American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Feature: Management of Postoperative Pain to Minimize Opioid Misuse

As the opioid crisis emerged during the early 2000s, concerns about the risk of dependence initially focused on patients taking the drugs for chronic pain. More recently, however, it has become clear that postoperative opioid prescribing comes with some risk of misuse as well.

Researchers have found widespread over-prescription of opioids to postoperative patients, raising concerns that large numbers of leftover pills are in danger of misuse. They have also discovered that some surgical patients do become chronic opioid users. A 2017 analysis of insurance claims data in JAMA Surgery found that roughly 6 percent of patients filled an opioid prescription more than 90 days after a surgical procedure.1 The fraction of those patients who go on to misuse opioids remains unknown.

“If the number is even 1 percent, in my opinion that’s too many. If we as a system are creating a problem 1 percent of the time in something that we’re doing a million times a year, then we have a responsibility to do better,” said Jonah Stulberg, MD, PhD, MPH, Assistant Professor of Surgery, Northwestern Memorial Hospital, Chicago.

At the 2018 Clinical Congress, he and others will considered current opioid prescription patterns and discussed strategies to minimize excessive use of the opioids while continuing to provide adequate pain treatment to patients who need it.

“Surgeons prescribe about 10 percent of all narcotics in the country,” said Cornelius Thiels, DO, MBA, General Surgery Resident, Mayo Clinic, Rochester, MN. “We should be giving out the right amount.”

Prescribing Practices

As co-moderator of a panel Thursday on opioid-sparing practices for special patient populations, Dr. Thiels will discuss an analysis of 7,651 patients that he and colleagues published in the October 2017 Annals of Surgery, which concluded that nearly all were overprescribed opiates at discharge.2 The patients, treated from 2013 to 2015 at three academic medical centers in Minnesota, Arizona and Florida, received a median of 375 oral morphine equivalents, or nearly 50 five-milligram oxycodone tablets.

Several Clinical Congress presentations document similar overprescribing. The Michigan Opioid Prescribing Engagement Network found that in 2015–2016 the average oral morphine equivalent prescribed to patients following six common surgical procedures exceeded recommended amounts roughly threefold. In systematic reviews at the University of North Carolina, eleven patients undergoing radical cystectomy received on average 34 tablets of 5 mg oxycodone at discharge and took only 12, while 264 patients who underwent urologic procedures consumed only about half of their initial prescriptions.

Research presented at the 2018 Clinical Congress also indicates that postoperative prescribing practices can have an effect on the rate of long-term opioid use. A study by researchers from Harvard Medical School, for example, found that among 2,097 opiate-naïve patients treated from 2002 and 2015, those who received larger initial supplies of opioids were more likely to engage in long-term use and doctor shopping four to six months later.

The risk of long-term opioid use varies by procedure, however, with some producing higher rates. A comparison of 200 patients who underwent either unilateral inguinal hernia repair, laparoscopic cholecystectomy or laparoscopic appendectomy at two public hospitals in Chicago between July 2015 and December 2017 found that those recovering from hernia repair were almost twice as likely as average to refill their opioid prescriptions. A hospital network database analysis of 3,720 burn injuries between 2012 and 2017 found that 4.7 percent of opioid-naïve patients had been diagnosed with either chronic opioid use or opioid use disorder one year after injury, about 10 times the rate observed across all surgical patients.

“Any type of surgery, small or large, can put a patient at risk of long-term opioid dependence, and that’s a complication—you should 100 percent recover from that in theory, and if you go into long-term opioid dependence then you didn’t 100 percent recover and we didn’t do our job right,” Dr. Thiels said.

ERAS Protocols

To reduce the risk of opioid dependence, institutions have turned to enhanced recovery protocols that reduce or eliminate use of opioids in pain management.

“People who were already doing or were interested in enhanced recovery protocols are pulling out components relating to pain and showing how those are effective or ineffective,” said Dr. Stulberg, who is moderating a panel session at Clinical Congress entitled “Opioid-Sparing Practices in Surgery: Acute Management of Postoperative Surgical Pain.”

At the 2018 Clinical Congress, several groups report the results of such studies. Northwell Health in Great Neck, New York, found that adopting an enhanced recovery after surgery (ERAS™) protocol reduced average opioid use from 91.77 to 54.52 morphine equivalents. A review that compared pediatric patients undergoing elective colorectal procedures at Children’s Healthcare of Atlanta found that after the institution of an ERAS protocol, the percentage of patients receiving an opioid prescription after discharge fell from 64.6 percent to 34.3 percent. And an ERAS protocol at Cleveland Clinic Akron General in Akron, Ohio, demonstrated that the goal of opioid-free surgery is achievable; of 140 opioid-naïve patients undergoing colon resection with anastomosis, 119 did not require postoperative narcotics. The Akron hospital’s protocol uses a multimodal analgesic approach that employed patient education, preemptive analgesia, ketamine-based non-opioid general anesthesia, modified liposomal bupivacaine nerve blocks and postoperative programmed non-narcotic analgesics.

Patient Satisfaction

Moreover, such protocols do not appear to increase pain scores or reduce patient satisfaction. A study at Louisiana State University Health Sciences Center, New Orleans, LA, evaluated a pain management regimen for mastectomy that excluded opioids, using a nerve block with liposomal bupivacaine and IV ketorolac and sending patients home with prescriptions for acetaminophen with codeine. Only three of 72 patients returned to the emergency department within 30 days complaining of pain, and none had to be readmitted.

Researchers at Guthrie Clinic, Sayre, PA surveyed 121 patients who underwent thyroidectomy and/or parathyroidectomy and were treated postoperatively with acetaminophen and ibuprofen. On follow up at 7–10 days, all but two reported adequate pain control and did not require an oral opioid/narcotic prescription. Similarly, a study of prescription data for 788 patients undergoing laparoscopic cholecystectomy and appendectomy in the 28-hospital Michigan Surgical Quality Collaborative found no difference in reported patient satisfaction 30 days postprocedure whether patients were prescribed 0–10, 10–20 or more than 20 five-milligram oxycodone tablets (or equivalent).

However, surgeons should resist pressure to eliminate opioid indiscriminately, Dr. Thiel said. In a September 2018 Annals of Surgery paper, he and colleagues describe how they used a comprehensive survey of 3,412 patients undergoing 25 procedures to develop postoperative opioid prescribing guidelines for the Mayo Clinic that gives surgeons flexibility to prescribe narcotics when justified.3 The guidelines, instituted in February 2018, have dramatically reduced opioid prescriptions without negatively influencing patient satisfaction.

“Our goal has been to do this in an evidence-based, patient-centered way, but that’s not the approach the rest of the country outside of medicine is taking unfortunately. The government and insurance companies have taken the one-size-fits-all, regulation approach and that worries us,” Dr. Thiels said. “That’s one of the things we’re trying to work on now, is how we can tackle this and not just let the pendulum swing the other way.”

  1. Brummett CM, Waljee, JF, Goesling J et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504. Abstract
  2. Thiels CA, Anderson SS, Ubl DS et al. Wide variation and overprescription of opioids after elective surgery. Ann Surg. 2017; 266(4):564-573. Abstract
  3. Thiels CA, Ubl DS, Yost KJ et al. Results of a prospective, multicenter initiative aimed at developing opioid-prescribing guidelines after surgery. Ann Surg. 2018;268:(3):457-468. Abstract