Prescription Default Nudges for Opioid Reduction after Major Surgery (NORMS): A Randomized Controlled Trial

Area of Science:

• Surgery
• Health Informatics
• Pain Management

Background:

• Addressing the national opioid crisis requires optimizing postoperative opioid prescribing.
• Electronic health record (EHR) behavioral nudges offer a potential solution but need testing in surgical settings.

Purpose of the Study:

• To evaluate the impact of an EHR-based default "nudge" intervention on opioid prescribing after common surgical procedures.
• To assess the effectiveness of pre-populated opioid prescriptions in reducing morphine milligram equivalents (MME) at discharge.

Main Methods:

• A randomized clinical trial involving 118 surgical clinicians at an academic medical center.
• Clinicians were randomized to control or intervention groups using an electronic discharge order set.
• The intervention arm featured suggested pre-populated opioid and adjunct prescriptions; MME prescribed at discharge was the primary outcome.

Main Results:

• The study analyzed 663 surgical encounters; median opioid prescription was 75 MME.
• Intention-to-treat analysis showed no significant difference in MME between groups (adjusted difference: 2.4 MME).
• However, surgeons accepting pre-populated defaults (21% of intervention arm) prescribed significantly less opioids (adjusted difference: -22.5 MME).

Conclusions:

• Default EHR nudges for opioid prescribing did not reduce overall postoperative opioid use.
• A subset of surgeons accepting defaults demonstrated substantial opioid reduction.
• Stronger default interventions and co-interventions may be necessary to optimize opioid prescribing effectively.