Mandatory drug monitoring program decreases postoperative opioid prescriptions
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The implementation of a mandatory prescription drug monitoring program led to an immediate decrease in opioid prescribing in three surgical specialties, according to findings published in JAMA Health Forum.
Specifically, opioids were prescribed less to patients who underwent general, obstetric/gynecologic or orthopedic surgery.
“We estimated that the Controlled Utilization Review and Evaluation System (CURES) mandate was associated with more than 100,000 fewer opioid tablets in circulation after five quarters of CURES mandate implementation in [one] health care system alone,” Rivfka Shenoy, MD, MS, a general surgery resident in the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues wrote.
About CURES
In July 2016, California passed legislation mandating the use of CURES in response to the opioid epidemic. The mandate was implemented on Oct. 2, 2018, according to the researchers. It requires physicians to consult CURES before they can prescribe a controlled substance. The program also integrates electronic health record alerts that are associated with changes in the quantity of opioid medications prescribed after surgery. Physicians can bypass the CURES consultation if they prescribe a 5-day or fewer supply of opioid medications postoperatively.
Changes in opioid prescribing
To assess the impact of CURES, Shenoy and colleagues conducted a cross-sectional study on opioid prescribing patterns within the health care system of Sutter Health in Northern California between Jan. 1, 2015, and Feb. 1, 2020. They used electronic health record data to examine opioid prescribing trends among 93,760 patients who underwent general, obstetric/gynecologic or orthopedic surgery. The patients’ mean age was 46.7 years; 67.9% were women.
Among the study cohort, opioids were prescribed to 65,911 patients before the mandate and 27,849 patients after implementation.
Before CURES, the Sutter Health system was already experiencing a decrease in opioid prescribing, according to Shenoy and colleagues. During the initial period of the program, total morphine milligram equivalents (MMEs) at discharge further decreased by 5.3% in general surgery, 12.2% in obstetric/gynecologic surgery and 9.6% in orthopedic surgery, as did the total number of tablets in each specialty by 10.5%, 15.7% and 9.2%, respectively.
However, reductions in opioid prescriptions were inconsistent in common surgeries. For example, total tablets prescribed for patients who underwent a cesarean delivery decreased initially while the median MMEs did not. Moreover, neither tablet totals nor MMEs decreased for patients who underwent knee arthroscopies.
Overall, the proportion of prescriptions for longer than 5 days decreased significantly during initial implementation across the three specified surgical specialties. The mean MMEs prescribed before and after the CURES mandate were 198.2 vs. 123.1 for general surgery, 189 vs. 137.2 for obstetric/gynecologic surgery and 360.9 vs. 259.7 for orthopedic surgery. Also, the average total number of tablets prescribed before and after the CURES mandate was 32.6 vs. 20.8 for general surgery, 31.9 vs. 21.4 for obstetric/gynecologic surgery and 48.0 vs. 36.3 for orthopedic surgery.
While the mandated program may have “substantial implications for reducing the number of opioid tablets statewide ... the implementation of an [electronic health record] alert to prompt adherence to the CURES mandate introduced a disruption to physician workflow at the health care system examined,” Shenoy and colleagues wrote.
Perspective
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Anita Gupta, DO, MPP, PharmD
The study highlights the important need for patient-centered opioid prescribing guidelines in the future. The increasing policy mandates and regulatory requirements must align with the needs of patients while addressing the serious underlying concerns of opioid prescribing to ensure that safe, responsible opioid prescribing can continue in the future. The study also highlights the unmet needs in opioid prescriber education, data-driven evidence and evidence-based understanding in utilizing opioids safely. Moreover, the data presented in the research raises the question on how best to address the lack of clear data-driven metrics focused on patient outcomes that align with real-world evidence. Future innovation and research are necessary to address the increasing concerns of opioid prescribing disparities and opioid prescriber avoidance as presented in the research.
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