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Seeking an Optimal Opioid Prescribing Pattern Based on Type of Surgery

October 2, 2017
An analysis of median opioid prescription length, refill probability following an assessment of eight common surgical procedures offer a general recommendation on the amount of pain relief that may be anticipated.

With Louis L. Nguyen, MD, MBA, MPH, and Jeffrey Fudin, BS, PharmD, FCCP, FASHP

Guidelines for prescribing opioid pain medication with regard to acute pain recommend the lowest dose possible for the shortest duration needed to relieve pain, but specific guidelines for outpatient pain relief following surgery are still lacking.

Now, an analysis of more than 200,000 patients who had one of eight common surgical procedures may offer more clear guidance for this much needed pain management population. The study was published in JAMA Surgery.1  

Devising prescribing guidelines for post-surgical use of opioids.

"Optimal” prescription lengths varied widely, according to senior study author Louis L. Nguyen, MD, MBA, MPH, associate professor of surgery at Harvard Medical School and a vascular surgeon at Brigham & Women's Hospital in Boston. The most effective length for a pain prescription ranged from as little as four days for general surgery to 15 days for musculoskeletal surgeries.

"Too few [officials, legislators, and others] realize how much variation there is in the prescription habits for patients, especially after surgery," Dr. Nguyen told Practical Pain Management, "There is an important balance between giving them enough and not too much."  

A Closer Look at the Study Details

Nguyen's research team conducted this study to give guidance to practitioners concerned about the focus on the overprescribing of opioids. As many as 259 million opioid prescriptions were issued in 2012, quadrupling the total in 1999, the researchers said, “we sought to add quantifiable data instead of picking numbers out of the air."

The researchers looked at prescribing patterns from data in the Military Health System Data Repository and the TRICARE insurance program, encompassing 215,140 men and women with an average of 40 years old. Participants had a surgical procedure between January 1, 2005 and September 30, 2014. Everyone filled at least one opioid pain medicine prescription within 14 days of their surgery and 19.1% requested at least one refill.

Prior to surgery, all patients were opioid-naïve; anyone who had filled an opioid prescription within the six months prior to their surgery was excluded from the study, Dr. Nguyen said. Not all were active military; some participants were spouses or retirees. Treatment was provided by a variety of institutions.

"We looked at the refill rate as a proxy for how closely the initial prescription matched the needs of the patient," said Dr. Nguyen. They calculated the median prescription lengths and the early nadir in the probability of refill (the initial prescription duration linked with the lowest modeled risk of refill).

Seeking to Capture Opioid Prescribing Patterns

In practice, he said, the optimal length for a prescription fell between the observed median prescription length and the early nadir.

The median prescription lengths were:

  • 4 days for appendectomy and cholecystectomy
  • 5 days for inguinal hernia repair
  • 4 days for hysterectomy
  • 5 days for mastectomy
  • 5 days for anterior cruciate ligament and rotator cuff repair
  • 7 days for discectomy

The optimal lengths for various procedures (lying between the observed median length of prescription and the early nadir) were:

  • 4 to 9 days for general surgery procedures
  • 4 to 13 days for women's health procedures
  • 6 to 15 days for musculoskeletal procedures1

Study Caveats and Takeaway Messages

The numbers should be viewed as just guidelines, Dr. Nguyen said, the pain-relieving needs for each patient will be a little different as these are opioid-naïve patients. It's a starting point, a reference for prescribing habits that can be adjusted to the specific needs of the patient."

In conducting this analysis, the researchers drew attention to the uncertainty of finding optimal prescribing practices for opioid pain medicines, especially for postop outpatient pain management, ''where few guidelines exist."

Despite that lack of any clinical treatment consensus, governmental regulations limiting the length of initial prescriptions have been passed recently in several states, including New York and Massachusetts. Large pharmacy benefit managers (PBMs), including CVS CareMark and Express Scripts, have announced restrictions on the length of opioid prescriptions for first-time users, with critics condemning the one-size-fits-all approach.2

For PCPs, Dr. Nguyen said the new study results may provide valuable information for patients whose pain persists beyond a ''typical'' recovery period. For instance, if a patient had a surgery for which the average need for an opioid is 14 days, yet the patient presents to his PCP complaining he is still in significant pain 30 days out, it may indicate tolerance and potential drug issues, said to Dr. Nguyen, "or it could be indicative that a variation in need naturally exists."

The calculations arrived at in this analysis may also be a reference point for pain specialists, he said.

Outside Perspective on Findings Offered

Jeffrey Fudin, BS, PharmD, FCCP, FASHP, president and director of scientific and clinical affairs for Remitigate LLC, reviewed the findings.

"I think the most important finding of this study is that patients need to be assessed individually and that seven days of prescribed analgesia might not be enough for some patients," he told Practical Pain Management.

"The study included specific procedures, including but not limited to inguinal hernia repair, mastectomy, and hysterectomy, all of which have a very high incidence of neuroplasticity" said Dr. Fudin, so "if pain is insufficiently treated, the risk that the painful sequelae following such procedures may turn into a chronic pain syndrome that would require long-term opioid therapy. Therefore, we must treat patients as individuals instead of as an assembly line of post-surgical objects that will fit an analgesic mold."

Another salient point, he said, is that orthopedic procedures such as rotator cuff and ACL repair would respond better to NSAIDs alone (if there are no contraindications for use in the particular patient) after the first three to five days following surgery.

Among the study limitations, the rates of unused prescriptions were not captured, which might be as high as 70% in some groups, Dr. Fudin said, and the authors also did not have information on the use of non-opioid pain relievers, such as NSAIDs.

Pain specialists may be aware of the findings drawn from this study simply from their own clinical experience, he said, and “for primary care providers, the study results may persuade them to be less reluctant to prescribe opioids when needed.”

Dr. Nguyenhas no financial conflicts to disclosure. Dr. Fudin is a consultant for Clarity, Collegium, Endo and Egalet. He is on the speakers' bureau for Astra Zeneca, DepoMed, Endo, Iroko Pharmaceuticals and Pernix Therapeutics and the advisory board for Egalet and DepoMed.

Last updated on: October 2, 2017
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