SLR - April 2019 - Anmy Vu

Development of an Institutional Opioid Prescriber Education Program and Opioid-Prescribing Guidelines: Impact on Prescribing Practices

Reference: Stepan JG, Lovecchio FC, Premkumar A, Kahlenberg CA, Albert TJ, Baurley JW, Nwachukwu BU. Development of an institutional opioid prescriber education program and opioid-prescribing guidelines: impact on prescribing practices. J Bone Joint Surg Am. 2019 Jan 2;101(1):5–13. doi: 10.2106/JBJS.17.01645.

Scientific Literature Review

Reviewed By: Anmy Vu, DPM
Residency Program: Memorial Medical Center, Long Beach, CA

Podiatric Relevance:
As podiatric surgeons amid an epidemic of opioid dependence and addiction, it is of utmost importance to efficaciously control postoperative pain without putting our patients at risk. Opioids are now the most common class of prescribed medications in the United States, with many associated deaths. No guidelines exist for the treatment of acute pain after orthopaedic surgery. The authors attempt to develop an institutional education program and guidelines for opioid prescriptions following ambulatory surgery.

Methods: This was a retrospective study in which a one-hour mandatory opioid education program was completed by all hospital prescribers, followed by postop opioid guideline dissemination. Analysis of all postoperative narcotic prescriptions after ambulatory procedures was then evaluated over four months before and after the intervention. Prescribers were not aware that their prescriptions were being tracked. Stratification of prescriptions were divided into three separate orthopaedic services: foot and ankle, hand and sports medicine.

Results: There was a significant decrease in opioid prescriptions after education/dissemination of guidelines in comparison with preintervention cohort procedures (p<0.001) performed by sports/hand specialties. With six procedures alone, there were almost 30,000 fewer opioid pills prescribed per year in the postintervention group. However, interestingly enough, there was no significant change (p>.05) in either number of pills or oral morphine equivalents prescribed after any of the procedures performed by the foot and ankle service (ankle arthroscopy, bunion surgery, achilles tendon repair).

Conclusions: Prescriber education programs led to significant decreases in excessive opioid prescribing practices in the setting of ambulatory surgery at the Hospital for Special Surgery in New York, NY for all studied orthopaedic services (sports and hand) except for foot and ankle. The top three procedures performed by foot and ankle surgeons at this facility was ankle arthroscopy, bunion surgery and Achilles tendon repair. This study shed light on how opioids are the leading cause of death in patients who are <50 years old and that more than 20,000 Americans have died from overdoses since 2015.  Yet, there was a slow adoption of guidelines in the foot/ankle group. Thus, we as a podiatric subspecialty should be cognizant of the use of opioids in postoperative pain management and its risk to patients. Podiatric surgeons should strive to reduce unnecessary opioid prescriptions.

Educational Opportunities