Reducing Use Of Opioids Post-Surgery

New guideline for post-surgery opioid use is based on the number of pills administered to the patient before discharge. The guideline improved patient satisfaction rate with pain management.

After a major surgery, a new prescribing guideline tailored to patients' specific needs reduced the number of opioid pills prescribed. The researchers reported greater than 90 percent patient satisfaction rate with pain management and the highest compliance rate to date with appropriate disposal of leftover pills.

This study is published in Journal of the American College of Surgeons (JACS) and was selected for the 2020 New England Surgical Society Program.

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‘New guideline for post-surgery opioid use are based on the number of pills administered to the patient before discharge. The guideline improved patient satisfaction rate with pain management, compliance rate of appropriate disposal of leftover pills and can decrease opioid addiction.’
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The prescribing guidelines developed by surgeons at the Dartmouth-Hitchcock Medical Center, Lebanon, N.H. is based on the number of opioids pills taken by patients on the day before they are discharged from the hospital.

The study’s lead author J. Barth Jr., MD, FACS, section chief of general surgery, states that the guideline recommend discharging patients with no prescription for opioids if they have taken no opioids on the day before. Accordingly, 15 pills if they have taken one to three pills, and 30 pills if they have had four or more pills.

Dr Barth said that these guideline were designed to satisfy the pain management needs of about 85 percent of patients and showed that the number of opioids taken on a day before discharge was the best predictor of how many opioids patients used after discharge.

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The latest study involved general surgery, colorectal, gynecological, thoracic, and urological operations.

Dr. Barth said, “In this new prospective study we found that 93 percent of patients had their post-surgery opioid needs satisfied. This finding means that this guideline can be used for a wide variety of operations to guide surgeons on how many opioids to prescribe when sending patients home after surgery.”

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Patient’s Pain Perception

This is a prospective study that enrolls patients before they've achieved the study outcome--in this case, an operation and their opioid use afterward--whereas a retrospective study evaluates outcomes after the fact.

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Prescription drug abuse is consuming prescription medications in a way different from that as prescribed by the doctor. It is becoming a colossal health problem which can lead to addiction and even death.

Minimizing opioid use among surgical patients is an important strategy for medicine as studies show that up to 10 percent patients who have undergone surgery, but have not used opioids before, may go on to becomes chronic opioid users.

The Study

The study enrolled 229 patients after their initial operation admitted to the hospital for at least 48 hours. After their discharge the patients were prescribed non-opioid medications acetaminophen and ibuprofen, as well as opioids based on the guideline. The researchers used a protocol different from the post-discharge opioid prescribing guideline:

Patients who were not prescribed opioids- calculated as zero oral morphine milligram equivalents (MME) a day prior to discharge were sent home with five oxycodone 5-mg pill equivalents (PEs)
Patients who were given up to 30 MME received 15 PEs
Patients who were given 30 MME or more received 30 PEs

Lower the use of opioid before discharge, higher was the patient satisfaction with pain management. Even though opioids were prescribed, 73 percent of the zero-MME group used no opioids at home, and 85 percent used two pills or less.

Role of Surgeons

Researchers said that the surgeons play an important role in minimizing opioid use in their patients by setting expectations for pain management. This involves informing the patients that they are likely to be discharged with either no opioids or a small amount based on their opioid use on the day before they go home.

Dr Barth said, “Explain to the patient, 'We've studied this issue; we've figured out how many opioids you are likely to need. The other part of that discussion involves letting patients know that they should expect some pain that our goal isn't to get rid of every last bit of their pain. That was something that surgeons tried to accomplish years ago, but that's not what we're aiming for now. A low level of discomfort is acceptable, and patients need to have that expectation. By prescribing non-opioid analgesics the surgeon sets the expectation that they should be used. It's a big difference if a surgeon prescribes non-opioid analgesics compared with just recommending that a patient take acetaminophen or ibuprofen that they might have at home."

In this study, 95 percent patients took either acetaminophen or ibuprofen and 70 percent took both.

Disposal Rate Of Opioids

A key component in responsible opioid management is proper disposal of unused pills. 60 percent of patients had leftover pills at the end of this study.

Dr Barth said, “We worry about unused pills because those pills could be used by that individual patient and might predispose them for long-term or chronic use. Those excess pills could also be diverted to others and perpetuate opioid misuse in the community."

The researchers used several strategies like educating patients about the potential for opioid misuse and diversion, another strategy was to install a drop box for leftover pills in the institution's pharmacy, located near the surgeons' outpatient offices to encourage patients to properly dispose of leftover pills.

83 percent of patients disposed of their excess opioids using a method that complies with Food and Drug Administration recommendations. Overall, 2,604 pills were prescribed in the study; only 187 of them (7 percent) were kept by patients.

Source-Medindia