Opioid Prescribing Recommendations

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Brescia et al. 2020 (Level 1 evidence)

• DOI: https://doi.org/10.1016/j.athoracsur.2020.11.015
• Analyzed data from 1495 patients undergoing primary cardiac surgery via median sternotomy at 10 hospitals from January-December 2019.
• Median prescription size decreased from 20 pills to 12 pills after recommendation.
• Patients using 0 pills before discharge were prescribed 0 pills.
• Patients using 1 to 3 pills before discharge were prescribed 20 pills but used only 7.
• Patients using 4 or more pills before discharge were prescribed 32 pills but used 24.

Wagner et al. 2021 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.athoracsur.2021.10.005
• Analyzed data from 1924 patients undergoing coronary artery bypass grafting and/or valve surgery through a sternotomy at 10 institutions from January-December 2019.
• 47% of patients did not take any opioids on day before discharge and among these patients, 54% did not receive an opioid prescription at time of discharge.
• Patients who received an opioid prescription at discharge used 2.4 ± 3.0 pills on day before discharge while those that did not receive a prescription took 0.2 ± 0.6 pills.

SUPPORTING LITERATURE

Akinbade et al. 2022 (Level 1 evidence)

• DOI: 10.1403/njcp.ncjp_544_18
• RCT with 90 patients undergoing impacted third molar extraction randomized to receive either tramadol or celecoxib.
• Greater pain control and tolerability with celecoxib than with tramadol

Freilich et al. 2020 (Level 3 evidence)

• DOI: 10.1016/j.joms.2020.02.032
• Survey was sent to 118 oral and maxillofacial surgeons and collected self-reported data on opioid prescribing patterns for dental extractions.
• 92% of respondents do not regularly prescribe opioids to their patients; opioids are prescribed regularly in small amounts (8-12 doses) for a select few invasive procedures, such as the placement of 6 or more dental implants.

DATA ANALYSIS

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 609 Opioid Naïve Patients from 55 Michigan Hospitals

SUPPORTING LITERATURE

Haskins et al 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1007/s00464-022-09123-y
• Analyzed data from 17,530 patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018.
• 9652 patients had at least one opioid prescription filled in the perioperative period.
• 0.4% were found to have persistent postoperative opioid use at 365 days postoperatively.
• The risk of progression to persistent postoperative opioid use was less than 1%.
• Persistent postoperative opioid use was most common during the first 30 days.
  

DATA ANALYSIS

Enterolysis – Laparoscopic

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 64 Opioid Naive Patients from 31 Michigan Hospitals

SUPPORTING LITERATURE

Chiem et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1097/pq9.0000000000000548
• 641 patients (3yo-18yo) were assigned to study groups based on time period, and were given either standard anesthesia, multimodal anesthesia, or opioid-free anesthesia for inguinal hernia repair. Pain scores were measured.
• Opioids can be safely minimized without sacrificing satisfaction with pain management. Only 12% of patients required a rescue dose of morphine in PACU.

Hageman et al. 2022 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2022.02.039
• Retrospective review of 15 studies were compared with a retrospective review of patients at the authors’ institution. Opioid use was analyzed.
• Opioids were mostly administered while admitted during the first 24h after surgery. One institution used opioids sparingly in PACU and successfully eliminated opioid prescriptions at discharge.

Svetanoff et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2021.10.012
• Patients were contacted 1-4 weeks after different day surgeries and were surveyed about opioid use. Results between procedure types were compared.
• 89% of inguinal hernia patients filled opioid scripts at discharge, and 91% of those opioids went unused. 94% of patients using non-opioid pain relief methods were satisfied with pain management.

DATA ANALYSIS

Transanal Excision of Rectal Tumor

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 71 Opioid Naive Patients from 19 Michigan Hospitals

SUPPORTING LITERATURE

Swaraup et al. 2018 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jss.2018.04.005
• Analyzed opioid prescribing trends and patient use of opioids for 42 outpatient anorectal operations at a single institution from May 2016-April 2017. Procedures included 6 transanal excision of rectal tumors.
• 90% were prescribed opioids postoperatively with a median of 20 pills (range 0-120 pills)
• For those prescribed an opioid, the median number of pills taken was 4.
• 80% of pills prescribed were not used.
• Most patients had adequate pain control after surgery with little to no use of opioids.
  

DATA ANALYSIS

Thyroidectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 814 Opioid Naive Patients from 57 Michigan Hospitals

SUPPORTING LITERATURE

Lou, I. 2017

• DOI: https://doi.org/10.1245/s10434-017-5781-y
• Annals of surgical oncology
• Analyzed data from patients undergoing thyroid and parathyroid surgery at two large academic institutions from 1 January-30 May 2014.
• 83% of patients took ten or fewer OMEs, and 93% took 20 or fewer OMEs.
  

Shindo et al. 2018

• DOI: 10.1001/jamaoto.2018.2427
• Analyzed data from 1702 individuals who underwent thyroid and parathyroid surgery as a single institution from 1 January 2012-31 December 2017.
• 57.5% were discharged without any opioid prescription for parathyroidectomy, 37.5% for hemithyroidectomy, and 33.3% for total thyroidectomy.
• Recommended prescription = “little, if any, postoperative opioids”

Sada, A. The Journal of surgical research. 2020. (Level 3 Evidence)

• https://doi.org/10.1016/j.jss.2019.07.039
• Analyzed data from patients undergoing parathyroidectomy at three institutions between 13 March 2017 – 19 January 2018
• A total of 91 patients were included; 90% were opioid-naive.
• Median prescribed was 10 pills but median consumed was 0 pills
• Over 50% of patients undergoing parathyroidectomy did not consume any opioid, and very few needed more than 2 doses of opioid.
• Top users reported higher pain scores than standard users
• Of those receiving a prescription, 94.6% had left-over opioids at the time of survey meaning that 82% of prescribed opioids were unused.

DATA ANALYSIS

Laparscopic Appendectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 3887 Opioid Naive Patients from 70 Michigan Hospitals

SUPPORTING LITERATURE

Dr. Robert Bree Collaborative & Agency Medical Directors’ Group (Level 4 evidence)

• Prescribing Opioids for Postoperative Pain — Supplemental Guidance 2018
• Reviewed data collected from academics, pain experts, and practicing surgeons.
• Recommended prescription = 0-12 tablets
  

DATA ANALYSIS

Laparoscopic Cholecystectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 9877 Opioid Naive Patients from 70 Michigan Hospitals

SUPPORTING LITERATURE

Hlavin et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.3390/jcm11185453
• Analyzed data from veterans at the Veteran’s Affairs Pittsburgh Healthcare System (VAPHS) who underwent a cholecystectomy, inguinal hernia repair, or an umbilical hernia repair between November 2019-October 2020
• Recommended opioid prescription for cholecystectomy: 8 pills
• Number of days prescribed = 2.8
  

DATA ANALYSIS

Laparoscopic Colectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 1735 Opioid Naive Patients from 65 Michigan Hospitals

SUPPORTING LITERATURE

Vu et al. 2022 (Level 3 evidence)

• DOI: http://doi.org/10.1097/SLA.0000000000004240
• Retrospective observational study of patients undergoing minimally invasive or open colectomy from January 2017- May 2018. Analyzed data from 562 patients at 43 institutions.
• No difference in opioid consumption or likelihood of using no opioids between open vs minimally invasive colectomy. discharge. The size of the postoperative prescription, patient age, and diagnosis are more important in determining opioid use.
• Age > 65yo and diagnosis of cancer/adenoma were associated with less opioid use
• Patients only used 28% of the opioid tablets prescribed

Nguyen et al. 2019 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jsurg.2019.11.010
• Prospective cohort study of opioid naive patients who underwent general surgery at a single institution between November 2017- February 2018.
• Patients who underwent laparoscopic surgery were prescribed 18.3% fewer MME.
• Smaller prescription amounts were not associated with an increased rate of opioid refills.
• 19.1% of patients who were given a prescription did not fill it and patients were not less likely to fill their prescriptions after opioid counseling.

Bleicher et al. 2021 (Level 3 evidence)

• DOI: http://doi.org/10.1016/j.jss.2021.01.048
• Retrospective study of 596 patients who underwent major abdominal surgery at a single institution. Assessed inpatient opioid use and discharge prescriptions.
• Median length of stay = 3.5 days
• Discharge prescription = 5.1 days
• Lack of patient-centered opioid prescribing led to an over- and under prescribing of opioids for patients.

Eurosurg Collaborative 2019 (Level 3 evidence)

• DOI: 10.1002/bjs.11326
• Cohort study including 4164 patients undergoing elective colorectal resection between January- April 2018
• Mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not
• Mean recovery time for patients receiving NSAIDS = 4-6 days
• Mean recovery time for patients not receiving NSAIDS = 4-8 days
• Conclusion: NSAIDs did not reduce recovery time after colorectal surgery, but they did reduce postoperative opioid requirement.

SUPPORTING LITERATURE

Marti et al. 2021 (Level 2 evidence)

• DOI: https://doi.org/10.3390/jcm11185453
• Retrospective chart review comparing pain management in a historical cohort (control) compared to pain management in a test cohort that used multimodal analgesia
• Multimodal cohort patients had lower pain scores on POD 0, POD 1, and POD 2 compared to historical cohort patients using opioid PCA

Brown et al. 2019 (Level 2 evidence)

• DOI: 10.1308/rcsann.2019.0172
• Analyzed data from 81 patients undergoing laparoscopic living-donor nephrectomy over a 25-month period at a single institution between 17 April 2013 and 20 May 2015.
• All patients up to 8 October 2013 received standard perioperative care while the rest followed an enhanced recovery protocol.
• Standard care = Analgesia provided with six-hourly intravenous paracetamol and patient-controlled morphine administration as required.
• Enhanced recovery = No intravenous fluid was administered. Patients were given a carbohydrate drink and received counseling prior to surgery. Analgesia was six-hourly intravenous paracetamol with oral oxycodone administration for breakthrough pain as required.
• Administered intraoperative fluid volume and time spent in the post-anesthetic care unit was relatively similar between the standard and the enhanced recovery group
• Conclusion: “Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients.”

Dong et al 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jclinane.2022.110751
• Retrospective analysis of 929 laparoscopic donor nephrectomy patients at a single institution from 3 April 2019- 9 June 2020
• Adoption of ERAS protocol led to a significant reduction in intraoperative fentanyl use and a significant increase in intraoperative
  hydromorphone use.
• ERAS protocol = +/− fentanyl 50μg for induction and intubation, hydromorphone 0.4 mg 10 min prior to incision, acetaminophen 1000 mg, ketorolac 30 mg per surgeon if estimated blood loss (EBL) was less than 300 ml and titrate hydromorphone 0.2 to 0.4 mg as needed at conclusion of surgery.
• Saw a significant reduction in opioid use with ERAS protocol, but no change in pain scores

DATA ANALYSIS

Enterostomy Closure – Laparoscopic

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 55 Opioid Naive Patients from 26 Michigan Hospitals

DATA ANALYSIS

Gastrorrhaphy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 66 Opioid Naive Patients from 30 Michigan Hospitals

DATA ANALYSIS

Minor Hernia Repair

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 11473 Opioid Naive Patients from 70 Michigan Hospitals

SUPPORTING LITERATURE

Lindros et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jss.2022.09.021
• Implementation of a patient-tailored opioid prescribing guideline for patients undergoing ventral hernia surgery at a single institution between March 2018-December 2019.
• Assessed opioid utilization and patient reported outcomes of 163 patients
• MME prescribed at discharge was lower for patients receiving guideline-based care (median = 65) than standard care (median = 100)
• The odds of receiving an opioid prescription after discharge did not differ between the groups. Pain scores did not differ
• Conclusion: patients who received tailored guideline prescriptions were discharged with lower dosages and did not require more opioid refills than patients receiving standard opioid prescriptions.
  

Gentle et al. 2022 (Level 3 evidence)

• DOI: https://doi.org/10.1007/s10029-022-02708-5
• Analyzed data from 490 patients who underwent a laparoscopic inguinal hernia repair (LIHR) at a single institution between March 2019- March 2021
• Collected information on opioid prescriptions at discharge and opioid refills
• Median number of tablets prescribed = 12 – 12% of patients were prescribed ≤ 5 tablets, 31% were prescribed 6-10 tablets, 40% 11-15 tablets, and 17% > 15 tablets – 46% of patients reported using 0 tablets after discharge, 70% reported using ≤ 4 tablets, and 84% reported using no more than 10 tablets
• Only 4% requested a refill and there was a 12% increase in odds of opioid refill for every 1 tablet of oxycodone prescribed at discharge
• Recommended prescription: 0-10 tablets
• Conclusion: “Most patients use fewer opioid tablets than prescribed” and “requests for opioid refills are rare following LIHR (4%)”

DATA ANALYSIS

Ileostomy/colostomy Creation, re-siting, or closure

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 379 Opioid Naive Patients from 56 Michigan Hospitals

SUPPORTING LITERATURE

Aryaie et al. 2018 (Level 1 evidence)

• DOI: https://doi.org/10.1007/s00464-018-6062-y
• Randomized study in which 97 patients undergoing colorectal surgery received either IV acetaminophen or placebo in addition to opioid PCA.
• Mean opioid consumption in study group = 2.86 ± 0.24 pills at 24hrs and 4.6 ± 0.44 pills at 48hrs
• Mean opioid consumption in control group = 4.9 ± 0.55 pills at 24 hrs and 7.96 ± 0.9 pills at 48 hrs
• Conclusion: IV acetaminophen helps to reduce opioid consumption for patients undergoing colorectal surgery.

Meyer et al. 2020 (Level 3 evidence)

• DOI: http://doi.org/10.1097/SLA.0000000000005025
• Cohort study of elective colorectal operations at a single institution from September 2019-Febuary 2020. Included 201 patients (100 patients before and 101 after guideline adoption).
• Saw a 41% reduction in mean prescription quantity and 53% reduction in excess pills per prescription.
• Saw no change in opioid consumption or refill rates
• Mean quantity of opioids prescribed after guideline adoption = 10.3 pills
• Mean opioid consumption after guideline adoption = 5.2 pills

DATA ANALYSIS

Pancreatectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 105 Opioid Naive Patients from 20 Michigan Hospitals

SUPPORTING LITERATURE

Kluger et al. 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.hpb.2021.10.021
• Analyzed data from 8325 patients undergoing pancreatomy between 2009-2017
• 35.6% used opioids within the year prior to surgery.
• Median used by opioid naive patients = 53.5 pills
• Median used by chronic opioid patients = 240 pills
• 15.1% of opioid naive patients used opioids, 77.3% of chronic opioid users used opioids, and 27.2% of intermittent users used opioids.
• Those who were prescribed ≥ 200 pills and a ≥ 14-day supply were most at risk of persistent opioid use.
• There was a 2-3 fold increase in anxiety, depression, and substance use disorder between the opioid naive and chronic patients.

Witt et al. 2022 (Level 3 evidence)

• DOI: http://doi.org/10.1002/jhbp.1216
• Analyzed data from 114 patients undergoing open or robotic pancreatectomy at a single institution between March 2019-May 2021
• Robotic PD patients required fewer opioids while maintaining similar pain scores
• Total inpatient opioid use: Robotic PD patients consumed 10.53 while open patients consumed 16.8 pills.
• Discharge prescription for robotic = 0 pills
• Discharge prescription for open = 3.3 pills

Maurer et al. 2021 (Level 2 evidence)

• DOI: http://doi.org/10.1097/SLA.0000000000005042
• Comparison of discharge opioid prescription before and after Enhanced Recovery After Surgery (ERAS) programs.
• Analyzed data from 3,983 patients undergoing hysterectomy between October 2016-November 2020 and pancreatectomy or hepatectomy between April 2017-November 2020 at a single institution.
• Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs.22.0 pills) and lower OME (129.4mg vs. 167.6mg) than pre-ERAS patients.

Kim et al. 2018 (Level 4 evidence)

• DOI: http://doi.org/10.1016/j.yasu.2018.03.002
• Review of pancreatomy analgesics including TAP Infiltration, Intrathecal Analgesia, Epidural Analgesia, Intravenous Patient Controlled Analgesia, and Continuous Infusion through a Wound Catheter.
• Epidural Analgesia (EA) is supported to be the most effective analgesic modality.

SUPPORTING LITERATURE

Hoehn et al. 2019 (Level 2 evidence)

• DOI: https://doi.org/10.1007/s11605-018-04091-y
• Retrospective chart review of opioid use, LOS, complications, and readmissions before and after implementation of ERAS protocol for LSG.
• After ERAS, 52% of LSG patients did not use opioids and 33% did not receive opioids of any kind.

Pardue et al. 2020 (Level 2 evidence)

• DOI: http://doi.org/10.1007/s11695-020-04980-9
• Retrospective cohort study of recovery time, pain scores, and opioid use among LSG patients before and after implementation of opioid-sparing protocol.
• Opioid-sparing protocol reduced recovery time and postoperative opioid use without changed pain scores.

Sapin et al. 2021 (Level 2 evidence)

• DOI: http://doi.org/10.1016/j.soard.2021.04.017
• Retrospective review of LOS, costs, and readmission rates before and after implementation of ERAS protocol for LSG.
• 61% fewer MMEs prescribed after ERAS, and shorter LOS with better patient outcomes.

DATA ANALYSIS

Small bowel resection or Enterolysis-open

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 438 Opioid Naive Patients from 58 Michigan Hospitals

SUPPORTING LITERATURE

Spinelli et al. 2021 (Level 2 evidence)

• DOI: http://doi.org/10.1007/s11605-012-2012-5
• Analyzed data from 90 patients who underwent laparoscopic ileocecal resection at two institutions. Study then compared patients who received an enhanced recover pathway (ERP) to patients who received conventional care
• Mean postoperative and total length of stay were shorter in the ERP group as well as a significantly earlier return of bowel function
• Suggests that “optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.”

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

SUPPORTING LITERATURE

Lee et al. 2019 (Level 2 evidence)

• DOI: http://doi.org/10.1245/s10434-018-6772-3
• Analyzed data from 847 patients who underwent breast or melanoma procedures between June 2016-September 2017 at a single institution.
• Mastectomy or wide local excision for melanoma: mean opioid prescribed = 13 pills
• Lumpectomy or breast biopsy: mean opioid prescribed = 12 pills (oxycodone 5 mg)

DATA ANALYSIS

Laparoscopic Hysterectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 3651 Opioid Naive Patients from 56 Michigan Hospitals

SUPPORTING LITERATURE

DeBlanc et al. 2022 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.ajog.2021.12.114
• Analyzed data from 2,359 individuals who underwent a hysterectomy at a single institution between 1 January 2018-31 October 2019.
• Recommended prescription for abdominal hysterectomy = 7 tablets.
• Recommended prescription for laparoscopic or vaginal hysterectomy = 5 tablets.

SUPPORTING LITERATURE

Bateman et al. 2022 (Level 3 evidence)

• DOI: http://doi.org/10.1097/AOG.0000000000002093
• Analyzed 720 women who had undergone a cesarean delivery at six academic medical centers in the United States from September 2014-March 2016.
• Median number of dispensed opioid tablets = 40.
• Median number of consumed opioid tablets = 20.
• Median leftover opioid tablets = 15.
• 85.4% filled an opioid prescription.

SUPPORTING LITERATURE

Atwood et al. 2021 (Level 3 evidence)

• DOI: http://doi.org/10.1016/j.artd.2020.12.021
• 61 patients undergoing THA were prescribed 84 doses of 5mg oxycodone and were surveyed at 2 weeks and 6 weeks postoperatively regarding consumption.
• At 2 weeks, an average of 28.1 doses were taken. At 6 weeks, an average of 31.9-33.1 doses were taken.

Cunningham et al. 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1186/s13011-021-00410-w
• Descriptive study using a national database to compare perioperative opioid filling volumes and rates in 487,942 patients undergoing primary total hip arthroplasty between 2010-2018.
• Initial opioid filling volume has not changed; however, the overall cumulative opioid filling volume has decreased 26% since 2010.
• States with legislation had larger magnitude of reductions in both initial and cumulative filling volume compared to states without legislation.

Zhao & Davis 2019 (Level 4 evidence)

• DOI: https://doi.org/10.1016/j.ijnurstu.2019.06.010
• Literature review on patient recovery after total hip arthroplasty
• Data collected by 26 September 2017- 12 March 2018 and included 605 articles collected from PubMed, Embase, and CINAHL.
• Non-opioid interventions such as acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, gabapentinoids, ketamine, peripheral nerve blocks, and local infiltration analgesia benefit patients after total hip arthroplasty for pain management.
• Recommend non-opioid interventions for effective pain management following total hip arthroplasty.

Nouraee et al. 2021 (Level 3 evidence)

• DOI: http://doi.org/10.1097/JHQ.0000000000000309
• Analyzed data from 3,142 patients undergoing total hip arthroplasty at five institutions between 23 August 2018- 23 August 2019.
• Mean inpatient opioids prescribed = 48.4 pills. Mean consumed = 27.3 pills
• Mean outpatient opioids prescribed = 40.9 pills. Mean consumed = 19.9 pills

Dattilo et al. 2020 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.arth.2020.04.089
• Retrospective analysis of patients undergoing total hip and total knee arthroplasty at a single institution between October 2017- August 2019
• (THA) Mean opioids consumed by opioid naive patients = 17 ± 15 pills.
• Postoperative prescription of 45 pills was sufficient for nearly 90% of THA patients.
• THA patients consumed less opioids and for a shorter duration than TKA patients.
  

Roberts et al. 2020 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.arth.2019.08.036
• Analyzed data from 723 opioid-naive patients at 7 hospitals in Michigan who underwent TKA (426 patients) and THA (297 patients). Patients were contacted within 3 months after surgery.
• Mean OME prescribed for TKA = 632mg. Mean consumed = 416mg.
• Mean OME prescribed for THA = 584mg. Mean consumed = 285mg.
• Recommended postoperative prescription = 50 pills for TKA and 30 pills for THA.

Tollemar et al. 2022 (Level 3 evidence)

• DOI: 10.1016/j.arth.2022.10.038
• Retrospective analysis of 120,889 opioid-naive patients who underwent THA and TKA between Jan 2015 and Nov 2019 and looked at prescription fill rates. – 30-day prescription fill rate for TKA = 59.6%
• 30-day prescription fill rate for THA = 26.1% – Odds of refill decreased by 2% (for THA) and 3% (for TKA) for every 75 OME added to the initial prescription (marginal increase that supports prescribing smaller amounts due to the small risk of needing refills)

Hannon et al. 2019 (Level 1 Evidence)

• DOI: 10.1016/j.arth.2019.01.065
• RCT prescribing either 30 (161 patients) or 90 (143 patients) 5mg OxyIR pills at discharge after undergoing THA and TKA.
• No difference in MME consumed at 90 days. No difference in pain scores at 30 days or outcome scores at 6 weeks.

MARCQI 2020 (Level 4 Evidence)

• marcqi.org
• Discuss alternatives and opioid-weaning strategies with patients
• Avoid prescribing benzodiazepines with opioids, only prescribe one opioid at a time, and prescribe naloxone for high-risk patients
• Initial prescriptions should be less than 240 OME (for THA) or 320 OME (for TKA). Supplement with acetaminophen.

SUPPORTING LITERATURE

Thompson et al., 2022 (Level 4 evidence)

• DOI: http://doi.org/10.1177/23259671211009263
• Analyzed data from 168 patients undergoing ACLR, knee arthroscopies, or arthroscopic rotator cuff repairs over a 17-month period between June 2017- November 2018 performed at a single institution.
• Mean opioid consumption for knee arthroscopies was 7.2 ± 5.4.
• Patients consumed 47% of opioids prescribed (prescribed 15, consumed 7 on average).
• Recommended postoperative prescription = 10 pills.

Gazendam et al., 2022 (Level 1)

• DOI: http://doi.org/10.1001/jama.2022.16844
• Analyzed data from 200 patients undergoing outpatient arthroscopic shoulder or knee surgery from March 2021-March 2022 performed at 3 clinical institutions in Canada.
• Patients in opioid-sparing group for knee arthroscopies consumed 0-8 pills.
• Mean OMEs consumed in opioid-sparing group for knee arthroscopies was 8.4 mg.

Nouraee et al. 2021 (Level 3 evidence)

• DOI: http://doi.org/10.1097/JHQ.0000000000000309
• Analyzed data from 5,084 patients undergoing total knee arthroplasty at five institutions between 23 August 2018- 23 August 2019.
• Mean inpatient opioids prescribed = 56.6 pills. Mean consumed = 39.9 pills.
• Mean outpatient opioids prescribed = 49.3 pills. Mean consumed = 33.4 pills.

Roberts et al. 2020 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.arth.2019.08.036
• Analyzed data from 723 opioid-naive patients at 7 hospitals in Michigan who underwent TKA (426 patients) and THA (297 patients). Patients were contacted within 3 months after surgery.
• Mean OME prescribed for TKA = 632mg. Mean consumed = 416mg.
• Mean OME prescribed for THA = 584mg. Mean consumed = 285mg.
• Recommended postoperative prescription = 50 pills for TKA and 30 pills for THA.

Tollemar et al. 2022 (Level 3 evidence)

• DOI: 10.1016/j.arth.2022.10.038
• Retrospective analysis of 120,889 opioid-naive patients who underwent THA and TKA between Jan 2015 and Nov 2019 and looked at prescription fill rates. – 30-day prescription fill rate for TKA = 59.6%
• 30-day prescription fill rate for THA = 26.1% – Odds of refill decreased by 2% (for THA) and 3% (for TKA) for every 75 OME added to the initial prescription (marginal increase that supports prescribing smaller amounts due to the small risk of needing refills)

Hannon et al. 2019 (Level 1 Evidence)

• DOI: 10.1016/j.arth.2019.01.065
• RCT prescribing either 30 (161 patients) or 90 (143 patients) 5mg OxyIR pills at discharge after undergoing THA and TKA.
• No difference in MME consumed at 90 days. No difference in pain scores at 30 days or outcome scores at 6 weeks.

MARCQI 2020 (Level 4 Evidence)

• marcqi.org
• Discuss alternatives and opioid-weaning strategies with patients
• Avoid prescribing benzodiazepines with opioids, only prescribe one opioid at a time, and prescribe naloxone for high-risk patients
• Initial prescriptions should be less than 240 OME (for THA) or 320 OME (for TKA). Supplement with acetaminophen.

SUPPORTING LITERATURE

Shah et al. 2020 (Level 2 evidence)

• https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0140
• MUSIC collaborative. Monitored opioid use and consumption patterns among patients undergoing robotic prostatectomy beginning in May 2018
• Before implementation of pain-control optimization pathway (MPROP), 64% of opioids were unused by patients
• Pathway targets all phases of care: preoperative, intraoperative and hospital course, discharge, and 30 days after the procedure
• After implementation, 33% of opioids were left unused by patients
• Preoperative incudes extensive counseling regarding postoperative pain control
• Intraoperative and hospital course includes oral and IV narcotic medications administered on an as-needed basis
• At discharge, patients are given a prescription for ≤6 tablets and strict instructions to only use for severe, breakthrough pain

DATA ANALYSIS

Carotid Endarterectomy

• Patient Reported Outcomes data collected via Michigan Surgical Quality Collaborative
• January 1, 2018 – October 31, 2021
• 94 Opioid Naive Patients from 19 Michigan Hospitals

SUPPORTING LITERATURE

Balceniuk et al. 2019 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.avsg.2019.08.070
• Retrospective review of opioid prescribing and consumption following CEA and TCAR.
• 79% of opioids prescribed for carotid revascularization were not consumed.

Gifford et al. 2020 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jvs.2019.05.068
• Retrospective review of prescribing patterns following various vascular procedures.
• Overall median MME prescribed across 9 vascular procedures was 0 MME. CEA among the lowest with an individual median of 0 MME.

SUPPORTING LITERATURE

Viitanen et al. 2003 (Level 1 evidence)

• DOI: http://doi.org/10.1093/bja/aeg196
• Randomized controlled trial with 160 children (1yo-6yo) undergoing adenoidectomy were randomized to receive one of the following rectal medications: acetaminophen; ibuprofen; acetaminophen with ibuprofen; or placebo.
• Intraoperative use of rectal acetaminophen and ibuprofen reduces need for oral analgesia after discharge.

Alghamdi et al. 2020 (Level 3 evidence)

• DOI: http://doi.org/10.2147/JPR.S281275
• 10 patients (3yo-8yo) were given opioid-free anesthesia for adenoidectomy and pain scores were measured.
• Opioids can be safely eliminated without sacrificing satisfaction with pain management.

SUPPORTING LITERATURE

Kelley-Quon et al. 2022 (Level 2 evidence)

• DOI: http://doi.org/10.1097/XCS.0000000000000056
• Analyzed data from 1,524 children who underwent appendectomy at 10 institutions from January-December 2019.
• Opioid prescribing can be minimized using institutional protocols.
• After intervention, overall prescribing decreased from 18.2% to 4% and mean pain satisfaction scores were high.

Cina et al. 2022 (Level 2 evidence)

• DOI: http://doi.org/10.1016/j.jpedsurg.2022.04.019
• Retrospective study of appendectomy patients (average age 11yo) and opioid prescribing/consumption patterns.
• Analyzed data from 1,789 pediatric patients who underwent an appendectomy at a single institution between January 2014-December 2017.
• Older age, previous opioid exposure, and shorter hospital stay are all associated with increased risks of chronic opioid use.

Creamer et al. 2020 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2020.09.067
• Retrospective study of appendectomy patients (median ge of 10yo) and pain scores, opioid exposure, and discharge opioid prescribing habits.
• Analyzed data from 258 pediatric patients who underwent an appendectomy at a single institution between 1 April- 31 December 2018.
• Post-guidelines there was a significant decrease in the number of doses of opioids, length of hospitalization, and days of opioid exposure.
• Number of doses pre-guideline = 0-26.
• Number of doses post-guideline = 0-11.

Manworren et al. 2021 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.pmn.2021.02.011
• Prospective exploratory and descriptive study of appendectomy patients.
• Analyzed data from 96 pediatric patients (mean age of 14yo) who underwent a laparoscopic appendectomy at a single institution
• Prescribed 16 ± 6.5 opioid pills to treat pain at home. Patients used 6.6 ± 6.3 pills by pill count but self-reported 5.6 ± 5.1 pills.
• Of the 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills (92%) were dispensed, 167.5 (22.4%)
  were used for the reason prescribed, 488 (65.2%) were returned to families for disposal, and 53.5 (7.1%) were missing.

SUPPORTING LITERATURE

Chung et al. 2018 (Level 3 evidence)

• DOI: 10.1542/peds.2017-2156
• Retrospective cohort study that analyzed the prevalence of and indications for outpatient opioid prescriptions and the incidence of opioid-related adverse events in children undergoing dental extraction at a single institution between 1999-2014.
• 1362503 outpatient opioid prescriptions; The annual mean prevalence of opioid prescriptions was 15%
• 437 cases of opioid-related adverse events confirmed by medical record review; 88.6% were related to the child’s prescription and 71.2% had no recorded evidence of deviation from the prescribed regimen.
• Adverse events increased with age and higher opioid dose. Adverse events accounted for 38.3% of prescriptions.

Chua et al. 2021 (Level 3 evidence)

• DOI:10.1016/j.amepre.2021.02.008.
• Used IBM MarketScan Dental, Commercial, and Medicaid Multi-State Databases to analyze data from privately and publicly insured patients aged 13–64 years who underwent a dental extraction between 2011-2018. Included 8,544,098 procedures among 5,562,589 unique patients.
• When ≥1 initial prescription did occur the 90-day risk of overdose was 5.8 per 10,000 procedures and the 90-day risk of overdose in a family member was 1.7 per 10,000 procedures.
• When ≥1 initial prescription did not occur, the 90-day risk of overdose was 2.2 per 10,000 procedures and the 90-day risk of overdose in a family member was 1.0 per 10,000 procedures.

Moore & Hersh 2013 (Level 4 evidence)

• DOI:10.14219/jada.archive.2013.0207
• Systematic review to determine the safety and analgesic efficacy of combining ibuprofen and N-acetyl-p-aminophenol (APAP).
• Found that ibuprofen and APAP may be a more effective analgesic with fewer side-effects than current treatments for third molar extractions.
• Number of doses of ibuprofen + APAP to treat pain = 1.6
  

SUPPORTING LITERATURE

Chiem et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1097/pq9.0000000000000548
• 641 patients (3yo-18yo) were assigned to study groups based on time period, and were given either standard anesthesia, multimodal anesthesia, or opioid-free anesthesia for inguinal hernia repair. Pain scores were measured.
• Opioids can be safely minimized without sacrificing satisfaction with pain management. Only 12% of patients required a rescue dose of morphine in PACU.

Hageman et al. 2022 (Level 3 evidence)

• DOI: 0.1016/j.jpedsurg.2022.02.039
• Retrospective review of 15 studies were compared with a retrospective review of patients at the authors’ institution. Opioid use was analyzed.
• Opioids were mostly administered while admitted during the first 24h after surgery. One institution used opioids sparingly in PACU and successfully eliminated opioid prescriptions at discharge.

Svetanoff et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2021.10.012
• Patients were contacted 1-4 weeks after different day surgery and were surveyed about opioid use. Results between procedure types were compared.
• 89% of inguinal hernia patients filled opioid scripts at discharge, and 91% of those opioids went unused. 94% of patients using non-opioid pain relief methods were satisfied with pain management.

SUPPORTING LITERATURE

Slater et al. 2022 (Level 2 evidence)

• DOI: https://doi.org/10.1016/j.jpedsurg.2021.08.004
• Opioid education was administered to providers, and opioid prescribing data was collected before and after the education was administered.
• There was a significant and sustainable decrease in opioid prescribing (75.8% vs. 22.8% of patients) after administering opioid education to providers.
  

DATA ANALYSIS

• Patient Reported Outcomes data collected via OPEN
• January 1, 2021 – December 31, 2021
• 114 patients from Michigan Medicine
• Age: 8 months to 16 years (median 1.7 years)

SUPPORTING LITERATURE

Koo et al. 2020 ( Level 4 evidence)

• DOI: 10.1097/JU.0000000000000514
• 15-member multidisciplinary expert panel used a 3-step modified Delphi method to develop recommendations for postoperative opioid prescribing. Recommendations were for opioid naive patients without chronic pain conditions and included 16 endourological and minimally invasive urological procedures.
• Recommended prescription = 0-15 tablets
• Supports contextualizing postoperative pain management with patient goals and preferences and maximizing nonopioid therapies.

Grau et al. 2019 (Level 2 evidence)

• DOI: 10.1097/JU.0000000000000020
• Assessed the impact of a 2-phase Plan-Do-Study-Act cycle to decrease opioid prescriptions following pediatric urological surgery.
• Analyzed data pertaining to opioid dosing and pain scores. Included 25 children at a single institution from 2016-2017.
• No significant differences were found between pain scores in the 5-dose group (31 patients) and the 10-dose group (24 patients).
• Previous recommendation = 10 doses over 5 days
• New recommended prescription = 0-2 doses

Corona et al. 2019 (Level 3 evidence)

• DOI: https://doi.org/10.1016/j.jpurol.2021.01.008
• Evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major institutions (Michigan Medicine & University of Wisconsin) between 2016-2017.
• Included 811 circumcisions and 883 inguinal surgeries.
• Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery.
• 95.4% of patients received an opioid prescription, 75% of whom received a prescription for 15 doses or more
• Median number of doses prescribed for circumcision = 20
• Younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed.