Patient-specific guidance for opioid use after inpatient general surgery

Reuters Health Information: Patient-specific guidance for opioid use after inpatient general surgery

Patient-specific guidance for opioid use after inpatient general surgery

Last Updated: 2017-12-19

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - For inpatients having general surgery, receiving opioids the day before hospital discharge best predicts postdischarge use, according to a new guideline from Dartmouth University surgeons.

This guideline will satisfy the at-home opioid needs for 85% of these postsurgical patients: "If no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge," the authors write in the Journal of the American College of Surgeons, online November 29.

"We studied six different operations (on the stomach, pancreas, liver, colon and large hernias) and found that the type of surgery did not affect the number of opioid pills the patients used after discharge. If we utilize these guidelines in the future, we expect that the number of pills prescribed will decrease by 40%!" senior author Dr. Richard J. Barth, Jr., of the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, told Reuters Health.

"Opioids can be prescribed in a patient-specific manner so each patient gets the number they need. The guideline is very easy to apply in routine clinical practice because it is simple and the data on inpatient opioid use the day prior to discharge is readily obtained from the medical records," said Dr. Barth, who also is a professor of surgery at Dartmouth Geisel School of Medicine in Hanover, New Hampshire.

The researchers reviewed the records of all 333 patients who underwent surgery at their medical center and were discharged to home. After excluding chronic opioid users and patients with complications, they included 234 patients in the analysis.

The authors interviewed the participants by mailed questionnaires and phone surveys. Overall, 85% of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Prescribing 15 opioid pills was sufficient for 88% of patients discharged on the first day after surgery. For patients discharged later than the first day after surgery, the number of opioid pills taken at home was related to the number taken the day before discharge (P<0.0001) and to patient age (P=0.006), but not to the type of surgery.

On the day before discharge, 41% of patients took no opioids, 33% took one to three pills, and 26% took more than four pills.

Of 40 outlier patients who took more pills than the guidelines recommended, 28 responded to phone interviews. Just over half of the respondents said they were using opioids for reasons other than the pain for which they had been prescribed.

Dr. Barth acknowledged that, because this was a single-institution study, results may differ by patient population and geographic region. "However," he added, "we expect that the general principle will hold true for any patient group: the number of opioids used the day prior to discharge will predict the number used at home."

Dr. Richard Rosenquist, professor of anesthesiology and chair of the Pain Management Department at Cleveland Clinic, in Ohio, said in an email, "It was extremely important to publish this guideline. Many postdischarge opioid prescriptions have been written on the basis of tradition and an effort to make sure that patients have enough medication so they do not need to call back to get more."

"This guideline . . . will markedly reduce the number of opioid pills prescribed for most patients without compromising the quality of care and will reduce the number of leftover pills that could potentially end up in the wrong hands or be abused," advised Dr. Rosenquist, who was not involved in the study.

Dr. Thomas Kosten, professor of psychiatry, neuroscience, pharmacology, immunology and rheumatology at Baylor College of Medicine in Houston, Texas, said in an email, "I mostly treat addictions, including opioid addiction, and see these problems much more frequently than typical surgeons see them . . . . I am not surprised by the results. I find this overprescribing very common among surgeons, even among my patients who have known opiate dependence histories and let the surgeon know that."

"Guidelines from surgeons themselves based on data are more likely to be followed than guidelines published by government agencies or by addiction treaters, like me," he noted.

Dr. Kosten, who also was not involved in the study, questioned the authors' goal to relieve 85% of the patients' pain. "Is this a realistic percentage of patients, and was the pain completely relieved, partially relieved, or just endurable? Was that bar set to allow for any impairment in activity level?"


J Am Coll Surg 2017.

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