Opioid prescribing patterns at discharge for surgical patients

Abstract

Statistics from the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse have illustrated the extent and gravity of deaths involving prescription opioids. Data from the last 2 decades showed a steady increase in prescription opioid deaths from 1999 until peaking in 2011.1,2 Rates have slowly started to decline since then, but the number of prescription opioid-related deaths still tops 17,000 annually as of 2017.1,2 Although this is less than the number of deaths currently caused by synthetic narcotics such as fentanyl, illicit use of fentanyl is frequently preceded by abuse of prescription opioids. Current opioid prescribing trends indicate that extended-release forms of opioids make up <10% of total opioid prescribing and the rate of prescribing for day supply of opioids of <30 days exceeds that of ≥30 days.3 This indicates that short-term prescribing for acute conditions such as surgery constitutes most opioid prescriptions. By medical specialty, surgeons are the fifth largest prescribers of opioids in the United States and one of the very few groups whose prescribing rates have increased despite the opioid epidemic.4 From 2010 to 2016, the rate of opioid prescribing by surgeons increased by 18%.5 Not only did the rate increase, but so did the average oral milligram morphine equivalents (MME or OME) per prescription from 240 in 2010 to 403 in 2016.5 Excessive prescribing of opioids for postoperative analgesia is a contributor to the public health crisis of opioid addiction and misuse; yet, there is a paucity of literature comparing opioid-based to opioid-free analgesia, particularly in North America, where the crisis is most rampant. Reliance on opioids for acute pain management is much higher in the United States compared with most other countries for which such data are available.6 Fiore and colleagues, performed an extensive literature search of 8 databases for studies with surgical patients using opioid-free postoperative analgesia. With just over 400 studies fulfilling the authors' criteria, only 5% of them came from the United States.7 Most studies came from Europe and Asia and were predominantly focused on general, orthopedic, and obstetric/gynecologic surgery. Although there were many studies focused on inpatient postoperative opioid-free regimens, relatively few examined opioid versus opioid-free regimens after discharge. The authors shared that postoperative pain-related outcomes in countries with low opioid prescribing rates are superior to North American outcomes. The authors concluded that there is considerable opportunity for research aimed at building evidence for opioid-free analgesia regimens after discharge, particularly in countries where the opioid crisis is a full-blown epidemic. Potential reasons why such research has outpaced the United States in countries where opioids are far less of a problem are unique societal issues within the United States such as industry promotion of opioids as "safe," pain scores as markers of quality care, and pain-related questions on patient satisfaction scoring surveys. Safety issues and excessive prescribing Although opioids have long been the mainstay of acute postoperative pain management, emerging data reveal the breadth and depth of opioid-related adverse events. Urman and colleagues reviewed data on >13,000 opioid-naive surgical patients and found that 91% received opioids in their postoperative course and 10% of those patients experienced an opioid-related adverse drug event (ORADE). These ORADEs were associated with higher hospitalization cost, increased length of stay, lower odds of discharge to home, and increased odds of death.8 Perhaps the most shocking finding of this study is that the development of an ORADE while inpatient did not seem to change opioid prescribing at discharge; several patients experiencing such events still went home with opioid prescriptions. Hah and colleagues found that prescribing opioids to previou