By Bob Kronemyer
A study adhering to a new opioid prescribing guideline in the Journal of the American College of Surgeons found a dramatic decrease in the number of pills prescribed following a broad range of major surgeries, along with a greater than 90% patient satisfaction rate for pain management and the highest compliance rate to date for appropriate disposal of leftover pills.
“We previously showed in 2017, that for mainly outpatient operations, patients were being prescribed more opioids than they used [Ann Surg 2017;265(4):709-714],” said principal investigator Richard Barth Jr., MD, a professor and the chief of general surgery at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H. “Patients used only about one-fourth of their opioids.”
Based on these outcomes, Dr. Barth recommended that surgeons in his group practice decrease prescribed opioids. “This caused patients to start using about only 50% of their opioids, while still very happy with their pain control,” he said.
In another study, Dr. Barth and his colleagues concluded that the best predictor of opioid consumption at home was the amount of opioids that patients took the day before discharge (J Am Coll Surg 2018;226[6]:996-1003).
“The main purpose of the current study was to validate [this] guideline,” Dr. Barth said. “So, it is a very patient-centric guideline. It takes into account the fact that there can be a lot of variability of the pain experience and how much pain individual patients incur, even as a result of the same stimulus.”
The new study (J Am Coll Surg 2021 Jan 30. doi:10.1016/j.jamcollsurg.2020.12.057) enrolled 229 adult patients who were admitted to Dartmouth-Hitchcock Medical Center for at least 48 hours after their initial operation, which ranged from thoracic to urologic surgery, between October 2018 and December 2019.
At discharge, patients received prescriptions for acetaminophen and ibuprofen, as well as opioids, based on the guideline.
Patients who took no opioids, which was calculated as zero oral morphine milligram equivalents (MME), were sent home with five oxycodone 5-mg pill equivalents (PEs) on the day before discharge, whereas patients who used up to 30 MME received 15 PEs and patients who used 30 MME or more received 30 PEs.
The lower the opioid usage was before hospital discharge, the higher was the level of patient satisfaction with pain management: 99% in the zero-MME group, 90% in the intermediate-MME group and 82% in the 30-plus–MME group (P=0.001).
In addition, despite being given an opioid prescription, 73% of the zero-MME group did not use any opioids at home and 85% used two pills or fewer.
“Previous investigators have educated patients about ways to dispose of their pills, but in the best studies only 20% to 30% of patients dispose of their excess pills in a Food and Drug Administration–compliant fashion,” Dr. Barth said. “In contrast, by supplementing education with a reminder phone call and setting up a convenient drop box in the pharmacy next to the surgeon’s office where the patient visits for a postoperative check, we increased disposal compliance to 83%.”
A patient questionnaire also enabled patients to take some responsibility for weaning themselves off opioids.
“I was very pleasantly surprised that we were able to get so many patients to responsibly dispose of their excess opioids,” Dr. Barth said. “But none of our results should come as a surprise to clinicians.”
The three postoperative medication regimens are easy for surgeons to remember and implement across the country, Dr. Barth said, as is the proper disposal of opioids.
“As surgeons, we need to take ownership and responsibility for the opioids we prescribe,” he said. “By doing this, I believe we are going to minimize the number of patients with repeated opioid prescriptions and even potentially with opioid dependence and overdose.”
Maureen Hill, MD, a clinical instructor in surgical oncology at Fox Chase Cancer Center, in Philadelphia, said the study confirms that postoperative opioids can be prescribed in a patient-centered fashion, rather than based on procedure alone.
“I am not surprised by these results, as the authors’ previous data was strong and suggested this finding,” said Dr. Hill, who was not part of the current study. She also said the guideline is applicable to a wide range of surgical patients.
Furthermore, the opioid-dispensing guideline is easy to follow, Dr. Hill said, because it is based solely on patient use within the 24 hours prior to discharge. “This is information that is easily obtained in the medical record,” she said. “The conversion to discharge prescription amount is also simple and will take little additional effort on the [part of the] provider to ensure appropriate prescribing based on the investigators’ algorithm.”
The study’s “great success in ensuring appropriate opioid disposal demonstrates that patient education is key to obtaining this goal,” Dr. Hill said.
Originally published by our sister publication, Pain Medicine News