Opioid Use After Discharge in Postoperative Patients: A Systematic Review

Post-discharge Opioid Consumption After Minimally Invasive and Open Colectomy: Does Operative Approach Matter?

OBJECTIVE

To determine if patients consume less opioid after minimally invasive colectomy compared to open colectomy.

BACKGROUND

Opioids are overprescribed after surgery, and surgeons are under increasing pressure to reduce postoperative opioid prescribing. In colorectal surgery, minimally invasive approaches are partly justified by reduced inpatient opioid use, but there are no studies comparing post-discharge opioid consumption between minimally invasive and open colectomy.

METHODS

This was a retrospective observational study of adult patients undergoing colectomy from January 2017 to May 2018 in the Michigan Surgical Quality Collaborative database. After postoperative day 30, patients were contacted by phone or email and asked to report post-discharge opioid consumption. The main outcome measure was post-discharge opioid consumption, and the primary predictor was surgical approach (minimally invasive vs open). Zero-inflated negative binomial regression analysis was used to test for an association between surgical approach and opioid consumption.

RESULTS

We identified 562 patients who underwent minimally invasive or open colectomy from 43 hospitals. After multivariable adjustment, no significant difference was demonstrated in opioid consumption (P = 0.54) or the likelihood of using no opioids (P = 0.39) between patients undergoing minimally versus open colectomy. Larger prescriptions were associated with more opioid use and a lower likelihood of using no opioids. Age greater than 65 and diagnosis of cancer/adenoma were associated with less opioid use.

CONCLUSIONS

Patients undergoing minimally invasive and open colectomy consume similar amounts of opioid after discharge. The size of the postoperative prescription, patient age, and diagnosis are more important in determining opioid use. Understanding factors influencing postoperative opioid requirements may allow surgeons to better tailor prescriptions to patient needs.

Routine Opioid Prescriptions Are Not Necessary After Breast Excisional Biopsy or Lumpectomy Procedures

BACKGROUND

Opioid analgesics are overprescribed after surgery. In August 2018, the authors replaced routine discharge opioid prescription with a nonsteroidal anti-inflammatory drug (NSAID) for patients who had a lumpectomy or excisional biopsy (lump/ex). This study compared patient-reported post-discharge pain scores for patients treated before and after the change in routine discharge medication.

METHODS

Patients were categorized based on treatment before and after a change in discharge medication as follows: study period 1 (routine opioids), study period 2 (routine NSAID). Pain severity was assessed with an electronic survey on postoperative days (PODs) 1 to 5. Multivariable generalized estimating equations tested the association between pain severity and discharge in the first versus the second study period.

RESULTS

Lump/ex was performed for 1606 patients between December 2017 and June 2019. Of these patients, 789 (49%) reported pain scores and were analyzed (328 in study period 1, 461 in study period 2). Opioid prescription at discharge decreased from 96% in period 1 to 14% (95% confidence interval [CI], 11-18%) in period 2. Only 1% of the patients discharged with NSAID were later prescribed an opioid. The maximum reported pain score on any POD for all the patients was severe for 30 patients (3.8%), moderate for 217 patients (28%), mild for 430 patients (54%), and none for 112 patients (14%). The estimated risk for moderate or greater pain on POD 1 was 36% for period 1 and 34% for period 2. The proportion of patients reporting moderate or greater pain was nonsignificantly lower for the patients treated in period 2 (odds ratio [OR], 0.91; 95% CI 0.67-1.22; P = 0.5).

CONCLUSIONS

For patients undergoing lump/ex, a clinically meaningful difference in reported post-discharge pain scores can be excluded with a change to routine NSAID at discharge. Patients undergoing lump/ex should not be routinely discharged with opioids.

The opioid epidemic in pediatrics: a 2020 update

PURPOSE OF REVIEW

Over the last 3 years and for the first time in 60 years, life expectancy in the United States has declined across all racial groups primarily because of drug overdoses, alcohol abuse, and suicide. A public health response to the opioid crisis must expand its focus to more broadly include children, adolescents, and young adults while increasing efforts toward preventing new cases of opioid addiction, early identification of individuals with opioid-abuse disorder, and ensuring access to effective opioid addiction treatment, while simultaneously continuing to safely meet the needs of patients experiencing pain.

RECENT FINDINGS

Although a multimodal approach to pain management is fundamental in current practice, opioids remain an essential building block in the management of acute and chronic pain and have been for over 5000 years as they work. Left over, unconsumed opioids that were appropriately prescribed for pain have become the gateway for the development of opioid use disorder, particularly in the vulnerable adolescents and young adult patient populations. How to reduce the amount of opioids dispensed, improve methods of disposal in an environmentally safe way, and proactively make naloxone, particularly nasal spray, readily available to patients (and their families) receiving prescription opioids or who are at risk of opioid use disorder are highlighted in this review.

SUMMARY

We describe the historical use of opioids and the scope of the current opioid crisis, review the differences between dependence and addiction, and the private and public sectors response to pain management and highlight the issue of adolescent vulnerability. We conclude with a proposal for future directions that address both public and patient health needs.

Leftover opioids following adult surgical procedures: a systematic review and meta-analysis

BACKGROUND

US opioid prescribing and use escalated over the last two decades, with parallel increases in opioid misuse, opioid-related deaths, and concerns about diversion. Postoperatively prescribed opioids contribute to these problems. Policy makers have addressed this issue by limiting postoperative opioid prescribing. However, until recently, little data existed to guide prescribers on opioid needs postoperatively. This meta-analysis quantitatively integrated the growing literature regarding extent of opioids leftover after surgery and identified factors associated with leftover opioid proportions.

METHODS

We conducted a meta-analysis of observational studies quantifying postoperative opioid consumption in North American adults, and evaluated effect size moderators using robust variance estimation meta-regression. Medline, EMBASE, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Database of Systematic Reviews were searched for relevant articles published January 1, 2000 to November 10, 2018. The Methodological Index for Non-Randomized Studies (MINORS) tool assessed risk of study bias. The proportion effect size quantified the primary outcome: proportion of prescribed postoperative opioids leftover at the time of follow-up. Primary meta-regression analyses tested surgical type, amount of opioids prescribed, and study publication year as possible moderators. Secondary meta-regression models included surgical invasiveness, age, race, gender, postoperative day of data collection, and preoperative opioid use.

RESULTS

We screened 911 citations and included 44 studies (13,068 patients). The mean weighted effect size for proportion of postoperative opioid prescriptions leftover was 61% (95% CI, 56-67%). Meta-regression models revealed type of surgical procedure and level of invasiveness had a statistically significant effect on proportion of opioids leftover. Proportion of opioids leftover was greater for "other soft tissue" surgeries than abdominal/pelvic surgeries, but did not differ significantly between orthopedic and abdominal/pelvic surgeries. Minimally invasive compared to open surgeries resulted in a greater proportion of opioids leftover. Limitations include predominance of studies from academic settings, inconsistent reporting of confounders, and a possible publication bias toward studies reporting smaller leftover opioid proportions.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

A significant proportion of opioids are leftover postoperatively. Surgery type and level of invasiveness affect postoperative opioid consumption. Integration of such factors into prescribing guidelines may help minimize opioid overprescribing while adequately meeting analgesic needs.

Evidence for Continuing Buprenorphine in the Perioperative Period

OBJECTIVE

Given there are conflicting recommendations for the perioperative management of buprenorphine, we conducted a retrospective cohort study of our surgery patients on buprenorphine whose baseline dose had been preoperatively continued, tapered, or discontinued.

MATERIALS AND METHODS

We reviewed charts of patients on buprenorphine who had received elective surgery at Stanford Healthcare from January 1, 2013 to June 30, 2016. Our primary outcome of interest was the change in pain score, defined as mean postoperative pain score-preoperative pain score. We also collected data on patients' tapering procedure and any postoperative nonbuprenorphine opioid requirements.

RESULTS

Out of ∼1200 patients on buprenorphine, 121 had surgery of which 50 were admitted and included in the study. Perioperative continuation of transdermal buprenorphine resulted in a significantly lower change in pain score postoperatively (0.606±0.878) than discontinuation (4.83±1.23, P=0.012). Among sublingual patients, there was no statistically significant difference in the change in pain score between those who were tapered to a nonzero dose versus discontinued (P=0.55). Continuation of sublingual buprenorphine resulted in fewer nonbuprenorphine scheduled opioid prescriptions than its taper or discontinuation (P=0.028). Finally, tapers were performed with great variability in the tapering team and rate of taper.

DISCUSSION

On the basis of our findings, we implemented a policy at our institution for the continuation of perioperative buprenorphine whenever possible. Our work reveals crucial targets for the education of perioperative healthcare providers and the importance of coordination among all perioperative services and providers.

Reducing the Number of Opioids Consumed After Discharge Following Elective Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

To reduce opioids consumed after discharge from hospital after elective cesarean delivery by 50%.

METHODS

This was a 2-week parallel group non-blinded randomized controlled trial at Mount Sinai Hospital. Eligible women undergoing elective cesarean delivery were assigned by random number generation to receive the hospital's standard post-cesarean opioid prescription of 20 1-mg hydromorphone tablets or a prescription for 10 1-mg hydromorphone tablets if opioids were required in hospital or no hydromorphone if no opioids were required in hospital. Patients completed a study questionnaire at 2 weeks postpartum detailing outcome measures. The primary outcome was the amount of opioid consumed after discharge.

RESULTS

A total of 40 women were randomly assigned to a study group and 37 were included in the data analysis; 17 patients were in the control group and 20 in the experimental group. The median number of tablets consumed did not differ between groups (P = 0.407). The median number of excess tablets prescribed was 20 (range 2-18) in the control group and 0 (range 0-10) in the experimental group (P < 0.001).

CONCLUSIONS

The current standard discharge practice of giving 20 1-mg hydromorphone tablets to all patients post-discharge after cesarean delivery contributes to a substantial excess of opioids in the community. These opioids can be diverted for unintended or accidental usage, and exacerbate larger societal issues of opioid misuse and addiction. Decreasing the number of opioids prescribed with tailored discharge prescriptions based on in-hospital opioid use provides nearly all patients with adequate pain control.

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA.

METHODS

Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model.

RESULTS

More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P < .01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P < .01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%.

CONCLUSION

People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation.

LEVEL OF EVIDENCE

Diagnostic Level III.

Safe Opioid Storage and Disposal: A Survey of Patient Beliefs and Practices

Objective

To evaluate knowledge, practices, and beliefs of US patients receiving prescription opioids regarding opioid storage, disposal, and diversion.

Design

Internet-based, cross-sectional survey conducted between September and October 2018. Fisher’s exact tests and Kendall’s Tau-c were used to assess associations with storage and disposal outcomes.

Participants

Patients aged ≥18 years with acute (n=250) or chronic noncancer (n=250) pain were prescribed an oral opioid within 90 days of the survey.

Results

Mean (SD) patient age was 48 (14.7) years, 57.2% were female, 82.6% lived with ≥1 person in the home, and 28.0% had remaining/unused pills. One-third of all patients received safe opioid storage (35.2%) and/or disposal (31.4%) counseling from a healthcare provider, while 50.0% received neither storage nor disposal information. Only 27.4% of all patients stored their opioids in a locked location, and 17.9% of those with remaining/unused pills disposed of their medication. Patients who received any opioid counseling were more likely to keep their medication in a locked location compared with those who did not (42.4% vs 12.4%, respectively; P<0.0001), as were those who perceived any risk of opioid diversion in the home compared with those who perceived no risk or were unsure (53.7% vs 24.2%, respectively; P<0.0001). Disposal rates did not differ based on counseling received (20.8% counseled vs 16.1% not counseled; P=0.5011) or perceived diversion risk (27.8% perceived any risk vs 16.4% perceived no risk or unsure; P=0.3166).

Conclusion

The proportion of patients receiving prescription opioids who receive safe storage/disposal counseling from a healthcare provider appears suboptimal. Further research is warranted to develop effective ways to improve patient opioid storage/disposal education and practices.

Implementing and Evaluating a Multihospital Standardized Opioid Curriculum for Surgical Providers

OBJECTIVE

(1) To identify gaps in providers knowledge on opioid medication and dosing, patient-specific characteristics that require alterations in dosing, and patient monitoring and treatment adjustments. (2) To evaluate an educational intervention aimed at minimizing these deficits.

DESIGN

Observational prospective study. Providers took an anonymous paired pre-and posteducation knowledge assessment before and after participating in a 75-minute educational session. Results before and after the educational session were compared.

SETTING

Surgical providers included nurse practitioners, physician assistants, preinterns, and general surgery residents across 4 quaternary care hospitals in Boston. Participants There were 194 participants and 174 completed both pre- and posteducation knowledge assessments.

RESULTS

Average scores on the educational assessment increased from 59% before the course to 68% after the session. Posteducation, providers reported increased comfort in prescribing and 95% stated that the curriculum would impact their practice.

CONCLUSIONS

Surgical providers at multiple hospitals have significant gaps in knowledge for optimal prescribing and management of opioid prescriptions. A 75-minute opioid education session increased prescriber knowledge as well as comfort in prescribing. This multicenter study demonstrates how an educational initiative can be implemented broadly and result in decreased knowledge gaps.

Pre-emptive pain management program is associated with reduction of opioid prescription after minimally invasive pulmonary resection

Background

We developed and implemented a pre-emptive pain management program wherein providers agreed to have non-opioid pain medication as a standard pain management strategy at discharge accompanied by patient education about the program.

Methods

A retrospective case-control study of prospectively collected data of patients who underwent minimally invasive pulmonary resection. We compared the outcomes among patients who were managed with pre-emptive pain management program with enhanced recovery after surgery (Pre-emptive), enhanced recovery program after surgery alone (ERAS) and standard care (control).

Results

Of the 443 patients, 132 patients (30%) were in the pre-emptive pain management group, 90 (20%) patients were in the ERAS only group and 221 (50%) in the control group. There were significantly fewer complications (15.9% vs. 23.3% vs. 38%, P<0.001), shorter median length of hospital stay (2 vs. 3 vs. 3 days, P<0.001), lower 30-day readmission rates (2.3% vs. 3.3% vs. 11.3%, P=0.002), and fewer opioid prescriptions at discharge (17.4% vs. 76.7% vs. 83.7%, P<0.001) in the pre-emptive pain management group compared to the ERAS and control groups. Multivariate logistic regression analyses showed that the pre-emptive pain management program (OR 0.06; 95% CI, 0.03, 0.11, P<0.001) and robotic surgery (OR 0.52; 95% CI, 0.3, 0.88, P=0.02) were associated with lower odds of patients being discharged to home with opioid prescriptions. The median pain score in the pre-emptive pain group at 30 days after surgery was 1.5 on a pain scale of 1–10.

Conclusions

The pre-emptive pain management program was associated with a decrease in opioid prescriptions after elective pulmonary resections. Successful implementation of this program can lead to significant decreases in the amount of prescription opioids in the community.

Nonopioid versus opioid analgesia after hospital discharge following cesarean delivery: a randomized equivalence trial

OBJECTIVE

To determine whether pain score after cesarean delivery is equivalent among women receiving outpatient nonopioid vs opioid analgesics.

STUDY DESIGN

In this trial 170 women with cesarean delivery were randomized to outpatient ibuprofen plus acetaminophen (nonopioid, n=85) or ibuprofen plus hydrocodone-acetaminophen (opioid, n=85). Primary outcome was pain score on a visual analog scale at 2-4 weeks postpartum, which was obtained from 149 (88%) women. Treatments were considered equivalent if the difference between the mean pain scores of each group and its 95% confidence interval were between -10 and 10 mm. A zero-inflated negative binomial model was used to estimate the difference between group means.

RESULTS

Treatments were not equivalent; mean pain score was lower (better) in the nonopioid group (12.3±19.5 vs 15.9±20.4 mm, adjusted mean difference, 4.8; 95% CI, -2.1 to 11.9 mm).

CONCLUSION

Pain score 2-4 weeks after cesarean delivery was lower in women receiving nonopioid analgesics.

Impact of Policy Interventions on Postoperative Opioid Prescribing

OBJECTIVE

To assess postoperative opioid prescribing in response to state and organizational policy changes.

METHODS

We used an observational study design at an academic medical center in the Northeast United States over a time during which there were two important influences: 1) implementation of state rules regarding opioid prescribing and 2) changes in organization policies reflecting evolving standards of care. Results were summarized at the surgical specialty and procedure level and compared between baseline (July-December 2016) and postrule (July-December 2017) periods.

RESULTS

We analyzed data from 17,937 procedures from July 2016 to December 2017, two-thirds of which were outpatient. Schedule II opioids were prescribed in 61% of cases and no opioids at all in 28%. The median morphine milligram equivalent (MME) prescribed at discharge decreased 40%, from 113 MME in the baseline period to 68 MME in the postrule period. Decreases were seen across all the surgical specialties.

CONCLUSIONS

Postoperative opioid prescribing at the time of hospital discharge decreased between 2016 and 2017 in the setting of targeted and replicable state and health care organizational policies.

POLICY IMPLICATIONS

Policies governing the use of opioids are an effective and adoptable approach to reducing opioid prescribing following surgery.

Persistent Opioid Use After Hysterectomy in the United States, 2005-2015

OBJECTIVE

To assess variables associated with opioid prescriptions filled perioperatively after hysterectomy and the risk of prolonged opioid use through 1 year after hysterectomy.

METHODS

In this retrospective cohort study, we used the 2005-2015 IBM MarketScan databases to identify women aged at least 18 years who underwent hysterectomy. For opioid use, we identified filled prescriptions for opioid medications. We excluded women with prevalent opioid use, defined as an opioid prescription filled 180 to 30 days preoperatively or at least two prescriptions filled in the 30 days before surgery. We defined perioperative opioid use as any opioid prescription filled within 30 days before or 7 days after surgery. We used log-binomial regression to identify independent predictors of perioperative opioid prescription fill. To assess the risk of long-term opioid use, we estimated the proportion of women with ongoing monthly opioid prescriptions through 12 months after surgery and the proportion of women with any opioid prescription 3-6 months after surgery, mimicking published estimates.

RESULTS

Among 569,634 women who underwent hysterectomy during the study period, 176,537 (30.9%) were excluded owing to prevalent opioid use. We found that 331,322 (84.3%) women filled a perioperative opioid prescription, with median quantity of 30 pills (interquartile range 25-40), and that younger (adjusted risk ratio [adjRR]18-24 0.91) and older (adjRR65-74 0.84; adjRR75+ 0.70) patients were less likely to receive a perioperative prescription compared with women aged 45-54. The proportion of women with continuous monthly fills of opioids through 2, 3, 6, and 12 months after surgery was 1.40%, 0.34%, 0.06%, and 0.02%, respectively.

CONCLUSION

Most women who underwent hysterectomy in the United States from 2005 to 2015 filled a perioperative opioid prescription with a median quantity of 30 pills. The risk of prolonged opioid use through 6 months is quite low, at 0.06% or 1 in 1,547.

Standardized, Patient-specific, Postoperative Opioid Prescribing After Inpatient Orthopaedic Surgery

BACKGROUND

Opioid-related mortality has increased over the past 2 decades, leading to the recognition of a nationwide opioid epidemic and prompting physicians to reexamine their opioid prescribing practices. At our institutions, we had no protocol for prescribing opioids upon discharge after inpatient orthopaedic surgery, resulting in inconsistent and potentially excessive prescribing. Here, we report the results of the implementation of a patient-specific protocol using an opioid taper calculator to standardize opioid prescribing at discharge after inpatient orthopaedic surgery.

METHODS

The opioid taper calculator is a tool that creates a patient-specific opioid taper based on each patient's 24-hour predischarge opioid utilization. We implemented this taper for patients discharged after inpatient orthopaedic surgery at our two institutions (Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus). We compared discharge opioid quantities between orthopaedic patients postimplementation and quantities prescribed preimplementation. We also compared discharge opioid quantities between orthopaedic and nonorthopaedic surgical services over the same time period.

RESULTS

Nine-months postimplementation, a patient-specific taper was used in 74% of eligible discharges, resulting in a 24% reduction in opioids prescribed at discharge, along with a 35% reduction in variance. Over the same time frame, a smaller reduction (9%) was seen in the opioids prescribed at discharge by nonorthopaedic services. The most notable reductions were seen after total joint arthroplasty and spinal fusions. Despite this reduction, most patients (65%) reported receiving sufficient opioids, and no substantial change was observed in 30-day postdischarge opioid prescription refills after versus before protocol implementation (1.58 versus 1.71 fills per discharge).

DISCUSSION

Using the opioid taper calculator, a patient-specific taper can be successfully used to standardize opioid prescribing at discharge after inpatient orthopaedic surgery without a substantial risk of underprescription.

LEVEL OF EVIDENCE

Level II.

Robot-Assisted Radical Prostatectomy Associated with Decreased Persistent Postoperative Opioid Use

Introduction: Minimally invasive surgery offers reduced pain and opioid use postoperatively compared with open surgery, but large-scale comparative studies are lacking. We assessed the incidence of persistent opioid use after open and robot-assisted radical prostatectomy (RARP).

Materials and Methods: We performed a retrospective claims database cohort study of opioid-naive (i.e., no opioid prescriptions 30–180 days before index surgery) adult males who underwent radical prostatectomy for prostate cancer from July 2013 to June 2017. For patients who filled a perioperative opioid prescription (30 days before to 14 days after surgery), we calculated the incidence of new persistent postoperative opioid use (≥1 prescription 90–180 days after surgery). Multivariable logistic regression was performed to investigate the association between the surgical approach, patient risk factors, and persistent opioid use.

Results: Twelve thousand two hundred seventy-eight radical prostatectomy patients filled an opioid prescription perioperatively (1510 [12%] open and 10,768 [88%] robot assisted). Of these, 846 (6.9%) patients continued to fill opioid prescription(s) 90 to 180 days after surgery. Patients undergoing RARP were 35% less likely to develop new persistent opioid use compared with those undergoing open radical prostatectomy (6.5% vs 9.7%; adjusted odds ratio 0.65; 95% confidence interval 0.54, 0.79). Other independent risk factors included living in the southern, western, or north central United States; preoperative comorbidity; and tobacco use.

Conclusions: Approximately 6.9% of opioid-naive patients continued to fill opioid prescriptions 90 days after radical prostatectomy. The risk of persistent opioid use was significantly lower among patients undergoing a robot-assisted vs open approach. Further efforts are needed to develop postoperative opioid prescription protocols for patients undergoing radical prostatectomy.

Effect of a Standardized Electronic Medical Record Order Set on Opioid Prescribing after Tonsillectomy

Objective

Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)–based order set.

Methods

Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission.

Results

Analysis of 276 preorder set and 128 post–order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post–order set cohort. Variability between prescriptions and providers was significantly decreased in the post–order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified.

Discussion

An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels.

Implications for Practice

A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

A prospective observational study of pediatric opioid prescribing at postoperative discharge: how much is actually used?

PURPOSE

Research describing opioid misuse in children after surgery currently describes single specialties, short follow-up, and heterogeneous data not conducive to comparative discussion. Our primary objective was to quantify opioids prescribed to pediatric surgical patients on discharge from hospital. Secondary objectives were quantifying opioids remaining unused at four-week follow-up, and family attitudes to safe storage and disposal.

METHODS

We conducted a prospective observational study under counterfactual consent with telephone follow-up at four weeks of children who had undergone a surgical procedure and filled an opioid prescription at The Hospital for Sick Children, Toronto, ON, Canada. Exclusion criteria included opioid use within the previous six months, history of chronic pain, or discharge to a rehabilitation facility. Pre- and post-discharge prescribing, dispensing, and consumption data were collected prospectively in addition to parental reports of home opioid use. Opioid-dosing was converted to oral morphine milligram equivalents (MME).

RESULTS

There were 8,672 MMEs prescribed to 110 patients. Twenty-one patients were lost to follow-up, accounting for 1,416 MME. Of the remaining 7,256 MME, 67% went unused. At follow-up, 78% of unused opioid remained in the home. Most opioids were stored in an easily accessible location in the home.

CONCLUSION

These findings confirm overprescribing of opioids to pediatric surgical patients. Families tend not to return opioids that exceed post-discharge analgesic requirements at home and many of the reported disposal methods are unsafe. We recommend future studies focus on optimizing opioid prescriptions to meet, but not excessively surpass, home pain management requirements, and to encourage safe opioid disposal/return methods.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03562013); registered 7 June, 2018.

The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action

Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.

Postoperative opioid-prescribing patterns among surgeons and residents at university-affiliated hospitals: a survey study

Background

Overprescribing of opioids to patients following surgery is a public health concern, as unused pills may be diverted and contribute to opioid misuse and dependence. The objectives of this study were to determine current opioid-prescribing patterns for common surgical procedures, factors that affect surgeons’ prescribing behaviour and their perceived ability to manage patients with opioid use disorder.

Methods

Survey participants included all consultant and trainee surgeons at the University of Toronto. The survey, which was administered electronically, included 52 multiple-choice, rank-order and open-text questions eliciting information on current prescribing patterns, prescribing of adjunct pain medications, and education and other factors related to opioid prescribing. Staff surgeons were also asked about how they manage patients with a suspected opioid issue.

Results

Eighty surgical trainees and 40 staff surgeons responded to the survey (response rate 32%). Five staff surgeons (12%) felt adequately educated to prescribe pain medications (including opioids) at discharge. Staff surgeons prescribed Tylenol 3 more frequently than other opioids. Twenty (51%) of 39 staff surgeons reported that they sought further help for their patients when an opioid use disorder was suspected.

Conclusion

Our results support existing studies showing a large degree of variability in postoperative opioid prescribing. Institutional guidelines have been shown to be effective in curbing excessive opioid prescribing without increasing unnecessary emergency department visits for uncontrolled pain. Thus, there is an opportunity to develop institutional guidelines to educate surgical teams in the prescribing of opioids and about services available for patients with a substance use disorder.

Chronic opioid use following anterior cervical discectomy and fusion surgery for degenerative cervical pathology

BACKGROUND CONTEXT

Although prescribing opioid medication on a limited basis for postoperative pain control is common practice, few studies have focused on chronic opioid use following anterior cervical discectomy and fusion (ACDF).

PURPOSE

To determine the prevalence of and risk factors for chronic opioid use following one and two-level ACDF for degenerative cervical pathology.

DESIGN

Retrospective cohort.

PATIENT SAMPLE

Using an insurance claims database, we identified patients aged 18-64 who underwent one or two-level primary ACDF from 2010 to 2015 for degenerative cervical pathology.

OUTCOME MEASURES

Opioid prescription strength at various timepoints pre- and postoperatively and development of chronic postoperative opioid use.

METHODS

Prescription opioid use was examined during the following periods: 90 days before 7 days preceding surgery (preoperative), 6 days preceding surgery to 90 days following surgery (perioperative) and from 91 to 365 days following surgery (postoperative). The primary outcome was chronic postoperative opioid use, defined as ≥120 days' supply of opioid prescriptions filled or ≥10 opioid prescriptions between 3 and 12 months postoperatively. Secondary outcomes were high-dose (>90 morphine milligram equivalents [MME]/day) and very high-dose (>200 MME/day) opioid prescriptions. A multivariate logistic model (area under the ROC curve 0.75, p<.001) was built to predict long-term opioid use.

RESULTS

Among 28,813 patients who underwent ACDF, most were female (55%) and underwent single-level ACDF (68%), with mean age of 50±8.0 years. Fifty-two percent of patients filled an opioid prescription in the preoperative period, 95% of patients filled a prescription in the perioperative period, and 39% of patients filled a prescription in the postoperative period. High-dose and very high-dose opioid prescriptions in the perioperative period were identified in 45% and 24% of patients, respectively, whereas 17% met criteria for chronic postoperative opioid use. The odds of chronic opioid use were highest in the Western US (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3, 1.6). Duration of opioids prescribed was also highest in the Western US (median 111 days, interquartile range 11-336), p<.001. Factors associated with the highest risk for chronic opioid use were preoperative opioid use (OR 5.7, 95% CI 5.3, 56.2), drug abuse (OR 3.5, 95% CI 2.6, 4.5), depression (OR 1.7, 95% CI 1.6, 1.9), anxiety (OR 1.5, 95% CI 1.4, 1.6), and surgery in the western region of the United States (OR 1.5, 95% CI 1.3, 1.6).

CONCLUSIONS

Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery, and certain patient factors increase risk for chronic opioid use following ACDF. Intervention focusing on patients with these factors is essential to reduce long-term use of prescription opioids and postoperative care.

Minimally invasive sigmoidectomy for diverticular disease decreases inpatient opioid use: Results of a propensity score-matched study

BACKGROUND

Patients undergoing gastrointestinal surgery are at high risk for postoperative opioid use.

METHODS

We evaluated inpatient opioid use among patients undergoing sigmoidectomy for diverticular disease from the Premier Hospital Database and compared across surgical approaches using propensity score-matching analysis.

RESULTS

After the day of surgery, minimally invasive (MIS) patients were administered significantly lower doses of parenteral opioids (median daily morphine milligram equivalents [MME]: 33.3 versus 48.3, p < 0.001). Within MIS, significantly less parenteral opioids were used by the robotic-assisted (RS) than the laparoscopic (LS) group (median daily MME: 30.0 versus 36.8, p = 0.012). MIS patients were more likely than open to start oral opioids on the day of surgery (MIS vs. OS: 8.7% vs. 6.6%, p < 0.001; RS vs. LS: 12.6% vs. 10.2%, p = 0.048).

CONCLUSION

Minimally invasive sigmoidectomy for diverticular disease was associated with less postoperative parenteral opioid use and starting oral opioids sooner after surgery compared to the open approach.

Opioid Use Following Bariatric Surgery: Results of a Prospective Survey

BACKGROUND

Opioid use after bariatric surgery is not clearly understood. Few guidelines exist to inform opioid-prescribing practices after bariatric surgery.

OBJECTIVE

To understand opioid use following bariatric surgery.

SETTING

University hospital.

METHODS

Bariatric surgery patients at a single center were prospectively surveyed at the time of their post-operative visit (January-May 2018). Patients were asked about their opioid use following surgery, whether they received education about opioid use and what they did with leftover medications. Demographic and operative details were obtained from the medical record.

RESULTS

Among 33 patients, the majority (n = 29, 88%) were female with a median age of 40 (20-68) and body mass index of 44.8 (33-78.5). Most patients had leftover narcotics (n = 25, 73%). The median number of pills used was 15 (0-48). Only 12 patients (36%) thought that they had been prescribed "too much" pain medication. Most patients reported receiving education about expectations for post-operative pain (n = 22, 69%); few recalled education about reducing or stopping opioids (n = 13, 40%). More than half of patients (n = 17, 53%) kept their leftover opioids rather than disposing of them or bringing them to an approved turn in location.

CONCLUSIONS

Despite most patients having leftover opioids following surgery, few patients recognized possible overprescription. Education regarding opioid use following surgery is inconsistent, potentially contributing to the amount of retained opioids currently available. Future guidelines should focus on determining the appropriate amount of opioids to be prescribed following surgery and standardizing and improving education given to patients.

Post-surgical opioid stewardship programs across Australia and New Zealand: Current situation and future directions

Community harm associated with prescription opioids is causing global concern, and post-hospital discharge prescribing is contributing to the problem. We surveyed anaesthetists in Australia and New Zealand to determine which opioid stewardship measures are currently in place, and to gauge interest in participating in future health services research on introducing an opioid stewardship bundle of care. A total of 87 anaesthetists from 87 hospitals were invited to participate, and 45 (52%) responded. The extent of nine current opioid stewardship measures reported was highly variable. One respondent (2%) reported no measures introduced at their hospital; 12 (27%) one to two measures; 16 (36%) three or four measures; 13 (29%) five to seven measures; and 3 (7%), all nine measures were in place. Respondents were often interested in being contacted about future trial participation ( n = 33, 73%); however, concerns regarding feasibility of introducing an opioid stewardship bundle of care were widespread ( n = 22, 49%). It is possible that the variability in Australian and New Zealand opioid stewardship practice is due, in part, to the current limited evidence base for the individual measures, in addition to challenges in research translation. We have found that interest in further research on opioid stewardship is high. Comprehensive, locally adapted, evidence-based opioid stewardship measures may increase the safety of patients and the community following opioid therapy.

Prescription patterns and opioid usage in sinonasal surgery

BACKGROUND

Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery.

METHODS

All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills.

RESULTS

Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used <50% and 36.1% used >50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates.

CONCLUSION

Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.

Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery

OBJECTIVES

The topic of prescription opioid overuse remains a growing concern in the United States. Our objective is to provide insight into pain perception and opioid use based on a patient cohort undergoing common otologic and neurotologic surgeries.

STUDY DESIGN

Prospective observational study with patient questionnaire.

SETTING

Single academic medical center.

SUBJECTS AND METHODS

Adult patients undergoing otologic and neurotologic procedures by two fellowship trained neurotologists between June and November of 2018 were included in this study. During first postoperative follow-up, participants completed a questionnaire assessing perceived postoperative pain and its impact on quality of life, pain management techniques, and extent of prescription opioid use.

RESULTS

A total of 47 patients met inclusion and exclusion criteria. The median pain score was 3 out of 10 (Interquartile Range [IQR] = 2-6) with no significant gender differences (P = .92). Patients were prescribed a median of 15.0 (IQR = 10.0-15.0) tablets of opioid pain medication postoperatively, but only used a median of 4.0 (IQR = 1.0-11.5) tablets at the time of first follow-up. Measured quality of life areas included sleep, physical activity, work, and mood. Sleep was most commonly affected, with 69.4% of patients noting disturbances.

CONCLUSIONS

This study suggests that practitioners may over-estimate the need for opioid pain medication following otologic and neurotologic surgery. It also demonstrates the need for ongoing patient education regarding opioid risks, alternatives, and measures to prevent diversion.

A Societies for Pediatric Urology survey of opioid prescribing practices after ambulatory pediatric urology procedures

INTRODUCTION

Opioid dependence and abuse has been declared a national public health emergency, and overprescribing of opioids after surgery has been identified as a driving factor. To date, opioid prescribing after pediatric urology ambulatory surgery has not been well-described.

OBJECTIVE

The study's objective was to assess pediatric urologists' practices in prescribing opioids for routine ambulatory procedures.

STUDY DESIGN

A 23-question survey was created, including eight case vignettes describing routine procedures (orchiopexy, hydrocele repair, circumcision) across three age groups (8 months, 3 years, 13 years). Multiple choice questions asked about typical opioid type and duration for each case. Respondent attitudes and practice types were also evaluated. The survey was administered through the Societies for Pediatric Urology.

RESULTS

Of the 102 respondents, 48% reported prescribing postoperative opioids for all cases described (Figure 1). Fourteen percent reported prescribing no opioids for all cases. Longer prescription duration was associated with older age (p = 0.003). Acetaminophen-hydrocodone was prescribed most commonly, while a few respondents reported prescribing acetaminophen-codeine. North Central and Southeastern respondents were more likely to prescribe opioids for all cases described (p = 0.003). The majority of respondents work in academic settings and had >10 years in practice. Only 16% believe that their patients take the majority of opioids prescribed, while only 35% provide education to their patients on proper disposal.

DISCUSSION

There is significant variability in reported opioid prescribing practices after ambulatory procedures amongst pediatric urologists. Only 16% of respondents believe that patients take the majority of opioids prescribed, and only 14% reported never prescribing opioids for these procedures. There is an opportunity for guidelines and standardization of care for postoperative analgesia in this patient population. Given that overprescribing can lead to abuse and misuse, further work needs to be done to establish postoperative analgesia needs and to educate providers and families on proper prescribing and disposal.

CONCLUSION

Pediatric urologists report prescribing opioids frequently after routine ambulatory procedures in infants, children, and adolescents despite believing that patients do not take the majority of the prescribed medication.

Specialty-specific reduction in opioid prescribing after common pediatric surgical operations

BACKGROUND

Opioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair.

METHODS

Retrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic.

RESULTS

Postoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention.

CONCLUSIONS

The efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber.

TYPE OF STUDY

retrospective comparative chart review.

LEVEL OF EVIDENCE

IV.

Impact of a Standardized Multimodal Analgesia Protocol on Opioid Prescriptions After Common Arthroscopic Procedures

Background:

Excessive prescription of opioids has become a national problem. Providers must attempt to decrease the amount of opioids prescribed while still providing patients with adequate pain relief after surgery.

Hypothesis:

Implementing a standardized multimodal analgesic protocol will decrease the amount of opioids prescribed at the time of surgery as well as the total amount of opioids dispensed postoperatively.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients who had undergone meniscectomy, rotator cuff repair (RCR), or anterior cruciate ligament (ACL) reconstruction at our institution were identified by Current Procedural Terminology code 12 months prior to and 6 months after the initiation of a standardized multimodal postoperative pain protocol. Records were reviewed to extract demographic data, amount of opioids prescribed at the time of surgery, amount and frequency of opioid refills, and call-ins regarding pain medication or its side effects. A Wilcoxon rank-sum test was used to evaluate differences in opioid prescriptions between pre- and postprotocol, and significance was set to P < .05.

Results:

The mean amount of opioids prescribed at the time of surgery decreased from 63.5 to 22.3 pills (P < .0001) for meniscectomy, from 73.3 to 39.7 (P < .0001) for ACL reconstruction, and from 75.6 to 39.8 (P < .0001) for RCR. The percentage of patients receiving a refill of opioids during the postoperative period also decreased for all groups: from 13% to 4% (P = .0051) for meniscectomy, 29.2% to 11.4% (P = .0005) for ACL reconstruction, and 47.3% to 24.4% (P < .0001) for RCR. There was no significant difference in patient calls regarding pain medication or its side effects.

Conclusion:

Institution of a standardized multimodal analgesia protocol significantly decreased the amount of opioids dispensed after common arthroscopic procedures. This reduction in the amount of opioids given on the day of surgery did not result in an increased demand for refills. Our study also demonstrated that 20 opioid pills were adequate for patients undergoing meniscectomy and 40 pills were adequate for ACL reconstruction and RCR in the majority of cases. This protocol serves as a way for providers to decrease the amount of opioids dispensed after surgery while providing patients with alternatives for pain relief.

Opioid Prescribing After Surgery in the United States, Canada, and Sweden

IMPORTANCE

Small studies and anecdotal evidence suggest marked differences in the use of opioids after surgery internationally; however, this has not been evaluated systematically across populations receiving similar procedures in different countries.

OBJECTIVE

To determine whether there are differences in the frequency, amount, and type of opioids dispensed after surgery among the United States, Canada, and Sweden.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients without previous opioid prescriptions aged 16 to 64 years who underwent 4 low-risk surgical procedures (ie, laparoscopic cholecystectomy, laparoscopic appendectomy, arthroscopic knee meniscectomy, and breast excision) between January 2013 and December 2015 in the United States, between July 2013 and March 2016 in Canada, and between January 2013 and December 2014 in Sweden. Data analysis was conducted in all 3 countries from July 2018 to October 2018.

MAIN OUTCOMES AND MEASURES

The main outcome was postoperative opioid prescriptions filled within 7 days after discharge; the percentage of patients who filled a prescription, the total morphine milligram equivalent (MME) dose, and type of opioid dispensed were compared.

RESULTS

The study sample consisted of 129 379 patients in the United States, 84 653 in Canada, and 9802 in Sweden. Overall, 52 427 patients (40.5%) in the United States were men, with a mean (SD) age of 45.1 (12.7) years; in Canada, 25 074 patients (29.6%) were men, with a mean (SD) age of 43.5 (13.0) years; and in Sweden, 3314 (33.8%) were men, with a mean (SD) age of 42.5 (13.0). The proportion of patients in Sweden who filled an opioid prescription within the first 7 days after discharge for any procedure was lower than patients treated in the United States and Canada (Sweden, 1086 [11.1%]; United States, 98 594 [76.2%]; Canada, 66 544 [78.6%]; P < .001). For patients who filled a prescription, the mean (SD) MME dispensed within 7 days of discharge was highest in United States (247 [145] MME vs 169 [93] MME in Canada and 197 [191] MME in Sweden). Codeine and tramadol were more commonly dispensed in Canada (codeine, 26 136 patients [39.3%]; tramadol, 12 285 patients [18.5%]) and Sweden (codeine, 170 patients [15.7%]; tramadol, 315 patients [29.0%]) than in the United States (codeine, 3210 patients [3.3%]; tramadol, 3425 patients [3.5%]).

CONCLUSIONS AND RELEVANCE

The findings indicate that the United States and Canada have a 7-fold higher rate of opioid prescriptions filled in the immediate postoperative period compared with Sweden. Of the 3 countries examined, the mean dose of opioids for most surgical procedures was highest in the United States.

Home Disposal Kits for Leftover Opioid Medications After Surgery: Do They Work?

BACKGROUND

Postoperative overprescribing is common, and many patients will have excess medications. An effective method to encourage disposal is lacking. We hypothesized that a convenient home disposal kit will result in more appropriate disposal of excess opioids.

MATERIALS AND METHODS

We conducted a single-center prospective observational pilot study to evaluate the effectiveness of a postoperative opioid disposal kit. Patients in the intervention group received an opioid disposal kit and educational handout before discharge from the hospital. At the first follow-up visit, patients completed a survey in which they reported the remaining amount of pain medications from their original prescription and their plan for the excess medication. Patients were asked about risk factors for chronic opioid use. We used multivariable Poisson regression to identify independent factors associated with an increased likelihood of appropriate opioid disposal.

RESULTS

The survey was offered to 904 patients with a response rate of 91.7%. After excluding those with missing data, 571 patients were included in the study. Overall, 83 (14.5%) patients never filled an opioid prescription, and 286 (60.0%) patients had tablets remaining at the time of the follow-up visit. Among those with tablets remaining, 52 received a home disposal kit, whereas 234 patients with tablets remaining did not. Patients who received the kit were more likely to dispose of opioid medications (54.9% versus 34.8%, relative risk = 1.8, 95% CI 1.3-2.5). No confounders were identified during multivariable analysis that increased a patient's likelihood of disposing excess medications.

CONCLUSIONS

The provision of a convenient home disposal kit postoperatively increased patient-reported opioid disposal.

A prospective study of opioid use for postoperative pain management after breast operation

BACKGROUND

The opioid epidemic has necessitated increased attention to prescribing practices. This study seeks to prospectively quantify postoperative opioid use after breast operation.

METHODS

Consecutive patients undergoing breast operation at a single institution in 2018 prospectively tracked each dose of medication and completed a survey of perceptions regarding their opioid prescription.

RESULTS

Of 100 patients, 88 completed log, survey, or both. The tab quantity required to fulfill the needs of 80% of patients was: Partial mastectomy (PM) 3, PM with sentinel lymph node biopsy 6, PM with bilateral reduction 8, total mastectomy 34, and bilateral mastectomy 47. Of survey respondents, 51.2% felt they had been prescribed too much pain medication. Most (83.0%) had leftover tabs, and 67.9% indicated they kept them in their home.

CONCLUSIONS

The majority of patients were overprescribed opioids after breast operation. A reduction could be achieved by targeting the needs of 80% of the population.

Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial

IMPORTANCE

Although opioids are an important component of pain management for children recovering from surgery, postoperative opioid prescribing has contributed to the current opioid crisis in the United States because these medications are often prescribed in excess and are rarely properly disposed. One potential strategy to combat opioid misuse is to remove excess postoperative opioids from circulation by providing patients with drug disposal products that enable safe disposal of opioids in the home garbage.

OBJECTIVE

To determine whether the provision of a drug disposal bag increases proper opioid disposal among the families of pediatric patients undergoing ambulatory surgery.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled 202 parents or guardians of children 1 to 17 years of age who underwent otolaryngologic or urologic surgery at the outpatient surgery centers of a tertiary children's hospital in Columbus, Ohio, from June to December 2018 and who received an opioid prescription prior to discharge.

INTERVENTIONS

Families randomized to intervention were provided a drug disposal bag containing activated charcoal and instructions for use plus standard postoperative discharge instructions on opioid use, storage, and disposal. Families in standard care arm received standard postoperative discharge instructions only. All participants completed a baseline survey and a follow-up survey 2 to 4 weeks postoperatively.

MAIN OUTCOMES AND MEASURES

Primary outcome was proper opioid disposal, defined as disposal using a drug disposal bag or a disposal method recommended by the US Food and Drug Administration.

RESULTS

Of 202 parents or guardians enrolled, 181 completed follow-up (92 in intervention arm and 89 in standard care arm). Most patients in both groups were white (75 [73.5%] vs 79 [80.6%]) and male (63 [61.2%] vs 54 [54.6%]), and the median (interquartile range) age was 6 (5-9) years in the intervention arm and 7 (6-10) years in the standard care arm. For intention-to-treat analyses, 92 families receiving a disposal bag and 89 families not receiving a disposal bag were included. Among them, 66 families (71.7%) randomized to receive a disposal bag reported properly disposing of their child's opioids, whereas 50 parents (56.2%) who did not receive a disposal bag reported proper opioid disposal (difference in proportions, 15.5%; 95% CI, 1.7%-29.3%; P = .03). Among only those families who filled an opioid prescription and had leftover opioids after resolution of their child's pain, 66 of 77 parents or guardians (85.7%) who had received a disposal bag and 50 of 77 parents or guardians (64.9%) who had received standard care reported properly disposing of their child's opioids (difference in proportions, 20.8%; 95% CI, 7.6%-34.0%).

CONCLUSIONS AND RELEVANCE

Results of this study indicated that providing drug disposal bags to families of children receiving postoperative opioids increased the likelihood of excess opioid disposal. Greater availability of disposal products may complement ongoing prescribing reduction efforts aimed at decreasing opioid misuse.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03575377.

The James A. Rand Young Investigator's Award: Large Opioid Prescriptions Are Unnecessary After Total Joint Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial is to determine whether the quantity of opioid pills prescribed at discharge is associated with the number of opioid pills consumed or unused by patients after primary hip and knee arthroplasty within 30 days after discharge.

METHODS

A total of 304 opioid-naïve patients were randomized to receive either 30 or 90 5-mg oxycodone immediate-release (OxyIR) pills at discharge. Daily opioid consumption, number of unused pills, and pain scores were calculated for 30 days with a patient-completed medication diary. Statistical analysis involved t-test, rank-sum, chi-squared tests, and multiple linear regression with alpha = 0.05.

RESULTS

Of the 304 patients randomized, 161 patients were randomized to receive 30 pills and 143 to receive 90. In the first 30 days after discharge, the median number of unused pills was 15 in the 30 group vs 73 in the 90 group (P < .001). Within 90 days of discharge, 26.7% of the 30 group and 10.5% of the 90 group requested a refill (P < .001), leading to a mean of 777.1 ± 414.2 morphine equivalents vs 1089.7 ± 536.4 prescribed (P < .0001). There was no difference between groups in mean morphine equivalents consumed. Regression analysis demonstrated that being prescribed 90 OxyIR pills was independently associated with taking more OxyIR pills (P = .028). There was no difference in pain scores within the first 30 days and in patient-reported outcome scores at 6 weeks postoperatively.

CONCLUSION

Prescribing fewer OxyIR pills is associated with a significant reduction in unused opioid pills and decreased opioid consumption with no increase in pain scores and no difference in patient-reported outcomes.

LEVEL OF EVIDENCE

Level I. Randomized controlled trial.

Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids

BACKGROUND

Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake.

METHODS

For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation.

RESULTS

Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001).

CONCLUSION

The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.

Inpatient Opioid Use After Pancreatectomy: Opportunities for Reducing Initial Opioid Exposure in Cancer Surgery Patients

BACKGROUND

Despite advances in enhanced surgical recovery programs, strategies limiting postoperative inpatient opioid exposure have not been optimized for pancreatic surgery. The primary aims of this study were to analyze the magnitude and variations in post-pancreatectomy opioid administration and to characterize predictors of low and high inpatient use.

METHODS

Clinical characteristics and inpatient oral morphine equivalents (OMEs) were downloaded from electronic records for consecutive pancreatectomy patients at a high-volume institution between March 2016 and August 2017. Regression analyses identified predictors of total OMEs as well as highest and lowest quartiles.

RESULTS

Pancreatectomy was performed for 158 patients (73% pancreaticoduodenectomy). Transversus abdominus plane (TAP) block was performed for 80% (n = 127) of these patients, almost always paired with intravenous patient-controlled analgesia (IV-PCA), whereas 15% received epidural alone. All the patients received scheduled non-opioid analgesics (median, 2). The median total OME administered was 423 mg (range 0-4362 mg). Higher total OME was associated with preoperative opioid prescriptions (p < 0.001), longer hospital length of stay (LOS; p < 0.001), and no epidural (p = 0.006). The lowest and best quartile cutoff was 180 mg of OME or less, whereas the highest and worst quartile cutoff began at 892.5 mg. After adjustment for inpatient team, only epidural use [odds ratio (OR) 0.3; p = 0.04] predicted lowest-quartile OME. Preoperative opioid prescriptions (OR 8.1; p < 0.001), longer operative time (OR 3.4; p = 0.05), and longer LOS (OR 1.1; p = 0.007) predicted highest-quartile OME.

CONCLUSIONS

Preoperative opioid prescriptions and longer LOS were associated with increased inpatient OME, whereas epidural use reduced inpatient OME. Understanding the predictors of inpatient opioid use and the variables predicting the lowest and highest quartiles can inform decision-making regarding preoperative counseling, regional anesthetic block choice, and novel inpatient opioid weaning strategies to reduce initial postoperative opioid exposure.

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse

Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.