Ohio Study Examines Effectiveness of Opioid Guidelines

By Scott G. Weiner via Multibriefs

In the face of the ongoing tragedy of the current U.S. opioid epidemic, multiple groups are attempting to create guidelines that influence opioid prescribing behavior. From hospitals to state governments, from the CDC to physician specialty societies, guidelines are being produced, as they are easy and inexpensive to create and don't require legislation or enforcement.

The America College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM) have created guidelines specifically for emergency physicians, as have multiple cities and states. But the question remains: Do guidelines work, and if so, what is the magnitude of their effect?

To answer the question, we studied the Ohio Prescription Drug Monitoring Program (PDMP). We chose to study Ohio for three reasons:

• the state has disproportionately struggled with opioid overdoses and deaths
• the PDMP is only of a handful that provides the specialty of the prescriber of each opioid to researchers
• Ohio released comprehensive prescribing guidelines targeting emergency departments in April 2012.

The Ohio guidelines are similar to other opioid guidelines and recommend best practices, such as limiting prescriptions to no more than a three-day supply, avoiding long-acting opioids, not refilling lost/destroyed/stolen prescriptions, educating patients about the risks of opioids, and checking the PDMP prior to prescribing. We chose to study about two years before and two years after the release of these guidelines with the goal of quantifying their effect.

Our study, which was recently published in Annals of Emergency Medicine, sheds some interesting light on the effect of opioid prescribing guidelines on how EPs prescribe.

First, prescriptions for opioids were already decreasing markedly from 2010 until the guidelines were released. To compensate for this, we used a statistical technique called "interrupted time series analysis," which compares the slope of the decrease before and after the guidelines, as opposed to just looking at averages.

We found that, overall, prescribing decreased at a steeper rate after the guidelines. It could be argued that the steeper decrease was due to the overall awareness of the issue in 2012. However, when we compared EP prescribing to that of orthopedic surgeons, who had a similar number of prescriptions to EPs at the start of the study, EP prescribing decreased at a greater rate.

We were also curious to find out about prescriptions for greater than three days' supply, as those were specifically discouraged by the guidelines. Those prescriptions also decreased at a greater rate following the guidelines.

Finally, we evaluated prescriptions for the five most commonly prescribed opioids. Prescriptions for hydrocodone, oxycodone, codeine and hydromorphone were already decreasing, but tramadol prescriptions were increasing steeply before the guidelines and then started decreasing after the guidelines.

In all, the guidelines appear to have been associated with a significant decrease in the number and type of opioids prescribed by EPs.

Despite the decreases seen, implementing guidelines for emergency physicians is not a panacea solution. We know from multiple studies that EM is responsible for less than 5 percent of all opioid prescriptions (despite more than 130 million ED visits per year), and that number shrinks to under 2 percent if total morphine equivalents are calculated.

Still, EM-targeted guidelines may help avoidance of opioid-naive patients becoming dependent and set expectations for patients with chronic pain. They may be a small part of the solution to the opioid epidemic, but every effort counts.

Scott G. Weiner, M.D., MPH, FACEP, FAAEM an attending emergency physician and assistant clinical director in the Department of Emergency Medicine at Brigham and Women's Hospital in Boston. He is the Director of B-CORE: The Brigham Comprehensive Opioid Approach and Education Program. Dr. Weiner completed his residency training at the Harvard-Affiliated Emergency Medicine Program at Beth Israel Deaconess Medical Center and MPH degree at Harvard School of Public Health. He is the president-elect of the Massachusetts College of Emergency Physicians. His research focuses on technological innovations that improve the care of ED patients presenting with pain, including usage and optimization of online prescription drug monitoring programs (PDMPs) and tablet-based screening tools.