing with the orthopedic teams.

Barreveld said that the hospital's chief of spine surgery "told all of the physician assistants, residents, as well as the surgeons to prescribe 30 pills or less. For the second part, we had educational material for patients on how to taper opioids after surgery."

"We were concerned that if we prescribed fewer pills to patients, they would be requesting more refills at 6 weeks, but what we saw was that there were actually less refill requests," she added.

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