Standardized prescribing guidelines reduce frequency and quantity of opioids prescribed

April 20, 2021

In response to the Minnesota Legislature's 2018 call for opioid reform, Ophthalmology staff at Mayo Clinic in Rochester, Minnesota, launched a quality improvement study to determine the effect of implementing standardized opioid prescribing guidelines on prescription patterns for acute pain after ophthalmic surgery. "Despite the low overall number of opioid prescriptions written by ophthalmologists compared with other types of surgeons, any reduction in overprescribing is warranted," says Sanjay V. Patel, M.D., Ophthalmology chair at the time of the study.

The department's intent was to determine the impact of pain management education and opioid prescribing guidelines on prescribing patterns and to avoid opioid prescriptions of more than 80 oral morphine equivalent (OME) after any ophthalmic surgery.

Pain management education

The study team provided pain management education to all ophthalmic surgeons and trainees, including information about alternatives for pain control and pain medicine consultation. Surgeons were encouraged to supply no more than a seven-day course of opioids when deemed necessary; any further opioid requirements were to be managed by a pain medicine specialist. Target guidelines were posted in every operating room. Electronic flags were built into the electronic health record to alert prescribers if they were exceeding guidelines.

Guidelines standardization

The team used electronic health records to identify opioid prescriptions for acute postoperative pain for all opioid-naive patients 18 years of age or older who received ophthalmic surgery at Mayo Clinic in Rochester, Minnesota, in the study period (preimplementation period Oct. 1, 2017, through April 30, 2018, and postimplementation Oct. 1, 2018, through April 30, 2019). "The dates were chosen to prevent any bias that might have been introduced immediately before or after guidelines implementation," says Dr. Patel.

For the purposes of the study, the team defined opioid-naive patients as those who did not have a history of long-term opioid use and had not received a prescription for opioids between 90 days and seven days before surgery.

The team compared postoperative opioid prescribing patterns — the frequency of opioid prescriptions, quantity of opioid prescribed and opioid prescription refill rates — before and after the June 2018 implementation of education and standardized guidelines. All prescriptions containing an opioid agonist, an opioid partial agonist or a combination opioid, with a Drug Enforcement Administration Schedule II or III, were included in the analysis.

"We sought input from all surgeons to reach consensus for the prescribing level appropriate for each ophthalmic procedure within their subspecialty, relative to levels with other subspecialties within the department and guidelines for general and orthopedic surgery as reference data," says Erick D. Bothun, M.D., Ophthalmology Quality Chair at Mayo Clinic in Rochester, Minnesota, and study lead. "The department agreed to target a maximum prescription of 80 OME after ophthalmic surgery."

Results from the three target prescribing categories included:

  • Level 0 surgical procedures (0 OME recommended), including most anterior segment, eyelid and vitrectomy procedures, were the most commonly performed and least likely to be associated with opioid use — 2.3% before intervention and 1% after intervention. "Guidelines led to significant reductions in the number of Level 0 surgical procedures that received more than 40 OME," says Dr. Bothun.
  • The team noted similar improvement for Level 1 surgical procedures (40 or fewer OME recommended), including keratorefractive surgery, insertion of tube shunt or scleral buckle, adult strabismus, and globe trauma. "Although opioids were prescribed for 12.5% of Level 1 surgeries after intervention, none of the Level 1 surgical procedures was associated with prescriptions for more than 80 OME, compared with 4% before intervention," says Dr. Bothun.
  • Level 2 surgical procedures (80 or fewer OME recommended), including orbitotomy, enucleation or evisceration, and brachytherapy plaque surgery, were assumed to result in the greatest risk of patients' postoperative pain. All Level 2 cases met the recommended guidelines after intervention and none was prescribed more than 80 OME, compared with 5% before intervention.

The proportion of patients prescribed opioids decreased from 4.4% to 3.0%, and when opioids were prescribed, the OME also decreased from 93 to 42. The proportion of refill prescriptions for opioids did not differ, indicating similar levels of pain control before and after intervention. There were significant increases in the number of patients managed with less than 40 OME or without any opioids.

"The process of developing standardized opioid prescribing guidelines and discussing postsurgical pain management reduced the overprescribing of opioids without increasing refill rates," says Dr. Bothun. "The data indicate that we still have opportunity for improvement, and even refinement of the prescribing guidelines, and continued discussion and education will be important."

This study was published in Ophthalmology in 2020.

American Board of Ophthalmology Continuing Certification eligibility

One of the components for Continuing Certification by the American Board of Ophthalmology (ABO) is participation in an Improvement in Medical Practice activity. George B. Bartley, M.D., Ophthalmology at Mayo Clinic in Rochester, Minnesota, and current American Board of Ophthalmology chief executive officer, notes: "This opioid project qualified for such credit for all Mayo Clinic ophthalmologists who participated. The ABO hopes that other departments or group practices will consider replicating this project, or investigating another clinical challenge relevant to the care of their patients."

For more information

Starr MR, et al. Impact of standardized prescribing guidelines on postoperative opioid prescriptions after ophthalmic surgery. Ophthalmology. 2020;127:1454.

Improvement in medical practice menu. American Board of Ophthalmology.