Opioid Prescribing Patterns, Patient Use, and Postoperative Pain After Hysterectomy for Benign Indications

Abstract

Objective To quantify physician prescribing patterns and patient opioid use in the two weeks after hysterectomy at an academic institution, and determine whether patient factors predict postsurgical opioid use and pain recovery. Methods We conducted a prospective quality initiative study by recruiting all English-speaking patients undergoing hysterectomy for benign, non-obstetric indications at a university hospital between August and December 2015, excluding those with major medical morbidities or substance abuse. Before hysterectomy, patients completed the Fibromyalgia Survey, a validated measure of centralized pain. Following hysterectomy, opioid use (converted to oral morphine equivalents) and pain scores (0–10 numeric rating scale) were collected by a daily diary and a structured telephone interview 14 days after surgery. Primary outcomes were total opioid prescribed and consumed in the 2 weeks after hysterectomy. Secondary outcomes included daily opioid use and daily pain severity for 14 days after hysterectomy. Results Of 103 eligible patients, 102 (99%) agreed to participate, including 44 (43.1%) laparoscopic, 42 (41.2%) vaginal, and 16 (15.7%) abdominal hysterectomies. Telephone surveys were completed on 89 (87%) participants, diaries were returned from 60 (59%) participants. Diary non-responders had different baseline characteristics than non-responders. Median amount of opioid prescribed was 200 oral morphine equivalents (interquartile range (IQR) 150–250). Patients reported using approximately half of the opioids prescribed, with a median excess of 110 morphine equivalents (IQR 40–150). The best fit model of total opioid consumption identified preoperative Fibromyalgia Score, overall body pain, preoperative opioid use, prior endometriosis, abdominal hysterectomy (compared to laparoscopic), and uterine weight as significant predictors. Highest tertile of Fibromyalgia Score was associated with greater daily opioid consumption (13.9 [95% CI 3.0 – 24.8] greater OME at baseline, p=0.02). Conclusion Gynecologists at a large academic medical center prescribe twice the amount of opioids than the average patient uses after hysterectomy. A personalized approach to prescribing opioids for postoperative pain should be considered.

Phenotypic features of central sensitization

“…One might predict that peripherally driven interventions (e.g., surgery) would be less successful in individuals where CS is driving the pain experience. Such a hypothesis is supported by several studies, were higher scores on the PSD scale were associated with greater need for opioids and poorer outcomes following knee and hip arthroplasty and hysterectomy (As-Sanie et al, 2017; Brummett et al, 2015; Janda et al, 2015). …”

“…One might predict that peripherally driven interventions (e.g., surgery) would be less successful in individuals where CS is driving the pain experience. Such a hypothesis is supported by several studies, where higher scores on the PSD scale were associated with greater need for opioids and poorer outcomes following knee and hip arthroplasty and hysterectomy (As-Sanie et al, 2017;Brummett et al, 2015;Janda et al, 2015). MPQ Pain quality and intensity (Melzack, 1987) BPI Pain distribution and intensity (Cleeland, 2009) Pain detect Pain distribution, intensity quality: differentiate nociceptive from neuropathic (Freynhagen, Baron, Gockel, & Tolle, 2006) BDI-II Depressive symptomatology (Beck et al, 1996) CESD-R Depressive symptomatology (Eaton et al, 2004) PHQ -9 Depressive symptomatology (Kroenke et al, 2001) STAI Anxiety symptoms (Spielberger et al, 1983) GAD-7 Anxiety symptoms (Spitzer et al, 2006) HADS Both anxiety and depressive symptoms (Snaith, 2003) PANAS Positive and negative affect (Watson et al, 1988) PROMIS Negative Emotions Negative emotions (Cella et al, 2010) MASQ Perceived cognitive difficulties (Seidenberg et al, 1994) MISCI Perceived cognitive difficulties (Kratz et al, 2015) MFI Fatigue experience (Smets et al, 1995) PROMIS Fatigue Fatigue experience and impact (Cella et al, 2010) Fatigue profile Fatigue experience and impact (Kratz et al, 2016) (Continues)…”

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

“…Pain generated from laparoscopic hysterectomy includes incisional pain, which can be severe initially, but subsides within the first half day; visceral pain, which takes longer (up to a day) to resolve; and shoulder pain, which is milder, typically appears within 24 hours and can last for several days 7. Typical length for use of opioid rescue drugs is approximately 4 days in a recent US study 6. Laparoscopic hysterectomies are increasingly performed as ambulatory procedures,78 emphasizing the need for standardized pain management on discharge.…”

“…The present recommendations take this into account by suggesting a framework of basic analgesic interventions, supplemented by rescue medications, that can serve as a gold standard which can readily be implemented and against the backdrop of which future interventions need to be tested 10. Also, as individualized treatment plans seek to take into account patient-specific factors such as chronic pain,6 or pre-existing opioid therapy,86 our recommendations can serve as the common basis from which to tailor and adapt analgesic plans.…”

Verordnungsprävalenz und -muster von Schmerzmitteln bei Frauen in gynäkologischen Praxen

“…Eine der am häufigsten auftretenden Schmerzarten bei Frauen sind chronische Bekkenschmerzen, die mit Endometriose [11], prämenstruellem Syndrom [12] oder Harnwegsinfekten [13] in Zusammenhang stehen können. In den letzten Jahren ist das Interesse an den Verordnungsmustern von Schmerzmitteln bei Frauen gestiegen [7,[14][15][16][17][18][19][20][21][22][23]. So zeigte beispielsweise eine Studie aus dem Jahr 2017, dass zwischen 25% und 60% der Frauen in Frankreich, Deutschland und Großbritannien solche Arzneimittel verordnet wurden [7].…”