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Peer Pressure Can Help Trim Opioid Orders

When it comes to reducing opioid prescriptions for patients with pain, peer pressure is a powerful force.

A system that offers clinicians a look at how often their fellow physicians prescribe opioids to patients with noncancer pain led to significant decreases in the likelihood that providers would order the potentially addictive medications, researchers have found. The new study, published in JAMA Health Forum, also showed that requiring physicians to justify an opioid prescription did not appear to change behavior.

More than 564,000 people died from overdoses involving opioids, including prescription and illicit painkillers, between 1999 and 2020, according to the Centers for Disease Control and Prevention (CDC). Opioids were involved in more than 68,000 deaths in 2020, nearly nine times the number of such fatalities in 1999.

Part of the solution could be to influence physicians to prescribe fewer opioids by using the power of positive reinforcement and indirect suggestions, according to Kevin Kraemer, MD, professor of medicine and clinical and translational science at the University of Pittsburgh School of Medicine.

“We thought in this case we could influence physicians,” Kraemer said. “If they do decide to prescribe opioids, they decide to do it in a safe way.”

Researchers used three intervention groups of prescribers to study how prescribing would change in response to various nudges. A control group received pop-up notifications on opioid prescription guidelines via the electronic health record at the time of a new opioid prescription.

A “justification” group received the pop-up notifications and had to enter a written explanation for why they decided to prescribe opioids for the given patient. A third group received pop-up notifications and monthly feedback by email that provided individual benchmark reports for an individual physician compared with their peers.

A fourth group (“justification/comparison”) received the pop-ups, wrote the justification note, and received the comparison emails.

Kraemer and his team ran the multisite, randomized clinical trial across three healthcare systems that included 48 primary care practices and 525 participating clinicians between September 2018 and January 2021.

Patients in the trial had never received an opioid prescription, were aged 18 years or older, and had been diagnosed with acute, noncancer musculoskeletal pain or nonmigraine headache.

Doctors who received clinical comparison emails alone had a 41% (P =.02) lower likelihood of prescribing an opioid for a patient after the first visit (P = .02) and a 27% lower likelihood of their patients continuing to receive an opioid prescription after 3 months (P = .01) than their peers in the control group. Results from other groups charting changes in prescriptions were statistically insignificant, according to the researchers.

Too Little Too Late?

Kraemer’s team applied for grants to support the study in 2016. But by the time funding came through 2 years later, prescription rates were already much lower.

The clinics involved in the study reported a 3.1% prescribing rate at the index study visit, while prior prescribing data showed that the rate was 15% to 20%.

Still, Kraemer said, healthcare systems now know that the interventions can reduce unsafe opioid prescriptions, and programming notifications into electronic health records is an easy task.

Daniel Brooks, MD, medical director of Outpatient Toxicology Clinic at Banner Health University Medical Center Phoenix, said he wished the study had been published years ago.

In 2016, Kraemer was ahead of the curve, Brooks said. The opioid epidemic is ongoing in 2022, and many healthcare systems have already built in notifications so that physicians will think twice about their prescribing patterns.

Now Brooks worries electronic health record “nudges” will contribute to alert fatigue and will continue to take up the limited, valuable time physicians have with their patients.

“We have nurses too busy documenting stuff that doesn’t matter,” he said. “At the end of the day, we don’t have time to sit down and talk with our patients.”

The study was independently supported. Smith and Jones have disclosed no relevant financial relationships.

JAMA Health Forum. Published online July 2, 2022. Full text

Kelly Ragan is a journalist living in Colorado.

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