Midcoast Maine Prescription Opioid Reduction Program
- Need: Reduction in the number of emergency department dental patients abusing opioid prescriptions in rural southeastern Maine.
- Intervention: Using a one-page opioid prescription guideline, opioid prescribing and emergency room visits for dental pain decreased.
- Results: The rate of opioid prescription dropped nearly 20% after implementation, and in comparing the 12-month period before and after implementation, dental pain emergency department visits decreased from 26 to 21 per 1,000.
Effective (About evidence-level criteria)
In 2012, the state of Maine led the nation in prescriptions for opioids. According to the National Institute on Drug Abuse, from 1990-2010 unintended U.S. deaths caused by prescription opioid overdoses quadrupled, surpassing deaths involving heroin and cocaine. In that same time period, the annual number of opioid prescriptions almost doubled, rising from 120 to 210 million.
In 2011, prescription protocol guidelines were implemented in the emergency departments (ED) of Miles Memorial Hospital and St. Andrews Hospital, both located in the rural region of midcoast Maine. Together, they have a combined annual patient volume of roughly 17,000.
These guidelines are a one-page, easy-to-understand protocol utilized by physicians and nurses for evaluating patients complaining of pain. The overall goal is to deter patients who may be abusing prescription drugs or other illicit substances.
The guidelines recommend providers make a thorough effort to verify a patient’s recent medication history, and also suggest a consideration to reduce or deny prescription refills for opioids allegedly lost or stolen.
In addition, providers are encouraged to avoid prescribing controlled substances to patients with a known history of taking these medications for pain management.
Disgruntled pain patients who are denied pain prescriptions often bring about lawsuits and complaints about inappropriate treatment. The guidelines served as official hospital policy, giving emergency room providers increased confidence in having their denial decisions supported by legal and hospital representatives.
The guidelines are contained on a one-page document, Protocol for the Prescription of Controlled Substances by Emergency Department Providers
The study’s objective was guideline use to limit prescriptions to patients more likely to abuse opioids.
In analyzing the effectiveness of the guidelines, researchers observed all patients aged 16 years and older who were discharged with a diagnosis of a painful dental condition. Patients were excluded if they had objective evidence of dental pain, such as being admitted, transferred, received intravenous antibiotics or had an oral incision and drainage procedure.
Program leaders observed a 17% absolute reduction in departmental opioid prescription rate for ED patients discharged with painful dental conditions. However, in relative (not absolute) terms, opioid prescription reduced 71%.
Comparing data for one year prior to guideline implementation with the following year, the proportion of ED and urgent care visits accounted for by patients claiming dental pain fell from 26 to 21 per 1,000 visits. This 19% decrease is most likely attributed to word-of-mouth conversations about the new prescription restrictions among patients that used pain, theft, or loss to access opioid prescriptions.
Further information on program results:
Fox, T.R., Li, J., Stevens, S. and Tippie, T. (2013). A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine, 62(3), 237–240. Article abstract
Case study. The Centers for Disease Control and Prevention's March 2018 Rural Health Policy Brief, "Preventing Opioid Overdoses In Rural America."
Significant time for protocol review, endorsement and implementation.
Opioid overdose mortality data is compelling evidence for protocol needs and annual data is published by the Center for Disease Control and Prevention.
Using highly adaptable protocols and guidelines helps implementation into a community and culture.
Having administrative support can help move policy through the ranks. For the midcoast Maine protocol program, the emergency department chairman served as the primary advocate for the program.
Time should be allotted for administrative approval process which can be lengthy.
An “easy to read” protocol not only improves provider compliance, it impacts time for legal and hospital board review process.
James Li, MD Emergency Department
Emergency department and urgent care services
Pharmacy and prescription drugs
Prescription drug abuse
February 19, 2016
April 16, 2018
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