The opioid epidemic in acute care surgery-Characteristics of overprescribing following laparoscopic cholecystectomy

Rate and predictors of postoperative opioid use and high opioid exposure after surgery in New Zealand: a retrospective study

BACKGROUND

Although excessive opioid use is a significant global health issue, there is a lack of literature on the prescribing patterns for postoperative opioid use and exposure after discharge among surgical patients. This study aimed to examine the rate and predictors of opioid dispensing and high opioid exposure after hospital discharge from surgery in New Zealand (NZ) between January 2007 to December 2019.

METHODS

This is a retrospective population-based cohort study inclusive of all ages and surgical specialties. Data were obtained from the NZ Ministry of Health's national health databases.

RESULTS

1 781 059 patients were included in the study and 20.9% (n = 371 882) of surgical patients received opioids within 7 days after hospital discharge. From those who were dispensed with opioids after hospital discharge, 36.6% (n = 134 646) had high opioid exposure. Orthopaedic surgery (AOR 6.97; 95% CI 6.82-7.13) and history of opioid use (AOR 3.18; 95% CI 2.86-3.53) increased the odds of postoperative opioid dispensing and high opioid exposure respectively. Severe multi-morbidity burden (AOR 0.76; 95% CI 0.73-0.78) and alcohol misuse (AOR 0.84; 95% CI 0.77-0.93) lowered the odds of postoperative opioid dispensing and high opioid exposure respectively.

CONCLUSIONS

Our findings suggest a concerning rate of high opioid exposure among surgical patients after discharge. The predictors for postoperative opioid dispensing and high opioid exposure identified in our study provide insight into opioid prescribing patterns in NZ and inform future postoperative pain management.

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.

Opioid Use, Disposition, and Parent Satisfaction Following Common Pediatric Surgical Procedures

INTRODUCTION

There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers.

METHODS

We conducted phone surveys 30 days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control.

RESULTS

We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1 month to 246 months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal.

CONCLUSIONS

Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

Comparing Rationale for Opioid Prescribing Decisions after Surgery with Subsequent Patient Consumption: A Survey of the Highest Quartile of Prescribers

BACKGROUND

Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions-from nudges to reminders-have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown.

STUDY DESIGN

Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure-as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption.

RESULTS

During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%).

CONCLUSIONS

The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients.

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.

Preoperative transversus abdominis plane block decreases intraoperative opiate consumption during minimally invasive cholecystectomy

BACKGROUND

The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as multimodal drug regimens and regional anesthetic blocks (like transversus abdominis plane (TAP) block), have been introduced to the perioperative period in hopes of decreasing postoperative opiate use. However, the effect of these interventions on intraoperative opiate use has not been examined. We hypothesized that preoperative TAP block would be associated with decreased intraoperative opiate use during minimally invasive cholecystectomy.

METHODS

This was a retrospective review of patients undergoing minimally invasive cholecystectomy between June 2018 and January 2021. Perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements.

RESULTS

261 patients were included in this study, of which 62 (23.8%) received preoperative TAP block and 199 (76.2%) did not. Preoperative TAP block was associated with decreased intraoperative opiate use (0.199 vs 0.312, p < 0.001), while there were no statistically significant differences associated with other analgesic adjuncts including preoperative acetaminophen (p = 0.485), celecoxib (p = 0.112), gabapentin (p = 0.165), or intraoperative ketorolac (p = 0.200). On multivariate analysis, preoperative TAP block was independently associated with decreased intraoperative opiate use (< 0.001), while chronic cholecystitis on final pathology was associated with increased intraoperative opiate use (p = 0.002).

CONCLUSION

The use of preoperative TAP block was associated with decreased intraoperative opiate use during minimally invasive cholecystectomy and should be considered for routine use. Future research should investigate whether preoperative TAP blocks and a subsequent decrease of intraoperative opiates, also result in a decrease in postoperative opiate use and improvements in postoperative outcomes.

Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy

BACKGROUND

Surgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy.

METHODS

In a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts.

RESULTS

There were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001).

CONCLUSION

Performing a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.

Development and design of a mobile application for prescription opioid clinical decision-making: a feasibility study in New York City, USA

OBJECTIVES

Excessive opioid prescribing is a contributing factor to the opioid epidemic in the USA. We aimed to develop, implement and evaluate the usability of a clinical decision-making mobile application (app) for opioid prescription after surgery.

METHODS

We developed two clinical decision trees, one for opioid prescription after adult laparoscopic cholecystectomy and one for posterior spinal fusion surgery in adolescents. We developed a mobile app incorporating the two algorithms with embedded clinical decision-making, which was tested by opioid prescribers. A survey collected prescription intention prior to app use and participants' evaluation. Participants included opioid prescribers for patients undergoing (1) laparoscopic cholecystectomy in adults or (2) posterior spinal fusion in adolescents with idiopathic scoliosis.

RESULTS

Eighteen healthcare providers were included in this study (General Surgery: 8, Paediatrics: 10). Intended opioid prescription before app use varied between departments (General Surgery: 0-10 pills (mean=5.9); Paediatrics: 6-30 pills (mean=20.8)). Intention to continue using the app after using the app multiple times varied between departments (General Surgery: N=3/8; Paediatrics: N=7/10). The most reported reason for not using the app is lack of time.

CONCLUSIONS

In this project evaluating the development and implementation of an app for opioid prescription after two common surgeries with different prescription patterns, the surgical procedure with higher intended and variable opioid prescription (adolescent posterior spinal fusion surgery) was associated with participants more willing to use the app. Future iterations of this opioid prescribing intervention should target surgical procedures with high variability in both patients' opioid use and providers' prescription patterns.

A Personalized Opioid Prescription Model for Predicting Postoperative Discharge Opioid Needs

BACKGROUND

Opioid overprescribing after surgery is common. There is currently no universal predictive tool available to accurately anticipate postdischarge opioid need in a patient-specific manner. This study examined the efficacy of a patient-specific opioid prescribing framework for estimating postdischarge opioid consumption.

METHODS

A total of 149 patients were evaluated for a single-center retrospective cohort study of plastic and reconstructive surgery patients. Patients with length of stay of 2 to 8 days and quantifiable inpatient opioid consumption (n = 116) were included. Each patient's daily postoperative inpatient opioid consumption was used to generate a personalized logarithmic regression model to estimate postdischarge opioid need. The validity of the personalized opioid prescription (POP) model was tested through comparison with actual postdischarge opioid consumption reported by patients 4 weeks after surgery. The accuracy of the POP model was compared with two other opioid prescribing models.

RESULTS

The POP model had the strongest association (R2 = 0.899; P < 0.0001) between model output and postdischarge opioid consumption when compared to a procedure-based (R2 = 0.226; P = 0.025) or a 24-hour (R2 = 0.152; P = 0.007) model. Accuracy of the POP model was unaffected by age, gender identity, procedure type, or length of stay. Odds of persistent use at 4 weeks increased, with a postdischarge estimated opioid need at a rate of 1.16 per 37.5 oral morphine equivalents (P = 0.010; 95% CI, 1.04 to 1.30).

CONCLUSIONS

The POP model accurately estimates postdischarge opioid consumption and risk of developing persistent use in plastic surgery patients. Use of the POP model in clinical practice may lead to more appropriate and personalized opioid prescribing.

Predictors of opioid-free discharge after laparoscopic cholecystectomy

BACKGROUND

Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare.

STUDY DESIGN

Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge.

RESULTS

Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge.

CONCLUSION

Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.

The butterfly effect: How an outpatient quality improvement project affected inpatient opioid's prescribing habits

Background

The aim of the study was to assess whether a quality improvement project focused on providers' education of responsible opioid prescribing, creating order sets to facilitate pre- and post-operative adjunct use, and decreasing the number of opioids prescribed following elective outpatient surgery affected opioid prescribing habits and the use of adjunct pain medication on the inpatient Emergency General Surgery (EGS) service.

Methods

Inpatient EGS opioid prescribing habits following laparoscopic cholecystectomy, laparoscopic and open inguinal hernia repair, or open umbilical hernia repair during the pre- and post-Acute Care Surgery Division-Quality Improvement (QI) periods were recorded retrospectively. Demographics, type and dose of opioids, and non-opioid adjuncts prescribed were collected. Opioids were converted to oral morphine equivalents (OME). Pre- and post-QI data were compared. Post-QI discharge opioids prescribed were compared to reported use of opioids. Patients' rating of pain management is reported.

Results

One hundred twenty-two and 62 patients were included during the pre- and post- QI periods, respectively. Post-QI, opioid prescribing decreased, and adjunct prescribing increased (31.1% vs. 72.6%; p < 0.001) at discharge. Interestingly, higher 24 h pre-discharge OME was associated with a higher OME prescribed at discharge (B = 1.255 [0.377 - 2.134]; p = 0.005). Of the 47 EGS patients who followed up in clinic post-ACS QI, 89.4% rated their pain management as excellent/good, 8.5% as fair, and 2.1% as poor.

Conclusions

Implementation of a multifaceted approach to decrease opioid prescribing in the outpatient setting organically affected opioid prescribing habits at discharge for inpatients.

Incidence and patterns of persistent opioid use in children following appendectomy

BACKGROUND

The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children.

STUDY DESIGN

A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis.

RESULTS

1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%).

CONCLUSION

Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population.

LEVEL OF EVIDENCE

III.

Prolonged Opioid Use After Lumbar Fusion Surgery: A Meta-Analysis of Prevalence and Risk Factors

BACKGROUND

Persistent opioid utilization after spine surgery is a rising complication among both preoperatively opioid-naïve and opioid-tolerant patients. To our knowledge, this is the first meta-analysis to determine the prevalence and characterize the risk factors that predispose patients to prolonged opioid use (≥3 months) after lumbar fusion.

METHODS

Studies were identified through searches in PubMed and EMBASE from each database's earliest records to February 1, 2022. We included observational studies examining the risk factors and rates of prolonged opioid use following lumbar fusion. Pooled odds ratios (ORs) or standardized mean differences with corresponding 95% confidence intervals (CI) were estimated using inverse-variance methods.

RESULTS

In this meta-analysis of 12 studies encompassing 80,935 patients, 40.2% of patients continued to fill opioid prescriptions ≥3 months after lumbar fusion. Significant sociodemographic predictors included Medicare or Medicaid insurance (OR=1.60, 95% CI 1.36-1.88), African-American ethnicity (OR=1.29, 95% CI 1.18-1.41), being from the Southern United States (OR=1.18, 95% CI 1.11-1.25), or women (OR=1.10, 95% CI 1.01-1.20). Being from the Midwestern United States (OR=0.80, 95% CI 0.75-0.85) was found to be a protective factor. Comorbidities associated with increased risk of prolonged opioid use were preoperative opioid use (OR=5.76, 95% CI 3.52-9.41), drug abuse (OR=3.11, 95% CI 2.37-4.08), alcohol abuse (OR=2.37, 95% CI 2.14-2.64), psychiatric disorders (OR=2.29, 95% CI 1.94-2.70), smoking history (OR=1.81, 95% CI 1.23-2.66), arthritis (OR=1.35, 95% CI 1.29-1.40), and higher American Society of Anesthesiologists score (standardized mean difference=0.72, 95% CI 0.61-0.82).

CONCLUSIONS

The high prevalence of prolonged opioid use after lumbar fusion underscores the importance of screening patients for comorbidities and implementing targeted strategies to minimize opioid misuse.

The NOpioid Project: a prospective observational feasibility study examining the implementation of a non-narcotic post-operative pain control regimen

BACKGROUND

Post-operative prescription of opioids has fueled an increase in opioid-associated morbidity and mortality. Alternative post-operative pain control with non-opioid pharmaceuticals can help counteract this effect. We investigated a non-opioid pain management protocol following emergent laparoscopic appendectomy and laparoscopic cholecystectomy.

METHODS

Our tertiary referral center performed a prospective observational feasibility study of patients from October 2019 to 2020 who underwent emergent laparoscopic appendectomies and cholecystectomies. Patients aged 18-65 with no prior history of chronic pain or opioid abuse, no contraindications to taking acetaminophen and ibuprofen, and Glomerular Filtration Rate > 60 ml/min were included. Counseling was provided about non-narcotic pain control. Patients were not prescribed narcotics at discharge and were instead prescribed ibuprofen and acetaminophen. Patients were surveyed at their 2-week post-operative appointment to assess pain control and other patient-reported outcomes, including quality of life (QOL).

RESULTS

Fifty-one patients met the inclusion criteria and completed the postoperative survey. Thirty-two were female (63%), average age 38, and BMI 30.4. 30 (59%) underwent laparoscopic appendectomy for acute non-perforated appendicitis and 21 (41%) underwent laparoscopic cholecystectomy for acute cholecystitis or symptomatic cholelithiasis. 88% of patients felt satisfied or neutral with their post-operative pain control at discharge. After 2 weeks, 34 patients (66.7%) rated QOL as high, 17 (33.3%) rated QOL as moderate, and none rated QOL as poor. Fascial suture was not associated with poor outcomes. Anxiety, depression, alcohol use, and prior abdominal surgery were not associated with increased need for post-operative narcotics. There were no significant differences between appendectomy and cholecystectomy in satisfaction with pain control or QOL (p > 0.05).

CONCLUSION

Patients undergoing surgery have an increased risk of developing an opioid disorder. The NOpioid Project demonstrated a non-narcotic multimodal pain regimen can be effectively adopted in the post-operative period after an emergent laparoscopic appendectomy or emergent laparoscopic cholecystectomy.

Decreasing opioid prescribing at discharge while maintaining adequate pain management is sustainable

Background

In 2018, using a pragmatic multimodal approach, discharge opioid prescriptions were reduced without affecting pain control management. Herein, we assessed whether this approach was sustainable and whether discharge opioid prescriptions could be further reduced.

Methods

This is a single center prospective study of patients who underwent elective outpatient procedures provided by our institution's Acute Care Surgery Division surgeons. Adult patients who underwent elective surgeries performed by surgeons in the Division of Acute Care Surgery from November 2018 to June 2021 and agreed to participate were included. The opioid prescriptions pre-populated in the order set at discharge were reduced from 20 pills to 10 pills in May 2020. Demographics, opioid information, non-opioid adjuncts prescribed, reported use of opioids prescribed, and patients' satisfaction were collected. Opioids were converted to oral morphine equivalents (OME).

Results

A total of 178 patients were included. Elective surgeries performed mainly included inguinal hernia repair (38.8%), laparoscopic cholecystectomy (30.3%), cyst excision (13.5%), and umbilical hernia (8.4%). One hundred twenty-five and 53 patients underwent an elective operation with a surgeon in the Acute Care Surgery Division before and after the number of opioids pre-populated in the order set at discharge was reduced from 20 pills to 10 pills, respectively. Reducing the pre-populated discharge opioid prescriptions led to a significant decrease in OME prescribed (75 [75-76.5] vs. 80 [75-150], p < 0.001) without affecting patients' satisfaction with pain management (excellent/good: 87.8% vs. 84%; p = 0.305).

Conclusions

Our pragmatic multimodal approach is sustainable and allows for additional opioid prescription reduction without affecting patients' satisfaction with pain management.

Opiate Prescriptions Vary among Common Urologic Procedures: A Claims Dataset Analysis

Objectives: This study aimed to better understand differences in the total days’ supply and fills of common opiates following urologic procedures. Materials and Methods: The Truven Health MarketScan® database was used to extract CPT codes from adults 18 years or older who underwent a urologic procedure with 90-day follow-up from 2012−2015 within the Austin−Round Rock, Texas metropolitan service area. A multivariate analysis and first hurdle modeling with a logistic outcome for any opiates was used to (1) assess differences in opioid prescribing patterns, (2) investigate opioid prescription outcomes, and (3) explore variability among opiate prescription patterns across seven urologic procedure categories. Results: Among the 2312 patients who met the inclusion criteria, 23.7% received an opiate, with an average total day’s supply of 6.20 (range 2.61−10.59). The proportion of patients receiving opiates varied significantly by procedure type (p = 0.028). Patients that had reconstructive procedures had the highest proportion of any opiates and the highest number of mean opiate prescriptions among the seven procedure categories (42% received opiates, p = 0.028, mean opiate prescriptions were 1.0 among all patients, p = 0.026). After adjustments, the multivariate analysis demonstrated that patients undergoing reconstructive procedures filled more opiate prescriptions (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.00−3.50, p = 0.05) compared to other subcategories. Of those that received opiates, reconstructive patients had a shorter time to fills (mean −18.4 days, CI −8.40 to −28.50, p < 0.001). Conclusion: Patients undergoing reconstructive procedures are prescribed and fill more opiates compared to other common urological procedures. The standardization and implementation of postoperative pain regimens may help curtail this variability.

Incidence and risk factors for prolonged postoperative opioid use following lumbar spine surgery: a cohort study

OBJECTIVE

Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid).

METHODS

The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90-180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days' supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use.

RESULTS

A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05).

CONCLUSIONS

In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

Opioid Use After Intensive Care: A Nationwide Cohort Study

OBJECTIVE

To describe opioid use after ICU admission, identify factors associated with chronic opioid use after critical care, and determine if chronic opioid use is associated with an increased risk of death.

DESIGN

Retrospective cohort study.

SETTING

Sweden including all registered ICU admissions between 2010 and 2018.

PATIENTS

Adults surviving the first two quarters after ICU admission were eligible for inclusion. A total of 265,496 patients were screened and 61,094 were ineligible.

INTERVENTIONS

Admission to intensive care.

MEASUREMENTS AND MAIN RESULTS

Among 204,402 individuals included in the cohort, 22,138 developed chronic opioid use following critical care. Mean opioid consumption peaked after admission followed by a continuous decline without returning to baseline during follow-up of 24 months. Factors associated with chronic opioid use included high age, female sex, presence of comorbidities, preadmission opioid use, and ICU length of stay greater than 2 days. Adjusted hazard ratio for death 6-18 months after admission for chronic opioid users was 1.7 (95% CI, 1.6-1.7; p < 0.001). In the subset of patients not using opioids prior to admission, similar findings were noted.

CONCLUSIONS

Mean opioid consumption is increased 24 months after ICU admission despite the lack of evidence for long-term opioid treatment. Given the high number of ICU entries and risk of excess mortality for chronic users, preventing opioid misuse is important when improving long-term outcomes after critical care.

Narcotic Free Cervical Endocrine Surgery: A Shift in Paradigm

BACKGROUND AND OBJECTIVE

The opioid epidemic has stimulated initiatives to reduce the number of unnecessary narcotic prescriptions. We adopted an opt-in prescription system for patients undergoing ambulatory cervical endocrine surgery (CES). We hypothesized that empowering patients to decide whether or not to receive narcotics for pain control would result in fewer unnecessary opioid prescriptions.

METHODS

We enrolled all patients scheduled for outpatient CES between July 2017 and June 2018 in a narcotic opt-in program. Patient demographics, procedure characteristics, and postoperative pain scores were collected prospectively. Statistical analyses were performed to correlate clinical predictors with narcotic request. Results were compared against a historical control group. The study was approved by the University IRB.

RESULTS

A total of 216 consecutive patients underwent outpatient CES following implementation of the program. Only nine (4%) requested prescription narcotic medication at discharge, and no patient called after discharge to request analgesic medications. Compared with our prior treatment paradigm, we achieved a 96.6% reduction in the number of narcotic tablets prescribed, and a 98% reduction in unconsumed tablets. Univariate analysis suggested history of substance abuse (P < 0.001), anxiety (P = 0.01), depression (P < 0.001), baseline narcotic use (P = 0.004), highest pain postoperatively (P = 0.004), and incision length (P = 0.007) as predictive for narcotic request. Multivariate analysis retained significance with incision length and history of substance abuse.

CONCLUSION

By empowering patients undergoing ambulatory CES to accept or decline a prescription, we reduced the number of prescribed narcotic tablets by 96.6%. Although longer incisions and prior substance abuse predict higher likelihood of requesting pain medication on discharge, 207 of 216 patients were treated with acetaminophen alone.

Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery

OBJECTIVE

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions.

METHODS

The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type.

RESULTS

The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid).

CONCLUSIONS

In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery.

Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines

BACKGROUND

The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines.

METHODS

This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs).

RESULTS

Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01).

CONCLUSIONS

Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

Cancer survivorship and its association with perioperative opioid use for minor non-cancer surgery

PURPOSE

Reducing high-risk prescription opioid use after surgery has become a key strategy in mitigating the opioid crisis. Yet, despite their vulnerabilities, we know little about how cancer survivors use opioids for non-cancer perioperative pain compared to those with no history of cancer. The purpose was to examine the association of cancer survivorship with the likelihood of receiving perioperative opioid therapy for non-cancer minor surgery.

METHODS

Using 2007-2014 SEER-Medicare data for breast, colorectal, prostate, and non-cancer populations, we conducted retrospective cohort study of opioid-naïve Medicare beneficiaries who underwent one of six common minor non-cancer surgeries. Modified Poisson regression estimated the relative risk of receiving a perioperative opioid prescription associated with cancer survivorship compared to no history of cancer. Stabilized inverse probability of treatment weights were used to balance measurable covariates between cohorts.

RESULTS

We included 1486 opioid-naïve older adult cancer survivors and 3682 opioid-naïve non-cancer controls. Cancer survivorship was associated with a 5% lower risk of receiving a perioperative opioid prescription (95% confidence interval: 0.89, 1.00; p = 0.06) compared to no history of cancer. Cancer survivorship was not associated with the extent of perioperative opioid exposure.

CONCLUSION

Cancer survivors were slightly less likely to receive opioid therapy for non-cancer perioperative pain than those without a history of cancer. It is unclear if this reflects a reduced risk of opioid-related harms for cancer survivors or avoidance of appropriate perioperative pain therapy. Further examination of cancer survivors' experiences with and attitudes about opioids may inform improvements to non-cancer pain management for cancer survivors.

Using provider-focused education toolkits can aid enhanced recovery programs to further reduce patient exposure to opioids

Background

Evidence-based perioperative analgesia is an important tactic for reducing patient exposure to opioids in the perioperative period and potentially preventing new persistent opioid use.

Study design

We assessed the impact of a multifaceted optimal analgesia program implemented in the setting of a mature surgical pathway program at an academic medical center. Using existing multidisciplinary workgroups established for continuous process improvement in three surgical pathway areas ((colorectal, gynecology, and urologic oncology (cystectomy)), we developed an educational toolkit focused on implementation strategies for multimodal analgesia and non-pharmacologic approaches for managing pain with the goal of reducing opioid exposure in hospitalized patients. We analyzed prospectively collected data from pathway patients before dissemination of the toolkit (July 2016–June 2017; n = 869) and after (July 2017–June 2018; n = 838). We evaluated the association between program implementation and use of oral morphine equivalents (OME), average pain scores, time to first ambulation after surgery, urinary catheter duration, time to solid food after surgery, length of stay, discharge opioid prescriptions, and readmission.

Results

Multivariate regression demonstrated that the program was associated with significant decreases in intraoperative OME (14.5 ± 2.4 mEQ (milliequivalents) reduction; p < 0.0001), day before discharge OME (18 ± 6.5 mEQ reduction; p < 0.005), day of discharge OME (9.6 ± 3.28 mEQ reduction; p < 0.003), and discharge prescription OME (156 ± 22 mEq reduction; p < 0.001). Reduction in OME was associated with earlier resumption of solid food (0.58 ± 0.15 days reduction; p < 0.0002).

Conclusion

Our multifaceted optimal analgesia program to manage perioperative pain in the hospital was effective and further improved analgesia in the setting of a mature enhanced recovery program.

Assessment of Unused Opioids Following Ambulatory Surgery

Background

Surgery is a risk factor for opioid initiation and subsequent abuse. Discharge opioid prescription patterns after surgery are often varied and not evidence based, which may lead to unnecessary prescription of opioids. We aimed to assess opioid prescribing and unused opioid prescriptions in ambulatory surgery patients at our academic hospital.

Methods

We conducted a retrospective observational study based on phone survey and electronic medical records. Adult patients who underwent ambulatory surgery at our large, multisite, tertiary-care hospital system were asked whether they were using the opioids that were prescribed at discharge. Our main outcomes were opioid prescription (defined as being prescribed an opioid on discharge) and unused opioid prescription (defined as being prescribed an opioid but not taking any opioids on postoperative day 1). We evaluated predictors of opioid prescription and unused opioid prescription through univariable and multivariable analyses. We also stratified outcomes by surgical service.

Results

Of 4248 adult patients who underwent ambulatory surgical procedures, 3279 (77.2%) responded to the survey. Of all responders, 2146 (65.4%) were prescribed postoperative opioids, and 1240 (57.8%) reported not taking them on postoperative day 1. The highest rates of unused opioid prescriptions were for patients whose primary service were orthopedic surgery (65%) and plastic surgery (62%).

Discussion

Opioid prescribing and unused opioid prescriptions are prevalent in our hospital’s ambulatory surgical population. Patients undergoing selected ambulatory surgical procedures may not require as much opioid as is currently being prescribed.

Impact of Policy Interventions on Postoperative Opioid Prescribing

OBJECTIVE

To assess postoperative opioid prescribing in response to state and organizational policy changes.

METHODS

We used an observational study design at an academic medical center in the Northeast United States over a time during which there were two important influences: 1) implementation of state rules regarding opioid prescribing and 2) changes in organization policies reflecting evolving standards of care. Results were summarized at the surgical specialty and procedure level and compared between baseline (July-December 2016) and postrule (July-December 2017) periods.

RESULTS

We analyzed data from 17,937 procedures from July 2016 to December 2017, two-thirds of which were outpatient. Schedule II opioids were prescribed in 61% of cases and no opioids at all in 28%. The median morphine milligram equivalent (MME) prescribed at discharge decreased 40%, from 113 MME in the baseline period to 68 MME in the postrule period. Decreases were seen across all the surgical specialties.

CONCLUSIONS

Postoperative opioid prescribing at the time of hospital discharge decreased between 2016 and 2017 in the setting of targeted and replicable state and health care organizational policies.

POLICY IMPLICATIONS

Policies governing the use of opioids are an effective and adoptable approach to reducing opioid prescribing following surgery.

Reduced Opioid Prescription Practices and Duration of Stay after TAP Block for Laparoscopic Appendectomy

BACKGROUND

We evaluated whether TAP blocks performed at the time of appendectomy resulted in reduced total oral morphine equivalent (OME) prescribed and fewer 30-day opioid prescription (OP) refills.

STUDY DESIGN

Single institution review of historical data (2010-2016) was performed. Adults (≥ 18 years) that underwent appendectomy for appendicitis with uniform disease severity (AAST EGS grades I, II) were included. Opioid tolerance was defined as any preoperative OP ordered 1-3 months prior to appendectomy or < 1 month unrelated to appendicitis; opioid naïve patients were without OP. Intraoperative TAP blocks (admixture of liposomal/regular bupivacaine) were performed at surgeon discretion. Risk factors for discharge prescription > 200 OME were assessed using logistic regression and quantified using odds ratios (OR) and 95% confidence intervals (CI).

RESULT

There were 960 patients with uniform appendicitis severity. During appendectomy, 145 (15%) patients received TAP blocks. There were 46 patients that were opioid tolerant (5%) and the majority of the cohort received discharge OP (n = 914, 95%) with a median prescription OME volume of 225 [150-300]. Only 76 patients required 30-day opioid prescription refill. On regression, factors associated with a discharge prescription > 200 OME included ≥ 65 years of age (OR 0.64 (95%CI 0.41-0.98)) and no TAP block (OR 1.7 (95%CI 1.2-2.5)) but not preoperative opioid utilization.

CONCLUSIONS

TAP blocks in low-grade appendicitis were associated with reduced OME prescribed, hospital duration of stay, and fewer refills without impacting operative time or total hospital costs.

Opioid stewardship after emergency laparoscopic general surgery

Background

Opioid administration in postoperative patients has contributed to the opioid crisis by increasing the load of opioids available in the community. Implementation of evidence-based practices is key to optimizing the use of opioids for acute pain control. This study aims to characterize the administration and prescribing practices after emergency laparoscopic general surgery procedures with the goal of identifying areas for improvement.

Methods

A retrospective chart review of 200 patients undergoing emergency laparoscopic appendectomies and cholecystectomies was conducted for a 2-year period at a single institution. Eligible patients were opioid-naïve adults admitted through the emergency department. Opioid administration and discharge prescriptions were converted to oral morphine equivalents (OME), and analyzed and compared with published literature and local guidelines.

Results

Opioid analgesia was provided as needed to 69% of patients in hospital with average dosing of 26.7 OME/day; comparatively, 99.5% of patients received prescriptions for opioids on discharge at an average dosing of 61.7 OME/day. The average dosing in the discharge prescriptions was not correlated with in-hospital needs (Pearson=−0.04; p=0.56); and higher narcotic doses were associated with combination opioid prescriptions compared with separate opioid prescriptions (73.8 (1.90) vs. 50.1 (1.90) OME/day; p<0.01). This difference was driven by the combination medication, Percocet.

Conclusions

In the immediate postoperative period, most patients were managed in hospital with opioid analgesia dosages that fell within guidelines. Nearly all patients were provided with prescriptions for opioids on discharge, these prescriptions both exceeded local guidelines and were not correlated with in-hospital narcotic needs or pain scores.

Level of evidence

Level 3 retrospective cohort study.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients

Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.

How low can you go: Achieving postoperative outpatient pain control without opioids

BACKGROUND

Postoperative outpatient narcotic overprescription plays a significant role in the opioid epidemic. Outpatient opioid prescription ranges from 150 to 350 oral morphine equivalent (OME) for a laparoscopic cholecystectomy or appendectomy, with 75 OME (10 pills of 5 mg of oxycodone) being the lowest recommendation (National Institute on Drug Abuse, 2018). We hypothesized that the addition of nonopioid medications to the outpatient pain control regimen would decrease the need for narcotics.

METHODS

In this prospective, observational pilot study, we prescribed a 3-day regimen of ibuprofen and acetaminophen to patients after uncomplicated laparoscopic cholecystectomies and appendectomies. An additional opioid prescription for 5 pills of 5 mg of oxycodone (37.5 OME) was written for breakthrough pain. During their postoperative visit, we evaluated patients' adherence to the pain control regime, their postdischarge opioid use, and the adequacy of their pain control.

RESULTS

Sixty-five patients were included in the study (52% male). The majority (80%) of surgeries were performed urgently or emergently. The visual analog scale pain score at home was significantly better than upon discharge (3.7 vs. 5.5, p = 0.001). The average number of oxycodone pills taken postdischarge was 1.8 pills. Half (51%) of the patients did not take any opioids. All but four patients reported that their pain was adequately controlled. No patient required additional opioid prescriptions or visited the emergency department.

CONCLUSION

This study demonstrated that opioids can be eliminated in at least half of the patients and that five pills of 5 mg of oxycodone (37.5 OME) is sufficient for outpatient pain control when a 3-day course of ibuprofen and acetaminophen is prescribed.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Early In-Hospital Pain Control Is a Stronger Predictor for Patients Requiring a Refill of Narcotic Pain Medication Compared to the Amount of Narcotics Given at Discharge

BACKGROUND

The United States is combating an opioid epidemic. Orthopedic surgeons are the third highest opioid prescribers and therefore have an opportunity and obligation to assist in the efforts to reduce opioid use and abuse. In this article, we evaluate risk factors for patients requiring an opioid refill after primary total knee arthroplasty, with the goal to reduce opioid prescriptions for those patients at low risk of requiring a refill in order to reduce the amount of unused medication.

METHODS

We retrospectively reviewed narcotic-naïve patients who underwent total knee arthroplasty from December 2017 to May 2018. We performed multivariable analysis on demographics and preoperative, operative, and postoperative characteristics to determine risk factors for requiring a prescription refill following hospital discharge.

RESULTS

One-hundred fifty-seven patients were included in the analysis. Sixty percent of patients required a prescription refill. Risk factors included younger age (P = .003) and increased pain on postoperative day one (P < .001). The amount of narcotic medication given at discharge did not independently affect the refill rate (P = .21).

CONCLUSION

There is strong evidence that elderly patients and those with good pain control on postoperative day 1 are at a lower risk of requiring a narcotic refill postoperatively. With this information, physicians may begin to tailor narcotic prescriptions based on patient risk factors for requiring a prescription refill rather than provide patients with the same number of pills for a given surgery in an effort to reduce unused narcotic medication.

Inconsistency in Opioid Prescribing Practices After Pediatric Ambulatory Hernia Surgery

INTRODUCTION

Nonmedical opioid use is a major public health problem. There is little standardization in opioid-prescribing practices for pediatric ambulatory surgery, which can result in patients being prescribed large quantities of opioids. We have evaluated the variability in postoperative pain medication given to pediatric patients following routine ambulatory pediatric surgical procedures.

METHODS

Following IRB approval, pediatric patients undergoing umbilical hernia repair, inguinal hernia repair, hydrocelectomy, and orchiopexy from 2/1/2017 to 2/1/2018 at our tertiary care children's hospital were retrospectively reviewed. Data collected include operation, surgeon, resident or fellow involvement, utilization of preoperative analgesia, opioid prescription on discharge, and patient follow-up.

RESULTS

Of 329 patients identified, opioids were prescribed on discharge to 37.4% of patients (66.3% of umbilical hernia repairs, 20.6% of laparoscopic inguinal hernia repairs, and 33.3% of open inguinal hernia repairs [including hydrocelectomies and orchiopexies]). For each procedure, there was large intrasurgeon and intersurgeon variability in the number of opioid doses prescribed. Opioid prescription ranged from 0 to 33 doses for umbilical hernia repairs, 0 to 24 doses for laparoscopic inguinal repairs, and 0 to 20 doses prescribed for open inguinal repairs, hydrocelectomies, and orchiopexies. Pediatric surgical fellows were less likely to discharge a patient with an opioid prescription than surgical resident prescribers (P < 0.01). In addition, surgical residents were more likely to prescribe more than twelve doses of opioids than pediatric surgical fellows (P < 0.01). Increasing patient age was associated with an increased likelihood of opioid prescription (P < 0.01). There were two phone calls and two clinic visits for pain control issues with equal numbers for those with and without opioid prescriptions.

CONCLUSIONS

There is significant variation in opioid-prescribing practices after pediatric surgical procedures; increased awareness may help minimize this variability and reduce overprescribing. Training level has an impact on the frequency and quantity of opioids prescribed.