The EPIC Problem With the CDC Opioid Guideline

When the Centers for Disease Control (CDC) published its opioid-prescribing guideline in 2016, it became a de facto national standard, almost as if it were a government regulation.

Why? There was no other standard or guideline. And federal drug enforcers spy on prescribing patterns in state prescription drug management programs (PDMPs).

However, the CDC guideline has been criticized for being a one-duration-fits-all standard and for not addressing varying per-day dosage needs.

In response, CDC said its guideline was merely a guideline, not a rule.

Everyone else still sees it as “the” rule. Many states passed laws setting seven days (see below) as the maximum for an opioid prescription—or five, in the case of New Jersey, whose then-governor, Chris Christie, bathed in national headlines by pushing the “toughest” opioid law through the state legislature.

Baking a Guidelineinto EHR systems

Electronic health record (EHR) systems are also an issue, says a Johns Hopkins Medicine (JHM) study published online in August and in the October issue of the Journal of the American College of Surgeons:

They “often have arbitrarily set prescribing defaults that are not procedure specific. The recommendations presented (in the JHM study) can be used to create smarter defaults. Changing the default is 1 easy step to aide prescribers who are overprescribing. Indeed, next steps at our institution include hospital-wide electronic medical record changes in the default number of opioid tablets to prescribe and ease of access to published guidelines within a patient’s chart.”

Johns Hopkins uses the Epic Systems Corporation’s EHR. More than 200 million patients are treated by caregivers using Epic software, Epic says on its website. A JHM page, “Why Epic?” says Epic is used by more than 250 health care organizations serving 47% of the U.S. population.

The JHM critique wasn’t aimed specifically at Epic. Its point was that the CDC’s 2016 first-draft guideline is written into EHRs as the easiest way for a physician to write an opioid prescription, and that it’s too high in most cases.

We asked Epic about its default opioid prescribing settings. A company spokesperson wrote back, “In Epic’s Foundation System, the defaults are set based on CDC guidelines—5 day supply for adults, 3 days for children…Our defaults have been updated in response to the CDC guidelines…We have a utility customers can run to find meds in preference lists and SmartSets*with high default duration and pill count so they can identify those that need to be updated.”

*A preference list is a list which allows a physician to select a single order from a set of standard orders. A SmartSet is a “group of orders and other elements, such as notes, chief complaints…and levels of service, that are commonly used together to document a specific type of visit.”

In both preference lists and SmartSets, “Having the pain medication prescription…configured with a specific number of pain pills makes it efficient for the provider to sign the orders and go. A number of Epic hospitals have found that configuring this Order Set for smaller quantities of pills will effectively reduce the number of pills dispensed,” the Epic spokesperson said.

Asked if Epic is considering changes in light of the JHM study, the spokesperson said, “Our emphasis is on standardizing default settings” and “We are looking at procedure-specific limits, but our emphasis is on setting defaults lower as recommended by CDC guidelines. We are also looking at how to help users prescribe appropriately based on the last 24 hours prior to discharge.”

“Additional note: Epic provides multiple layers of decision support above and beyond setting defaults in order sets and preference lists. Users are presented warnings for dosing, co-existing medical conditions, medication interactions, and patient-specific risk factors to further inform clinical decision making,” the Epic spokesperson said.

CDC guideline is confusing, actually; it only sort-of says five days

If you scroll down to recommendation #6 of the CDC guideline, the boldfaced sentence and the next two paragraphs say that often, less than a three-day supply of opioids is needed, and only rarely is a prescription needed for longer than seven…but maybe five, and some of the cited experts say fewer than 14 days.

Epic saw all those numbers, and a committee chose five days as a conservative maximum.

Is the CDC guideline embedded in other EHRs? We’ve sent queries to several vendors.