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University of Kentucky uses stepwise protocols to reduce opioid prescriptions
As the state of Kentucky began to tackle the opioid epidemic by passing legislation on the amount, duration and procedures for which controlled substances can be prescribed, the University of Kentucky began to establish additional opioid-prescribing guidelines and protocols for each of its surgical services.
“For acute injuries and postoperatively, unless there are extenuating circumstances, we have limited prescribing opioids for no more than a 2-week duration,” Eric S. Moghadamian, MD, division chief for orthopedic trauma and medical director of the orthopedic clinics at the University of Kentucky, told Healio.com/Orthopedics. “Additionally, ... we have taken a look at our general prescribing practices and general prescribing practices nationwide, as well as some of the literature regarding pill count and unused pills, and subsequently reduced the volume of pills and the duration we are now prescribing.”
Changes in opioid prescriptions
How many and what type of medications are prescribed are based on whether the injury or surgery type is categorized as mild, moderate or severe, according to Moghadamian. This is done through a stepwise process using non-pharmacologic and pharmacologic analgesics, which Douglas Oyler, PharmD, noted includes acetaminophen, NSAIDs and other therapy before moving to opioids. Oyler, who is the director of the office of opioid safety at UK HealthCare, added they have also removed extended release opioids from their guidelines and algorithm due to the risk of overdose when used in acute pain management.
“If you give [opioids] as an extended release product, in the first couple of weeks [the patient has] about a four- to five-fold risk of overdose vs. if they are given an immediate release product,” Oyler said. “So, we wanted to move away from using those products altogether as much as possible.”
Oyler said they also began educating prescribers on morphine-milligram equivalence and which patients should receive a prescription of naloxone in conjunction with opioids.
“We have built this into our [electronic medical record] EMR too,” he said. “It has templates so [prescribers] can easily prescribe naloxone for high-risk patients.”
Set patient expectation
Moghadamian noted they are currently performing a retrospective review on the changes in the overall prescriptions written and the number of pills prescribed and filled. However, even before collecting this information, he said they have seen a drastic reduction in the number of opioid pills prescribed to patients.
“The number of prescription refill requests that we get has also been drastically reduced because our patients are educated, they understand, based on our protocol and based on the legislation, we are limited on how much we can and how much we are willing to prescribe now,” Moghadamian said.
According to Oyler, having the entire surgical team and staff on the same page has helped set patient expectation when it comes to postoperative pain management. Moghadamian noted these changes at the University of Kentucky have not only created a safer pain management regimen for patients, but also providers do not have to “deal with multiple refill requests and patients diverting a large number of opioid prescriptions.”
Moghadamian added other hospitals and practices should not be hesitant about implementing their own pain management protocols to reduce opioid prescriptions.
“We used to have a misconception that because the injuries we treat and our procedures are painful, that these patients needed large amounts of pain medication and that we were doing them a disservice if we did not provide that for them,” Moghadamian said. “What we realized is the patients do not need it. There is little benefit, especially for acute pain problems, and by reducing the number of opioids I have not seen any additional problems with patients being less satisfied with their pain control.” – by Casey Tingle
Disclosures: Moghadamian and Oyler report no relevant financial disclosures.