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Study: Alerts Can Decrease High-Dose Opioid Prescribing

A Recent Cedars-Sinai Study Published in the Journal of Pain Tested Interventions to Promote Appropriate Use of Opioids

A recent Cedars-Sinai study found a combination of interventions improved satisfaction among patients being treated for chronic pain and reduced high-dose opioid prescribing.

The study, published in the Journal of Pain, compared patient education and clinical decision support for managing opioids. A simple patient education intervention improved overall satisfaction with patient communications, while a carefully crafted electronic alert showed greater potential to reduce high-dose opioid prescribing. No difference was found in pain interference between the two groups.

Brennan Spiegel, MD, MSHS“The goal of our study was to help patients and doctors make safer decisions when prescribing opioids for chronic pain while also seeking to avoid the stigma sometimes attributed to using pain medications,” said Brennan Spiegel, MD, MSHS director of Health Services Research, George and Dorothy Gourrich Chair in Digital Health Ethics, and the study’s lead author. “We want to make sure we’re maximizing the appropriateness of dosing so we’re helping people manage their pain without doing harm.”

The study was funded by a Patient-Centered Outcomes Research Institute grant. One in 5 American adults experience chronic pain. Overdose deaths In the U.S. related to prescription opioids increased by over 4 times compared to 20 years, according to the National Institutes of Health, constituting a public health crisis.

Itai Danovitch, MD“Patients and their physicians both struggle to manage chronic pain, particularly when opioids become involved,” said Itai Danovitch, MD, chair of the Department of Psychiatry and Behavioral Neurosciences. “We now understand that opioids are double-edged swords—when it comes to chronic pain, their harms are often greater than their benefits. Our study showed that both clinical decision support and patient education can have positive effects. We need continued support to help physicians adopt best practices, and we need effective education to empower patients to promote their own health.” 

Investigators compared the effectiveness of physician-directed clinical decision support administered through the electronic health record versus patient-directed education to promote the appropriate use of opioids through a cluster-randomized trial. 

The trial included 82 primary care physicians at Cedars-Sinai and 951 of their patients with chronic pain. They measured outcomes based on satisfaction with patient-physician communication, patient interference, physical function, depression, high-risk opioid prescribing, and co-prescribing of opioids and benzodiazepines.

The outcomes were the same in both groups on most measures, but patient education was linked to higher satisfaction with communications and the electronic alerts with lower opioid dosing.

Dodging Alert Fatigue

Cedars-Sinai has been on the forefront of using clinical decision support, Spiegel said. Too many alerts, however, can lead to them being ignored.

The alert in this study was a point-of-care reminder that would pop up on the computer screen to help identify if opioids were being prescribed but might not be the most appropriate intervention. Teryl Nuckols, MD, MSHS

“We worked very closely with our colleagues in primary care in the Medical Delivery Network to make sure the alert was appropriate,” Spiegel said. “We wanted them to have a direct role in crafting it and vetting it, which isn’t always the case with the alerts doctors routinely experience in the electronic health record.” 

In addition, to avoid alert fatigue, the alerts had clear action items rather than simply providing additional information. For example, the medical network runs and opioid withdrawal program, and the alerts had a button to refer patients to the program if appropriate.

As many as 85% of alerts are simply dismissed by clinicians, said Teryl Nuckols, MD, MSHS, director of the Division of Internal Medicine.

“That these alerts can be effective in reducing the rate of high dose opioids is a powerful finding,” she said. “It’s not easy to change clinician behavior, and the engagement work that was done seems to have made a significant difference.”

Scalable Interventions

The other arm of the study provided ready-made materials to patients, arming them with questions to ask should opioids be prescribed to them and informing them of the risks.

The study team also included a chronic pain patient who created a newsletter that was sent out to patient participants each month, providing updates about the research and information about the team. In addition, the research team formed a patient advisory panel who met quarterly to advise on all aspects of the study.

Ultimately, the study concluded that patient educational materials is an inexpensive, easily scaled intervention that can improve satisfaction with patient-provider communications. Clinical decision support is a more resource-intensive undertaking, but provided benefits that education alone could not. Using the combination in primary care warrants further study, Spiegel said.

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