Since the early 1990s, the United States has been fighting the epidemic of opioid addiction. Increases in the prescription of over-the-counter opioid pain medications were correlated with a notable rise in overdose deaths as early as 1999.1 These trends may have been driven in part by national efforts to improve the assessment and management of pain among patients and the “pain as a fifth vital sign” culture.2 In this issue of Pediatrics, Bryl et al3 describe their quality improvement (QI) initiative to decrease prescription of opioid medications at discharge from their urban pediatric emergency department. Evaluation of data showing that nearly half of the opioid-related deaths among patients 0 to 21 years in the San Diego area involved patients seen at their institution prompted a call to action. As the largest pediatric provider in that region, achieving a decrease in the group’s prescription of opioid medications could have a significant impact on this population.
The team used rigorous QI methods to guide their initiative. These included developing a specific aim; defining outcome, process, and balancing measures; and implementing interventions by using plan-do-study-act cycles. Statistical process control charts were used to track and analyze their data. Their results were dramatic: they achieved >90% reductions in their primary outcome measures of opioid doses prescribed per week and per visit in the emergency department. Importantly, they did not see any concerning trends in their balancing measures of return visits or poor pain control assessed on follow-up phone calls.
What Can Be Learned From the Work of Bryl and Colleagues?
First, among their interventions, the strongest appeared to be the use of clinical decision support as a “nudge” in the form of fixed discharge dosage limits within the electronic medical record (EMR).4 First described in 2008, clinical nudges represent low-cost, highly effective strategies for changing behaviors by limiting choice, leading to decreased variation. These types of interventions are often instrumental in sustaining change long-term.
Second, any effort to reduce opioid prescriptions must use a balanced approach to achieve safe prescribing while adequately treating pain. Bryl et al3 used several balancing measures, including follow-up phone calls to discharged patients, and found no evidence of undertreatment. It is notable, however, that the group only reached 17% of patients, making it difficult to assess the impact of this project’s dosage choice on pain management at this time.
Third, although the overall QI methods used were robust, their QI team did not include patients and families. When developing initiatives involving direct patient care, it is important to consider inclusion of patients and families, because these stakeholders can provide pivotal information related to patient adherence and preferences.
The work of Bryl et al3 should be considered in the larger context of opioid reduction efforts. With their study, they support the current literature that leftover opioid medication can be a major source of misuse, abuse, and diversion.5 It is evident that reducing overall opioid doses prescribed may be an important avenue toward addressing the opioid crisis. However, opioid prescribing for children and adolescents accounts for only a fraction of the overall opioids prescribed.6,7 This highlights the critical need for partnering with general emergency medicine colleagues and adult health care providers to ensure improved stewardship of opioid prescribing. Groenewald et al8 suggest best practices include: “1) create guidelines to guide responsible opioid prescribing and reduce leftover medications, 2) educate adolescents about risks of opioids and how to safely dispose of opioids, and 3) reduce illicit prescriptions by using state Prescription Drug Monitoring Programs (PMPs).” The study by Bryl et al3 demonstrates how use of QI methodology can bring these strategies to front line providers in the pediatric emergency department.
Initiatives involving guideline development, EMR modifications, and education have broad applicability and are easily implemented, making them ideal interventions for most emergency departments. The dramatic overall opioid reduction achieved by Bryl et al3 is not surprising. In a previous study, Guarisco et al9 used similar interventions in a general emergency department setting and demonstrated a 70% reduction in prescription rates for some physicians, without negatively impacting patient satisfaction scores. This suggests that such opioid reduction outcomes could be successfully replicated in other institutions and interventions are generalizable to all age groups. Another impressive achievement with this study is the sustainability of the initiative. Although strategies such as education have been shown to wane over time, fixed function changes, such as EMR dosing limits, are neither time-bound nor provider-dependent and are easily tracked for data collection.
And the Final Take-Away?
This initiative provides a wonderful example of a project which can be undertaken within other emergency departments to decrease opioid prescribing in the pediatric population. Thoughtful QI efforts and a commitment to change can have broad implications in the care we provide to our patients.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/2020-1180.
FUNDING: No external funding.
electronic medical record
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.