Quality indicators for opioid stewardship

We applaud the excellent work of Rizk et al.1 in developing a standard set of quality indicators to guide an opioid stewardship program. Given the substantial noise regarding quality metrics, stewardship programs may often feel overwhelmed; the succinct list provided by the authors should be used to guide established and newly initiated programs toward a common set of outcomes. Furthermore, the subsequent ranking of quality indicators allows for thoughtful tracking of high-impact metrics on a large scale. We encourage the authors, performance improvement companies, and accrediting organizations to align their best-practice measures to provide increased clarity for programs and health systems. For example, two exclusions listed in the supplementary appendix were metrics 25 and 34, which respectively focused on electronic prescribing of controlled substances (EPCS) and prescription drug monitoring program (PDMP) utilization. Both of these metrics were recently discussed by the Centers for Medicare and Medicaid Services (CMS).2 EPCS is more secure, can cross-reference the PDMP, reduces medication errors, and is simpler for prescribers and patients than are traditional paper prescriptions.3 While technical logistics and financial constraints may currently limit the implementation of EPCS at some facilities, its use likely increases the reliability and feasibility of metrics surrounding discharge prescribing (metrics 5, 9, 12, 16, and 18); furthermore, transition to this system may be legally mandated in the future,4 and inclusion of EPCS in the metrics that opioid stewardship programs should track allows for better alignment across agencies. We are therefore curious as to the rationale for exclusion of this metric from the final set. Additionally, while the data regarding effectiveness of mandatory PDMP review in changing prescriber behavior are mixed, the rationale for the exclusion of this metric is also unclear, particularly given the encouragement from accrediting organizations,5 CMS,2 and multiple state legislative bodies to review PDMP data prior to prescribing opioids.