Procedure Determines How Long Post-Surgical Patients Should Receive Opioids

by Brenda Mooney

November 9, 2017

Study Uses MHS Data to Create Guidelines for Painkillers

BOSTON – How long should patients use opioids after common surgical procedures?

Until now, there hasn’t been much consensus on the answer. A new study analyzing prescription data from the DoD’s Military Health System Data Repository recently sought to remedy that, however.

A study team led by researchers at the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston and including participation from the Uniformed Services University of the Health Sciences in Bethesda, MD, pointed out that few guidelines detail the optimal way to prescribe postsurgical painkillers, balancing pain control without increasing the risk of addiction.

The goal was to examine whether prescriptions were appropriate—looking at the rate of refills as one indicator—and to develop recommendations.

To do that, the researchers focused on slightly more than 200,000 MHS patients who had no recent history of opioid use. Nationally, representative subjects in the study, which was published in JAMA Surgery, had undergone one of eight common surgical procedures between 2006 and 2014 and were prescribed opioid medications to help control pain.1

Results indicated that median prescription length for first-time opioid prescriptions ranged from four to seven days, and, according to the type of procedure performed, the percentage of patients requiring refills could be anywhere from 11.3% to 39.3%.

Average duration of the prescription also was affected by the procedure category; that varied from nine days for general surgery procedures to 15 days for musculoskeletal procedures.

“While seven days may be more than adequate for many patients undergoing common general surgery and gynecological procedures, prescription length limits may need to be extended to 10 days, recognizing that as many as 40 percent of patients may still require a refill at a seven-day limit for pain management, particularly following many orthopedic and neurosurgical procedures,” explained Rebecca Scully, MD, MPH, a BWH surgical resident.

Data was derived from the Military Health System Data Repository, which tracks care delivered to active, disabled and retired members of the U.S armed forces and their dependents. Initially identified were 215,140 adult patients, average age 40.1, who had filled at least one postsurgical pain medication prescription within 14 days of surgery. They all had undergone one of eight common procedures:

  • cholecystectomy,
  • appendectomy,
  • inguinal hernia repair,
  • ACL reconstruction,
  • rotator cuff tear repair,
  • discectomy,
  • mastectomy or

Excluded from the study were those with a prior diagnosis of chronic pain, substance dependence or an opioid prescription within six months preceding the index procedure.

Most of the patients, more than 122,000, underwent general surgery. Another nearly 48,000 had musculoskeletal procedures and the remaining nearly 45,000 had a mastectomy or hysterectomy.

Mathematical Model

A mathematical model was employed to determine the optimal length of opiate prescription, which was four to nine days for general surgery procedures, four to 13 days for women’s health procedures and six to 15 days for musculoskeletal procedures.

The median prescription lengths were determined to be four days (interquartile range [IQR], three to five days) for appendectomy and cholecystectomy, five days (IQR, three to six days) for inguinal hernia repair, four days (IQR, three to five days) for hysterectomy, four days (IQR, three to six days) for mastectomy, five days (IQR, four to eight days) for anterior cruciate ligament repair and rotator cuff repair, and seven days (IQR, five to10 days) for discectomy.

For general surgery procedures the greatest probability of refill, 10.7%, occurred with nine-day initial prescription and was 13 days for women’s health procedures—a 16.8% probability of refill—and 15 days for musculoskeletal procedures—with a 32.5% probability of refill.

Overall, 19.1% of patients required a refill during the 14 days after their procedure.

[Click Image to Enlarge] Modeled Proportion of Individuals Requiring Opioid Pain Medication Refill by Length of Initial Prescription by Procedure GroupAdjusted proportion of individuals requiring repeated opioid prescription after procedure by duration of initial prescription. Risk was adjusted for age, sex, race/ethnicity, socioeconomic status, and postoperative complications. The modified Charlson Comorbidity Index was used to adjust for comorbidities. MSK indicates musculoskeletal.

The report emphasized the paucity of guidelines for pain management in the postoperative, outpatient setting. For example, the researchers point to the American College of Occupational and Environmental Medicine guidelines on opioid treatment, which include postoperative pain but note the recommendations are limited to screening patients who continue opioid pain medications beyond the second postoperative week, prescribing a maximum daily dose of 50 mg morphine equivalent in opioid-naive patients, and discontinuing opioids for patients who have reached meaningful functional recovery.

The American Pain Society, meanwhile, recommends instructing patients on opioid use at the transition to outpatient care but doesn’t make recommendations on type or duration of analgesia. The Institute for Clinical Systems Improvement recommends limiting initial prescriptions to three days or 20 tablets with appropriate adjuncts, education and follow-up, without specification regarding the type of procedure performed, study authors wrote.

The report described how some governmental entities have sought to address the nationwide opioid crisis by limiting the length of initial prescriptions of opioid pain medication, typically to a week or less. New York and Massachusetts have recently passed such legislation, it added.

“The optimal length of opioid prescription after common surgical procedures likely lies between the observed median prescription length and the early nadir in the modeled probability of refill: four to nine days for general surgery procedures, four to 13 days for women’s health procedures, and six to 15 days for musculoskeletal procedures,” the researchers explained. “Although a seven-day limit on initial opioid prescription appears to be adequate for many common general surgery and gynecologic procedures, for patients undergoing orthopedic and neurosurgical interventions, a seven-day limit may be inappropriately restrictive and place an undue burden on patients and clinicians.”

The study emphasized that orthopedic procedures appeared to be associated with the highest refill rates and the highest median length of initial prescriptions, noting that data tracks with previous research finding chronic use of postoperative opioid medications higher after orthopedic and neurosurgical procedures. In fact, the authors stated, for noncancer pain, orthopedic surgeons prescribe opioids more frequently than any other provider type and, among Medicare beneficiaries, have the highest frequency of opioid pain medication claims of any surgical specialty.

While some criticism has been directed at the specialty, study authors suggested that orthopedic patients actually require a longer duration of pain relievers. The problem, they stated, has been a lack of understanding of what is appropriate in post-surgical pain management.

“We recognize that the opiate crisis is being addressed on many social, legislative, and policy levels,” noted author Louis Nguyen, MD, MBA, MPH. “We hope our paper provides a quantitative analysis of current prescribing patterns and sheds light on the optimal prescription in patients undergoing surgical procedures.”

  1. Scully RE, Schoenfeld AJ, Jiang W, Lipsitz S, et. al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical ProceduresJAMA Surgery, 2017 DOI: 1001/jamasurg.2017.3132

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