Opioid prescribing habits of Emergency Department providers in response to an educational intervention

Tory Makela, MS4; Benjamin Aaker, MD

Introduction: Prescription opioid misuse and dependency has been a rising cause for concern in the United States in recent years, and many of these cases began with an initial prescription in the Emergency Department (ED). Prior studies found that patients seen by “high intensity” prescribers, who prescribe greater quantities of opioids than 75% of other ED physicians within the same hospital, are significantly more likely to suffer from long-term opioid use. Other studies have shown that educational interventions on appropriate opioid prescription in surgical settings have resulted in fewer post-operative opioid prescriptions and less variance in prescribing habits by providers. This study investigates whether a similar educational intervention within an ED setting results in decreased opioid utilization. It is hypothesized that the educational intervention provided to ED providers will result a reduction in the amount of opioids prescribed.

Methods: This study is retrospective analysis of patient charts from an ED in southeast South Dakota in the year prior to and after an educational intervention was given to providers in April 2015. Only charts with a diagnosis of back, abdominal, or head pain were included, and encounters in which the patient left against medical advice or left without being seen were excluded. Opioids administered in the ED and prescribed were converted to morphine milligram equivalents (MMEs), and a two-sample t-test was used to compare pre-exposure and post-exposure opioid utilization for the group overall, individually for each physician, and by diagnosis subset. Lastly, a two-sample t-test was performed to evaluate the mean number of non-opioid treatments utilized in the pre- and post-exposure periods.

Results: Opioids prescribed and total opioids were not significantly different in the group overall, by ICD diagnosis subset, or individually by provider. Opioids administered orally varied in significance based on chief complaint, with a decrease in oral administration in the back pain diagnosis subset and an increase in oral administration in the head and abdominal pain diagnosis subsets and overall group. There was also a significant difference in the average amount of non-opioid treatments prescribed per patient encounter, increasing from 0.797 to 0.890 (p=0.02) in the post-intervention period.

Conclusion: Overall, the educational intervention on the topic of opioid prescribing guidelines did not have the expected impact on amounts of opioids administered or prescribed during the study period. Total opioids utilized and opioids prescribed did not vary between the pre- and post-intervention groups overall, by subset diagnosis, or by provider. There was, however, an increase in utilization of non-opioid treatments that could be indicative of a partial response to the educational intervention. This study showed that long-term effects of education regarding recommended opioid utilization may be less effective than indicated by prior studies, which had shorter post-intervention investigation windows.