The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges

Abstract

Background: There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice.

Methods: AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects.

Discussion: The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.

Keywords: Behavioral economics; Nudges; Opioid use disorder; Randomized controlled trial.

Copyright © 2021 Elsevier Inc. All rights reserved.

Figures

Figure 1:. EHR Justification Warnings and Alerts

Figure 1: A) An accountable justification for opioid-naive prescribing, B) An accountable justification for persons with opioid prescriptions in the past 30 days and at-risk for long-term use, C) An accountable justification for persons with opioid prescriptions in the past 90 days and at-risk for long-term use, D) Precommitment and accountable justification for failure to initiate an opioid taper.

Figure 2:. EHR Workflow Schemas for Accountable Justification Prompts

Figure 2: A) Workflow for opioid-naive AJ alert B) Workflow for initial opioid refill AJ prompt C) Workflow for tapering AJ alert