Anderson M; Hallway A; Brummett CM; Waljee JF; Englesbe MJ; Howard RA. Patient-Reported Outcomes After Opioid-Sparing Surgery Compared With Standard of Care. JAMA Surgery. Published online 27 January 2021. DOI: 10.1001/jamasurg.2020.5646
- Patients participating in an opioid-sparing postoperative pathway received and used fewer opioids but reported less pain and similar satisfaction compared with patients receiving standard of care.
- In the opioid-sparing pathway, 36.8% of patients did not receive an opioid prescription compared with 0% of patients receiving standard of care.
- Importantly, more patients in the opioid-sparing group received no opioid prescription, which avoids the risk of diversion into communities.
Massie L, Gunaseelan V, Waljee J, Brummett C, Schwalb JM. Relationship between initial opioid prescription size and likelihood of refill after spine surgery. The Spine Journal. Published online 16 January 2021.DOI: https://doi.org/10.1016/j.spinee.2021.01.016
- About 26.3% of opioid-naïve patients obtained refills of their opioid prescriptions within 30 days of surgery.
- The likelihood of obtaining a refill was unchanged with the size of the initial perioperative prescription across procedure categories.
- Patient factors associated with increased likelihood of refills included age 30 to 39 years, female gender, anxiety disorder, mood disorder, and history of alcohol/substance abuse.
- For opioid-naïve patients, surgeons can prescribe lower amounts of opioids after elective surgery for degenerative spinal disease without concern of increased need for refills.
Keller DS, Kenney BC, Harbaugh CM, Waljee JF, Brummett CM. A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery. Surgery. Published Online 4 December 2020. DOI: https://doi.org/10.1016/j.surg.2020.11.006
- Over 2% of ambulatory anorectal procedures develop new persistent opioid use.
- Logistic regression found new persistent opioid use was associated with perioperative opioid fills, increased comorbidity, tobacco use, and pain disorders; there was no significant association with procedure performed.
- Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed.
- This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.
Cho HE, Hu H, Gunaseelan V, Chen J, Englesbe MJ, Chung KC, Waljee JF. Does Surgical Intensity Correlate With Opioid Prescribing? Classifying Common Surgical Procedures. Ann Surg: July 24, 2020. Publish Ahead of Print doi: 10.1097/ SLA.0000000000004299
- Surgical intensity, classified as 5 ordinal clusters – low, mid-low, mid, mid-high, and high, is positively associated with initial opioid prescribing and rates of refill.
- Median amount of opioid prescribed increased as the cluster-order increased: 150 oral morphine equivalents (OME) for low-intensity, 225 OME for mid-intensity, and 300 OME for high-intensity surgeries.
- Rates of refill increased as surgical intensity also increased, from 17.4% for low, 26.4% for mid, and 48.9% for high-intensity procedures.
Finney FT, Gossett TD, Hu HM, et al. Rate of Opioid Prescriptions for Patients With Acute Ankle Sprain. Ann Intern Med. 2019;171(6):441-443. doi:10.7326/M19-0679
- Among opioid naïve patients who did not fill an opioid prescription one year before sprain diagnosis, 8.3% filled an opioid prescription within 7 days of diagnosis, and, in this group, the rate of new, persistent opioid use (filled an opioid prescription 91 to 180 days after diagnosis and initial opioid exposure) was 8.4%.
- The most commonly prescribed opioid was hydrocodone (62.3%), followed by tramadol (15.6%) and oxycodone (11.5%).
- Most prescriptions were provided by physicians (77.4%) and advanced practice providers (18.9%) in emergency medicine and primary care settings.
Howard R, Alameddine M, Klueh M, et al. Spillover Effect of Evidence-Based Postoperative Opioid Prescribing [published correction appears in J Am Coll Surg. 2019 Apr;228(4):720]. J Am Coll Surg. 2018;227(3):374-381. doi:10.1016/j.jamcollsurg.2018.06.007
- After introducing evidence-based prescribing recommendations for laparoscopic cholecystectomy, prescribing decreased for four other surgical procedures, with no significant increase in refill requests.
- Implementing evidence-based prescribing recommendations contributes to increased awareness of safe and appropriate opioid prescribing practices.
Howard R, Fry B, Gunaseelan V, et al. Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan. JAMA Surg. 2019;154(1):e184234. doi:10.1001/jamasurg.2018.4234
- The quantity of opioid prescribed is associated with higher patient-reported opioid consumption, with patients using .5 more pills for every additional pill prescribed.
- The use of patient-reported opioid consumption to improve prescribing practices is key to combating the opioid epidemic.
Cron DC, Hwang C, Hu HM, et al. A statewide comparison of opioid prescribing in teaching versus nonteaching hospitals. Surgery. 2019;165(4):825-831. doi:10.1016/j.surg.2018.10.005
- In Michigan, surgical patients discharged from teaching hospitals fill significantly larger opioid prescriptions and have higher rates of high-risk prescribing compared with patients discharged from nonteaching hospitals.
- All hospitals, particularly teaching hospitals, should devote adequate resources to facilitating safe postoperative opioid prescribing.
Cron DC, Lee JS, Dupree JM, et al. Provider Characteristics Associated With Outpatient Opioid Prescribing After Surgery. Ann Surg. 2020;271(4):680-685. doi:10.1097/SLA.0000000000003013
- Advanced practice providers account for 1-in-5 postoperative opioid prescriptions.
- Postoperative opioid prescriptions written by advanced practice providers are 18% larger than those written by physicians.
- All providers should be involved in postoperative care to understand prescribing practices and identify barriers to reducing prescribing.
Larach DB, Waljee JF, Hu HM, et al. Patterns of Initial Opioid Prescribing to Opioid-Naive Patients. Ann Surg. 2020;271(2):290-295. doi:10.1097/SLA.0000000000002969
- The proportion of initial prescriptions for surgery, emergency, and dental care increased by nearly 16% from 2010 to 2016.
- Dental care prescribing saw the greatest growth, with a 68% increase, while surgical patients received the highest proportion of potent opioids (90.2%).
- Evidence-based guidelines for surgical and dental prescribing are necessary to curb iatrogenic opioid morbidity and mortality.