Patterns of opioid use and prescribing for outpatient anorectal operations

Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement

INTRODUCTION

The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures.

METHODS

One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control.

RESULTS

Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control.

CONCLUSIONS

We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

Effectiveness of Topical Ketorolac in Post-hemorrhoidectomy Pain Management: A Clinical Trial

Background

Postoperative pain management is one of the major challenges of surgeons and anesthesiologists.

Objectives

This study aimed to determine the efficacy of topical ketorolac in post-hemorrhoidectomy pain management.

Methods

This clinical trial was conducted on 84 candidates for hemorrhoidectomy (grade-II hemorrhoids) who visited Ali ibn Abi-Talib hospital of Rafsanjan, Kerman, Iran (2020 - 2021). The participants were selected through convenience sampling and randomly assigned to three groups of 28. The subjects were treated in topical (4 mL 0.5% Marcaine + 1 mL ketorolac at the surgical site), intramuscular (4 mL 0.5% Marcaine at the surgical site + 1 mL ketorolac intramuscularly), and control (4 mL 0.5% Marcaine at the surgical site) groups. Pain intensity was measured using the Numerical Pain Rating Scale 1, 6, 12, and 24 hours after surgery. The obtained data were analyzed using two-way repeated measures analysis of variance.

Results

Female and male patients constituted 46.4% and 53.6% of the participants, respectively. The mean pain intensity was significantly lower in the topical group than in intramuscular and control treatments in all four stages of pain assessment (P < 0.001). Some participants were treated with pethidine due to high pain intensity. However, the mean pain intensity gradually reduced over time in all three groups.

Conclusions

Study findings suggested that the topical administration of ketorolac and Marcaine was more effective than Marcaine used alone for relieving pain in patients undergoing hemorrhoidectomy.

Developing Opioid Prescription Guidelines After Anorectal Surgery: Do Patient-Reported Outcomes and Risk Factors Influence Consumption?

BACKGROUND

Opioids prescribed to address postoperative pain drive opioid-related deaths in the United States. Prescribing guidelines have been developed for many general surgical procedures, which have decreased opioid prescription and consumption. The literature on opioids after anorectal surgery is lacking.

OBJECTIVE

We analyzed our data on opioid prescription and consumption to create opioid-prescribing guidelines for anorectal procedures.

DESIGN

We designed a prospectively collected postoperative survey given to consecutive patients undergoing anorectal surgery by colorectal surgeons.

SETTINGS

Patients had surgery at 2 academic, university-affiliated hospitals.

PATIENTS

Patients undergoing anorectal surgery from May 3, 2018, to December 18, 2019, were included in the study. Patients were excluded if they were <18 years of age, had a concurrent abdominopelvic surgery, consumed opioids in the week before their operation, or were without follow-up at 3 months postoperatively.

MAIN OUTCOME MEASURES

The primary outcome of this study was the number of opioid pills needed to fulfill consumption of 80% of patients. Secondary outcome measures were patient, operative, and postoperative factors associated with increasing pill consumption.

RESULTS

Eighteen 5-mg oxycodone tablets were needed to fulfill the needs of 80% of patients. An overall median of 8 pills was consumed. Pill prescription was independently predictive of increased consumption. The only patient factor associated with increased consumption was race; no other patient or operative factors were predictive of consumption.

LIMITATIONS

Limitations of this study include its partially retrospective nature, use of self-reported data, and lack of racial diversity among our cohort.

CONCLUSIONS

Without any clinical factors predictive of increased consumption, prescription guidelines can be standardized to ≤18 5-mg oxycodone tablets across anorectal surgery patients. As prescription is correlated with consumption, further work is needed to determine whether lesser quantities of opioids prescribed offer similar postoperative pain relief for patients undergoing anorectal surgery. See Video Abstract at http://links.lww.com/DCR/B821 .DESARROLLO DE PAUTAS PARA LA PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE CIRUGÍA ANORRECTAL: ¿INFLUYEN EN EL CONSUMO LOS RESULTADOS INFORMADOS POR EL PACIENTE Y LOS FACTORES DE RIESGO?

ANTECEDENTES

Los opioides recetados para tratar el dolor posoperatorio provocan muertes relacionadas con los opioides en los Estados Unidos. Se han desarrollado pautas de prescripción para muchos procedimientos quirúrgicos generales y estas han conducido a una disminución de la prescripción y el consumo de opioides. Hay una carencia de literatura sobre el uso de opioides después de cirugía anorrectal.

OBJETIVO

Analizamos nuestros datos sobre prescripción y consumo de opioides para crear pautas de prescripción de opioides para procedimientos anorrectales.

DISEO

Diseñamos una encuesta postoperatoria recopilada prospectivamente que se administró a pacientes consecutivos sometidos a cirugía anorrectal por cirujanos colorrectales.

AJUSTES

Los pacientes fueron operados en dos hospitales académicos afiliados a la universidad.

PACIENTES

Se incluyeron en el estudio pacientes sometidos a cirugía anorrectal desde el 3/05/2018 hasta el 18/12/2019. Se excluyó a los pacientes que tenían menos de 18 años, a los que se sometieron a cirugía abdominopélvica concurrente, a los que consumieron opioides en la semana anterior a la operación, o si no tenían seguimiento a los 3 meses del postoperatorio.

PRINCIPALES MEDIDAS DE DESENLACE

El desenlace principal de este estudio fue el número de píldoras de opioides necesarias para satisfacer el consumo del 80% de los pacientes. Las medidas de desenlace secundarias fueron los factores del paciente, operatorios y posoperatorios asociados con el aumento del consumo de píldoras.

RESULTADOS

Fueron necesarios dieciocho comprimidos de oxicodona de 5 mg para cubrir las necesidades del 80% de los pacientes. Se consumió una mediana general de 8 píldoras. La prescripción de la píldora fue un predictor independiente de un mayor consumo. El único factor del paciente asociado con un mayor consumo fue la raza; ningún otro paciente o factores operativos fueron predictivos del consumo.

LIMITACIONES

Las limitaciones de este estudio incluyen su naturaleza parcialmente retrospectiva, el uso de datos autoinformados y la falta de diversidad racial entre nuestra cohorte.

CONCLUSIONES

Sin ningún factor clínico que prediga un aumento del consumo, las pautas de prescripción se pueden estandarizar a dieciocho o menos comprimidos de oxicodona de 5 mg en pacientes sometidos a cirugía anorrectal. Como la prescripción se correlaciona con el consumo, se necesita más trabajo para determinar si cantidades menores de opioides prescritos ofrecen un alivio del dolor posoperatorio similar para los pacientes sometidos a cirugía anorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B821 . (Traducción-Juan Carlos Reyes ).

Efficacy of a password-protected, pill-dispensing device with mail return capacity to enhance disposal of unused opioids after cancer surgery

BACKGROUND

Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery.

METHODS

A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction.

RESULTS

Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved.

CONCLUSIONS

Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.

Health Care Costs and Resource Utilization Among Patients With Crohn's Disease With and Without Perianal Fistula

BACKGROUND

Perianal fistula (PAF), a complication of Crohn's disease (CD), is associated with substantial economic costs and poor prognosis. We determined prevalence of PAF CD in the United States and compared costs and health care resource utilization (HRU) of PAF CD patients with matched non-PAF CD patients.

METHODS

This was a retrospective cohort study of claims data from the IBM MarketScan Commercial Database from October 1, 2015, to September 30, 2018. Eligible patients were aged 18 to 89 years with ≥2 CD diagnoses. Patients with PAF CD had ≥1 PAF diagnosis or procedure code and were matched with non-PAF CD patients. Cumulative prevalence of PAF CD in the US population was calculated across total patients in MarketScan. All-cause and gastrointestinal (GI)-related costs and HRU were compared between groups using a generalized linear model (GLM).

RESULTS

Cumulative 3-year prevalence of PAF was 7.70% of patients with CD (N = 81,862) and 0.01% of the US population. Among PAF CD (n = 1218) and matched non-PAF CD (n = 4095) patients, most all-cause costs and HRU were GI-related. Mean total all-cause and GI-related health care costs per patient and per year for PAF CD were $85,233 and $71,612, respectively, vs $40,526 and $29,458 for non-PAF CD (P < .0001). Among PAF CD vs non-PAF CD patients, GLM-adjusted proportions of patients with GI-related inpatient, outpatient, or pharmacy visits, mean GI-related inpatient length of stay, and mean GI-related surgeries were higher (P < .0001 for all comparisons).

CONCLUSIONS

Costs and HRU are significantly higher for patients with PAF CD vs non-PAF CD patients, highlighting the economic burden of the disease.

A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use

BACKGROUND

Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases.

OBJECTIVE

To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction.

METHODS

A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time.

RESULTS

Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge (median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P  =  0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time.

CONCLUSIONS

An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.

Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis

BACKGROUND

While there is an increasing burden of chronic postoperative opioid use and opioid abuse in the United States, opioid use following inflatable penile prosthesis (IPP) surgery has not been well described.

AIM

Describe postoperative opioid use following IPP surgery.

METHODS

Seventy-four consecutive patients undergoing IPP implantation by a single surgeon were enrolled. Self-reported diaries tracked the type and amount of medication taken for 2 weeks following IPP surgery. High opioid consumers were defined as those consuming more than the median amount (10 mg) of opioids during the first 2 weeks postoperatively. Multivariate analyses were performed using stepwise backward elimination.

OUTCOMES

Quantification of opioid use postoperatively and factors related to high opioid use.

RESULTS

Fifty-six patients were included after 7 were excluded for preoperative opioid use and 11 were excluded for inability to contact. Median age was 67.5. Devices used were Boston Scientific (41, 73%) and Coloplast (15, 27%). All patients received local anesthetic. Most surgeries (44, 79%) were performed as outpatient. Preoperative analgesia with acetaminophen, celecoxib, and pregabalin was administered in 44 (78%), 44 (78%), and 28 (50%) of cases respectively; 32 (57%) of patients received 2 medications, 21 (36%) received three medications. In hospital median morphine equivalents was 7.5 (interquartile range [IQR] 0-7.5). Oxycodone prescribed at discharge was 50 mg (29, 52%), 75 mg (4; 7%), and 100 mg (23; 41%). Median milligrams of oxycodone used was 10 mg (IQR 0-23.5) at 7 days and 10 (IQR 0-37.5) at 14 days postdischarge. On univariate analysis, factors associated with an increased likelihood of high opioid use were morphine equivalents utilized in hospital (odds ratio [OR] 1.13, P < .05) and milligrams oxycodone prescribed at discharge (OR 1.05, P < .001) while patient demographics, procedure characteristics, and analgesic types were not found to be predictive of high opioid use. On multivariate analysis, milligrams oxycodone prescribed at discharge (OR 1.04, P < .005) were associated with an increased likelihood of high opioid use after discharge.

CLINICAL IMPLICATIONS

Increased understanding of opioid use after IPP surgery may improve prescribing patterns after discharge.

STRENGTHS & LIMITATIONS

This study quantified post discharge opioid use over the first 14 postoperative days. It is limited by single surgeon, small sample size, and retrospective design.

CONCLUSION

Provider opioid prescribing patterns were associated with high opioid consumption postoperatively and a substantial amount of opioids prescribed at discharge remain unused by patients, suggesting that we can reduce or replace the amount of opioids that are prescribed. Ehlers ME, Mohan CS, Akerman JP, et al. Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis. J Sex Med 2021;18:1915-1920.

Inpatient Opioid Consumption Variability following Total Knee Arthroplasty: Analysis of 4,038 Procedures

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

Reduction of Opioid Overprescribing and Use Following Standardized Educational Intervention: A Survey of Patient Experiences Following Anorectal Procedures

BACKGROUND

A pilot study conducted at our institution showed that a significant amount of prescribed postoperative opioids is left unused with the potential for diversion and misuse.

OBJECTIVE

This study aimed to evaluate the impact of provider- and patient-targeted educational interventions on postoperative opioid prescription and use following anorectal procedures.

DESIGN

Patients were enrolled on July 2019 through March 2020 after implementing educational interventions (study) and were compared with the pilot study group (control) enrolled on August 2018 through May 2019. A telephone survey was conducted 1 week postoperatively.

SETTINGS

This study was conducted at a 600-bed, safety-net hospital in southern California.

PATIENTS

Adult patients undergoing ambulatory anorectal procedures were included. Patients who had undergone an examination under anesthesia, had been incarcerated, and had used opioids preoperatively were excluded.

INTERVENTIONS

Educational interventions were developed based on the pilot study results. Providers received education on recommended opioid prescription quantities and a multimodal pain regimen. Standardized patient education infographics were distributed to patients pre- and postoperatively.

MAIN OUTCOME MEASURES

The primary outcomes measured were total opioid prescribed, total opioid consumed, pain control satisfaction levels, and the need for additional opioid prescription.

RESULTS

A total of 104 of 122 (85%) patients enrolled responded to the survey and were compared with the 112 patients included in the control group. Despite similar demographics, the study cohort was prescribed fewer milligram morphine equivalents (78.8 ± 11.3 vs 294.0 ± 33.1, p < 0.001), consumed fewer milligram morphine equivalents (23.0 ± 28.0 vs 57.1 ± 45.8, p < 0.001), and had a higher rate of nonopioid medication use (72% vs 10%, p < 0.001). The 2 groups had similar pain control satisfaction levels (4.1 ± 1.3 vs 3.9 ± 1.1 out of 5, p = 0.12) and an additional opioid prescription requirement (5% vs 4%, p = 1.0).

LIMITATIONS

This study was limited by its single-center experience with specific patient population characteristics.

CONCLUSION

Educational interventions emphasizing evidence-based recommended opioid prescription quantities and regimented multimodal pain regimens are effective in decreasing excessive opioid prescribing and use without compromising satisfactory pain control in patients undergoing ambulatory anorectal procedures. See Video Abstract at http://links.lww.com/DCR/B529.

REDUCCIN DE LA SOBREPRESCRIPCIN Y EL USO DE OPIOIDES DESPUS DE UNA INTERVENCIN EDUCATIVA ESTANDARIZADA UNA ENCUESTA DE LAS EXPERIENCIAS EN PACIENTES POSTOPERADOS DE PROCEDIMIENTOS ANORRECTALES

ANTECEDENTES:Un estudio piloto realizado en nuestra institución mostró que una cantidad significativa de opioides posoperatorios recetados no se usa, con potencial de desvío y uso indebido.OBJETIVO:Evaluar el impacto de las intervenciones educativas dirigidas al paciente y al proveedor sobre la prescripción y el uso de opioides posoperatorios después de procedimientos anorrectales.DISEÑO:Los pacientes se incluyeron entre julio de 2019 y marzo de 2020 después de implementar intervenciones educativas (estudio) y se compararon con el grupo de estudio piloto (control) inscrito entre agosto de 2018 y mayo de 2019. Se realizó una encuesta telefónica una semana después de la cirugía.ENTORNO CLÍNICO:Hospital de 600 camas en el sur de California.PACIENTES:Pacientes adultos sometidos a procedimientos anorrectales ambulatorios. Los criterios de exclusión fueron pacientes que recibieron un examen bajo anestesia, pacientes encarcelados y uso preoperatorio de opioides.INTERVENCIONES:Se desarrollaron intervenciones educativas basadas en los resultados del estudio piloto. Los proveedores recibieron educación sobre las cantidades recomendadas de opioides recetados y un régimen multimodal para el dolor. Se distribuyeron infografías estandarizadas de educación para el paciente antes y después de la operación.PRINCIPALES MEDIDAS DE RESULTADO:Opioide total prescrito, opioide total consumido, niveles de satisfacción del control del dolor y necesidad de prescripción adicional de opioides.RESULTADOS:Un total de 104 de 122 (85%) pacientes inscritos respondieron a la encuesta y se compararon con los 112 pacientes incluidos en el grupo de control. A pesar de una demografía similar, a la cohorte del estudio se le prescribió menos miligramos de equivalente de morfina (MME) (78,8 ± 11,3 frente a 294,0 ± 33,1, p <0,001), consumió menos MME (23,0 ± 28,0 frente a 57,1 ± 45,8, p <0,001) y presentaron una mayor tasa de uso de medicamentos no opioides (72% vs 10%, p <0,001). Los dos grupos tenían niveles similares de satisfacción del control del dolor (4,1 ± 1,3 frente a 3,9 ± 1,1 de 5, p = 0,12) y la necesidad de prescripción de opioides adicionales (5% frente a 4%, p = 1,0).LIMITACIONES:Experiencia en un solo centro con características específicas de la población de pacientes.CONCLUSIÓN:Las intervenciones educativas que enfatizan las cantidades recomendadas de prescripción de opioides basadas en la evidencia y los regímenes de dolor multimodales reglamentados son efectivas para disminuir la prescripción y el uso excesivos de opioides sin comprometer el control satisfactorio del dolor en pacientes sometidos a procedimientos anorrectales ambulatorios. Video Resumen en http://links.lww.com/DCR/B529.

Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review

OBJECTIVE

This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery.

METHODS

We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale.

RESULTS

Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria.

CONCLUSION

Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.

A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery

BACKGROUND

Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures.

METHODS

The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents).

RESULTS

A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P < .001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P < .001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P < .0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P < .0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P < .00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P < .0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed.

CONCLUSION

Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

Opioid Consumption Patterns After Anorectal Operations: Development of an Institutional Prescribing Guideline

BACKGROUND

Closer scrutiny of prescription patterns following surgery could contribute to the national effort to combat the opioid epidemic.

OBJECTIVE

This study aimed to define opioid consumption patterns following anorectal operations for development of an institutional prescribing guideline.

DESIGN

This was a retrospective cohort study.

SETTING

The study was conducted at a single tertiary care center.

PATIENTS

Patients undergoing outpatient anorectal surgery between July 2018 and January 2019 were included.

MAIN OUTCOME MEASURES

The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills.

RESULTS

There were 174 operations categorized into 4 operation categories: 72 hemorrhoid excisions, 55 fistulas-in-ano operations, 8 anal condyloma fulgurations, and 39 miscellaneous operations (14 sphincterotomies, 16 anal biopsies/skin tag excisions, and 9 transanal rectal lesion excisions). Prescription quantity was varied (range, 3-80 equianalgesic oxycodone 5-mg pills). Overall, 39% of patients consumed no pills, 18% consumed all, and 5% required refills. Of total pills prescribed, 63% of were unconsumed. Consumption was significantly different by operation category (average 13.6 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 6.3 after fistula-in-ano operations, 5.8 after condyloma fulguration, and 2.9 after miscellaneous operations; p < 0.001). Home opioid requirements would be met for 80% of patients using the following guideline: 27 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 13 after fistula-in-ano operations, 20 after anal condyloma fulguration, and 4 after miscellaneous operations. Guideline adoption would result in a 41% reduction in excess pills per prescription.

LIMITATIONS

The study was limited by its retrospective, single-center design and because opioid consumption was self-reported.

CONCLUSIONS

Opioid prescribing patterns and consumption are widely variable after anorectal operations and appear to be highly dependent on the operation category. It is noteworthy that 63% of opioids prescribed after anorectal operations were unused by the patient and may pose a significant public health risk. Based on the usage patterns observed in this study, prospective studies should be performed to optimize opioid prescribing. See Video Abstract at http://links.lww.com/DCR/B374. PATRONES DE CONSUMO DE OPIOIDES DESPUÉS DE OPERACIONES ANORRECTALES: DESARROLLO DE UNA GUÍA PARA PRESCRIPCIÓN INSTITUCIONAL: Una revisión enfocada de los patrones de prescripción después de la cirugía podría contribuir al esfuerzo nacional para combatir la epidemia de opioides.Este estudio tuvo como objetivo definir los patrones de consumo de opioides después de las operaciones anorrectales para el desarrollo de una guía para prescripción institucional.Estudio de cohorte retrospectivo.El estudio se realizó en un solo centro de atención de tercer nivel.pacientes de cirugía anorrectal ambulatoria entre julio de 2018 y enero de 2019.El estudio valoro el numero de recetas medicas y consumo de píldoras equianalgésicas de oxicodona de 5 mg.174 operaciones se clasificaron en cuatro categorías: 72 extirpaciones de hemorroides, 55 operaciones de fistula anal, 8 fulguraciones de condilomas anales y 39 operaciones misceláneas (14 esfinterotomías, 16 biopsias anales / extirpaciones de lesiones de piel y 9 escisiones de lesiones rectales por vía transanal). La cantidad de medicamentos recetados fue variada (rango: 3-80 pastillas de oxicodona equianalgésica de 5 mg). En general, el 39% de los pacientes no consumió píldoras, el 18% consumió todo y el 5% requirió equianalgesica adicional. Del total de píldoras recetadas, el 63% no se consumió. El consumo fue significativamente diferente según la categoría de la operación (promedio de 13,6 píldoras de oxicodona equianalgésica de 5 mg después de las hemorroidectomías, 6,3 después de las operaciones de fístula en el ano, 5,8 después de la fulguración del condiloma y 2,9 después de las operaciones misceláneas, p <0,001). Los requisitos de opioides en el hogar se cumplirían para el 80% de los pacientes con las siguientes pautas: 27 píldoras de oxicodona equianalgésicas de 5 mg después de las hemorroidectomías, 13 después de las operaciones de fístula anal, 20 después de la fulguración del condiloma anal y 4 después de operaciones misceláneas. La adopción de la guía daría como resultado una reducción del 41% en el exceso de píldoras por receta.El estudio estuvo limitado por su diseño retrospectivo de un solo centro y el consumo de opioides fue autoinformado.Los patrones de prescripción de opioides y el consumo son variables después de las operaciones anorrectales y parecen ser altamente dependientes de la categoría de la operación. En particular, el 63% de los opioides recetados después de las operaciones anorrectales no fueron utilizados por el paciente y pueden representar un riesgo significativo para la salud pública. Según los patrones de uso observados en este estudio, se deben realizar estudios prospectivos para optimizar la prescripción de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B374.

Overprescription of Opioids Following Outpatient Anorectal Surgery: A Single-Institution Study

BACKGROUND

Surgeons contribute to the opioid epidemic by overprescribing opioids for postoperative pain. Excess, unused opioids may be diverted for misuse/abuse.

OBJECTIVE

This study aimed to characterize opioid prescribing and use among patients undergoing outpatient anorectal procedures and to assess the adequacy of postoperative pain management.

DESIGN

This is a retrospective cohort study, prospective cross-sectional survey.

SETTINGS

Patients were treated by colorectal surgeons in an academic medical center between January 2018 and September 2019.

PATIENTS

Six hundred twenty-seven patients undergoing an outpatient anorectal procedure were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the opioids prescribed at discharge, opioid prescription refills, patient-reported outcomes regarding opioid use, and the adequacy of postoperative pain management in terms of pain intensity and pain interference. Opioids were standardized to 5-mg oxycodone pills. Patient-reported outcomes were assessed by using previously validated instruments.

RESULTS

The majority of patients underwent fistula surgery (n = 234) followed by examination under anesthesia (n = 183), hemorrhoidectomy (n = 131), incision and drainage (n = 51), and pilonidal excision (n = 28). Most patients received opioids (78% fistula, 49% examination under anesthesia, 87% hemorrhoidectomy, 71% incision and drainage, 96% pilonidal). Patients undergoing examination under anesthesia received the fewest opioid pills (median 10; range 3-50) followed by patients undergoing fistula surgery (median13, range 1-50), incision and drainage (median 15, range 3-120), pilonidal excisions (median 15, range 3-60), and hemorrhoidectomies (median 28, range 3-60). Regardless of procedure, the majority of patients used fewer than 5 opioid pills postoperatively. Patients undergoing pilonidal excisions had the largest number of excess unused pills (median 14, range 0-30) followed by patients undergoing fistula surgery and incision and drainage (median 7, ranges 0-30 and 5-17), hemorrhoidectomy (median 6, range 0-50), and examination under anesthesia (median 2, range 0-23). Whereas patients undergoing hemorrhoidectomy reported higher pain levels following discharge, most reported minimal interference with day-to-day activities due to pain regardless of the procedure performed.

LIMITATIONS

The limitations of this study included recall bias and sample bias.

CONCLUSIONS

The majority of patients do not need more than five to ten 5-mg oxycodone equivalents to achieve adequate pain management after outpatient anorectal surgical procedures. See Video Abstract at http://links.lww.com/DCR/B347. EXCESO DE PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE UNA CIRUGÍA ANORRECTAL AMBULATORIA: UN ESTUDIO DE UNA SOLA INSTITUCIÓN: Cirujanos contribuyen a la epidemia de opioides al recetar en exceso opioides para el dolor postoperatorio. El exceso de opioides no utilizados puede ser desviado por para mal uso o abuso.Caracterizar la prescripción y el uso de opioides entre pacientes sometidos a procedimientos anorrectales ambulatorios y evaluar la efectividad del tratamiento del dolor postoperatorio.Estudio de cohorte retrospectivo, encuesta transversal prospectiva.pacientes tratados por cirujanos colorrectales en un centro médico académico entre enero de 2018 y septiembre de 2019.se incluyeron 627 pacientes que se sometieron a un procedimiento anorrectal ambulatorio.Opioides recetados al alta, reabastecimientos de prescripción de opioides, resultados informados por el paciente con respecto al uso de opioides y efectividad del manejo del dolor postoperatorio en términos de intensidad del dolor y trastornos secundarios a dolor. Los opioides se estandarizaron con píldoras de oxicodona de 5 mg. Los resultados informados por los pacientes se evaluaron utilizando instrumentos previamente validados.La mayoría de los pacientes fueron sometidos a cirugía de fístula (n = 234) seguida de un examen bajo anestesia (EUA; n = 183), hemorroidectomía (n = 131), incisión y drenaje (I&D) (n = 51) y escisión pilonidal (n = 28). La mayoría de los pacientes recibieron opioides (78% fístula, 49% EUA, 87% hemorroidectomía, 71% I&D, 96% pilonidal). Las EUA recibieron la menor cantidad de píldoras opioides (mediana 10, rango 3-50) seguidas de fístula (mediana 13, rango 1-50), I y D (mediana 15, rango 3-120), pilonidales (mediana 15, rango 3-60) y hemorroides. (mediana 28, rango 3-60). Independientemente del procedimiento, la mayoría de los pacientes usaron menos de cinco píldoras opioides después de la operación. Los pacientes pilonidales tuvieron el mayor número de píldoras no utilizadas en exceso (mediana 14, rango 0-30) seguido de fístula e I&D (mediana 7, rangos 0-30 y 5-17, respectivamente), hemorroidectomía (mediana 6, rango 0-50) y EUA (mediana 2, rango 0-23). Si bien los pacientes con hemorroidectomía informaron niveles de dolor más altos después del alta, la mayoría de pacientes informaron un mínimo de interferencia con las actividades diarias debido al dolor, independientemente del procedimiento realizado.Sesgo de recuerdo autoinformado, sesgo de muestra.La mayoría de los pacientes no necesitan más de cinco a diez equivalentes de oxicodona de 5 mg para lograr un manejo adecuado del dolor después de procedimientos quirúrgicos anorrectales ambulatorios. Consulte Video Resumen en http://links.lww.com/DCR/B347. (Traducción-Dr. Adrian Ortega).

Opioid Prescriptions After Hemorrhoidectomy

BACKGROUND

Hemorrhoids cause more than 4 million ambulatory care visits in the United States annually, and hemorrhoidectomy is associated with significant postoperative pain. There are currently no evidence-based opioid-prescribing guidelines for hemorrhoidectomy patients.

OBJECTIVE

The purpose of this study was to investigate patterns of opioid prescribing and to identify factors associated with opioid refill after hemorrhoidectomy.

DESIGN

This was a retrospective database review.

SETTINGS

The study was conducted using the Department of Defense Military Health System Data Repository (2006-2014).

PATIENTS

Opioid-naïve patients aged 18 to 64 years enrolled in TRICARE insurance who underwent surgical hemorrhoidectomy were included in this study.

MAIN OUTCOME MEASURES

We measured patterns of opioid prescriptions and predictors of a second opioid prescription within 2 weeks of the end date for the first prescription after hemorrhoidectomy.

RESULTS

A total of 6294 patients were included; 5536 (88.0%) filled an initial opioid prescription with a median 5-day supply, and 1820 (32.9%) required an opioid refill. The modeled risk of refill based on initial prescription supply ranged from a high of 39.2% risk with an initial prescription of 1-day supply to an early nadir (26.1% risk of refill) with an initial 10-day supply. A variety of sociodemographic and clinical characteristics influenced the likelihood of opioid refill, including black race (OR = 0.75 (95% CI, 0.62-0.89)), history of substance abuse (OR = 3.26 (95% CI, 1.37-7.34)), and length of index opioid prescription (4-6 d, OR = 0.83 (95% CI, 0.72-0.96) or ≥7 d, OR = 0.67 (95% CI, 0.57-0.78) vs 1-3 d).

LIMITATIONS

Variables assessed were limited because of the use of claims-based data.

CONCLUSIONS

There is wide variability in the length of prescription opioid use after hemorrhoidectomy. Approximately one third of patients require a second prescription in the immediate postoperative period. The optimal duration appears to be between a 5- and 10-day supply. Clinicians may be able to more efficiently discharge patients with adequate analgesia while minimizing the potential for excess supply. See Video Abstract at http://links.lww.com/DCR/B112. PRESCRIPCIÓN DE MÉDICAMENTOS OPIOIDES DESPUÉS DE HEMORROIDECTOMÍA: Las afecciones hemorroidarias ocasionan anualmente más de cuatro millones de consultas ambulatorias en los Estados Unidos. La hemorroidectomía esta asociada con dolor postoperatorio muy significativo. Actualmente no existen pautas claras para la prescripción de medicamentos opioides después de hemorroidectomía, basada en la evidencia.Investigar los patrones de prescripción de medicamentos opioides e identificar los factores asociados con la acumulación de dichos opioides después de una hemorroidectomía.Revisión retrospectiva de una base de datos.Almacén de datos del Sistema de Salud militar del Departamento de Defensa de los Estados Unidos de América (2006-2014).Todos aquellos sometidos a hemorroidectomía quirúrgica, sin tratamiento opiode previo, comprendiodos entre 18-64 años y beneficiarios de seguro TRICARE.Patrones de prescripción de recetas de opioides, predictores de una segunda receta de opioides dentro las dos semanas posteriores a la fecha de finalización de la primera receta después de la hemorroidectomía.6.294 pacientes fueron incluidos en el estudio. 5.536 (88,0%) completaron una receta inicial de opioides con un suministro promedio de cinco días, y 1.820 (32,9%) pacientes requirieron reabastecerse de opioides. El riesgo modelado de reabastecimiento de opiodes basado en el suministro de la prescripción inicial, varió desde un alto riesgo (39.2%) con una prescripción inicial de suministro por día, hasta un acmé temprano (26.1% de riesgo de reabastecimiento) con un suministro inicial de 10 días. Una gran variedad de características socio-demográficas y clínicas influyeron en la probabilidad del reabastecimeinto de los opioides, incluida la raza negra (OR 0.75, intervalo de confianza (IC) del 95% (0.62, 0.89)), los antecedentes de abuso de substancias (OR 3.26, IC del 95% (1.37, 7.34)) y la duración del índice de la prescripción de opioides (4-6 días (OR 0.83, IC 95% (0.72, 0.96)), o 7 días o más (OR 0.67, IC 95% (0.57, 0,78)) comparados a 1-3 días.Las variables analizadas fueron limitadas debido al uso de datos basados en reclamos.Existe una gran variabilidad en la duración del uso de opioides recetados después de hemorroidectomía. Aproximadamente un tercio de los pacientes requieren una segunda prescripción en el postoperatorio inmediato. La duración óptima parece estar entre un suministro de cinco y 10 días. Los médicos pueden dar de alta de manera más eficiente a los pacientes con analgesia adecuada y minimizar el potencial de exceso de suministro. Consulte Video Resumen en http://links.lww.com/DCR/B112. (Traducción-Dr. Xavier Delgadillo).

Opioid Prescribing Patterns After Anorectal Surgery

BACKGROUND

Anorectal procedures are frequently performed and have the potential to be particularly painful. There are no evidence-based guidelines regarding opioid prescribing after anorectal surgery and limited data on how surgeons determine opioid prescriptions after anorectal procedures. We hypothesize significant variations in prescribing practices. The aim of this study is to determine current opioid prescribing patterns after anorectal surgery.

METHODS

A survey was sent to members of the American Society of Colon and Rectal Surgeons. It included demographics, opioid prescribing habits after anorectal procedures, and factors influencing prescribing. Median morphine equivalents were calculated. Respondents prescribing higher than the median for >4 procedures were considered high prescribers.

RESULTS

519 surveys were completed (3160 sent). 38.6% of respondents were high prescribers, and 61.4% were low prescribers. There were significant differences by years in practice (P = 0.049), hospital type (P = 0.037), region (P < 0.001), and procedures performed per month (P < 0.001). 73% prescribed a standard quantity of opioids for each procedure. The mean milligrams of ME prescribed overall was 129 (SD 82); by procedure the quantities were as follows: hemorrhoidectomy 188 (111), condyloma treatment 149 (105), fistulotomy 146 (98), advancement flap 144 (97), LIFT 140 (93), abscess drainage 107 (91), sphincterotomy 105 (85), chemodenervation 64 (34). Nearly, all (98%) surgeons used local anesthesia. 91% typically prescribed adjunctive medications. In multivariable analysis, performing <10 anorectal procedures per month or practicing in the Northeast or outside the US was associated with low prescribers. High prescribers were more likely to be in practice for >10 y, report >25% of patients request refills, or significantly consider patient satisfaction or phone calls when prescribing.

CONCLUSIONS

Opioid prescribing patterns are highly variable after anorectal procedures. Creating opioid prescribing guidelines for anorectal surgery is important to improve patient safety and quality of care.

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.

A Pathway for Developing Postoperative Opioid Prescribing Best Practices

OBJECTIVE

Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model.

SUMMARY BACKGROUND DATA

During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder.

METHODS

We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations.

RESULTS

Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores.

CONCLUSION

A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.