Decreasing Opioids & Increasing Multimodal Pain Prescription in Opioid Naïve Orthopaedic Trauma Patients – The Power of a Standardized Protocol

From the 2021 HVPAA National Conference

Alexandra Dunham (Johns Hopkins School of Medicine), Zachary Enumah, Kent Stevens, Travis Rieder, Casey Humbyrd, Babar Shafiq

Background

Post-operative prescribing practices have relied heavily on opioids for pain management, particularly in orthopaedic trauma. To reduce opioid use and improve pain management we developed a standardized, multimodal pain treatment protocol for opioid naïve orthopaedic trauma patients undergoing a single stage surgery.

Objectives

We sought to:

  • Establish feasibility of our protocol
  • Characterize its impact on prescribing patterns

Methods

A cohort of orthopaedic trauma patients treated by a single surgeon at our large, tertiary academic center were identified from our trauma database. Patients treated before (1/1/17-12/31/17) versus after (7/1/18-8/31/19) implementation of the protocol were compared. We compared type of pain medications and quantity of opioids prescribed at discharge and at each post-operative visit up to 3 months.

Results

In the pre-implementation cohort of 89 patients, 86 were prescribed an opioid at discharge, averaging 465 MME (morphine milligram equivalents). Nine patients (10%) were prescribed the full multimodal complement. Of this cohort, 21 patients were prescribed an opioid refill at the 2-week visit, averaging 560 MME; 9 patients at the 6-8-week visit, averaging 600 MME; and 2 patients at 3-months, averaging 225 MME.

In the post-implementation cohort of 102 patients, 95 were prescribed an opioid at discharge, averaging 273 MME (40% reduction). 54 patients were prescribed the full multimodal complement (53%). Post-implementation, there was convergence and reduced variability in opioid prescription amount at time of discharge. Eleven patients were prescribed an opioid refills at the 2-week visit, averaging 368 MME (34% reduction); 5 patients at the 6-8-week follow up, averaging 170 MME (72% reduction); and 3 patients at the 3-month follow up, averaging 305 MME (36% increase).

Conclusion

There was an overall reduction in MME prescribed at time of discharge and through follow-up. Furthermore, there was an increase in frequency to prescribing non-narcotic multimodal pain therapies.

Clinical Implications

Implementation of a standardized, multimodal pain treatment protocol for opioid naïve orthopaedic trauma patients at a large level 1 trauma center is effective at decreasing post-operative opioid prescription amounts and can be easily implemented across a diverse set of orthopaedic injuries.

 

Click here to register for the 2022 Architecture of High Value Health Care National Conference!

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog