Opioid Prescribing Too High After Minimally Invasive Surgery
—By David Wild
Las Vegas—Opioid prescribing after minimally invasive surgery (MIS) remains unacceptably high, according to research conducted at the University of California, San Francisco (UCSF). Of nearly 400 MIS patients surveyed, 90% said they were prescribed opioids after surgery, and 13% of these patients asked for a refill as late as three months after the procedure.
The study, which was presented at the 2019 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 7353), demonstrates that despite efforts to tackle opioid prescribing, it remains a problem and can lead to significant hazards for patients.
Solmaz Manuel, MD, an assistant clinical professor in the Department of Anesthesiology and Perioperative Care at UCSF, and her colleagues asked 393 adult patients who underwent ambulatory MIS at UCSF over an eight-month period whether they were prescribed opioids for postoperative pain control and whether they were taking them. The most common procedures were hysterectomy, myomectomy, salpingectomy, oophorectomy, diagnostic laparoscopy, hernia repair and cholecystectomy.
“We had heard anecdotally from numerous patients who had undergone MIS that they were sent home with unnecessary opioid-based pain medications, sometimes even after refusing them in the recovery unit,” Dr. Manuel said.
Those reports were confirmed in 84.7% of patients contacted by phone the day after surgery who responded to their questions. Just over 90% of these individuals said they had been prescribed opioids, and 61% said they were taking them.
Additionally, a follow-up analysis of medical data at 90 days indicated that 13.4% of those prescribed postoperative opioids requested a refill during the postoperative period. A patient’s sex, ASA physical status, type of surgical procedure, duration of surgery and postoperative pain score were associated with opioid prescribing.
Patients who have undergone a cholecystectomy, hernia repair, hysterectomy or myomectomy as well as those who had a peritoneal catheter placed were most likely to report taking a prescribed opioid the day after surgery.
She said the high post-MIS opioid prescribing rates are likely due to a confluence of factors.
“These include patient expectations of an opioid prescription, the inconvenience of prescribing and filling opioid prescriptions after discharge from the hospital,” Dr. Manuel said.
Alternatives to Opioids
“Although this data is from a single center, from my point of view it is probably consistent with national practice and highlights potential short-term opioid abuse, perhaps even addiction, caused by postoperative opioid consumption,” said Andrew Leibowitz, MD, the chair of anesthesiology at Mount Sinai Health System and a professor of anesthesiology and surgery at Icahn School of Medicine at Mount Sinai, in New York City, who was not involved in the study.
Rather than prescribing opioids after MIS, Dr. Leibowitz said patients should receive “generous wound infiltration” with local anesthesia and be instructed to take acetaminophen with or without a nonsteroidal anti-inflammatory drug for at least two days postoperatively.
“In my humble opinion, none of these patients should be prescribed more than five to 10 days of opiates,” he said. “If needed, they can receive another prescription after a follow-up visit.”
He emphasized that unused opioids “are at risk of diversion, in-home abuse or accidental consumption, and problematic safe and nonpolluting disposal.”
Pointing to the number of patients in the study who requested a refill during the 90-day postoperative period, Dr. Leibowitz said that proportion of patients should be “close to zero by 30 days.” He also noted that 39% of patients who were prescribed opioids in the study did not need to take them.
Dr. Manuel said her team is working with UCSF surgeons to design “a simple preoperative educational and expectation management intervention for patients scheduled for ambulatory surgery.”
While they will be cautious not to deny opioids to those who need them, “we do hope to do a better job individualizing our prescribed treatments to their needs.”