Appropriate Opioid Prescribing for Acute Pain after Surgery

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1 Appropriate Opioid Prescribing for Acute Pain after Surgery Richard J. Barth Jr. Professor of Surgery Chief, Section of General Surgery Dartmouth Hitchcock Medical Center Clinical Trials Network Webinar February 13, 2018

2 The faces of the opioid epidemic in NH

3 The Opioid Epidemic: Introduction Prescription opioid deaths quadrupled in last 15 years Overdoses now leading cause of injury related deaths 19,000 die in US annually, 400 in NH (2016) Opioid prescribing has also quadrupled in the past 15 years and is highly prevalent: 82.5 prescriptions per 100 persons per year Dart R. NEJM 2015; 372: 241 Paulozzi L. J Saf Res 2014; 51: 125.

4 Link between increased opioid prescribing and increasing opioid overdose deaths FDA and Surgeon General: The crisis will continue unabated unless clinicians stop prescribing opioids far in excess of clinical need. Califf R. NEJM 2016; 374: 1480

5 Surgeons play an important role in the opioid epidemic Surgeons commonly prescribe opioids after surgery Prescribing opioids for our patients has risks for them: People who undergo general surgical operations (breast surgery, cholecystectomy) have a relative risk 2-3 X higher than the general population of becoming chronic opioid users. 5-10% of opioid naïve patients become chronic users after prescribed opioids for surgery. The pills our patients don t use can be used by others: Diversion: 71% of users get drugs by diversion.

6 5-10% of opioid naïve patients become chronic users after prescribed opioids for surgery Study N % chronic users Definition Alam ,000 7 On opioids 1 year after surgery Deyo ,000 5 >5 refills subsequent year Johnson , New script days after surgery Brummet ,000 6 New script days after surgery Jiang ,000 9 On opioids 90 days after surgery Shah ,295,000 5 On opioids 1 year after surgery

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8 The Problem for Surgeons Concern for individual patient Tendency to overprescribe: Want to minimize acute post-operative pain Avoid need for patients to have to return to clinic for a refill prescription Responsibility for population health Minimize diversion, overdose, and addiction Clinicians need to limit prescriptions Provide patients with lowest practical dose What is the balance? What is the ideal number to prescribe?

9 Literature Review: 2015 Few studies exist that address optimal post-operative opioid prescriptions Urologic, oral, hand, and upper extremity surgery No studies looking at best prescribing practices in general surgery J Oral Maxillofac Surg 71: , 2013 J Hand Surg Am. 2012;37A: J Hand Surg Am. 2015;40(2):341e346 J Urology :

10 Ann Surg 2017, 265: Ann Surg 2017, in press J Am Col Surg., 2017 in press.

11 Methods The 5 most common outpatient procedures performed June-Dec 2015: partial mastectomy, partial mastectomy with sentinel lymph node biopsy, laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, open inguinal hernia repair Post-operative opioid prescription data and opioid refill data were obtained Patients with recent opioid use, history of opioid abuse, and those with postoperative complications were excluded We called patients and asked them how many opioids they took.

12 Cases Performed and Analyzed Partial Mastectomy Partial Mastectomy with Sentinel Lymph Node Laparoscopic Cholecystectomy Laparoscopic Inguinal Hernia Repair Open Unilateral Inguinal Hernia Repair ALL CASES Cases Performed Number Patients Excluded Chronic opioid use/ abuse Complications (8%) (5%) (3%) Patients Analyzed

13 Opioid Prescriptions Patients Receiving Opioid Prescription PM (175) 129 (73.7%) PM SLNB (104) 92 (88.5%) LC (208) LIH (76) IH (79) 205 (98.6%) 76 (100%) 79 (100%) Opioid Pills Prescribed Mean Median Range

14 Frequency of opioids prescribed (A) and taken (B) after partial mastectomy Percent Surveyed Popultion Percent Total Population A 30 N=175 Median= 20 Range= B Pills Prescribed Pills Taken

15 Frequency of opioids prescribed (A) and taken (B) after partial mastectomy with sentinel lymph node biopsy Percent Surveyed Population Percent Total Population 25 N=104 Median= 20 Range= 0-60 A Pills Prescriped B Pills Taken

16 Frequency of opioids prescribed (A) and taken (B) after laparoscopic cholecystectomy Percent Surveyed Population Percent Total Populatoin N=208 Median= 30 Range= A Pills Prescribed B Pills Taken

17 Frequency of opioids prescribed (A) and taken (B) after laparoscopic inguinal hernia repair Percent Total Population Percent Surveyed Population N=76 Median= 30 Range= A Pills Prescribed B Pills Taken

18 Frequency of opioids prescribed (A) and taken (B) after unilateral open inguinal hernia repair Percent Total Population Percent Surveyed Population N=79 Median= 30 Range= A B 40 Pills Prescribed Pills Taken

19 Home Opioid Use Summary: Only ¼ of pills were taken!

20 Ideal Number of Pills Calculated for each case by determining the number of pills that would fulfill the opioid use of > 80% of the patients Percent Surveyed Population35 84% Pills Taken PM PM PM LC LIH LC LIH I SLNB SLNB H Ideal # pills Ideal # pills Median # pills actually prescribed 57% decrease

21 Effect of provider education intervention We presented opioid use data and these guidelines at Grand Rounds, GS section meeting, sent s, resident teaching session April, May 2016 Recommended use acetaminophen and ibuprofen first, then opioids What % of pts will have 50% reduction in pain for 6 hours (Cochrane)? Ibuprofen and acetaminophen: 73% 23% placebo: 17% ibuprofen alone: 52% Oxycodone: Ibuprofen and acetaminophen as effective as opioid plus acetaminophen in RCT ER setting acute pain Observed opioid prescribing patterns same 5 outpatient operations, June- September 2016, 224 patients Collected data on opioid use Derry S. Cochrane Library 2013; 6:DC Derry C. Cochrane Library 2013; 6:DC010210

22 Comparison of opioid prescriptions pre vs post provider education Mean number of opioid pills prescribed (SD) Median number of opioid pills prescribed Range Operation Pre Post p-value Pre Post Pre Post PM PM SLNB LC LIH IH

23 Effect of education intervention on total number of opioid pills actually prescribed 53% decrease!

24 Were patient s pain medication needs met? Of 224 patients, Only 34% of the prescribed opioids were taken. Only 1 patient (<0.5%) required an opioid refill. Answer: YES!

25 Prescriptions in excess of guidelines 32% of total patients were prescribed more pills than recommended 34 providers wrote prescriptions 6 attendings, 41% excessive 27 residents, 35% excessive 4 providers wrote for half of all the excessive prescriptions

26 % Patients Analgesic use after partial mastectomy No Opioid Acetaminophen or NSAID Both Acetaminophen and NSAID Opioid Only 0 Partial Mastectomy

27 % Patients Analgesic use after Lap CCY Laparoscopic Cholecystectomy No Opioid Acetaminophen or NSAID Both Acetaminophen and NSAID Opioid Only

28 Conclusions An educational intervention resulted in a marked decrease in opioids prescribed for 5 general surgery operations Number of pills prescribed decreased by 53% All 5 operations showed a statistical decrease in pills prescribed Patient pain was not worse: only 1 of 224 patients obtained opioid refill 85% of pts used either acetaminophen or NSAID Opportunity: only 21% used both acetaminophen and NSAID Much less variability in number pills prescribed

29 How many opioids should be prescribed to patients who are discharged after surgery which requires an inpatient admission? Laws limiting number of pills prescribed to a 7 day supply Ambiguity: Is a 7 day supply 21 pills (1 every 6 hrs while awake) or 84 (2 every 4 hrs)? Do you assume the patients will use less pills every day? Is 7 days the right number, or 5, or 10?

30 Methods Six common inpatient operations July Dec, 2016: Studied 333 patients Excluded patients chronic opioid use, complications, discharged to nursing facility 85% sent home with opioid prescription

31 90% of patients answered questionnaire or phone call Home Opioid Use

32 Analysis Groups DC on POD =1 DC on POD 2 Home opioid use Inpatient use on day prior to discharge Home opioid use

33 Percent Home opioid use for patients discharged on POD Home Opioid Use After Discharge (Pills)

34 Univariate and multivariate analysis of factors associated with home opioid use We found: 1) The number of pills taken the day prior to discharge was the best predictor of how many opioids were used at home 2) Opioid use at home after inpatient admission was independent of the operation performed

35 Variable n Pills taken after discharge, Mean, (SD) Univariate p value Multivariate p value Age < Less than (18) (9) Gender Male 57 8 (17) Female 98 9 (13) Surgery type Colectomy 64 5 (10) Liver 11 7 (10) Hernia (27) Pancreas 10 6 (7) Bariatric (15) Foregut (14) Length of stay days (18) 3+ days 98 6 (12) Use of either Tylenol or Ibuprofen No (22) Yes (12) Number of pills taken the day prior to discharge < < (4) (9) (21)

36 Percent No opioid pills taken day prior to discharge Home Opioid Use After Discharge (Pills)

37 Percent 1-3 opioid pills taken on day prior to discharge Home Opioid Use After Discharge (Pills)

38 Percent 4 opioid pills taken day prior to discharge Home Opioid Use After Discharge (Pills)

39 Prescription guidelines to satisfy 85% of patients home opioid usage Discharge Date POD =1 Number to Prescribe 15 POD 2 Pills used on day prior to DC 0 pills pills 15 4 pills 30

40 Potential Savings in Opioid Pills Prescribed if our Guidelines were Used 40%

41 Guidelines will likely overestimate home opioid needs Use of non-opioid pain medication only 28% used both acetaminophen and ibuprofen Elderly- prescribe less Set the bar lower and E-prescribe refills If set at 65% of pts needs, then decrease # used by 60% Opioid use for non-surgical pain indications

42 Outliers 40 patients took more pills than the recommended prescription amount 7 7 Fear Non-surgical pain 7 Indigestion Post-op pain 47 53% took opioids for reasons other than surgical pain 14 As prescribed Sleep 18

43 What happens to excess pills? FDA approved disposal: First DH outpatient study: 9% Inpatient study 1 year later: 19% Take Back Days Buy back programs, Jean Liu, WRJ VA

44 Conclusions: Inpatient Prescriptions The strongest predictor of home opioid use was inpatient use the day prior to discharge Opioid use at home after inpatient admission was independent of the operation performed Established a guideline for discharge opioid prescribing easy to use and remember Use of this guideline will greatly decrease # opioids prescribed and will take care of patients pain

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