Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis

IMPORTANCE: Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse. OBJECTIVE: To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021. STUDY SELECTION: Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I(2) values. MAIN OUTCOMES AND MEASURES: The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies. RESULTS: Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, −22.61%; 95% CI, −30.70% to −14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, −8.64%; 95% CI, −17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, −0.30; 95% CI, −0.51 to −0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, −33.31%; 95% CI, −39.67% to −26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, −11.18%; 95% CI, −22.34% to −0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients’ satisfaction. CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed. TRIAL REGISTRATION: PROSPERO Identifier: CRD42020187251