The Development and Evaluation of a Patient-Centered Opioid Discharge Prescribing Guideline within the Electronic Health Record of a Health System

Project Summary Patients recovering from painful surgical procedures commonly receive opioids during their inpatient and post- operative periods to help manage pain and initiate the recovery process. Nonetheless, access to opioids after surgery puts patients at increased risk of becoming a chronic user. Over 80% of surgical patients receive opioids after low-risk surgery with many patients receiving opioids more than the amount needed to control pain. Overprescribing increases the risk of diversion and misuse. Conversely, under-prescribing may leave many patients open to uncontrolled pain and subsequent emergency care. Current opioid discharge clinical practice guidelines (CPGs) involve lowering maximum discharge defaults, high level warnings, defaults pegged to procedures received by patients, or warnings based on prior opioid utilization. However, research suggests that post-surgery pain management should be tailored to each patient based on individual pain experience and pain tolerance. These insights suggest that a patient- centered CPG for post-operative pain management is needed. However, patient-centered CPGs are cumbersome and time consuming to implement by hand from hospital electronic health records (EHR) at discharge. A 2020 National Academies of Sciences, Engineering, and Medicine document emphasized the need to find patient-centered opioid prescribing CPG for acute pain. A clinical decision support (CDS) tool is needed to quickly synthesize patient-specific data from the EHR to promote the use of patient-centered opioid discharge CPGs. Toward this goal, three recent studies provide a strong clinical rationale that inpatient opioid use the day before discharge affords a sound proxy for individual pain experience and pain tolerance at discharge to guide patient- centered post-discharge opioid prescribing. Surgeons in the General Surgery department at Prisma Health in South Carolina used this rationale to develop a patient-centered opioid discharge CPG that was implemented in their department in March 2018. The percentage of patients with CPG-compliant opioid discharge prescriptions increased from 10% to 25.8% after implementation,59 the department-wide average opioid discharge level fell, and the General Surgeons anecdotally found little negative patient response from these reductions. Despite these positive results, General Surgeons reported that the extra time required to apply the CPG within a busy practice limited its broader use which reflects findings in the literature. Currently, the patient-centered CPG requires providers to perform a detailed analysis of patient charts by hand that can add 5-10 minutes per patient to the discharge process. In addition, with only anecdote available, the evidence on patient outcomes from use of the patient-centered CPG is not definitive. We believe that a patient-centered opioid prescribing tool (PCOPT) that immediately incorporates patient- specific information from EHR into the discharge process will significantly increase compliance with the patient- centered opioid discharge CPG. In addition, we will implement the PCOPT using an effectiveness-implementation hybrid Type II study design to yield definitive evidence on the effects of the patient-centered CPG on patient outcomes on outcomes using orthopaedic trauma patients with a lower- extremity fracture. Our proposal is in response to the Special Emphasis Notice (SEN): AHRQ Announces Interest in Health Services Research to Address the Opioids Crisis (NOT-HS-18-015).