Opioid Use, Unspecified
Conditions
Keywords
Opioids, Behavioral Research
Brief summary
There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. The objective of the R21 pilot phase of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS) is to develop and test novel behavioral nudges to encourage adherence to pain and CDC guidelines for opioid prescribing for persons with noncancer pain. Interventions will leverage the electronic health record (EHR) to discourage unnecessary opioid prescribing through the application of behavioral insights-empirically-tested social and psychological interventions that affect choice.
Detailed description
There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. In 2017, the Centers for Disease Control and Prevention (CDC) issued the CDC Guideline for Prescribing Opioids for Chronic Pain to encourage safe and effective alternatives to opioids, discontinuation of opioids when patients do not resume normal activities and prudent dosing strategies. However, poor guideline adherence is a general concern and may impede uptake. Our prior studies have used insights from behavioral economics and social psychology to increase guideline adherence. The objective of the R21 pilot phase of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS) is to develop and test novel behavioral nudges to encourage adherence to pain and CDC guidelines for opioid prescribing for persons with noncancer pain. At the time of opioid prescribing, clinicians will be prompted with an EHR nudge when the prescribing history for the patient falls into one of the following three mutually exclusive categories: Opioid naïve, At-risk for long term use, or Long-term opioid recipient. The primary outcome is average weekly morphine milligram equivalents (MME) prescribed per-clinician.
Interventions
BEHAVIORALOpioid naive
Visit where the order is for an included opioid and there is no prior opioid prescription with a start date of greater than 1 day and less than 91 days
BEHAVIORALAt-risk for long term use
Visit where the order is for an included opioid, there is a prior opioid prescription with a start date greater than 1 day and less than 91 days, and there is no prior opioid prescription with a start date greater than 90 days
BEHAVIORALLong-term opioid recipient
Total opioid doses are at least 50 MME per day, there are two or more prior opioid prescriptions with two different start dates both greater than 1 day and less than 91 days, and there is a prior opioid prescription with a start date greater than 90 days and less than 181 days
Sponsors
National Institute on Aging (NIA)
Northwestern University
AltaMed Health Services Corporation
The Children's Clinic
University of Southern California
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* NM clinic that sees patients ≥ 18 years old whose leadership agrees to participate
Exclusion criteria
* None
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Average Weekly Milligram Morphine Equivalent (MME) | 34 weeks | Average per-clinician weekly milligram morphine equivalent (MME) in the 34-week period post-intervention |
Countries
United States
Participant flow
Recruitment details
41 primary care clinicians from 3 clinics at Northwestern Medicine in Chicago, Illinois were enrolled.
Pre-assignment details
Only clinicians listed as a treating member of the clinic receive the intervention.
Participants by arm
| Arm | Count |
|---|---|
| Clinical Decision Support Participating clinicians will receive any of three clinical decision support nudges within the electronic health record when eligibility criteria are met within a patient's chart:
Opioid naïve: Visit where the order is for an included opioid and there is no prior opioid prescription with a start date of greater than 1 day and less than 91 days
At risk for long term use: Visit where the order is for an included opioid, there is a prior opioid prescription with a start date greater than 1 day and less than 91 days, and there is no prior opioid prescription with a start date greater than 90 days
Long term opioid recipient: Total opioid doses are at least 50 MME per day, there are two or more prior opioid prescriptions with two different start dates both greater than 1 day and less than 91 days, and there is a prior opioid prescription with a start date greater than 90 days and less than 181 days | 41 |
| Total | 41 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Post-intervention | 5 clinicians were excluded from analysis due to lack of prescribing data | 5 |
Baseline characteristics
| Characteristic | Clinical Decision Support | — |
|---|---|---|
| Age, Categorical <=18 years | 0 Participants | — |
| Age, Categorical >=65 years | 8 Participants | — |
| Age, Categorical Between 18 and 65 years | 33 Participants | — |
| Average weekly milligram morphine equivalent (MME) At risk for long term use | 34.44 Weekly MME STANDARD_DEVIATION 168.03 | — |
| Average weekly milligram morphine equivalent (MME) Opioid naive | 34.88 Weekly MME STANDARD_DEVIATION 86.07 | — |
| Race and Ethnicity Not Collected | — | — Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | — |
| Race (NIH/OMB) Asian | 0 Participants | — |
| Race (NIH/OMB) Black or African American | 0 Participants | — |
| Race (NIH/OMB) More than one race | 0 Participants | — |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | — |
| Race (NIH/OMB) Unknown or Not Reported | 41 Participants | — |
| Race (NIH/OMB) White | 0 Participants | — |
| Region of Enrollment United States | 41 participants | — |
| Sex: Female, Male Female | 26 Participants | — |
| Sex: Female, Male Male | 15 Participants | — |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 41 |
| other Total, other adverse events | 0 / 41 |
| serious Total, serious adverse events | 0 / 41 |
Outcome results
Primary
Average Weekly Milligram Morphine Equivalent (MME)
Average per-clinician weekly milligram morphine equivalent (MME) in the 34-week period post-intervention
Time frame: 34 weeks
Population: Of the 41 clinicians enrolled in the study, 5 were excluded due to lack of prescribing information.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Clinical Decision Support Nudges | Average Weekly Milligram Morphine Equivalent (MME) | Opioid naïve | 34.62 Weekly MME per clinician | Standard Deviation 97.13 |
| Clinical Decision Support Nudges | Average Weekly Milligram Morphine Equivalent (MME) | At-risk for long term use | 22.37 Weekly MME per clinician | Standard Deviation 102.67 |
| Clinical Decision Support Nudges | Average Weekly Milligram Morphine Equivalent (MME) | Long-term opioid recipient | NA Weekly MME per clinician | — |
Comparison: Pre post comparison for Opioid Naïve patientsp-value: 0.4395% CI: [-0.03, 0.01]Mixed Models Analysis
Comparison: Pre-post comparison for at-risk for long term use patientsp-value: 0.2495% CI: [-0.051, 0.013]Mixed Models Analysis