A study has identified the top three surgical procedures in which high percentages of patients are discharged with prescriptions for more than 60 mg of oral morphine equivalents per day, and found that one of the procedures was surprising: cesarean delivery.
Physicians can help control the current high opioid death rate in the United States by reducing the amount they prescribe to patients, particularly those who are opioid-naive.
“As we all know, we are in the midst of an opioid epidemic,” said Neil D. Ray, MD, an assistant professor of anesthesiology at Duke University Medical Center, in Durham, N.C. “Thousands of people suffer opioid-related deaths each year, and about half of those are due to prescription opioids, not just illicit opioid use. With that in mind, we sought to categorize how patients are being discharged after surgical procedures, to see if we could identify opportunities for improvement with respect to prescribing patterns.”
Results Mostly Unsurprising
Reporting the results at the 2017 annual meeting of the American Society of Anesthesiologists (abstract A2219), Dr. Ray revealed that the three surgical procedures with the highest percentages of patients who were admitted as opioid-naive but discharged on more than 60 mg oral MEDD were joint replacement, spinal fusion and cesarean delivery.
Whereas the first two procedures came as little surprise to the investigators, the same could not be said for the obstetric counterpart. “The interesting part in all of this is what came out with C-sections,” Dr. Ray said. “There we found that approximately half of patients come in taking no opioids whatsoever, but are discharged on more than 60 mg of morphine per day.”
In comparison, 56% of patients undergoing joint replacement surgery and 42% of spinal fusion patients were being discharged on at least 60 mg daily of oral opioids. Joint replacement patients were discharged with a median of 145 mg oral MEDD, compared with 90 mg daily for women who had undergone cesarean delivery.
“The amount of opioids that C-section patients are being discharged with is quite remarkable,” Dr. Ray added, “and it shows how exposure to opioids can be a driving factor in patients becoming addicted.”
As Dr. Ray explained, classifying the problem is the first step toward managing it. “The next step is seeing exactly how much of these drugs patients are actually using. And I think that getting feedback from surgeons about optimal dosing strategies is a vital piece of this puzzle as well.” He suggested that opioid-sparing multimodal analgesic regimens might be of particular value for women undergoing cesarean delivery.
A question was asked regarding how providers were using the findings from the study. “We took this information to our obstetrics group first,” Dr. Ray replied. “They have standard order sets that they use, but we would like to implement varying prescription levels so they can vary what they give instead of giving the same amount to every patient.
“We also want to investigate how much drug their patients are using,” he added. “Many of them are actually only using a couple of pills after being discharged. So they don’t need to be given 120 pills; they can be discharged with maybe just five or 10.”
The session co-moderator Anupama Wadhwa, MBBS, asked, “What about advising surgeons not to use opioids at all, particularly for C-section, where we can use a multimodal approach?” Dr. Wadhwa is an associate professor of anesthesiology and pain medicine at the University of Louisville School of Medicine, in Kentucky.
“Unfortunately, there can understandingly be some degree of convenience that factors in,” Dr. Ray said. “Surgical teams usually discharge patients home with prescriptions for multiple medication options, including opioids to cover varying levels of pain. Some patients may mistake this as a requirement to take opioids.”
“In my mind,” said the other session co-moderator, Tariq Malik, MD, an assistant professor of anesthesia and critical care at the University of Chicago Pritzker School of Medicine, “things changed when we made pain the fifth vital sign, because it seems that once we became so focused on our customer service, that’s when the diversion started.”
“I would agree with that, especially when patient satisfaction is tied to remuneration,” Dr. Ray replied. “And that’s why we’re trying to do this, because many times what’s actually better for patients may be contradictory to what makes them satisfied. Yes, prescribing all patients opioids so there are few complaints may improve satisfaction scores, but at the expense of overprescribing and opioid addiction.”