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Postsurgery guideline could reduce opioid prescriptions by as much as 40 percent

Opioid use the last day in the hospital should determine how many opioid pills surgical patients take once they go home, according to new Journal of American College of Surgeons study

American College of Surgeons

CHICAGO (November 30, 2017): Rising rates of opioid prescriptions have been linked to the opioid epidemic, and a significant number of opioid deaths have been linked to prescriptions written by surgeons. However, new study results suggest that a more vigilant prescribing guideline for surgeons could reduce by as much as 40 percent the number of opioid pills prescribed after operations, and still meet patients' pain management needs. Study findings were published as an "article in press" on the Journal of the American College of Surgeons website ahead of print.

Lead study author Richard J. Barth Jr., MD, and colleagues at Dartmouth Hitchcock Medical Center in Lebanon, NH, have suggested the guideline. "We specifically looked at the number of opioid pills that surgical inpatients took the day before discharge from the hospital, and we found that this number was the strongest predictor of how many opioid pills the patients would use after discharge," Dr. Barth said.

The recommendation does not mean patients won't get enough pills to manage their pain after they leave the hospital. "The guideline was based on satisfying at least 85 percent of patients' home opioid requirement," Dr. Barth said.

The study included 333 hospital inpatients discharged to home after six different types of general surgery operations: bariatric procedures; operations on the stomach, liver, and pancreas; ventral hernia repair; and colon operations. The researchers followed up with the patients after discharge by using questionnaires and phone surveys; 90 percent of the discharged patients completed the follow-up process. The study group did not include any chronic opioid users.

This study represents the first time that specific guidelines have been proposed for prescribing opioids upon discharge after general surgery operations that require inpatient admission. Although some states have adopted laws to curb opioid prescriptions, they are ambiguous. Dr. Barth noted that several New England states limit doctors to prescribing a seven-day supply of opioids, but they include no limits on dosing. "So a seven-day supply could be 84 pills or 21 pills," he said.

The researchers found that patients typically took only a fraction of the opioids prescribed at discharge once they went home. While 85 percent of patients were prescribed an opioid after they went home, only 38 percent of prescribed opioid pills were taken. The study also looked at why a small fraction of patients took more opioids than the new guidelines called for. "Over half of them were taking opioids for non-pain-related reasons, such as to sleep better, or because they felt they should take all the pills the physician prescribed and other various and sundry reasons," Dr. Barth said.

Patients who undergo operations have a higher risk of becoming chronic opioid users than non-surgical patients do, according to previously published research Dr. Barth and his colleagues cited.1-4 Also, unused opioid pills laying around the home contribute to chronic opioid use; 71 percent of chronic opioid users receive their pills through diversionary methods like a relative's unused prescription.4,5

The guideline Dr. Barth and colleagues developed recommends the following schedule for post-discharge prescription based on the number of opioid pills taken the day before discharge: no pills for patients who took no opioids the day before they left the hospital; 15 pills for those who took one to three pills the day before; and 30 pills for those who took four or more pills on their last day in the hospital.

"This guideline was true for multiple different operations," Dr. Barth said. "It didn't matter whether someone had a colon operation, liver procedure or hernia repair; no matter what type of general surgery operation they had, this association held throughout all procedures studied. So the beauty of this finding is that one guideline would apply for multiple different surgical procedures."

A second factor that influenced patient opioid use after surgery was age. "Patients who were older ended up taking fewer opioids than younger patients," he said. Patients younger than age 60 averaged about 13 pills after discharge while those 60 and older averaged four pills.

The increased use of e-prescribing--in which a physician can send an electronic prescription directly to a pharmacy--is another factor that should encourage physicians to write prescriptions for fewer pills after surgery. "With e-prescribing, patients don't have to come back to the clinic if they need more pills," Dr. Barth said.

The guideline has already been adopted at Dr. Barth's institution and can easily be applied at other centers, he said.

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Dr. Barth's study coauthors are Maureen V. Hill, MD; Ryland S. Stucke, MD; Sarah E. Billmeier, MD, MPH; and Julia L. Kelly, MS, all of the department of surgery at Dartmouth Hitchcock Medical Center. Early study results were presented at the New England Surgical Society Annual Meeting, September 2017.

A video summary of study highlights can be viewed at: https://www.youtube.com/watch?v=uH25wIDmzDg

Citation: A Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures. Journal of the American College of Surgeons. Available at: http://www.journalacs.org/article/S1072-7515(17)32055-0/abstract.

1 Sun EC, Carnall BD, Baker LC, et al. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA 2016;176:1286-1293.

2 Alam A, Gomes T, Zheng H, et al. Long term analgesic use after low-risk surgery: A retrospective cohort study. Arch Int Med 2012;172:425-430.

3 Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study. BMJ 2014;348:g1251.

4 Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA 2017;152:e170504-e170504.

5 Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med 2015;372:241-248.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.

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