A Simple Way to Reduce Opioid Over-Prescribing by Plastic Surgery Residents
David W. Grant, MD, MASc1, Hollie A. Power, MD2, Linh N. Vuong, BSc3, Colin W. McInnes, MD1, Katherine B. Santosa, MD MS4, Jennifer F. Waljee, MD MPH MS4, Susan E. Mackinnon, MD1.
1Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, USA, 2Division of Plastic Surgery, University of Alberta, Edmonton, AB, Canada, 3Washington University in St. Louis School of Medicine, St. Louis, MO, USA, 4Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.
PURPOSE: Over-prescribing following surgery is a known contributor to the opioid epidemic, increasing the risk of opioid abuse and diversion. Trainees are the primary prescribers of these medications at academic institutions, and we previously identified over-prescribing in this population across the US and Canada. We hypothesized that a simple "intervention" could improve over-prescribing.
METHODS: All plastic surgery trainees at one institution completed an anonymous survey querying opioid-prescriber education, factors contributing to prescribing practices, and analgesic prescriptions written after eight common procedures. Oral morphine equivalents (OME) were calculated for each procedure. A simple 4-hour intervention was then administered to all residents in 1-hour sessions, during grand rounds over several weeks: (1) screening of HBO's documentary "Warning: This Drug May Kill You", (2) a 1-hour lecture by a St. Louis Police Department Special Forces Commander regarding how over-prescribing in St. Louis and nationally is linked to prescription opioids, heroin use, and crime; (3) a 1-hour lecture by a psychologist with decades of experience with opioid-addicted patients on the link between pain, psychiatric duress, and prescription opioid and heron use; and (4) a 1-hour lecture by a Pain Management Anesthesiologist on the basic science of pain and analgesia. The survey was repeated several months after completing the intervention. Mean oral morphine milligram equivalents (MME) prescribed pre- and post-intervention were compared using either students t-test or Mann-Whitney U tests, depending on data normality as determined by the Shapiro-Wilks test.
RESULTS: Response rate was >90% on both surveys. For all but 2 procedures (carpal tunnel release and abdominoplasty), there was a statistically significantly decrease in prescribed MME after the intervention. There was a statistically significant increase in residents who changed their prescriptions by the surgery performed (from 53% to 95%, p=0.002). There was no change in the number of residents adhering to the "one-prescriber rule" (37% to 50%, p=0.408).
CONCLUSION: A simple, largely passive, intervention can improve over-prescribing by plastic surgery residents. Coordination of care issues remain a problem, such as following the "one-prescriber rule" - which reflects the role residents play in peri-operative patient flow. The intervention has two very important characteristics that support its broader adoption: (1) it simply raised awareness - we did not create mandatory prescribing protocols, or otherwise specify the details of post-operative management. We identified the problem, and our residents adjusted their behaviors independently; (2) Three of the 4 hours of our intervention are available, now, for wide-spread dissemination to other training programs - for free. Two of the 3 hours of in-person lectures were converted to Prezi's and narrated, and are available here: https://surgicaleducation.wustl.edu/. The HBO supports public screenings of its documentary. Further work can help define (1) minimums for interventions to "raise awareness", and (2) the role post-op protocols play in reducing over-prescribing.
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