USACS Emergency Department Initiative Cuts Opioid Prescriptions in Half
Opioid epidemic. These two words have become all too familiar for families across the country. For Americans aged 18-44, a drug overdose is the leading cause of death. Over a million lives have been lost since 1999, making it one of the most pressing issues within healthcare today.
Despite knowing that the emergency department is not the primary contributor to the opioid epidemic, we at USACS looked inward to identify opportunities for improvement under our direct control. We turned our attention to EDs, which account for one-fifth of all opioid prescriptions. Recognizing this is a critical source, we sought to address the challenge of overprescribing and its contribution to opioid addiction and mortality.
“Beginning in June of 2020, several USACS physicians came together to deploy an audit and feedback quality improvement program,” explained Chief Medical Officer, Amer Aldeen, MD, FACEP, FAAEM. “The goal of this program was to study and address variability in opioid prescribing in our EDs across the country. Driven to provide safer alternative analgesics for our patients, we focused on two key methods: a peer comparison tool and direct clinician feedback.”
First, we used an online dashboard that allows our clinicians to compare their prescribing rates to site, regional, and national peers in blinded fashion. This produced awareness and accountability alongside a judicious approach to prescribing opioids. Secondly, one-on-one conversations were held between our national quality leaders and our high-prescribing clinicians. The goal of the conversation was by no means to force clinicians to prescribe fewer opioids—instead, it was to identify their status as outliers, hear their reasoning, and provide education about alternatives to opioids (ALTOs). By facilitating this communication, we promoted a shared commitment to continuous improvement and evidence-based pain management strategies.
“To evaluate our impact, we collected data over a two-year period,” shared Chief of Clinical Innovation, Jesse Pines, MD, MBA, MSCE. “This became the largest study of an ED opioid prescribing intervention, originally published in the Annals of Emergency Medicine. The study spanned 102 EDs in 17 states and compiled data from over 5 million discharges, 924 physicians, and 492 advanced practiced providers (APPs).”
Following implementation, we quickly saw the effect on clinician prescribing behavior. From 2020 to 2022, our ED prescriptions decreased from 10.36% of discharges to 6.92%. With continued focus on outliers, our latest measurements place us at 5.80% of discharged patients—an impressive 44% decrease. The most notable reductions occurred among our highest prescribers.
“These results exemplify the power of large, clinically relevant databases and clinician awareness,” stated Dr. Aldeen. “Clinicians had absolutely no idea where they stood relatively amongst their peers in opioid prescribing. Everyone we talked to was initially shocked. And almost everyone was open to feedback and education—importantly, even those who were resistant to feedback changed their prescribing behavior after a simple, non-punitive, one-on-one conversation.”
In addition to these findings, we gained valuable insight into potential causes of high prescribing rates. This knowledge is primarily attributed to discussions between clinicians and leadership. Key reasons included the mistaken impression that short course opioids do not increase the risk of abuse, a desire to please patients rather than argue, and the perception that their sites as a whole favored more liberal prescribing practices. Through their open and non-judgmental input, we were able to identify what was needed to implement actionable solutions.
“This dialogue provided the perfect chance to hear clinician concerns about why they might feel pressured to prescribe opioids,” said Dr. Pines. “We spoke about the importance of avoiding medications mistakenly thought not to be opioids (like tramadol) and leveraging ALTOs. We also provided educational resources on creating and approving pain management guidelines at the departmental level, optimizing geriatric pain management, and improving communication with patients.”
Across the board, this initiative has nationwide implications. Previous literature has been limited, primarily examining academic environments and smaller sample sizes. In contrast, our efforts deliver the depth and breadth of diverse practice settings, hospital systems, and geographic regions. When used in tandem, comparative information and direct communication proved to be highly effective. For those aiming to transform the culture of prescribing, this framework can serve as a valuable tool.
As Dr. Aldeen affirmed, “Our goal as a physician-owned and -led organization is to find solutions to take better care of patients. At USACS, physicians lead the charge to institute practice change at scale. It can be very difficult to change the practice behavior of clinicians, but as long as we are keeping patient care as our compass, we know we are headed in the right direction.”
To learn more, check out the USACS Research Group and our innovation case studies.