Implementation of Interventions to Maximize Opioid Disposal after Surgery in Routine Clinical Practice
*Yash Deshmukh 1, *Mateo Amezcua 1, *Brendan Barth 1, Robin Cotter 2, Richard J. Barth MD2
1Geisel School of Medicine at Dartmouth, White River Junction, VT; 2Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
Objectives: Despite guideline directed opioid prescribing after surgery, many patients are left with excess opioid pills. These can be diverted to others and are a risk for misuse, overuse, and dependency. Although interventions have been shown to increase opioid disposal in the context of research studies, it is unclear whether such interventions can be implemented in routine clinical practice.
Design: Prospective intervention trial.
Setting: Academic medical center.
Patients: All adult patients in general surgery, otolaryngology, plastic surgery, neurosurgery, urology and transplant surgery who were prescribed opioids after surgery were identified. Opioid disposal in 453 pre-intervention patients undergoing surgery between 3/1/23 - 6/30/23 was compared to 545 post-intervention patients undergoing surgery between 10/1/23 - 1/31/24. Pre-intervention patients were called 1-3 months after surgery and asked about opioid disposal; responses in post-intervention patients were recorded at the post-operative visit and were verified by phone calls 1-3 months after surgery.
Interventions:
1) Provide information sheet on the importance of excess opioid disposal and methods for FDA compliant disposal in after visit summary.
2) Send automated reminder message to dispose excess opioids in patient portal of the electronic medical record (EMR).
3) Trigger Best Practice Alert (BPA) pop-up to appear when provider opens patient note in EMR during post-operative visit. BPA reminds provider to discuss opioid disposal with patient and can record patient response.
Main Outcome Measure: Proportion of patients with excess opioids who disposed of their excess pills.
Results: Responses were obtained in 61% (279/453) of pre-intervention patients; 46% (130/279) had excess opioids. Responses were obtained in 74% (404/545) of post-intervention patients; 56% (227/404) had excess opioids.
The percentage of patients disposing of their excess opioids increased from 30% (39/130) pre-intervention to 85% (193/227) post-intervention, p < 0.00001.
47% of providers (257/545) discussed opioid disposal with their patients at their post-operative visit; 53% opted to skip the BPA without discussing opioid disposal. Patients who had a discussion with their provider at their post-operative visit were 23% more likely to dispose of their excess opioids than those who only received an information sheet and EMR reminders (93% vs 70%, p < 0.00001).
Conclusions: Interventions easily incorporated into the EMR can markedly increase excess opioid disposal after surgery. Discussions with trusted providers are a powerful tool to ensure disposal compliance rates, and providers can be prompted to initiate discussion with EMR reminders. When information on opioid disposal is combined with provider discussion of opioid disposal during the postoperative visit, opioid disposal rates of >90% can be achieved.
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