Journal Club: Postop Opioid Prescriptions

Postoperative Opioid Prescriptions

A recent article in the Annals of Surgery looked at post-discharge opioid prescriptions given to patients after surgery, comparing the US to the rest of the world. 

This prospective cohort study looked at 4690 patients with age ≥16yo from 14 institutions in 8 countries (USA, Brazil, China, Colombia, Lebanon, Mexico, Netherlands, and Thailand) in which researchers reviewed medical records to assess patterns of post-discharge opioid prescriptions following appendectomy, cholecystectomy, and inguinal hernia repair. 

The numbers are staggering: 

  • Overall 91% of US patients were prescribed opioids compared with 5% of non-US patients.
    • 83% of US patients without pain were prescribed opioids, compared with 9% of non-U.S. patients without pain.
  • The mean number of opioid pills prescribed was 23 in the US but only 1 in other countries. 
  • The mean number of oral morphine equivalents prescribed was 184 mg in the US and 5 mg in other countries. 
  • The number of opioid prescriptions, number of pills, and oral morphine equivalents prescribed were similar across all 4 pain-severity groups in US patients but were incrementally higher as pain severity progressed among non-US patients. 
  • Opioid refill rates were low, and non-opioid analgesic prescribing was similar among both groups. 

How does this information affect us as med-peds providers? 

First, it’s important to remember that the opioid epidemic involves all providers in the US. Surgeons are responsible for approximately 10% of all opioids prescribed in the US whereas family practice contributes the highest amount at 18% followed by internal medicine at 15%, according to a 2015 study. 

Second, we frequently see patients in our clinic (and on inpatient medicine consults) for preoperative clearance. These visits create an opportunity for us to provide preoperative opioid counseling regarding appropriate use and disposal of opioid medications. 

  • Preoperative opioid counseling has led to decreased opioid consumption postoperatively in small studies for carpal tunnel surgery, arthroscopic knee surgery, and elective orthopedic surgery.
  • Relatedly, the above study suggests that postoperative opioid prescriptions are highly independent of subjective pain severity among US patients, pointing to physician-related or system-related factors.  

Last, we often see patients for postoperative follow-up, which gives us another opportunity to discuss pain management issues with patients. 

What do you think about the article’s findings? What do you think we could do better as individual providers and as a practice? 

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