Variability of Opioid Use Following Sternotomy Surprises

Author: Naveed Saleh MD, MS

Anesthesiology News

A study of opioid use by patients after discharge from cardiac surgery necessitating sternotomy has found that overall, about 60% of these patients did not require opioids and that a minority of the patients used the lion’s share of medications.

“Rates of new, persistent use of opioids after surgery in opioid-naive patients can be as high as 6%, which can now be deemed the highest postsurgical complication,” said study author Marie-Louise Meng, MD, an assistant professor of anesthesiology at NewYork-Presbyterian/Columbia University Medical Center, in New York City. “Some surgical complications may not be preventable, but persistent opioid use should be, which is what we are trying to achieve. In addition, leftover undisposed opioids in households carry the risk for accidental ingestion, misuse and abuse. Considering the number of people who have surgery per year, this is a serious public health concern on a population level.”

The study used a telephone survey and an electronic health record review to calculate the amount of opioid medication consumed after cardiac surgery, as well as to analyze the trajectory of postoperative recovery in adult patients. Operations included coronary artery bypass graft surgery, one left heart valve repair or replacement, ascending aortic surgery and aortic root surgery. The survey was administered starting at 10 to 14 days after surgery, with 30 questions covering perception of pain, mood, opioid consumption, opioid storage and other topics. Of the 242 patients enrolled, 187 completed the survey.

Dr. Meng recommended tailoring opioid prescriptions to patient need, with a focus on multimodal opioid-sparing strategies. “Prescribers, which in the United States include doctors, physician assistants and nurse practitioners, need to review all analgesic medications and specifically the opioid intake in the last 24 hours prior to discharge,” she said.

“It has been suggested that patients who did not take any opioids during the last day of hospitalization may not use any after discharge,” Dr. Meng said. “Therefore, a conversation with the patient about what to expect once at home, and how to best take analgesic medication at home, may guide the prescription. This patient-centered process is called shared decision making, which has been shown to be effective in reducing unnecessary opioid prescriptions after surgery.” She emphasized that prescribers should review five aspects of their opioid medications, as listed in the Table.

According to Dr. Meng, red flags in the context of opioid prescribing following cardiac surgery include patients who have been taking high amounts of opioids postoperatively with or without nonopioid medication, leading to higher than usual opioid medication. In both cases, an excessive amount of in-hospital opioid use may lead to the perpetuation of high amounts of opioids being taken, overprescribing opioids and persistent opioid use.

Dr. Meng noted that physicians are responsible for opioid overprescription. “Physicians have been taught to liberally give opioids and are still conditioned to prescribe large amounts of opioids after surgery, without individual tailoring. The practice in the United States over the last two decades has been to prescribe excessive amounts of opioid pills under the premise that this will improve patient care, maximize patient satisfaction and prevent need for refills. This practice has resulted in gross overprescription of opioid medications and a huge reservoir of unused opioids in the community. Recent publications have made prescribers more aware of this issue, improving prescription patterns and maximizing the use of nonopioid analgesia to reduce the amount of opioids necessary in a patient’s recovery process,” she said.

In Search of the Middle Ground

Dr. Meng discussed the current and future implications of the study. “Prescribers now know that patients who require opioids after discharge from sternotomy only require, on average, nine tablets of oxycodone 5 mg,” she said, adding that some patients do not require any opioids.

“Additionally, our prescribers have maximized the utilization of nonopioid analgesia to allow the reduction of outpatient opioids prescribed from a median of 27 oxycodone 5-mg tabs prescribed to 16 tabs per patient. The median amount of leftover opioid tabs per patient has been reduced to nine from 15. Future opioid prescription reduction is therefore still possible. We have yet to improve the patient disposal of leftover opioid tablets, and future projects aimed at patient education are necessary. We will hopefully begin maximizing the use of gabapentin, acetaminophen, ketamine and dexmedetomidine perioperatively so as to minimize the intraoperative use of opioids as well,” Dr. Meng said.

“This is a highly topical issue,” said Linda Shore-Lesserson, MD, an anesthesiologist at North Shore University Hospital, in Manhasset, N.Y., and past president of the SCA, in a separate interview. “The opioid crisis surely blossomed from the over- and excessive prescription of postoperative painkillers. However, all of the media attention on the opioid crisis has unfortunately swung the pendulum too far in the direction of withholding opioid prescriptions from patients who are truly in need. We are in search of that middle ground whereby opioids are prescribed in low dose, for a short period of time and then discontinued appropriately.”

Dr. Shore-Lesserson continued, “Appropriately, cardiac surgery patients are an ideal demonstration of titrated dosing because the pain of sternotomy is often less than would be expected. This is an important message that emphasizes that pain management postoperatively is, importantly, patient-specific and not merely formulaic.”