The opioid epidemic in the U.S. resulted in \>50,000 opioid overdose deaths in 2019. Prescription opioids cause a third of opioid overdose deaths overall and 80% of those among older adults (aged ≥ 65). Surgery is a critical event when excessive opioids are prescribed. After surgery, 90% of patients are prescribed more opioids than they use and 90% of those with unused pills do not safely store or dispose of them. Excessive opioid prescribing after surgery can lead to long-term use, diversion, and opioid-related harms including sedation, constipation, hyperalgesia, physical dependence, opioid use disorder, or overdose.
Curbing excessive opioid prescribing after orthopedic surgeries such as knee or hip replacement is particularly important. These surgeries have more than doubled since 2000, opioids are typically required for post-operative pain, and patients undergoing these surgeries tend to be frail or older adults who have high risk for opioid-related harm. Compared with adults under age 65, older adults have twice the risk of post-surgical opioid-related sedation or delirium and increased risk of opioid-related falls, fractures, overdose, hospitalization, and all-cause mortality. Frailty, a syndrome of physiologic decline that is often but not always age-related is associated with increased sensitivity to analgesia and opioid-related harms.
Surgical providers often prescribe excessive opioids at the time of hospital discharge without patient instructions for gradually reducing use over time (tapering). A tapered dose schedule can provide effective post-operative pain control, guide patients to cease opioids within 7 days, and minimizes opioid withdrawal symptoms. Previous K12-funded work and other studies have found that surgical providers fear causing opioid-related harm particularly to older and frailer adults, but prescribe excessive opioids out of concern that patients would have poorly controlled pain, call for more medication or care, or be dissatisfied. In addition, opioid tapers are not prescribed due to the lack of knowledge and standardized procedures.
An algorithm was developed for patient-specific, post-operative opioid taper schedules that considers the patient's opioid requirements while hospitalized. Each taper was manually calculated and was not fully integrated into the electronic health record (EHR) in which the discharging providers work. Studies show that embedding default prescriptions in the EHR is effective at changing prescribing behavior. One pre-post observational study of a patient-specific, post-operative taper calculated outside the EHR reduced excessive prescribing. However, no clinical trials have examined patient-specific, post-operative opioid taper interventions that are embedded as defaults in the EHR. No studies have rigorously examined their impact on patient outcomes or the provider- patient-, and contextual factors that influence whether providers use the intervention with patients.
Excessive opioid prescribing after surgery remains a major driver of morbidity and mortality. EHR-embedded interventions with default settings have the potential to create scalable and lasting changes in provider prescribing practices to reduce excessive post-operative opioid prescribing and encourage tapers but have not been rigorously tested. Thus, this randomized controlled trial is proposed to test the effectiveness of DOTS to reduce excessive opioid prescribing and its impact on patient outcomes.
