A Quality Intervention Promoting Opioid Alternatives for Back or Neck Pain

From the 2019 HVPAA National Conference

Dr. Ashley Deutsch (Baystate Medical Center – University of Massachusetts Medical School), Dr. Adam Kellogg (Baystate Medical Center – University of Massachusetts Medical School), Dr. Jonathan Chinea (Baystate Medical Center – University of Massachusetts Medical School), Dr. Jonathan Morgan (Baystate Medical Center – University of Massachusetts Medical School)

Background

Reduction of opioid use and prescribing in the emergency department is an emerging goal for many. Higher than expected opioid prescribing levels were found at our institution for patients with back or neck pain, and lower than expected use of multimodal analgesia and physical therapy.

Objective

This quality improvement intervention aims to promote opioid alternative interventions in our ED for patients with neck and back pain.

Methods

A brief printed reference with details regarding suggested opioid alternative medications and doses was created.  In association Baystate Physical Therapy (PT) we implemented a mechanism for PT referral directly from the ED, bypassing the previously required primary physician referral.  A streamlined PT referral form was integrated into our electronic discharge instructions. We then presented a case-based didactic presentation to residents, attendings, and PAs/NPs, and provided spaced-repetition reinforcement via e-mailed summary with copies of our printed reference.  Pre and post intervention consecutive samples of 100 patient visits were pulled for abstraction by final ICD-10 code for neck or back pain and evaluated for use of opioids and opioid alternatives.

Results

Prior to the intervention, 34% of patients were administered an opioid analgesic in the ED and 24% were discharged with an opioid prescription, compared with 24% and 9% post. 39% were given an NSAID in the ED and 21% were given acetaminophen in the ED prior compared to 41% and 38% post.  Topical lidocaine was prescribed 0% prior and 8% post. Since February 2018 at least 16 patients followed up with PT following an ED referral, although this endpoint is difficult to capture and likely underreported.

Conclusions

There was a decrease in opioid use for back or neck pain following this quality intervention.  This intervention also facilitated patients transition to physical therapy for their chronic back pain.

Clinical Implications

Although we are unable to control for similar coexisting efforts such as new statewide restrictions on opioid prescribing, it may be reasonable for institutions to create a set of recommendations for multimodal analgesia, provide education to prescribers, and to facilitate opioid alternatives such as physical therapy.