Opioid prescribing patterns at discharge for surgical patients

Statistics from the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse have illustrated the extent and gravity of deaths involving prescription opioids. Data from the last 2 decades showed a steady increase in prescription opioid deaths from 1999 until peaking in 2011.1,2 Rates have slowly started to decline since then, but the number of prescription opioid-related deaths still tops 17,000 annually as of 2017.1,2 Although this is less than the number of deaths currently caused by synthetic narcotics such as fentanyl, illicit use of fentanyl is frequently preceded by abuse of prescription opioids. Current opioid prescribing trends indicate that extended-release forms of opioids make up <10% of total opioid prescribing and the rate of prescribing for day supply of opioids of <30 days exceeds that of ≥30 days.3 This indicates that short-term prescribing for acute conditions such as surgery constitutes most opioid prescriptions. By medical specialty, surgeons are the fifth largest prescribers of opioids in the United States and one of the very few groups whose prescribing rates have increased despite the opioid epidemic.4 From 2010 to 2016, the rate of opioid prescribing by surgeons increased by 18%.5 Not only did the rate increase, but so did the average oral milligram morphine equivalents (MME or OME) per prescription from 240 in 2010 to 403 in 2016.5 Excessive prescribing of opioids for postoperative analgesia is a contributor to the public health crisis of opioid addiction and misuse; yet, there is a paucity of literature comparing opioid-based to opioid-free analgesia, particularly in North America, where the crisis is most rampant. Reliance on opioids for acute pain management is much higher in the United States compared with most other countries for which such data are available.6 Fiore and colleagues, performed an extensive literature search of 8 databases for studies with surgical patients using opioid-free postoperative analgesia. With just over 400 studies fulfilling the authors' criteria, only 5% of them came from the United States.7 Most studies came from Europe and Asia and were predominantly focused on general, orthopedic, and obstetric/gynecologic surgery. Although there were many studies focused on inpatient postoperative opioid-free regimens, relatively few examined opioid versus opioid-free regimens after discharge. The authors shared that postoperative pain-related outcomes in countries with low opioid prescribing rates are superior to North American outcomes. The authors concluded that there is considerable opportunity for research aimed at building evidence for opioid-free analgesia regimens after discharge, particularly in countries where the opioid crisis is a full-blown epidemic. Potential reasons why such research has outpaced the United States in countries where opioids are far less of a problem are unique societal issues within the United States such as industry promotion of opioids as "safe," pain scores as markers of quality care, and pain-related questions on patient satisfaction scoring surveys. Safety issues and excessive prescribing Although opioids have long been the mainstay of acute postoperative pain management, emerging data reveal the breadth and depth of opioid-related adverse events. Urman and colleagues reviewed data on >13,000 opioid-naive surgical patients and found that 91% received opioids in their postoperative course and 10% of those patients experienced an opioid-related adverse drug event (ORADE). These ORADEs were associated with higher hospitalization cost, increased length of stay, lower odds of discharge to home, and increased odds of death.8 Perhaps the most shocking finding of this study is that the development of an ORADE while inpatient did not seem to change opioid prescribing at discharge; several patients experiencing such events still went home with opioid prescriptions. Hah and colleagues found that prescribing opioids to previously opioid-naive patients after surgery is a risk factor for persistent opioid use [adjusted odds ratio, 4.9 (95% confidence interval, 3.22-7.45)]. An alarming 6% to 10% of opioid-naive patients prescribed opioids after surgery become new persistent opioid users with similar rates between major and minor surgery.9,10 The problem is not just isolated to the United States. A large population database review of nearly 28,000 patients newly prescribed opioids in Ontario, Canada, after short-stay surgery showed that those who received said prescription were 44% more likely to become long-term opioid users at 1-year postop versus those who did not receive opioids at discharge.11 For patients who continue to use opioids within the first 3 months after surgery, surgeons account for most opioid prescriptions, with primary care physicians being a distant second according to Kleuh et al.12 However, for patients still using opioids 9 to 12 months after surgery, that pattern switched, and primary care providers were providing most of the opioid prescriptions. This suggests the need for better persistent opioid use risk screening tools and enriched care coordination and provider-to-provider communication. Hill and colleagues were among the first to bring to light the wide variation and excessive prescribing of opioids after several common general surgery procedures.13 The median number of pills prescribed at their institution, from several hundred patient records, was 20 to 30, but the range went from 0 all the way to 120. Using a postoperative phone survey, they found that just under 30% of the pills prescribed were ever used and only 2% of patients required a refill. They used these data to implement an intervention where routine use of nonsteroidal anti-inflammatory drugs and acetaminophen was encouraged, and prescribers were asked to limit opioid pills at discharge to <20.14 The total number of pills prescribed decreased by 53% and only 0.4% of patients requested a refill. Hill and colleagues then implemented a guideline for discharge prescribing after common general surgery procedures in patients who were opioid naive and had no surgical complications.15 If the patient took no opioids the day before discharge, no prescription was given (41% of patients). If 1 to 3 opioid doses were taken the day before discharge, 15 pills were prescribed (33% of patients). Only 26% of patients took >4 doses the day before discharge and received >15 pills upon discharge. The authors concluded that individualized patient discharge prescriptions on the basis of their utilization rather than standardized prescribing for all is an effective strategy to substantially decrease opioid prescribing while effectively managing pain. Sabatino and colleagues demonstrated that overprescribing was not limited to general surgery but also existed in common orthopedic procedures. They discovered a wide variation in opioid prescribing among the 5 most common orthopedic surgeries (including total hip and knee arthroplasty and lumbar decompression) performed at their institution. The median number of oxycodone 5 mg equivalents prescribed at discharge was 80 to 90 pills, with sizeable ranges from 0 to 300 pills.16 Upon a telephone survey postoperatively, on average, patients had 25 to 30 pills that were unused and only about 40% of the patients reported appropriate disposal of their unused pills. Quantity of opioids prescribed has been strongly correlated with quantity consumed.17 Despite the evolution of minimally invasive surgery techniques and widespread adoption of opioid-sparing strategies such as multimodal analgesia and enhanced recovery after surgery protocols, the average day supply of an opioid prescription has continued to increase over the last several years from 13 in 2006 to 18 in 2017.3 Several studies have used patient surveys to evaluate the actual usage of opioids after discharge versus the quantity prescribed.13,18,19 Invariably, these studies show that 50% to 80% of opioids prescribed go unused and the leftover pills are stored in unsecure locations, making them available for diversion or misuse. Overall, surgery teams prescribe far more opioids than most patients use.5,20 Hence, the American College of Surgeons (ACS) issued discharge opioid prescribing guidelines for 20 of the most common surgical procedures performed (Table 1).21 The median number of opioid tablets recommended was 12.5 for all 20 procedures, with a range of 0 to 20 tablets. The recommendation for most minimally invasive procedures included in these guidelines was 15 tablets or less. The Opioid Prescribing Engagement Network (OPEN) in Michigan also provides evidence-based recommendations on how many oxycodone tablets should be prescribed for specific procedure types ranging from dental extractions to abdominal surgery to total joint replacements and open cardiac procedures (OPEN 2019).22 Of 25 procedures covered, half of them suggest 10 tablets or less and no procedure, with the exception of total knee arthroplasty, suggests >30 tablets. From ORADEs to new persistent opioid abuse, safe consumption of opioids extends beyond the index patient. More than half of prescription drug misusers report obtaining them from a friend or family member.23Table 1: American College of Surgeons recommendations for ideal range of oxycodone 5-mg tablets to prescribe to opioid-naive patients on discharge after undergoing select procedures.21Opioid-sparing multimodal analgesia is now widely used across various surgery types and has been shown universally to decrease MME requirements for both opioid-naive and opioid-tolerant patients. Despite the success of such non–opioid-based therapies while institutionalized, prescribers struggle to translate these protocols and successes to the out-of-hospital arena and often revert to prescribing opioids upon discharge. This strongly suggests that physician behavior, rather than patient condition, is the primary driver of opioid prescribing practices. Brandal and colleagues examined the impact of a Enhanced Recovery After Surgery (ERAS) protocol for colorectal surgery patients at a large institution and found that although the ERAS protocol drastically reduced the MME used while inpatient, the proportion of patients discharged with an opioid prescription remained the same. Their study showed that 70% of patients with a combination of no before-surgery opioid use, low pain scores on the day of discharge, and below average MME use during their stay still received an opioid prescription at discharge.24 Arguably, these are patients who should not be discharged with any opioid prescription. Grace and colleagues, further explored the relationship between the quantity of opioids used in the 24 hours before discharge and the number of opioids prescribed for discharge for a variety of orthopedic surgery procedures. The average amount of opioids consumed in the 24 hours before discharge was 55 OME. Two-thirds of patients received a discharge prescription that allowed twice this amount daily (120 OME) and constituted the "excessive-prescription" cohort. Patients whose discharge prescription matched this daily amount (60 OME) constituted the "approximated-prescription" cohort. At each time point, 0 to 30, 31 to 60, and 61 to 90 days after discharge, the refill rate in the excessive-prescription group exceeded that of the approximated-prescription group.25 The authors concluded that discharge opioid prescriptions that approximated the total daily use in the 24 hours before surgery would curb overprescribing and potentially decrease refill requests. If opioid prescribing is driven by physician behavior rather than by individual patient needs, what information would prescribers need from the patient perspective to change their prescribing practices? Gan and colleagues interviewed patients undergoing major abdominal surgery and asked the patients to make preference and importance decisions using 4 attributes of pain: (1) degree of pain relief, (2) type of side effect, (3) severity of side effect, and (4) route of administration.26 Overall, they found that patients were willing to trade off some pain relief for less severe side effects. In terms of importance to the patient, side effect type and severity outweighed degree of pain control. The survey was repeated pre- and postoperatively to account for actual patient experience. Patient ranking of importance of side effects versus pain control did not change from before to after surgery. The same survey was given to physicians to rank what they believed was most important to the patient. Physicians ranked degree of pain control as the most important attribute and side effects second. Variability between individual prescribers Blay and colleagues carried out a retrospective cohort study of all inpatient discharges for 5 common surgeries from 2015 to 2016 and analyzed the number of tablets and the MME prescribed by attending surgeons, surgical residents, and advanced practice providers.27 Their results yielded a definite variance of prescribing patterns among members of the same surgical team for the same operation at a large academic teaching institution. Surgical residents, irrespective of year or specialty, prescribed a median of 20 tablets and 200 MME for laparoscopic cholecystectomy. This was statistically significantly different from both attending surgeons (30 tablets, 138 MME) and advanced practice providers (60 tablets, 150 MME). For laparoscopic appendectomy, the results were overall similar, but with far more variability among resident level, with senior residents prescribing almost twice as many pills as junior residents. The study concluded that attending surgeons are more likely to prescribe a higher number of pills, but fewer MME compared with surgical residents, but when compared with advanced practice providers, attending surgeons are more likely to order fewer pills and less MME. Despite the limitation of being a single-center study, there is known variation across multiple surgical specialties in terms of opioid prescribing; thus, the results are likely applicable and suggest that a deeper dive into the knowledge and attitudes of different provider types may be useful. Eid and colleagues, reported on the extensive variability in prescribing patterns among members of an acute care surgery service at a large academic teaching institution for the 3 most common surgeries performed: laparoscopic cholecystectomy, laparoscopic appendectomy, and inguinal hernia repair.28 Shockingly, 92.5% of patients were discharged with opioids and only roughly 70% were discharged with nonopioid pain medications. Overall, the number of pills prescribed ranged from 0 to 75 and the MME from 0 to 600. The mean number of pills prescribed was 17 to 20. This study showed a very wide range in the quantity of opioids prescribed and a heavy reliance on opioids instead of nonopioid options for the foundation of pain management. Inadequate education of surgical residents on postoperative pain management and opioid prescribing is a newly identified issue amid scrutinizing opioid prescribing patterns. The postoperative surgical trainee opioid prescribing practices (POST-OPP) survey distributed by the ACS revealed that among 427 survey respondents, only 35% agreed that they had received adequate training in opioid prescribing.29 The survey also revealed that surgical residents who received formal pain management and opioid prescribing training prescribed statistically significantly fewer MME at discharge. Chiu and colleagues assessed what drives surgical resident opioid prescribing practices at another large academic teaching hospital with an anonymous survey of 100 general surgery residents in years 1 to 5.30 Less than 10% of residents surveyed reported receiving any formal training in optimal pain management or in opioid prescribing. Although 60% reported encouraging non-opioid pain control methods, that still leaves 40% who do not even address it (and reported lack of knowledge on how to prescribe them) and use opioids as their foundation of acute pain treatment. Rough estimate MME prescribed for 5 common general surgery procedures ranged from 100 to 215 MME. High MME prescribers averaged 215 MME, whereas low MME prescribers averaged 107. The prevalence of high MME prescribing residents among those who did not receive opioid prescribing education was 3 times higher than residents who did receive such formal education. Attending surgeon or senior resident preference and standard prescribing habit for all patients, irrespective of surgery or individual risk factors, were the 2 most influential factors on resident opioid prescribing. Chiu and colleagues took these data and sought to standardize education on prescribing for postoperative analgesia. Their health system provided surgical resident education, changed the default opioid pill count in electronic medical record order sets, and created a guideline card for recommended postoperative opioid pills by surgery type. A pre- and postintervention study of 14,000 operations showed a 50% reduction in the MME prescribed at discharge without impacting the refill rate (3.3% vs. 3.1%).31 Factors influencing prescribing A large public hospital in an underserved, underinsured area of a major metropolitan area was able to demonstrate 50% reduction in the number of opioid pills prescribed at discharge after implementing standardized training and prescribing guidelines for all surgical staff.32 There was no change in emergency room visits for postoperative pain during the study period. All patients received a foundational regimen of acetaminophen plus a nonsteroidal anti-inflammatory drug and were only given narcotics if they had used them in the 24 hours before discharge. The procedures spanned laparoscopic abdominal procedures, laparotomy, total joint arthroplasty, robotic prostatectomy, and coronary artery bypass grafting and there was no surgery type in which >20 tablets of oxycodone were recommended for discharge. The most comprehensive study to date on interventions to reduce discharge opioid prescribing after surgery comes from Kaafarani et al33 at Massachusetts General Hospital. This study examined MME prescribed before and after intervention across 42 procedures from 11 specialties. The intervention was a multidisciplinary initiative with 4 specific components: (1) patient-focused education on the goal of tolerable pain, not NO pain; (2) staff-focused education including all disciplines that interact with surgical patients; (3) posters for prescribers on non-opioid options and safe opioid disposal; and (4) opioid prescribing guidelines for common surgical procedures. The study included >23,000 patients and scrutinized opioid prescribing by surgical subspecialty and prescriber type. The of the 42 procedures a of 20 oxycodone 5 mg pills and providers were to prescribe less on the basis of individual patient for >20 tablets included surgery discharged within days of surgery, and hernia MME was statistically significantly reduced across all of surgery for MME across all provider types from residents to practice providers to attending surgeons was significantly The of patients discharged without any opioids increased and refill did not increase in the postintervention period. The authors concluded that reduction in opioid prescribing is across multiple surgical disciplines on a large without an increased refill The success of such an intervention upon education of both patient and prescribers and for routine use of nonopioid 1: for optimal pain management at discharge. with to curb opioid prescribing In the last 2 and to curb opioid prescribing have These are in data that show that the of opioids prescribed for acute pain were unused and data from the that suggest that the of continued opioid use at 1 year after the first opioid prescription drastically with day supply of the first opioid prescription The risk of continued opioid use after the fifth day of use and after the day of by day supply per prescription for an opioid-naive patient by or as no opioid within the 90 to Most now have a limitation on day supply of opioids or at another to such The most common limitation is a supply for an opioid prescription to an acute and have the limitation of supply where only be to days with of few have a more with and a supply after surgical procedures. 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Although prescriber and use of the has been shown to decrease and is known about the impact of this or on surgical patients. and colleagues examined over patients in undergoing surgery before and after of They found that did not change the rate of opioid prescribing at discharge for the surgical population before vs. after and colleagues, performed a review of data from nearly procedures at an academic medical in the United States before and after of opioid prescribing and of They found that after the median MME prescribed at discharge decreased by 40% and were across all surgical the for opioids within 30 days after discharge also statistically significantly decreased from the pre- to period. and colleagues examined the impact that day supply had on opioid prescriptions at one large public institution in using nearly of the most common general surgery procedures of this decreased the number of patients discharged with an opioid prescription by decreased the number of prescriptions 3 days by and decreased the mean MME prescribed by They did not an increase in emergency visits within the 30 days after discharge. is within the Prevention that Opioid Recovery and for Patients and and should of decreased patient satisfaction scores to if they reduce opioid prescribing. The public on A within this of pain management questions in health care system surveys the is to of opioid use and of nonopioid pain management protocols and strategies to reduce opioid prescribing interventions aimed at opioid prescribing after surgery are into one of the intervention (1) (2) patient (3) provider education, (4) enhanced electronic health record and multidisciplinary of the supply or the ACS opioid prescribing guidelines has yielded in the quantity of opioids with no in refill or emergency room visits for pain. Several protocols have these or a across multiple surgery and hospital large public in different were able to reduce the number of pills prescribed after general surgery procedures by of the of discharge opioid prescription from physician to surgical at one institution in a decrease in the median amount of oxycodone prescribed by 50% without any impact on or refill in the 10 days after Most of the patients on that surgical were orthopedic, by abdominal surgery. and colleagues found that of guidelines for opioid prescribing after total joint arthroplasty was the factor associated with of 50% reduction in opioid prescribing before versus after Their guideline recommended a of tablets of oxycodone 5 mg or 80 tablets of They were able to their opioid prescribing by roughly 50% with the of this guideline without any increase in refill strategy that has in opioids prescribed at discharge is the default pill on discharge opioid prescriptions or order and colleagues examined the impact of both number of opioids prescribed and opioid education on the quantity of opioids consumed by patients in their surgical They their default pill count from to 30 They then a education on appropriate opioid use and non-opioid pain medications. the default pill count was from to 30, tablets consumed decreased from to and when education was to the tablets consumed decreased even further from to The authors concluded that opioids prescribed with education on appropriate utilization of and to opioids for pain control reduced the number of opioids consumed and created the to surgeons to better for opioid abuse and prescribing practices to optimal for opioid for adverse event using the for opioid abuse and the is into pain by of pain on the basis of surgery type and is over a pain that available and options is opioids to of use is unused at a prescription or other Drug is and colleagues a scoring system to the risk of prescription opioid use after surgery. The After Surgery was created using over patient from from to The risk ranges from 0 to with a of low 31 to and high included in the scoring discharge vs. length of stay procedure vs. and opioid within months The 3 that most on the scoring were opioid use, discharge and low The authors suggest that this scoring be into electronic medical record and be used to at the time of discharge prescribing. practice change for opioid prescribing is a multidisciplinary aimed first and at behavior and change opioid 2 suggests a general to change in any institution discharge opioid prescribing for surgical for implementing opioid prescribing with In the may which patients better to opioids for pain relief and which may be at higher risk for ORADE or may not to opioids for pain relief at of the for and the 1 opioid Patients with or are at a higher risk and may be better with nonopioid Patients with of or should have their opioid doses and patients with or are at the risk of ORADE and Patients with extensive of likely opioid consumption and may be at a higher risk for is to a very where minimally invasive surgery patients are discharged with opioids. This is being at some minimally invasive and robotic surgery practices with no increase in phone emergency room or impact on to opioid-free analgesia regimens, multimodal nonopioid pain management and specific patient education on these routine opioid-free minimally invasive surgery procedures become the new standard rather than the and recommendations to the number of opioids prescribed at discharge to actual versus pain management should be in all surgical should be to that not all opioid pills are created in terms of and using MME would be a more than the number of pills non-opioid pain management strategies for all surgical patients in with individualized prescribing on the basis of actual patient usage and risk for persistent postoperative opioid use or ORADE should be for patient. Perhaps most with the of minimally invasive surgical and multimodal pain management with many patients may not any opioids at discharge. Several studies have shown that opioid prescribing at discharge for surgical patients has not increased refill or emergency room visits for pain. the of unused prescription opioids after surgery that become available for surgery teams should their to the opioid by drastically the number of opioids prescribed for most surgery procedures and be even more than what of The authors that they have to

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