Wide Variation and Overprescription of Opioids After Elective Surgery

Thiels, Cornelius A.; Anderson, Stephanie S.; Ubl, Daniel S.; Hanson, Kristine T.; Bergquist, Whitney J.; Gray, Richard; Gazelka, Halena M.; Cima, Robert R.; Habermann, Elizabeth B.

doi:10.1097/sla.0000000000002365

Cited by 289 publications

(218 citation statements)

References 22 publications

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“…A number of investigations have demonstrated that surgeons overprescribe opioids at discharge, with wide variations in prescribing practices among providers 197. It is generally accepted that 6% of opioid-naive patients will become chronic opioid users after surgery, while the rate is as high as 21% for those who require chemotherapy after surgery 198 199.…”

Section: Resultsmentioning

confidence: 99%

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Nelson¹,

Bakkum-Gamez

Kalogera

et al. 2019

Int J Gynecol Cancer

479

338

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BackgroundThis is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.MethodsA database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.ResultsAll recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.ConclusionsThe updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

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Section: Resultsmentioning

confidence: 99%

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Nelson¹,

Bakkum-Gamez

Kalogera

et al. 2019

Int J Gynecol Cancer

479

338

View full text Add to dashboard Cite

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“…This is especially the case as the overprescription of this drug class has contributed to the creation of a national crisis in the USA and other parts of the world 27. Non-opioid constituents of multimodal analgesia ideally avoid opioid-related side effects, development of tolerance, and necessity for distribution of outpatient opioid prescriptions.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study

Stundner

Poeran

Ladenhauf

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

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Background and objectivesThe significance of intravenous over oral acetaminophen (APAP) as part of multimodal analgesic protocols is contested, particularly when considering its relatively high price and use in a surgical cohort such as total hip or knee arthroplasty (THA/TKA), which generally tolerates oral medications. This study aims to elucidate APAP’s effectiveness in a large, population-based patient sample.Methods1 039 647 THA/TKA procedures were sampled from the Premier Healthcare claims database 2011–2016. APAP use was categorized by intravenous/oral and use on the day of surgery, postoperative day 1 and thereafter. Outcomes were opioid utilization (in oral morphine equivalents), length and cost of hospitalization, and opioid-related adverse effects (respiratory, gastrointestinal, and naloxone use as a proxy). Mixed-effects models measured the associations between intravenous/oral APAP use and outcomes. Percent (%) change and 95% CIs are reported.ResultsOverall, 23.6% (n=245 454) of patients received intravenous APAP; of these, 56.3% (n=138 180) received just one dose on the day of surgery. After adjustment for relevant covariates, particularly use of >1 dose of intravenous APAP (compared with no use) on postoperative day 1 was associated with −6.0% (CI −7.2% to −4.7%) reduced opioid utilization; this was −10.7% (CI −11.4% to -9.9%) for use of > 1 dose oral APAP on postoperative day 1. Further comparisons regarding other outcomes also favored oral (over intravenous) APAP.ConclusionsThese results do not support the routine use of intravenous APAP in patients undergoing lower joint arthroplasty, especially since oral APAP shows more beneficial outcome patterns.

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“…Thus, the 7 day follow up data has been demonstrated to give a reasonable estimate of overall outpatient opioid use because the majority of patients in the study did not require a refill after mastectomy (refill rate 31.5%) and the time to refill was a mean of 8.38 days (median 7 days). Similarly, a study from Mayo Clinic found that less than 10% of patients undergoing either breast‐conserving surgery or mastectomy required a prescription refill after 30 days from the initial prescription . Lastly, the use of PVB was at the discretion of the surgeon and anesthesiologist.…”

Section: Discussionmentioning

confidence: 99%

“…Although numerous recent publications have examined opioid use after general surgery procedures, which include some breast surgical oncology (BSO) operations, there is a paucity of data examining opioid use for the range of BSO procedures performed . In addition, published research does not address surgeons’ impressions of opioid need after breast surgery, which can be a driver of prescription practice.…”

Section: Introductionmentioning

confidence: 99%

Surgeon perception versus reality: Opioid use after breast cancer surgery

Park

Kyrish

Terrell

et al. 2019

Journal of Surgical Oncology

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Background Few guidelines exist for an opioid prescription after breast surgical oncology (BSO) procedures. We sought to characterize opioid prescribing and use patterns by surgery type. Methods Patients (n = 332) undergoing BSO procedure were surveyed one week postoperatively for opioid use. The surgeons were surveyed about pain management preferences surgery type. CPT codes were collected for 2017 to calculate the amount of opioids used by surgery type relative to surgeon preference. Results Mean oral morphine equivalent (OME) preferred prescription for surgeons who did not tailor prescriptions by surgery type (n = 7, group A) was 177, whereas for those who did tailor (n = 10, group B) varied from 137 to 257 OME. There was a significant difference in opioid use by surgery type: 32 OME for segmental mastectomy (SM) ± sentinel lymph node dissection (SLND), 63 for SM + axillary lymph node dissection (ALND), 76 for total mastectomy (TM) ± SLND, 115 for TM + ALND (P < 0.001). Considering the type of surgeries performed group A prescribers would have 229190 unused OME and group B would have 230826 in 1 year. Conclusion Wide variation in opioid use by BSO procedure type was noted with substantial unused OME regardless ofprescribing preference. Evidence‐based guidelines are needed to tailor analgesic prescriptions according to the need.

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Wide Variation and Overprescription of Opioids After Elective Surgery

Abstract: The majority of patients were overprescribed opioids. Significant prescribing variation exists that was not explained by patient factors. These data will guide practices to optimize opioid prescribing after surgery.

Cited by 289 publications

References 22 publications

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study

Surgeon perception versus reality: Opioid use after breast cancer surgery

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