Use of post-discharge opioid consumption patterns as a tool for evaluating opioid prescribing guidelines

Impact of Nonhepatectomy Opioid Reduction Efforts on Posthepatectomy Opioid Prescription: Analysis of 2,005 Patients

BACKGROUND

Pathway-driven, postpancreatectomy opioid reduction interventions have proven effective and sustainable and may have a "halo effect" on other major abdominal cancer operations. This study aimed to analyze the sequential effects of expanding opioid reduction efforts from pancreatectomy on opioids prescribed after hepatectomy.

STUDY DESIGN

This was a retrospective cohort study using data from the electronic health record and a prospective quality improvement database for consecutive hepatectomy patients (September 2016 to February 2024). Cohorts were based on 5 distinct eras of opioid-related protocol updates E1 (preintervention historical baseline): September 2016 to March 2017; E2 (introduction of 5x-multiplier): April 2017 to September 2018; E3 (departmental opioid education program): October 2018 to December 2019; E4 (initial posthepatectomy pathways): January 2020 to June 2022; and E5 (updated pancreatectomy pathways influencing hepatectomy care): July 2022 to February 2024).

RESULTS

Of 2,005 patients, 31% underwent major hepatectomy, 14% intermediate, 46% minor, and 9% combination surgery/other. Most (79%) patients were performed via an open approach. The median hospital stay decreased from 5 to 4 days between E1 and E5. Both intraoperative (E1, 80 mg; E5, 37 mg; p < 0.001) and total inpatient (E1 181 mg, E5 86 mg; p < 0.001) median oral morphine equivalents were reduced by >50%. A 73% reduction in discharge oral morphine equivalents was observed between E1 (225 mg) and E5 (60 mg; p < 0.001), with clinically similar median pain scores at discharge (scores 1 to 2 of 10). Concurrent universal adoption of routine 3-drug nonopioid discharge prescriptions (E1 70%, E5 98%) correlated with the proportion of patients discharged opioid-free (E1 8%, E5 43%; p < 0.001).

CONCLUSIONS

Directed opioid reduction efforts for pancreatectomy influenced clinically meaningful posthepatectomy reductions in inpatient and discharge opioid volumes. A "halo effect" of intradepartmental opioid reduction efforts is attainable and corresponds to measurable increases in opioid-free or nearly opioid-free discharges after major abdominal cancer surgery.

Post-discharge opioid utilization patterns in orthopedic patients are underestimated: an explorative study

AIM

This study explores morphine use among patients after discharge following total hip (THA) or knee arthroplasty (TKA).

METHOD

Morphine use was monitored for 14 days post-discharge. Patients recorded their morphine intake and reported pain using a Visual Analog Scale (VAS). Incomplete reports were excluded from longitudinal analysis. Median tablet count and total morphine use in milligram equivalents (MME) were calculated. Patients were categorized as non-users (0 mmE), short-term users (<100 mmE), and consistent users (>100 mmE).

RESULTS

Of the 67 patients, six dropped out. Among the remaining, 22 (36.7%) took no morphine, while 38 (63.3%) took at least one dose, with a median VAS-score of 5. Short-term users (n = 19) averaged a total of 40 mmE, mainly in the first three days, while consistent users (n = 15) averaged in total 220 mmE during follow-up, tapering gradually. After 14 days, 3% continued usage. Four patients with incomplete data were excluded. However, for those was found that this was due to or related to the fact that they used a large amount of morphine.

CONCLUSION

Most patients used minimal or no morphine, tapering off within two weeks.

Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use

BACKGROUND

Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline.

STUDY DESIGN

We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed.

RESULTS

A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively.

CONCLUSIONS

Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.

Pain management in trauma: the need for trauma-informed opioid prescribing guidelines

Background/objectives

Surgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several years have yielded mixed results for pain management after trauma, with a limiting factor being the heterogeneity of clinical populations and treatment needs in individuals receiving opioids. The present analysis illuminates this gap between clinical guidelines and clinical practice through qualitative feedback from hospital trauma providers and unit staff members regarding current opioid prescribing guidelines and practices in the setting of traumatic injury.

Methods

The parent study aimed to implement a pilot screening tool for opioid misuse in four level I and II trauma hospitals throughout Wisconsin. As part of the parent study, focus groups were conducted at each study site to explore the facilitators and barriers of implementing a novel screening tool, as well as to examine the current opioid prescribing guidelines, trainings, and resources available for trauma and acute care providers. Focus group transcripts were independently coded and analyzed using a modified grounded theory approach to identify themes related to the facilitators and barriers of opioid prescribing guidelines in trauma and acute care.

Results

Three major themes were identified as impactful to opioid-related prescribing and care provided in the setting of traumatic injury; these include (1) acute treatment strategies; (2) patient interactions surrounding pain management; and (3) the multifactorial nature of trauma on pain management approaches.

Conclusion

Providers and staff at four Wisconsin trauma centers called for trauma-specific opioid prescribing guidelines in the setting of trauma and acute care. The ubiquitous prescription of opioids and challenges in long-term pain management in these settings necessitate additional community-integrated research to inform development of federal guidelines.

Level of evidence

Therapeutic/care management, level V.

Trial of the Patient-Centered 2 × 24-Hour Predischarge Opioid Consumption Opioid Prescribing Guideline

This diagnostic/prognostic study evaluates the 2 × 24-hour predischarge opioid consumption guideline for opioid prescribing.

Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags

OBJECTIVE

To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids.

DATA SOURCES AND STUDY SETTING

We collected patient surveys and electronic medical record data at an academic health system.

STUDY DESIGN

We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias.

DATA COLLECTION/EXTRACTION METHODS

From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy.

PRINCIPAL FINDINGS

We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up.

CONCLUSIONS

A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.

A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

Background

We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care.

Methods

Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates.

Results

Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742).

Conclusion

The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.