This study suggests that default options in the EMR are a powerful, low-cost tool to nudge clinicians to prescribe fewer opioids. Because baseline prescription quantities were already low in the two EDs, the overall number of opioid tablets prescribed did not change. But the significant shift to the default quantity, consistent with ED prescribing guidelines, suggests that this is a simple and scalable approach to change prescribing behavior while preserving clinician autonomy. This approach could have a significant impact in “right-sizing” post-operative opioid prescriptions for acute pain, for which quantities prescribed are significantly higher and 50-70% of tablets are never taken.
This study also suggests that default options must be implemented cautiously to avoid unintended consequences. A default option should be set at the lowest baseline quantity being prescribed to avoid inadvertently encouraging some clinicians to prescribe more than before the default was set. Second, beyond setting default quantities for specific departments and indications, health system level defaults should also be set low. This study found that opting out of the 10-tablet default led some to select the health system default of 28 tablets, which led to a small, unintended increase of prescriptions for more than 20 tablets.
Changing defaults in EMRs have been useful in changing clinician behavior in other contexts, such as increasing the rates of prescribing generic rather than brand-name drugs in primary care.
Further research is needed to evaluate the effects of implementing an opioid default option in EMRs on a larger scale, in systems with higher baseline prescription quantities, and over a longer timeframe. This research is ongoing in a newly-funded trial called REDUCE.