Optimizing Opioid Prescribing and Dosing Through Nudges

Background:

The opioid epidemic has incurred significant clinical and economic toll on the United States.  The human impact from the epidemic has adversely affected communities and many employers.  The patient-physician encounter is a microcosm of the social ramifications of the epidemic.  Physicians are concerned about clinical and legal consequences that may arise if they prescribe pain medication to Patients who may have developed a dependency or are outright abusing the medication.  Patients are concerned that their Physicians will unnecessarily reduce or outright discontinue their medication, affecting their quality of life and their activities or daily living.  As a result, there is an inherent lack of trust that builds between the Physician and Patient.  To address this lack of trust and encourage Physicians and Patients to have honest discussions about prescribing and taking opioid medications, we must encourage such discussions and open conversation.

Thesis:

If Physicians and Patients are provided a platform to anonymously express their sentiments, they will honestly convey their concerns.  Physicians will honestly state their rationale behind prescribing certain opioids to certain patients, and not prescribing certain opioids to certain patients.  Patients will honestly state their concerns around their use of opioid medications and their concerns around how they communicate with their Physicians.  The feedback will provide meaningful information on how we can bridge the trust gap that exists between Physicians and Patients regarding opioid prescriptions.

Nudges:

There are two types of nudges that exist with opioid prescribing: prospective and retrospective nudges.  In prospective nudges, the Physician and Patient are prompted to behave or converse in a specific way to encourage open discussion.  In retrospective nudges, the Physician and Patient are prompted to review a past action or past event to encourage change in future behavior.  Both nudges are necessary to optimize the Patient-Physician relationship.

Physician Prospective Nudges:

Prospective Nudges will prompt the Physician to consider why and how the Patient takes the opioid medication.  However, rather than encouraging a one-sided discussion, the nudge will prompt the Physician to encourage an open dialogue and discuss his or her concerns about the opioid epidemic with the Patient.  By revealing the Physician’s concerns, the Patient will feel more comfortable expressing his or her concerns as well.

The prospective Physician nudge will come through a computer based or mobile app-based questionnaire that will require the Physician to take 1-2 minutes to complete.  The nudges will come either monthly or quarterly.  The nudges will ask:

Do you prescribe medically indicated opioids for your patients?

Yes/No

Do you feel comfortable discussing your concerns about prescribing opioids to your patients?

Yes/No

Have you ever decided not to prescribe opioids or prescribe a lower dose of opioids to a patient?

Yes/No

How easy is it for you to obtain imaging studies and urine drug screens for your patients who are prescribed opioids?

Likert Scale – not very easy, not easy, neutral, easy, very easy

Have you ever decided not to prescribe opioids or prescribe a lower dose of opioids because you did not have access to imaging studies or urine drug screens?

Yes/No

Has your request for imaging studies or urine drug screens ever been denied by a patient’s insurance plan or because a patient cannot afford it?

Yes/No

Are you likely to continue prescribing opioids for a patient if it is difficult to obtain imaging studies or urine drug screens?

Likert Scale – not very likely, not likely, neutral, likely, very likely

Are you likely to prescribe medically indicated opioids if you have easier access to imaging studies or urine drug screens?

Likert Scale – not very likely, not likely, neutral, likely, very likely

How strongly do the opioid prescribing laws impact your willingness to manage patients who require opioid prescriptions?

Likert Scale – not very strongly, not strongly, neutral, strongly, very strongly

How strongly does your patient-physician relationship impact your willingness to manage patients who require opioid prescriptions?

Likert Scale – not very strongly, not strongly, neutral, strongly, very strongly

If you have better access to imaging studies and urine drug screens, would you feel more comfortable continuing a patient’s opioid medication?

Yes/No

How strongly do you believe better access to imaging studies and urine drug screens would improve your clinical decision making in continuing a patient’s opioid medication?

Likert Scale – not very strongly, not strongly, neutral, strongly, very strongly

How strongly do you believe better access to imaging studies and urine drug screens would improve your patient-physician relationship?

Likert Scale – not very strongly, not strongly, neutral, strongly, very strongly

The number of questions to ask per nudge and the order in which the questions will be asked can be adjusted per Physician participant.  However, all responses must be confidential and stored on a secure database.  The prospective nudges will prompt the Physician to think how he or she communicates with Patients and how he or she develops trust in his or her Patients.

Physician Retrospective Nudges:

Retrospective Nudges will prompt the Physician to review his or her prescription patterns at a broader level as opposed to the individual Patient level.  The retrospective nudges will be more informative and descriptive rather than a series of questionnaires.  We will send, either monthly or quarterly, to the Physician, statistics related to the opioid epidemic.  Statistics that will be sent in this nudge include:

Nationwide number of opioid deaths within past month and past quarter

Local number of opioid deaths within past month and past quarter

Number of overdoses among Patients seen by the Physician over the last one year within past month and past quarter

These three data points will inform the Physician about the significance of the opioid epidemic and how his or her practice and prescribing patterns compare to the local and national death statistics.  While sharing mortality rates can appear threatening, the goal is to educate the Physician and prompt the Physician to be more self-aware of how his or her broader prescription patterns compare to the statistical averages.

Local data will be limited to data within the specific county that the Physician practices.

Patient Prospective Nudges:

Prospective Nudges will prompt the Patient to consider why and how the Patient takes the opioid medication.  However, rather than coming across as if we are interrogating the Patient, we want the Patient to feel comfortable discussing their opioid use.  The questions will explain the Patient’s rationale for taking pain medications and how comfortable the Patient feels communicating that rationale.

The prospective Patient nudge will come through a computer based or mobile app-based questionnaire that will require the Patient to take 1-2 minutes to complete.  The nudges will come either monthly or quarterly.  The nudges will ask:

Why are you taking pain medications?

Acute pain, Chronic pain

Do you take it regularly or as needed?

Regularly, As Needed

How often do you take your pain medication as prescribed?

Likert Scale – not very often, not often, neutral, often, very often

How often do you skip a dose?

Likert Scale – not very often, not often, neutral, often, very often

How often do you take more than prescribed?

Likert Scale – not very often, not often, neutral, often, very often

Do you give extra medications to friends/family?

Yes/No

Have you asked for additional pain medication from friends/family?

Yes/No

Based upon your last doctor visit, do you feel comfortable that you will have the same medication dose as before?

Yes/No

Do you feel comfortable discussing your pain medication use with your doctor?

Yes/No

Have you ever asked your doctor for additional pain medications?

Yes/No

Have you ever asked your doctor for less pain medications?

Yes/No

How honest can you be with your doctor about your pain medications?

Likert Scale – not very honest, not honest, neutral, honest, very honest

How concerned are you that your doctor will reduce your pain medications without discussing with you?

Likert Scale – not very concerned, not concerned, neutral, concerned, very concerned

Do you store extra pain medications?

Yes/No

Does your pain medication help with anxiety and stress?

Yes/No

Do you have other symptoms with your pain?

Yes/No

Will you have withdrawals if you suddenly stopped your pain medications?

Yes/No

Do you need to take your medications to function?

Yes/No

How important are the pain medications to your daily livelihood?

Likert Scale – not very important, not important, neutral, important, very important

If you took less pain medications, would you still be able to function?

Yes/No

Do you believe you have a dependency to your medications?

Yes/No

Do you believe you have an addiction to your medications?

Yes/No

The number of questions to ask per nudge and the order in which the questions will be asked can be adjusted per Patient participant.  However, all responses must be confidential and stored on a secure database.  The prospective nudges will prompt the Patient to think how he or she communicates with Physicians and begin to self-analyze how and why the Patient takes the pain medication.

Patient Retrospective Nudges:

Retrospective Nudges will prompt the Patient to review his or her opioid use at a broader level.  The retrospective nudges will be more informative and descriptive rather than a series of questionnaires.  We will send, either monthly or quarterly, to the Patient, statistics related to the opioid epidemic.  Statistics that will be sent in this nudge include:

Nationwide number of opioid deaths within past month and past quarter

Local number of opioid deaths within past month and past quarter

Number of prescriptions dispensed at local pharmacies in the area

Number of Schedule I, Schedule II, and Schedule III prescriptions dispensed in the area

These three data points will inform the Physician about the significance of the opioid epidemic and how his or her practice and prescribing patterns compare to the local and national death statistics.  While sharing mortality rates can appear threatening, the goal is to educate the Physician and prompt the Physician to be more self-aware of how his or her broader prescription patterns compare to the statistical averages.

We will limit local data and prescription patterns to the specific county that the Patient sees his or her Physician.

Data Collection:

The data will be collected over a HIPAA certified platform confidential to all participants.  Physicians and Patients will be able to complete the prospective prompts either on their desktop or mobile platform.  We will use existing HIPAA certified platforms for this study.

Data for the retrospective prompts will be obtained from publicly available national databases.

Subject Recruitment:

Recruitment will be at random and voluntary.  We will randomly select primary care physicians and randomly select people within a local community.   We will begin by recruiting physicians in a specific region and then recruit patients within that region to ensure that we get both Physician specific and Patient specific data within a specific locality.

Data Analysis:

The duration of this program should last roughly two years.  Most clinical recommendations state that opioid tapering should begin after six months, and a two year benchmark will allow, at a maximum, four data points in which to review how the nudges affect opioid prescribing rates and opioid mortality.

All responses should be aggregated and de-identified, at a local level and at a national level.  The aggregated and de-identified nudge responses should be shared.  All Physician prospective nudges should be shared among other local Physicians.  All Patient prospective nudges should be shared among other local Patients.  The purpose in sharing the aggregated nudge responses is to inform individual Physicians or Patients of any major deviations or outlier responses they may have provided.  Such outlier events show sub-optimal prescribing patterns or sub-optimal medication use.

Overall, we hope the data will serve two purposes: (1) inform Patients and Physicians how their responses vary from the local and national averages, (2) reduce excessive prescriptions without harming the patient and reduce opioid related mortality.