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Striving for Evidence-Based Postoperative Opioid Prescribing While Optimizing Perioperative Pain Management—Shifting to Conservative Prescribing

Year: 2018

Type: article

Abstract: The study by Mark et al 1 presents the findings of a case-control cohort study of gynecologic oncology patients receiving ambulatory or minimally invasive surgery highlighting the effects of an ultrarestrictive opioid prescription protocol (UROPP).All patients receiving ambulatory or minimally invasive surgery were not prescribed opioids at hospital discharge unless they required more than 5 doses of oral or intravenous opioids in the 24 hours prior to discharge.Patients receiving laparotomy were prescribed either a 3-or 6-day supply of opioids at discharge based on whether they similarly required more than 5 opioid doses in the 24 hours prior to discharge.Overall, there were significant decreases in the mean number of opioid tablets prescribed at discharge comparing cases with controls after laparotomy (12.1 vs 43.6 tablets; P < .001),after major laparoscopic or robotic operations (1.3 vs 38.4 tablets; P < .001),and after ambulatory surgery (0.2 vs 13.9 tablets; P < .001).In the context of an overall 89% reduction in dispensed opioids, the UROPP did not increase the number of refill requests within the first 30 days, postoperative visit pain scores in the first 2 weeks, or postoperative complications.The authors described a promising strategy for markedly decreasing postoperative opioid prescribing without increasing pain.These actions greatly limit the potential for diversion and opioid misuse that can result from opioid overprescribing.In the context of the current opioid crisis, much attention is likely to be focused on the opioid prescribing aspects of the protocol.However, it is important to emphasize that the protocol encompasses more than personalized opioid prescribing.Patients received preoperative counseling related to postoperative pain management including discharge opioid prescribing per the protocol, opioid adverse effects, and nonopioid pain management strategies.Setting up expectations is likely to play a key role in improving postoperative outcomes.All patients participated in the enhanced recovery after surgery program for inpatient pain management (acetaminophen, gabapentin, cyclooxygenase-2 inhibitors preoperatively, and consideration of regional anesthesia).In addition, all patients were prescribed a 7-day supply of ibuprofen and acetaminophen at discharge.Successful implementation of ultrarestrictive opioid prescribing should only be carefully considered in the context of these other key components.There is wide variation in the use of multimodal analgesia protocols nationwide, 2 and nonopioid pain management must be optimized to minimize opioid prescribing at discharge.With increasing regulations across the country limiting opioid prescribing for acute pain, these study results show the feasibility and safety of an approach to address these regulations for gynecologic oncology patients.It is equally important to emphasize that 22 patients (3.5%) following UROPP implementation were removed from the analysis owing to protocol deviations.These cases involved larger excisions and patients with chronic opioid use prior to surgery.Chronic opioid users included in the analysis reverted back to baseline use within 30 days after surgery.It is unclear whether chronic opioid users excluded from the analysis had higher baseline levels of use, higher postoperative needs, or preoperative opioid tolerance that resulted in a protocol deviation.Preoperative opioid use was associated with increased mortality, 3 morbidity, and postoperative health care use 4 and research is needed to understand the effect of ultrarestrictive opioid prescribing in this high-risk cohort.With implementation of more restrictive opioid prescribing practices, it is important to fine-tune protocols +

Source: JAMA Network Open

DOI: 10.1001/jamanetworkopen.2018.5432

Author: Jennifer M. Hah

Institutions: Stanford Medicine, Stanford University

Language: English

Topic: Opioid Use Disorder Treatment

Subfield: Public Health, Environmental and Occupational Health

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $3,000