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.