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At AffirmHealth, we’re keenly focused on providing prescribing intelligence and clinical decision support tools that help the clinician prescribe responsibly at the point of care delivery while minimizing interruptions in normal workflow patterns. While we use our platform, AffirmHealth Shield, to help us execute on those goals, we also work with other professionals including clinical informaticists, pharmacists, and software developers to integrate with other solutions that can help reverse the course of overprescribing and overuse that are fueling the opioid epidemic in America. We believe there are two recent developments that are worth being aware of both for prescribers and patients.
On May 30th, Acting Commissioner of Food and Drugs at the Food and Drug Administration, Ned Sharpless, issued a statement on FDA’s request for information on requiring fixed quantity blister packaging for certain opioid medications. In that statement, Dr. Sharpless makes the valid point that many patients are prescribed “significantly more opioid pills than they actually use following surgical procedures or other acute pain conditions for which opioids are prescribed…This excess supply of opioids provides opportunities for misuse, abuse, overdose, and development of addiction, as well as the potential for these leftover pills to end up in the hands of a child, friend, or relative for whom they aren’t intended.”
As a result, FDA is working to help clinicians “right size” their prescribing so that the number of pills prescribed more appropriately matches the patient’s needs while minimizing excess. Part of that effort entails leveraging a newfound packaging authority granted to the FDA through the 2018 SUPPORT Act which Congress passed in response to the worsening opioid epidemic. Knowing from published studies that most patients use their opioids for between one and three days, and took fewer than 15 pills total, FDA is soliciting feedback on a system wherein certain opioids would be dispensed in single count blister packs (5, 10, or 15 tablets) instead of another amount written by a prescriber. Prescribers would still be able to write for a number of blister packs at their discretion, but the hope is that by repackaging materials in this way, that clinicians will be forced to give second thought to the number of pills they are prescribing.
Besides having the benefit of reducing variable prescribing practices by different clinicians, packing pills in this way would also have the benefit of easier standardization across medical conditions and procedures, facilitate more accurate inventory control, and ideally influence patient behavior in a manner that forces them to consider additional adjunct options for pain control.
This is certainly a valid approach and we encourage our readers to send their comments to the FDA’s request for information.
Default Pill Counts In Electronic Health Records
In a study that’s garnered more attention recently, AS Chiu et al published a paper in JAMA Surgery (Nov 2018) that showed the significant value that small changes in electronic health records can make in prescribing patterns. Using the Yale health system as their test bed, they tested the hypothesis that making a change in the automatically prepopulated fields of an EHR embedded e-prescribing system would change postoperative prescribing rates.
In an effort to minimize click counts, one thing EHRs will sometimes do is auto-populate certain fields that clinicians frequently use. Chiu et al. changed the default number of opioid pills prescribed from 30 to 12 and measured the number of opioid pills prescribed for three months before and after the intervention. They found that the median number of opioid pills prescribed decreased from 30 to 20 per prescription, that the number of scripts written for 30 pills decreased from 39.7% to 12.9%, and that the percentage of scripts written for 12 pills increased from 2.1% to 24.6%. Using a linear regression analysis, they were able to demonstrate a decrease of 5.22 opioid pills per prescription after the change which resulted in a total decrease of 34.41 MME per prescription with no change in opioid refill rates.
If we consider this for a moment, this is a fascinating study of human behavior. While the patient populations were the same before and after the intervention, and the perceived pain was presumably the same before and afterwards, this simple intervention showed a dramatic decrease in opioid prescribing in a way that could similarly drive “right size” prescribing similar to FDA’s efforts above.
Optimizing Drug Prescribing in the Future
Opioids will not be the last class of medications to face scrutiny in search of right sizing. With antibiotic resistance worsening and overall health care costs rising, we expect that there will be additional attention placed on optimization of drug prescribing to include antibiotics and other analgesics. This type of sizing influence is not only in the best interest of the patients, it should also help minimize waste, reduce risks of overdose, and minimize diversion to unintentional populations. These are laudable goals that the clinical community can and should support. These two interventions represent a smart approach to influencing prescribing behaviors in a way that does not completely disrupt clinician workflow or adversely affect the clinician-patient relationship
For more information on the U.S. Opioid Epidemic, news, and other related updates, please visit our Resources page and blog to stay informed on the latest happenings. AffirmHealth is dedicated to providing our clients with leading knowledge and reports of the ongoing opioid status in the United States.
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