Opioid-naive adults who underwent at least one of four low-risk surgical procedures—carpal tunnel release, laparoscopic cholecystectomy (gallbladder removal), inguinal hernia repair and knee arthroscopy—in the years 2004, 2008 and 2012 were prescribed over time an increasing mean opioid morphine equivalent for postoperative pain. The adjusted increase was highest for knee arthroscopy (18%), according to a JAMA research letter (2016 Mar 15. doi: 10.1001/jama.2016.0130. [Epub ahead of print]).

The study authors evaluated a cohort of 155,297 patients from the Clinformatics Data Mart Database. Within seven days after surgery, 80% of patients filled a prescription for an opioid, with 86.4% of prescriptions for either hydrocodone-acetaminophen or oxycodone-acetaminophen.

“Anesthesiologists, surgeons and intensivists spend a lot of time thinking about how best to care for surgical patients while in the hospital,” said first author Hannah Wunsch, MD, a staff physician in the Department of Critical Care Medicine at Sunnybrook Hospital, in Toronto.

“But more and more we recognize that what we do in the hospital is only part of the story and that many of the problems faced by patients occur after hospital discharge. There is a paucity of data on prescribing practices for patients after surgery.”

The authors were surprised by the amount of opioids prescribed per day for procedures that are considered relatively minor and, therefore, “are unlikely to be associated with a lot of postoperative pain for most people,” Dr. Wunsch said.

The researchers hope that their study, along with new guidelines and other research, will help clinicians recognize the need to evaluate their own prescribing practices.

“Individual prescribers may want to assess whether their prescribing habits have changed and why,” Dr. Wunsch said. “The increase in opioids prescribed may be due to a perception that pain was being undertreated in many patients, or it is an attempt to try to minimize the number of patients who need to be reassessed after discharge.”

Joseph V. Pergolizzi Jr., MD, adjunct assistant professor of medicine at Johns Hopkins School of Medicine, in Baltimore, said the study underscores the ongoing concern of excessive opioid prescribing in a postoperative pain setting.

However, he noted that pain is very individualized, so some patients may require more pain relief than others. In addition, because these patients are no longer under the direct supervision of a physician once discharged from the hospital, it is important that they “have adequate analgesic coverage, thus potentially being prescribed more than they use,” Dr. Pergolizzi said.

Because there are data lacking for a pain trajectory, “we do not know exactly what is going to happen for every person,” Dr. Pergolizzi said. “By not knowing individual pain phenotypes, physicians with the best intentions may overprescribe.” He also said there needs to be a balance between access to these medications for patients who need them and appropriate opioid prescribing, “so that excess amounts of opioids are not prescribed that could potentially find their way out into the general public.”

“There is clearly increasing awareness of the need to be judicious in prescribing opioids,” said Dr. Wunsch. “Care around surgery represents a unique opportunity to focus on ensuring adequate, but not excessive, acute pain treatment. However, the need for large quantities of opioids as the mainstay of routine postoperative care for many patients needs to be reassessed.”