Developing and piloting an adaptable oxycodone quality improvement strategy: steps towards opioid stewardship

Abstract

ObjectiveIn recent years, there have been considerable increases in both the utilisation and reported harms of prescription opioids in Australia. This report details the development of adaptable resources, implementation and the evaluation of pilot projects that optimise oxycodone prescribing and introduce concepts of opioid stewardship into hospital settings. MethodsAn adaptable suite of resources, based on principles of implementation science, was developed and used to facilitate the projects. Local prescribing practice audits of oxycodone guided the development of context-sensitive educational strategies that were piloted and evaluated in a repeat audit. The primary outcome was the proportion of oxycodone prescriptions indicating tailored prescribing practices. In emergency departments (EDs), a prescription was considered tailored if it was for ≤10 tablets. In surgery, tailored prescriptions were those given to patients who had required opioids in the 24h before discharge. ResultsCumulative results of the pilot projects in three EDs demonstrated improved rates of tailored oxycodone prescribing on discharge (62% vs 90%; P<0.0001). In the surgical setting of one hospital, tailored prescribing increased significantly (from 76% to 91%; P=0.013) and was accompanied by a halving of the proportion of patients receiving oxycodone prescriptions (36% vs 18%; P<0.001). ConclusionsThe implementation of facilitated, adaptable, prescriber-led quality improvement projects significantly improved tailored oxycodone prescribing practices and provides a platform to advance further opioid-related practice improvement in Australia. What is known about the topic?The increasing trend in opioid prescribing, misuse, harm and death in Australia, and the potential for hospital prescribing to contribute to long-term opioid use, is well known. Recent changes to the Pharmaceutical Benefits Scheme are designed to help better identify patients who need oxycodone on discharge and the quantity to prescribe, rather than default prescribing. However, how to implement tailored prescribing has not been described in detail in the Australian literature. What does this paper add?This paper adds to the mass of literature describing the ‘problem’ of opioid prescribing by providing a ‘solution’ in the form of evidence for the implementation of a facilitated and adaptable quality improvement strategy in emergency and surgical settings. The focus is not on a reduction of opioids, but rather on providing tailored pain management and opioid prescribing. What are the implications for practitioners?This paper provides a practical, pragmatic and achievable starting point for other Australian practitioners to adapt the described processes and take the first steps towards opioid stewardship in their setting.

Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department

“…Of these, 180 were kept for full-text review, and 63 unique studies were included in the review ( Figure 1 ). 12 , 27 , 28 , 29 , 30 , 31 , 32 , 35 , 36 , 37 , 39 , 40 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , …”

“… 69 , 94 , 102 All studies were published within the last 10 years (2013 to 2021). Studies used mainly preintervention-postintervention (n = 39) 12 , 28 , 30 , 31 , 32 , 35 , 39 , 40 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 92 , 93 , 94 , 99 , 100 , 101 , 102 and ITS (n = 21) 27 , 29 , 36 , 37 , 54 , 55 , 56 , 57 , 71 , 72 , 73 , 74 , 87 , 88 , 89 , 90 , 91 , ...…”

“… 103 , 104 The EPG intervention was used to help reduce opioid prescriptions in 21 studies 31 , 32 , 35 , 36 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ; PDMP, in 19 studies 27 , 28 , 29 , 30 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 ; EMR-QC, in 11 studies 37 , 39 , 40 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 ; CPC, in 10 studies 12 , 86 , 87 , 88 , 89 , 90 , …”

“… 103 , 104 Fifty-two studies 12 , 27 , 28 , 29 , 31 , 35 , 36 , 37 , 39 , 40 , 54 , 55 , 57 , 59 , 60 , 61 , 62 , 65 , 66 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 included a mix of pain problems, and 56 included both acute and chronic pain. 12 , 27 , 28 , 29 , 30 , 31 , …”

“…Ten of 21 ITS studies 27 , 36 , 54 , 55 , 56 , 57 , 88 , 89 , 90 , 91 demonstrated an overall moderate risk of bias (ROBINS-I); all other ITS and preintervention-postintervention studies 12 , 28 , 29 , 30 , 31 , 32 , 35 , 37 , 39 , 40 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 87 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , ...…”