Guidelines for Patient-Centered Opioid Prescribing and Optimal FDA-Compliant Disposal of Excess Pills after Inpatient Operation: Prospective Clinical Trial

Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention’s 2016 opioid prescribing guideline

“…In addition, setting a simple limit for opioid prescriptions to surgical patients without the ability to individualize the dosage has been shown to be problematic [ 23 ]. A better approach might be to evaluate pre-discharge inpatient opioid consumption to guide the opioid prescription at discharge [ 24 , 25 ]. Additional studies will be needed to determine the appropriate indications for applying the current CDC opioid guideline to the discharge opioid prescription to surgical patients.…”

A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

“…In the present study, we found that there were nearly twice as many patients receiving zero opioids at discharge in the 5x arm (33.5%) in comparison to the UC arm (18.0%). Although this study did not allow for a direct comparison to other tiered (eg, prescribing 5–15–30 pills depending on which tier of use in last 24 hours) protocols for standardizing postoperative opioid prescriptions, one theoretical benefit of the 5x-multiplier over a tiered system is that for patients weaned to zero before discharge, they are not prescribed any outpatient opioids [ 28 , 29 ]. An "opt-in" strategy, as highlighted in the randomized clinical trial by Zhu et al, found that less than half of the patients undergoing cervical endocrine surgery opted in for opioid prescriptions, and of those who opted out, none required rescue opioid prescriptions, suggesting that patients who do not need opioids at discharge are unlikely to desire them later [ 30 ].…”

“…Although at first glance those numbers may seem disappointing in that they are not 90%, even in a recent prospective trial of a 3-tier discharge prescription model, the compliance for correct prescription volumes was 91% in the lowest opioid users but down to 61% in the highest users (> 30 mg OME in last 24 hours). Thus, our real-world compliance of 58%–72% in a QI study seems reasonable and externally valid [ 28 ]. Lastly, there is a possibility that refill rates were underreported if occasional patients received opioid refills elsewhere (outside of our hospital), although this would be expected to be similar in both arms and is furthermore unlikely because most patients call their original surgeon for postoperative issues including refills.…”

“…Despite these limitations, this study represents a first-of-its-kind, 22-team prospective evaluation of the 5x-multiplier concept across a diverse practice of cancer surgery within a pragmatic QI initiative that did not require mandatory compliance but still yielded dramatic results, validating the feasibility and positive outcomes of using the 5x-multiplier. Additionally, this pragmatic study sets up a potential randomized controlled trial comparing the 5x-multiplier to a 3-tier discharge protocol and/or provider choice (usual care) [ 28 ].…”

Patient-Centered Default Opioid Orders—A Path Forward for Postoperative Opioid Stewardship

“…A recent trial found that, for patients who did not require opioids in the 24 hours prior to discharge, prescribing 5 pills at discharge satisfied the needs of 99% of these patients. 8 It may also be possible to provide more dynamic clinical decision support to generate personalized default postoperative dosages based on a given patient's clinical characteristics and predictive analytics from data sets on postoperative opioid consumption. In the meantime, enacting default options to "right-size" opioid prescriptions to be consistent with patient-reported analgesia needs carries no more risk than ignoring default options that were previously set passively and would likely greatly reduce opioidrelated harms and while minimizing unintended consequences.…”