Post-surgical Opioid Prescriptions not a 'One-Size-Fits All' Approach

Heidi Overton

For clinicians on the front lines of any emergent health care crisis, step one usually involves looking to peer-reviewed recommendations for guidance. However, as the opioid epidemic took hold, those dealing with patients in the post-surgical setting found that they had no such recommendations to guide them.

Even after the long-anticipated decision by President Donald Trump to declare the opioid addiction crisis a national public health emergency, surgical guidelines remained lacking, despite research noting that patients who underwent surgery had a higher risk of becoming chronic opioid users than nonsurgical patients.

Heidi Overton, MD, general surgery resident at Johns Hopkins Hospital and PhD candidate at the Bloomberg School of Public Health, was among a multidisciplinary expert panel of experts who decided that, for clinicians dealing with patients who had undergone surgery, enough was enough.

 
Surgical guidelines regarding opioids remain lacking, despite research noting that patients who underwent surgery had a higher risk of becoming chronic opioid users than nonsurgical patients.
Source: Shutterstock

“This project emerged when a group of clinical experts at our hospital recognized there were no guidelines for what to prescribe opioid-naïve patients after surgery,” Overton told Healio Rheumatology in an interview. “It took some time to develop procedure-specific acute pain management recommendations because much of the original conversation about the opioid crisis were related to the chronic pain management. There is great need to improve opioid prescribing practices in the post-operative setting, so we hope these guidelines can begin to make an impact in this area.”

The team comprised six groups of stakeholders including surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients and pharmacists. Twenty uncomplicated surgical procedures — including arthroscopic ACL/PCL repair, arthroscopic rotator cuff repair and open reduction and internal fixation of the ankle, among other procedures — among eight specialties underwent analysis, during which the experts used 5 mg oxycodone oral equivalents as the measure for an opioid dose.

The minimum number of opioid tablets recommended by the panel was zero, with 20 pills as the maximum for the orthopedic procedures. The median number of tablets that may be used was 12.5. Variation was reported in the maximum number of opioid tablets that may be used.

“The opioid epidemic is a real crisis and we know that overprescribing is part of the problem,” Overton said. “We know from recent research that one in 16 patients introduced to opioids at the time of surgery become dependent. We also know that, historically, we have prescribed opioids too liberally — more than 70% of the opioid pills that we prescribe are not used by patients.”

For 15% of the procedures, the recommended dose was zero tablets, while 55% of procedures were recommended a broader range of between one and 15 tablets — only 30% of the procedures were recommended a dose of 16 to 20 tablets.

“Understanding the wide variation and high rates of unused pills amongst post-surgical patients was the key that enabled surgeons to really begin the process of changing our opioid prescribing practices,” Overton said.

Slow to Arrive

G. Caleb Alexander, MD, MS, of the Johns Hopkins Bloomberg School of Public Health Center for Drug Safety and Effectiveness, was not involved in the study, but offered his insight in an interview with Healio Rheumatology.

G. Caleb Alexander

“This is a very important contribution to the literature and clinical care,” he said. “This type of analysis was long overdue. The bottom line is that opioids have been overprescribed in every clinical setting except hospice and palliative care. Overprescribing has persisted for years despite overwhelming evidence that the train has gone off the tracks.”

 Alexander acknowledged that surgery is a particularly broad and complicated setting with regard to opioid dosing, because procedures can vary widely in level of invasiveness and pain. “There is fairly strong consensus that the genesis of the epidemic was the treatment of chronic pain, and there is less evidence about surgery,” he said.

With this in mind, Alexander noted a few factors that contributed to the epidemic. “One is the subjectivity of pain, and another was the aggressive ‘pharma’ marketing for use of opioids in the treatment of pain,” he said. “There was a false narrative created that there is some inevitable conflict between reducing opioids and dealing with pain. The irony is that we are now seeing that the quality of care for people with pain often did not improve with the use of opioids.”

While Alexander recognized that clinicians do the prescribing and, therefore, should shoulder some of the blame, he also sees this moment as an opportunity. “The key question now is what we are going to do in 2018 that we didn’t do in 2017,” he said. “We are now seeing that we have the opportunity to both reduce the overuse of opioids and improve the quality of care for pain.”

Mitesh Patel, MD, assistant professor of medicine and health care management at the Perelman School of Medicine at the University of Pennsylvania, and director of the Penn Medicine Nudge Unit, stressed that there is still work to be done. “Physician prescribing patterns have contributed to the opioid epidemic, but the solution is likely not a ‘one size fits all’ approach,” he said. “This study offers expert consensus from one institution on how opioid prescribing recommendations might differ based on the type of operation. This is a step in the right direction, but other institutions will need to decide whether to adopt these or form their own institution-based guidelines.”

Dealing with individual Patients

Regardless of what is happening at the institutional level, the opioid epidemic, like so many others, will be fought in the clinic, one patient at a time. There is a perception that as the clinical community scales down opioid prescriptions, patients will continue to demand them. However, other findings from the study by Overton and colleagues demonstrated that patients requested even lower opioid amounts than surgeons.

Alexander grounded this point. “In my experience, it is very unusual to find a patient who insists on one type of therapy at the expense of dozens of others,” he said. In these cases, it is important for clinicians to explain the alternatives clearly and thoroughly. “If the patient understands that there are alternatives, it is exceedingly rare that the patient will demand opioids.”

A simple answer is ibuprofen: Unless medically contraindicated, Overton and colleagues noted that ibuprofen may be used for any patient.

For Alexander, it is about understanding the breadth of medications that can be used. “There are dozens of tools in the toolbox,” he said. “You don’t have to reach for opioids. It is worth repeating that opioids are not terribly effective for noncancer pain; other treatments may be just as effective or more effective.”

Like many clinicians, Alexander insists that there is a role for opioids. “I’m not an opioid nihilist,” he said. “We just have to ask ourselves whether the patient has shown signs of opioid use disorder.”

Overton underscored this point. “Some patient groups may have higher pain needs that can be addressed on an individual level, taking into account the individual’s medical history and previous experience with narcotic pain medication,” she said. “The guidelines are a reasonable starting point for informing patients, educating surgeons and setting prescribing defaults in the electronic medical record. The importance of the provider-patient relationship is paramount to ensure individual patients are appropriately counseled and evaluated in the post-operative setting.”

For Patel, the guidelines will be a starting point to answer many of these questions. “As with many treatments, differences may exist based on the clinical setting, patient experiences or other situations,” he said. “Guidelines are meant to set a framework for best practices on how to approach the standard patient. However, ultimately the physician and patient will need to discuss the guidelines and options to make the best shared decision.” — by Rob Volansky

For more information:

G. Caleb Alexander, MD, MS, can be reached at 615 N. Wolfe Street W6035, Baltimore, MD 21287; email: galexan9@jhmi.edu.

Heidi N. Overton, MD, can be reached at 600 N. Wolfe Street, Blalock 658, Baltimore, MD 21287; email: hoverto1@jhmi.edu.

Mitesh Patel, MD, can be reached at 3400 Civic Center Blvd, Philadelphia, PA 19104; email: Katharine.Delach@pennmedicine.upenn.edu.

References:

Overton HN, et al. J Coll Surg. 2018;doi:10.1016/j.jamcollsurg.2018.07.659.

Disclosures: Alexander, Overton and Patel report no relevant financial disclosures.

Heidi Overton

For clinicians on the front lines of any emergent health care crisis, step one usually involves looking to peer-reviewed recommendations for guidance. However, as the opioid epidemic took hold, those dealing with patients in the post-surgical setting found that they had no such recommendations to guide them.

Even after the long-anticipated decision by President Donald Trump to declare the opioid addiction crisis a national public health emergency, surgical guidelines remained lacking, despite research noting that patients who underwent surgery had a higher risk of becoming chronic opioid users than nonsurgical patients.

Heidi Overton, MD, general surgery resident at Johns Hopkins Hospital and PhD candidate at the Bloomberg School of Public Health, was among a multidisciplinary expert panel of experts who decided that, for clinicians dealing with patients who had undergone surgery, enough was enough.

 
Surgical guidelines regarding opioids remain lacking, despite research noting that patients who underwent surgery had a higher risk of becoming chronic opioid users than nonsurgical patients.
Source: Shutterstock

“This project emerged when a group of clinical experts at our hospital recognized there were no guidelines for what to prescribe opioid-naïve patients after surgery,” Overton told Healio Rheumatology in an interview. “It took some time to develop procedure-specific acute pain management recommendations because much of the original conversation about the opioid crisis were related to the chronic pain management. There is great need to improve opioid prescribing practices in the post-operative setting, so we hope these guidelines can begin to make an impact in this area.”

The team comprised six groups of stakeholders including surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients and pharmacists. Twenty uncomplicated surgical procedures — including arthroscopic ACL/PCL repair, arthroscopic rotator cuff repair and open reduction and internal fixation of the ankle, among other procedures — among eight specialties underwent analysis, during which the experts used 5 mg oxycodone oral equivalents as the measure for an opioid dose.

The minimum number of opioid tablets recommended by the panel was zero, with 20 pills as the maximum for the orthopedic procedures. The median number of tablets that may be used was 12.5. Variation was reported in the maximum number of opioid tablets that may be used.

“The opioid epidemic is a real crisis and we know that overprescribing is part of the problem,” Overton said. “We know from recent research that one in 16 patients introduced to opioids at the time of surgery become dependent. We also know that, historically, we have prescribed opioids too liberally — more than 70% of the opioid pills that we prescribe are not used by patients.”

For 15% of the procedures, the recommended dose was zero tablets, while 55% of procedures were recommended a broader range of between one and 15 tablets — only 30% of the procedures were recommended a dose of 16 to 20 tablets.

“Understanding the wide variation and high rates of unused pills amongst post-surgical patients was the key that enabled surgeons to really begin the process of changing our opioid prescribing practices,” Overton said.

PAGE BREAK

Slow to Arrive

G. Caleb Alexander, MD, MS, of the Johns Hopkins Bloomberg School of Public Health Center for Drug Safety and Effectiveness, was not involved in the study, but offered his insight in an interview with Healio Rheumatology.

G. Caleb Alexander

“This is a very important contribution to the literature and clinical care,” he said. “This type of analysis was long overdue. The bottom line is that opioids have been overprescribed in every clinical setting except hospice and palliative care. Overprescribing has persisted for years despite overwhelming evidence that the train has gone off the tracks.”

 Alexander acknowledged that surgery is a particularly broad and complicated setting with regard to opioid dosing, because procedures can vary widely in level of invasiveness and pain. “There is fairly strong consensus that the genesis of the epidemic was the treatment of chronic pain, and there is less evidence about surgery,” he said.

With this in mind, Alexander noted a few factors that contributed to the epidemic. “One is the subjectivity of pain, and another was the aggressive ‘pharma’ marketing for use of opioids in the treatment of pain,” he said. “There was a false narrative created that there is some inevitable conflict between reducing opioids and dealing with pain. The irony is that we are now seeing that the quality of care for people with pain often did not improve with the use of opioids.”

While Alexander recognized that clinicians do the prescribing and, therefore, should shoulder some of the blame, he also sees this moment as an opportunity. “The key question now is what we are going to do in 2018 that we didn’t do in 2017,” he said. “We are now seeing that we have the opportunity to both reduce the overuse of opioids and improve the quality of care for pain.”

Mitesh Patel, MD, assistant professor of medicine and health care management at the Perelman School of Medicine at the University of Pennsylvania, and director of the Penn Medicine Nudge Unit, stressed that there is still work to be done. “Physician prescribing patterns have contributed to the opioid epidemic, but the solution is likely not a ‘one size fits all’ approach,” he said. “This study offers expert consensus from one institution on how opioid prescribing recommendations might differ based on the type of operation. This is a step in the right direction, but other institutions will need to decide whether to adopt these or form their own institution-based guidelines.”

Dealing with individual Patients

Regardless of what is happening at the institutional level, the opioid epidemic, like so many others, will be fought in the clinic, one patient at a time. There is a perception that as the clinical community scales down opioid prescriptions, patients will continue to demand them. However, other findings from the study by Overton and colleagues demonstrated that patients requested even lower opioid amounts than surgeons.

Alexander grounded this point. “In my experience, it is very unusual to find a patient who insists on one type of therapy at the expense of dozens of others,” he said. In these cases, it is important for clinicians to explain the alternatives clearly and thoroughly. “If the patient understands that there are alternatives, it is exceedingly rare that the patient will demand opioids.”

A simple answer is ibuprofen: Unless medically contraindicated, Overton and colleagues noted that ibuprofen may be used for any patient.

For Alexander, it is about understanding the breadth of medications that can be used. “There are dozens of tools in the toolbox,” he said. “You don’t have to reach for opioids. It is worth repeating that opioids are not terribly effective for noncancer pain; other treatments may be just as effective or more effective.”

Like many clinicians, Alexander insists that there is a role for opioids. “I’m not an opioid nihilist,” he said. “We just have to ask ourselves whether the patient has shown signs of opioid use disorder.”

Overton underscored this point. “Some patient groups may have higher pain needs that can be addressed on an individual level, taking into account the individual’s medical history and previous experience with narcotic pain medication,” she said. “The guidelines are a reasonable starting point for informing patients, educating surgeons and setting prescribing defaults in the electronic medical record. The importance of the provider-patient relationship is paramount to ensure individual patients are appropriately counseled and evaluated in the post-operative setting.”

For Patel, the guidelines will be a starting point to answer many of these questions. “As with many treatments, differences may exist based on the clinical setting, patient experiences or other situations,” he said. “Guidelines are meant to set a framework for best practices on how to approach the standard patient. However, ultimately the physician and patient will need to discuss the guidelines and options to make the best shared decision.” — by Rob Volansky

For more information:

G. Caleb Alexander, MD, MS, can be reached at 615 N. Wolfe Street W6035, Baltimore, MD 21287; email: galexan9@jhmi.edu.

Heidi N. Overton, MD, can be reached at 600 N. Wolfe Street, Blalock 658, Baltimore, MD 21287; email: hoverto1@jhmi.edu.

Mitesh Patel, MD, can be reached at 3400 Civic Center Blvd, Philadelphia, PA 19104; email: Katharine.Delach@pennmedicine.upenn.edu.

References:

Overton HN, et al. J Coll Surg. 2018;doi:10.1016/j.jamcollsurg.2018.07.659.

Disclosures: Alexander, Overton and Patel report no relevant financial disclosures.

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