Impact of opioid prescribing guidelines on prescribing at discharge from endocrine surgery

Comparative Effectiveness of Different Opioid Regimens, in Daily Dose or Treatment Duration, Prescribed at Surgical Discharge: a Systematic Review and Meta-Analysis

BACKGROUND

Opioids are prescribed for postsurgical pain management, but a balance between achieving adequate pain control and minimising opioid-related harm is required. This study aimed to investigate the effectiveness of different opioid regimens, in daily dose or treatment duration, prescribed at surgical discharge.

METHODS

A systematic search of MEDLINE, EMBASE, CENTRAL, and ICTRP was performed from inception to 12 January 2025. Randomised controlled trials (RCTs) and non-RCTs comparing different daily doses or treatment durations of opioid analgesics were included. All surgeries were included, except those related to cancer treatment or palliative care. Eligible populations were adults (≥ 18 years) or individuals classified as adults according to the criteria of the respective studies. Data were extracted at immediate-term (≤ 3 days), short-term (> 3 to ≤ 7 days), medium-term (> 7 to ≤ 30 days), and long-term (> 30 days). Data from RCTs were pooled using a random-effects model. Risk of bias was assessed. Certainty of evidence from RCTs was evaluated with Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). The primary outcome was pain intensity. Adverse events were also measured.

RESULTS

A total of 8432 records were identified. In total, 12 RCTs with 7128 patients and 24 non-RCTs with 118,849 patients were included. Studies included orthopaedic, gynaecology and obstetric surgeries, ranging from minor to major procedures. Higher-doses of opioids were more effective than lower-doses in reducing immediate pain intensity (mean difference (MD) 4.36, 95% confidence interval (CI) 0.50-8.23, n = 364, three studies, I2 = 0%, high certainty). No difference in pain was found between higher-doses and lower-doses at other time points (moderate to high certainty). Longer-durations of opioid treatment showed no difference in pain at any time point (low to moderate certainty). More adverse events were reported with higher doses of opioids.

CONCLUSIONS

Higher-dose opioids provide a slight reduction in immediate post-discharge pain intensity but may lead to more adverse events. Longer durations of opioid treatment are probably not more effective in reducing pain than shorter treatment durations. Our findings suggest that clinicians may choose to prescribe lower doses of opioids or shorter durations of opioids without compromising pain control, even for major surgery.

A "just in time" educational intervention for opioid overprescribing in dialysis access surgery

BACKGROUND

Despite widespread efforts to combat the opioid epidemic, an ongoing contributor to opioid misuse remains post-operative opioid overprescribing by residents. The goal of this study was to evaluate the impact of a low-cost, reproducible "just in time" intervention on opioid prescribing in dialysis access operations.

METHODS

Standardized opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. Wilcoxon rank-sum test and tests of proportions were used to compare groups.

RESULTS

Overall, 299 patients underwent dialysis access procedures. There was a decrease in patients discharged with opioids following the intervention from 58% to 36% (p ​= ​0.003). For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents (p ​= ​0.03).

CONCLUSIONS

This low-cost and timely learning intervention may be a useful adjunct to reduce post-operative opioid prescriptions.

Effectiveness of a discharge analgesia guideline on discharge opioid prescribing after a surgical procedure from a tertiary metropolitan hospital

OBJECTIVE

The primary objective of this study was to evaluate the effectiveness of a discharge analgesia guideline on the number of days' supply of opioid analgesics provided among surgical patients upon hospital discharge. The secondary objective was to analyze the effect of this guideline on the provision of an analgesic discharge plan.

DESIGN

A retrospective historical control cohort study.

SETTING

A tertiary metropolitan hospital.

INTERVENTIONS

A discharge analgesia guideline recommending the supply of opioid analgesics on discharge based on patient use in the 24 hours prior to discharge and the supply of an analgesic discharge plan.

MAIN OUTCOME MEASURE(S)

The primary outcome measure was the number of days' supply of opioids. The secondary outcome measure was the proportion of patients receiving an analgesic discharge plan.

RESULTS

There was no change in the number of days' supply of opioids provided on discharge (median, interquartile range: 5, 3-9.75 vs 6, 4-10; p = 0.107) and in the proportion of patients receiving an analgesic discharge plan (26 percent vs 22.2 percent; p = 0.604). The results of two multivariable regression models showed no change in the number of days' supply of opioids (adjusted incidence rate ratio, 95 percent confidence interval [CI]: 1.1, 0.9-1.2) and the provision of an analgesic discharge plan (adjusted odds ratio, 95 percent CI: 0.6, 0.2-1.4) after adjusting for confounding variables.

CONCLUSION

Overall, our study found no change in the number of days' supply of opioids provided on discharge and the provision of an analgesic discharge plan after implementation of a discharge analgesia guideline, but we also found that prescribing practices already aligned with the guideline before its implementation.

Surgical treatment of adrenal tumors during pregnancy

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

Optimization of Opioid Discharge Prescriptions Following Thyroid and Parathyroid Surgery

OBJECTIVE

To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy.

METHODS

This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions.

RESULTS

A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%; P < .001; number needed to treat = 3) and an adjusted odds ratio (OR) of 0.08 (95% CI, 0.04-0.19; P < .001). The bundle was associated with reductions in opioid discharge prescriptions that exceeded 112.5 oral morphine milligram equivalents (33% pre- vs 10% postimplementation; adjusted OR, 0.20; P = .001) or 5 days of therapy (17% pre- vs 6% postimplementation; adjusted OR, 0.34; P = .049).

DISCUSSION

Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy.

IMPLICATIONS FOR PRACTICE

Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community.

REGISTRATION

The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.