By Sherree Geyer

Evidence-based prescribing guidelines reduced postoperative opioid consumption for nine general surgeries by roughly 30%, according to primary outcomes reported in a research letter in The New England Journal of Medicine (2019;381[7]:680-682).

Researchers at the University of Michigan (UM) analyzed data from 11,716 patients at 43 state hospitals to find mean prescription size fell from approximately 26 to 18 pills and opioid consumption from roughly 12 to nine pills between February 2017 and May 2018. Prescription size decreased by -1.3 pills per month after the guideline release, compared with -0.5 before, states the letter, a collaboration between the Michigan Surgical Quality Collaborative (MSQC) and Michigan Opioid Prescribing Engagement Network (Michigan-OPEN).

“Michigan-OPEN provided the aim of the project and Michigan Surgical the population,” said lead author Joceline Vu, MD, a general surgery resident at UM in Ann Arbor. “We’re surgeons and we touch people with opioids by prescribing them after surgery. A lot of the time, we give them that first exposure to opioids.

“We wanted to find out if these guidelines would make a difference in the way patients behave and found they worked. We kept following up and saw the numbers decrease as soon as we implemented those guidelines. We believe they were adopted by doctors, physician assistants and nurse practitioners across the state,” she added.

The letter attributed the decrease to “patients anchoring and adjusting their expectations for opioid use to smaller prescriptions. Despite the reductions in prescription size and opioid use, no clinically important changes in satisfaction or pain scores were observed,” it stated.


Michael Englesbe, MD, MSQC, the program director and a UM professor, added that, “anchoring and adjustment is the phenomenon we all experience regarding how much of something to utilize. Our work shows no relationship between patient-reported outcomes, such as pain scores, and the number of pills patients are given. This is likely related to the significant overprescribing we were all doing as surgeons.

“Patients need the best care,” he said. “This includes education and setting expectations as well as the right medications. When you tell patients the average patient takes four pills for a certain operation, it helps them manage their expectations and reduce opioid consumption following surgery,” he said.

Dr. Vu called “setting expectations” key to pain management. “Surgery’s not going to be pain-free, but we’re here for you. Lean on [acetaminophen and ibuprofen (Tylenol and Motrin, Johnson & Johnson)] first, and then we can give you opioids if we have to,” suggested Dr. Vu, who believes providers in other states should adopt the Michigan postsurgical guidelines.


“A patient in Nebraska is similar to a patient in Michigan and Florida. You probably don’t need to duplicate the work we’re doing. What are we writing for patients with gallbladder surgery? Use our guidelines and see if their behavior changes,” she said.

“Evidence-based guidelines are a move towards better pain care for the vast majority of patients,” Dr. Englesbe said. “For providers, this information offers evidence to help them better care for their patients. Presumably, these patients will be at lower risk of new chronic opiate use and addiction, though our research has not specifically shown that yet.”