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Variation of Opioid Prescribing Patterns among Patients undergoing Similar Surgery on the Same Acute Care Surgery Service of the Same Institution: Time for Standardization?

      Abstract

      Background

      Diversion of unused prescription opioids is a major contributor to the current United States opioid epidemic. We aimed to study the variation of opioid prescribing in emergency surgery.

      Methods

      Between October 2016 and March 2017, all patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, or inguinal hernia repair in the acute care surgery service of 1 academic center were included. For each patient, we systematically reviewed the electronic medical record and the prescribing pharmacy platform to identify: (1) history of opioid abuse, (2) opioid intake 3 months preoperatively, (3) number of opioid pills prescribed, (4) prescription of nonopioid pain medications (eg, acetaminophen, ibuprofen), and (5) the need for opioid prescription refills. The mean and range of opioid pills prescribed, as well as their oral morphine equivalent, were calculated.

      Results

      A total of 255 patients were included (43.5% laparoscopic appendectomy, 44.3% laparoscopic cholecystectomy, and 12.1% inguinal hernia repair). The mean age was 47.5 years, 52.1% were female, 11.4% had a history of opioid use, and 92.5% received opioid prescriptions upon hospital discharge. Only 70.9% of patients were instructed to use nonopioid pain medications. The mean and range of opioid pills prescribed were 17.4; 0–56 (laparoscopic appendectomy), 17.1; 0–75 (laparoscopic cholecystectomy), and 20.9; 0–50 (inguinal hernia repair), while the range of prescribed oral morphine equivalent was 0–600 mg for laparoscopic appendectomy/laparoscopic cholecystectomy and 0–375 mg for inguinal hernia repair. No patients required any opioid medication refills.

      Conclusion

      Even within the same surgical service, wide variation of opioid prescription was observed. Guidelines that standardize pain management may help prevent opioid overprescribing.
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      References

      1. US Centers for Disease Control and Prevention. Provisional counts of drug overdose deaths as of August 6, 2017. Available from https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf.

        • Lucas CE
        • Vlahos AL
        • Ledgerwood AM
        Kindness kills: the negative impact of pain as the fifth vital sign.
        J Am Coll Surg. 2007; 205: 101-107
        • Thiels CA
        • Anderson SS
        • Ubl DS
        Wide variation and overprescription of opioids after elective surgery.
        Ann Surg. 2017; 266: 564-573
        • Gasior M
        • Bond M
        • Malamut R
        Routes of abuse of prescription opioid analgesics: a review and assessment of the potential impact of abuse-deterrent formulations.
        Postgrad Med. 2016; 128: 85-96
        • Setnik B
        • Roland CL
        • Goli V
        • et al.
        Self-reports of prescription opioid abuse and diversion among recreational opioid users in a Canadian and a United States city.
        J Opioid Manag. 2015; 11: 463-473
        • Cicero TJ
        • Dart RC
        • Inciardi JA
        • Woody GE
        • Schnoll S
        • Muñoz A
        The development of a comprehensive risk-management program for prescription opioid analgesics: researched abuse, diversion and addiction-related surveillance (RADARS).
        Pain Med. 2007; 8: 157-170
        • Manchikanti L
        • Singh A
        Therapeutic opioids: a ten-year perspective on the complexities and complications of escalating use, abuse, and nonmedical use of opioids.
        Pain Physician. 2008; 11: 63-88
      2. Centers for Disease Control and Prevention. Opioid painkiller prescribing, where you live makes a difference. Atlanta, GA: Centers for Disease Control and Prevention; 2014.

        • Inciardi JA
        • Surratt HL
        • Cicero TJ
        • Beard RA
        Prescription opioid abuse and diversion in an urban community: the results of an ultrarapid assessment.
        Pain Med. 2009; 10: 537-548
      3. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: summary of national findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

        • Levy B
        • Paulozzi L
        • Mack KA
        • et al.
        Trends in opioid analgesic-prescribing rates by specialty, US, 2007–2012.
        Am J Prev Med. 2015; 49: 409-413
        • Bates C
        • Laciak R
        • Southwick A
        • et al.
        Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice.
        J Urol. 2011; 185: 551-555
        • Kaafarani HM
        • Weil E
        • Wakeman S
        • Ring D
        The opioid epidemic and new legislation in Massachusetts: time for a culture change in surgery?.
        Ann Surg. 2017; 265: 731-733
        • Califf RM
        • Woodcock J
        • Ostroff S
        A proactive response to prescription opioid abuse.
        New Engl J Med. 2016; 374: 1480-1485
        • Taylor S
        • Voytovich AE
        • Kozol RA
        Has the pendulum swung too far in postoperative pain control?.
        Am J Surg. 2003; 186: 472-475
        • Gandhi K
        • Heitz JW
        • Viscusi ER
        Challenges in acute pain management.
        Anesthesiol Clin. 2011; 29: 291-309
        • Lavand'homme P
        The progression from acute to chronic pain.
        Curr Opin Anaesthesiol. 2011; 24: 545-550
        • American Society of Anesthesiologists Task Force on Acute Pain Management
        Practice guidelines for acute pain management in the perioperative setting.
        Anesthesiology. 2012; 116: 248-273
        • Apfelbaum JL
        • Ashburn MA
        • Connis RT
        • et al.
        Practice guidelines for acute pain management in the perioperative setting.
        Anesthesiology. 2012; 116: 248-273
        • Rodgers J
        • Cunningham K
        • Fitzgerald K
        • et al.
        Opioid consumption following outpatient upper extremity surgery.
        J Hand Surg Am. 2012; 37A: 645-650
        • Hill MV
        • McMahon ML
        • Stucke RS
        Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.
        Ann Surg. 2017; 265: 709-714
        • Hill MV
        • Stucke RS
        • McMahon ML
        • Beeman JL
        • Jr BarthRJ
        An educational intervention decreases opioid prescribing after general surgical operations.
        Ann Surg. 2018; 267: 468-472
        • Cron DC
        • Englesbe MJ
        • Bolton CJ
        Preoperative opioid use is independently associated with increased costs and worse outcomes after major abdominal surgery.
        Ann Surg. 2017; 265: 695-701
        • Jiang X
        • Orton M
        • Feng R
        • et al.
        Chronic opioid usage in surgical patients in a large academic center.
        Ann Surg. 2017; 265: 722-727