The Opioid Crisis and Surgeons: National Survey of Prescribing Patterns and the Influence of Motivators, Experience, and Gender

Modifying Post-operative Opioid Stewardship Through a System of Educational Feedback

Background: The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns.Methods: An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered.Results: A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase.Discussion: An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED.

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury

OBJECTIVES

North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions.

DESIGN

A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels.

SETTING

A large healthcare system in North Carolina.

PATIENTS AND PARTICIPANTS

Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury.

INTERVENTIONS

The STOP Act limited the duration of opioid prescriptions in North Carolina.

MAIN OUTCOME MEASURE

Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome.

RESULTS

Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97).

CONCLUSIONS

Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Association Between Initial Opioid Prescription Duration and 30-Day Risk of Receiving Repeat Opioid Among Children

OBJECTIVE

Our study evaluated the association between initial opioid prescription duration and receipt of a repeat opioid prescription in children.

METHODS

Eligible individuals were children between 1 and 17 years of age who enrolled in a Medicaid Managed Care plan and filled an incident opioid prescription during 2013 to 2018. An incident prescription was defined as receipt of an opioid analgesic without a prior use for 12 months. A repeat opioid prescription was defined as receipt of a subsequent opioid prescription within 30 days since the end of incident opioid prescription. A hierarchical multivariable logistic regression model was fitted to test the association between incident opioid prescription duration and the likelihood of receiving a repeat prescription.

RESULTS

The cohort consisted of 17,086 children receiving an incident opioid prescription in which 6272 (36.7%) received 1 to 3 days' supply, 8442 (49.4%) received 4 to 7 days' supply, 1434 (8.4%) received 8 to 10 days' supply, and 938 (5.5%) received >10 days' supply. Of these incident opioid recipients, 1780 (10.4%) filled a repeat opioid prescription. The multilevel model results indicated that, children receiving 4 to 7 days' supply (adjusted odds ratio [aOR]: 0.98 {0.9-1.1}), 8 to 10 days' supply (aOR: 1.03 [0.8-1.3]), and >10 days' supply (aOR: 0.85 [0.7-1.1]) had comparable likelihoods of receiving a repeat prescription as those receiving 1 to 3 days' supply.

DISCUSSION

Nearly 10% of children who filled an opioid prescription for acute pain received a repeat prescription. Initial prescription duration was not associated with the risk of receiving a repeat prescription.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey

PURPOSE

To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed.

METHODS

We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021.

RESULTS

Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies.

CONCLUSIONS

Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches

PURPOSE

International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs.

METHODS

We performed a propensity score matched analysis of patients undergoing IHR between 2012 and 2021 in the Abdominal Core Health Quality Collaborative registry. 10,409 patients underwent a unilateral IHR via a posterior approach. Hernia repairs were performed via minimally invasive surgery (MIS) which includes laparoscopic and robotic transabdominal preperitoneal (TAPP), laparoscopic totally extraperitoneal (TEP), or open transrectus preperitoneal/open preperitoneal (TREPP/OPP) approaches. Propensity score matching (PSM) utilizing nearest neighbor matching accounted for differences in baseline characteristics and possible confounding variables between groups. We matched 816 patients in the MIS cohort with 816 patients in the TREPP/OPP group. Outcomes included patient reported quality of life, hernia recurrence, and postoperative opioid use.

RESULTS

Improvement was seen after TREPP/OPP as compared to MIS IHR in EuraHS at 30 days (Median(IQR) 7.0 (2.0-16.64) vs 10 (2.0-24.0); OR 0.69 [0.55-0.85]; p = 0.001) and 6 months (1.0 (0.0-4.0) vs 2.0 (0.0-4.0); OR 0.63 [0.46-85]; p = 0.002), patient-reported opioid use at 30-day follow-up (18% vs 45% OR 0.26 [0.19-0.35]; p < 0.001), and rates of surgical site occurrences (0.8% vs 4.9% OR 0.16 [0.06-0.35]; p < 0.001). There were no differences in EuraHS scores and recurrences at 1 year.

CONCLUSIONS

This study demonstrates a potential benefit of open posterior mesh placement over MIS repair in short-term quality of life and seroma formation with equivalent rates of hernia recurrence. Further study is needed to better understand these differences and determine the reproducibility of these findings outside of high-volume specialty centers.

Bupivacaine liposome use reduces length of post-anesthesia care unit stay and postoperative narcotic use following robotic inguinal herniorrhaphy

In the current opioid crisis, multimodal analgesic protocols should be considered to reduce or eliminate narcotic usage in the postoperative period. We assess the impact of bupivacaine liposome used along with a standard analgesia protocol following robotic inguinal hernia repair. A retrospective review of a prospectively maintained data including robotic inguinal hernia repairs (IHR) by two surgeons in the United States was performed. Within a multimodal analgesic protocol, local anesthetic was administered intraoperatively. One group received a mix of bupivacaine and bupivacaine liposome (BL), and one received standard bupivacaine (SB). Recovery room and home opiate doses were recorded. Primary outcomes included length of stay (LOS) and postoperative medication requirements. Statistical analysis was performed using Chi-square or Fisher's exact test and Mann-Whitney U test as appropriate. 122 robotic IHRs were included; 55 received BL and 67 received SB. Hospital LOS (hours) was reduced in the BL group (2.8 ± 1.1 vs 3.5 ± 1.2; p = 0.0003). There was no significant difference in recovery room parenteral MME requirements between the groups; however, BL group had less oral MME requirements (5.0 ± 6.5 MME vs. 8.1 ± 6.9 MME, p = 0.02). The BL group had a higher rate of zero opiate doses at home (44% vs 5%, p = 0.0005). Of those that did require opiates at home, there was a significant reduction in number of narcotic pills used by the BL compared to the SB group (median 1 vs 5, respectively; p < 0.0001). Intraoperative administration of BL as part of a pain management protocol may decrease length of hospital stay, and reduce or eliminate the need for narcotic analgesic use at home.

Examining current patterns of opioid prescribing and use after bariatric surgery

BACKGROUND

Evidence-based guidelines on the appropriate amount of opioid medications to prescribe following bariatric surgery are lacking. We sought to determine our current opioid-prescribing practices, patient utilization, and satisfaction with pain control following elective bariatric surgery.

METHODS

A retrospective chart review and phone survey were conducted on patients who underwent laparoscopic or robotic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from April 2018 to March 2019 at a single academic medical center. Opioid medications were converted to morphine milligram equivalents provided (MMEs).

RESULTS

In total, 192 patients met inclusion criteria. The median amount of opioid medication prescribed on discharge was 300 oral MMEs, although there was a significant difference between the MMEs prescribed to patients with and without chronic opioid therapy (median 300 MMEs opioid naïve vs. 375 MMEs chronic opioid therapy, p = 0.01). Significantly fewer SG patients required a refill of their opioid medication compared to RYGB (8.3% vs. 23.9%, p = 0.003). Of the 192 patients, 87 (45.3%) completed the phone survey. Fifty-six patients (64%) reported that they took half or less of the initially prescribed opioids. Of the patients with leftover medication, 36% reported that they did not dispose of the medication. Overall understanding of pain control options after surgery was significantly lower in patients who felt they were prescribed "too little" opioids (p = 0.01), patients requiring refills (p = 0.02), and patients who were not satisfied with their pain control (p = 0.02).

CONCLUSION

There is a gap between the amount of opioid medication prescribed and taken by patients following bariatric surgery in our practice. Patients who were least satisfied with their pain control reported knowledge gaps about pain control options that were more significant than patients who were more satisfied. Future initiatives should focus on the reduction of opioids prescribed to bariatric surgery patients post-operatively and on opioid education for patients.

Attending and Resident Surgeon Perspectives and Prescribing Practices of Pain Medication During the Opioid Epidemic

OBJECTIVE

Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes.

DESIGN

Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play.

SETTING

Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest.

PARTICIPANTS

Attending and resident physicians within the Departments of Surgery participated anonymously.

RESULTS

Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p < 0.05), discuss the potential of opioid abuse (31% vs. 6%; p < 0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p < 0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with >5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%).

CONCLUSION AND RELEVANCE

Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.

Variation in Postoperative Opioid Prescribing Among Upper-Extremity Surgery Providers

Purpose

To identify targets for corrective interventions and guide improved opioid stewardship, we studied opioid prescribing patterns of attending surgeons compared with surgical trainees for 2 upper-extremity surgeries: open reduction internal fixation (ORIF) of distal radius fractures (DRF), and carpal tunnel release (CTR).

Methods

We retrospectively reviewed records for all patients who underwent CTR or DRF ORIF at 6 hospitals across a large health system from 2016 to 2018. We collected prescriber training level (attending vs trainee), analgesic prescribed, and amount initially prescribed after surgery converted to oral morphine equivalents (OMEs). Regression models evaluated OMEs by prescriber and surgery type. Our final models included an interaction term between prescriber training level and year of surgery to assess group changes over time. No prescription guidelines or formal training was provided during the study period.

Results

We included 707 CTR and 383 DRF ORIF patients. Opioids prescribed by trainees ranged from 90 to 300 OMEs (median, 180 OMEs). Opioids prescribed by attendings ranged from 100 to 225 OMEs (median, 150 OMEs). Early in the analyses, trainees prescribed significantly more than attendings (320 versus 180). Over time, trainees reduced overprescribing significantly more, by an additional 40 OME/y. By the end of the analysis period, trainees were prescribing less OME than were attendings (112.5 vs 150). Both groups continued to prescribe more than recently suggested amounts for both procedures.

Conclusions

Our study found that both attendings and trainees overprescribed opioids after surgery. Trainees prescribed more than attendings over the study period; however, when analyzing for improvement over time and with no formal intervention or training, trainees showed greater improvement, eventually dropping to levels at or below that of attendings. Considering that most change was seen at the trainee level, education for established providers may be an area in which more improvement can be made.

Clinical relevance

Understanding which providers are more likely to overprescribe opioids can help guide interventions that improve opioid stewardship.

Misalignment of Stakeholder Incentives in the Opioid Crisis

The current opioid epidemic has killed more than 446,000 Americans over the past two decades. Despite the magnitude of the crisis, little is known to what degree the misalignment of incentives among stakeholders due to competing interests has contributed to the current situation. In this study, we explore evidence in the literature for the working hypothesis that misalignment rooted in the cost, quality, or access to care can be a significant contributor to the opioid epidemic. The review identified several problems that can contribute to incentive misalignment by compromising the triple aims (cost, quality, and access) in this epidemic. Some of these issues include the inefficacy of conventional payment mechanisms in providing incentives for providers, practice guidelines in pain management that are not easily implementable across different medical specialties, barriers in adopting multi-modal pain management strategies, low capacity of providers/treatments to address opioid/substance use disorders, the complexity of addressing the co-occurrence of chronic pain and opioid use disorders, and patients' non-adherence to opioid substitution treatments. In discussing these issues, we also shed light on factors that can facilitate the alignment of incentives among stakeholders to effectively address the current crisis.

Tackling the opioid epidemic: Reducing opioid prescribing while maintaining patient satisfaction with pain management after outpatient surgery

INTRODUCTION

Results of a quality improvement (QI) project to standardize our opioid prescribing practices following five common outpatient general surgery procedures are presented.

METHODS

Opioid prescribing habits were reviewed from June to December 2017. QI measures were implemented. We prospectively collected data on opioid prescribing habits and patients' pain management ratings from September 2018 to February 2019.

RESULTS

Following implementation, combination pills were less prescribed. More patients were prescribed adjuncts pre- (66% vs. 3%; p < 0.01) and post-operatively (85% vs. 50%; p < 0.01). One-third of pills were prescribed (1363 vs. 4185), with only 520 consumed. Average OME prescribed decreased from 179 to 127 mg (p < 0.001). At follow-up, 52 patients (54%) reported taking 11 pills (1-20) post-operatively for five days. Pain management was rated as good/excellent (88.6%) or fair (9.3%).

CONCLUSIONS

Using a pragmatic multimodal approach, decreasing opioid prescriptions at discharge allows for adequate pain management.

Are narcotic pain medications necessary after discharge following thyroidectomy and parathyroidectomy?

BACKGROUND

The aim of this study was to determine whether patients undergoing thyroidectomy and parathyroidectomy have similar postoperative pain if managed with an opioid-sparing regimen versus an opioid-containing regimen. We hypothesized that an opioid-sparing regimen would provide equivalent analgesia.

METHODS

We performed a prospective, randomized trial (clinicaltrials.govNCT03640247) comparing non-narcotic and narcotic postoperative pain regimens after discharge. Patients ≥18 y undergoing thyroidectomy or parathyroidectomy were eligible for inclusion. Patients were excluded if they were taking a narcotic. Patients in the nonnarcotic arm of the study received acetaminophen, alternating with ibuprofen, and patients in the narcotic arm received the same medications plus a narcotic.

RESULTS

Of 126 patients, 64 patients were in the nonnarcotic group and 62 were in the narcotic group. The mean age was 54 ± 14 y, and 108 (86%) patients were female. Median pain scores were similar on postoperative day #0 (narcotic group 7 versus nonnarcotic group 7.5), postoperative day #1 (narcotic group 6 versus nonnarcotic group 6), postoperative day #2 (narcotic group 5 versus nonnarcotic group 5), postoperative day #3 (narcotic group 4 versus nonnarcotic group 4), postoperative day #4 (narcotic group 3 versus nonnarcotic 3) and postoperative day #5 (narcotic group 2.5 versus nonnarcotic group 2, all P > .1). A total of 31 (50%) patients in the narcotic group did not take a narcotic. A total of 8 (12.5%) patients in the nonnarcotic group and of 31 (50%) patients in the narcotic group took a median total of 2 narcotic tablets.

CONCLUSION

An opioid-sparing pain medication regimen provides effective analgesia for most patients after thyroidectomy and parathyroidectomy.

First national survey on opioids prescribing practices of Canadian pediatric surgeons

PURPOSE

Prescription opioid misuse has become a public health concern globally. In Canada, little is known about the national prescription patterns in children. The purpose of the present study was to evaluate the opioid prescribing practices of pediatric surgeons in Canada.

METHODS

Following ethical approval, an electronic questionnaire was administered to all pediatric surgeons currently practicing in Canada. Questions included surgeon practice information, patterns of opioid prescription at discharge based on the type of surgery, type of opioid prescribed, and availability of training for surgeons/families.

RESULTS

Fifty-eight questionnaires were completed (response rate: 84%) by surgeons from 8 out of 8 Canadian provinces with pediatric surgery coverage. 33% of responders prescribed opioids (most commonly morphine) for day surgeries and 73% of Pediatric Surgeons prescribed opioids for major surgeries. Most responders (84%) declared that at their institution there was no formal training for residents/fellows in pain control and opioid prescribing. Similarly, 57% reported no education for families about opioids at discharge.

CONCLUSION

This first national survey on opioid prescribing practices across Canada reveals that opioids were prescribed to pediatric patients following a broad range of minor and major surgical procedures. Moreover, there seems to be a lack of education for surgeons and families about opioid use.

TYPE OF STUDY

Descriptive, cross-sectional, practice survey.

LEVEL OF EVIDENCE

Level 5.

Prescribing and Consumption of Opioids After Primary, Unilateral Total Hip and Knee Arthroplasty in Opioid-Naive Patients

BACKGROUND

This cohort study was designed to determine the discrepancy between the quantity of opioid prescribed vs that which was consumed after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in opioid-naive patients.

METHODS

Seven hundred twenty-three opioid-naive patients (426 TKAs and 297 THAs) from 7 hospitals in Michigan were contacted within 3 months of their surgery. Opioid prescribing and self-reported consumption was calculated in oral morphine equivalents (OMEs). Secondary outcomes included opioid refill in the first 90 days, pain in the first 7 days post-operatively, and satisfaction with pain care.

RESULTS

For TKA, the mean prescribing was 632 mg OME (±229), and the mean consumption was 416 mg (±279). For THA, the mean prescribing was 584 mg OME (±335), and the mean consumption was 285 mg (±301). There were no associations between the amount of opioid prescribed and the likelihood of refill, post-operative pain, or satisfaction with pain control. The amount of opioid prescribed was associated with increased consumption, such that each increase of 1 pill was associated with approximately an additional half pill consumed after adjusting for other covariates. Moreover, 48.2% felt that they received "More" or "Much more" opioid than they needed.

CONCLUSION

We recommend no more than 50 tablets of 5 mg oxycodone or its equivalent after TKA and 30 tablets after THA. Although dose reductions in other surgeries have not resulted in harm, continued assessment is needed to ensure that there are no unintended effects of opioid reduction, including worsened pain, decreased satisfaction, emergency department visits, or hospital readmissions.

LEVEL OF EVIDENCE

Level III; Retrospective, cohort study.

A prospective study of opioid use for postoperative pain management after breast operation

BACKGROUND

The opioid epidemic has necessitated increased attention to prescribing practices. This study seeks to prospectively quantify postoperative opioid use after breast operation.

METHODS

Consecutive patients undergoing breast operation at a single institution in 2018 prospectively tracked each dose of medication and completed a survey of perceptions regarding their opioid prescription.

RESULTS

Of 100 patients, 88 completed log, survey, or both. The tab quantity required to fulfill the needs of 80% of patients was: Partial mastectomy (PM) 3, PM with sentinel lymph node biopsy 6, PM with bilateral reduction 8, total mastectomy 34, and bilateral mastectomy 47. Of survey respondents, 51.2% felt they had been prescribed too much pain medication. Most (83.0%) had leftover tabs, and 67.9% indicated they kept them in their home.

CONCLUSIONS

The majority of patients were overprescribed opioids after breast operation. A reduction could be achieved by targeting the needs of 80% of the population.