post-op opiates: too many pills, too many left over

A recent article found that when opiates were prescribed post-op, only a small fraction were actually taken, but also that the more prescribed the more taken (see opioid postsurgery inc if lots of pills jamasurg2018 in dropbox or doi:10.1001/jamasurg.2018.4234).

Details:

--2392 patients who were at least 18 years old, had surgery, and were prescribed an opioid during a 9 month period in 2017 from 33 health systems in Michigan (the Michigan Surgical Quality Collaborative), in this retrospective, population-based analysis

--mean age, 55 years; 57% women, elective surgery 77%/emergency surgery 23%, outpatient procedures 46%/inpatient 54%

--12 procedures met their criteria of having at least 25 patients

--a single opioid pill was defined as the equivalent of one hydrocodone/acetaminophen 5/325mg

--they used the American Society of Anesthesiologist (ASA) class system to stratify patients, which reflects the intensity of the patients medical comorbidities/physical status (higher being worse: class 1 being a normal healthy patient, class 6 a brain-dead patient whose organs are being removed for donor purposes)

Results:

--Overall, 27% (range 3%-67%) of the prescribed opiates were actually consumed: only 9 pills of a median of 30 pills prescribed.

    -- 58% of the prescribed opiates (42,692 pills) were left over [this is a lower number than the last line suggested. not sure why]

-- surgical procedures, in descending order of frequency, along with median numbers of pills prescribed and consumed:

    -- inguinal/femoral hernia repair: 659 procedures, 30 pills prescribed, 8 pills consumed

    -- laparoscopic cholecystectomy: 603 procedures, 30 pills prescribed, 8 pills consumed

    -- laparoscopic appendectomy: 224 procedures, 30 pills prescribed, 8 pills consumed

    -- laparoscopic/robotic hysterectomy: 203 procedures, 30 pills prescribed, 7 pills consumed

    -- open incisional hernia repair: 159 procedures, 30 pills prescribed, 15 pills consumed

    -- vaginal hysterectomy: 113 procedures, 30 pills prescribed, 6 pills consumed

    -- laparoscopic colectomy: 112 procedures, 40 pills prescribed, 8 pills consumed

    -- open colectomy: 102 procedures, 40 pills prescribed, 12 pills consumed

    -- abdominal hysterectomy: 85 procedures, 40 pills prescribed, 20 pills consumed

    -- ileostomy/colostomy takedown: 59 procedures, 40 pills prescribed, 20 pills consumed

    -- thyroidectomy: 40 procedures, 30 pills prescribed, 1 pill consumed

    -- small bowel resection and enterolysis: 33 procedures, 30 pills prescribed, 7 pills consumed

-- 24% reported taking no opioids after surgery (especially those having thyroidectomy or laparoscopic colectomy)

-- quantity of opioid prescribed had the strongest association with patient-reported opioid consumption: 0.53 more pills consumed for every additional pill prescribed,  P < .001.

-- Patient-reported pain in the week after surgery was also significantly associated with higher consumption, but not as strongly as prescription size.

    --Compared to patients reporting no pain, patients used a mean 9 more pills if they reported moderate pain and 16 more pills if they reported severe pain (P < .001).

-- By patient characteristics:

    -- smokers took 4 more pills than non-smokers

    -- obese patients 2 more pills than nonobese.

    -- sicker patients (ASA class IV through V) took 7 more pills than those who were class I

    -- increasing age was associated with taking fewer pills, with a 65-year-old taking 4 fewer pills than a 35-year-old.

-- outpatient surgery was associated with taking 4 fewer pills

-- After adjusting for tobacco use, ASA class, age, procedure type, and inpatient surgery status, patients in the lowest quintile of opioid prescribing had significantly lower mean opioid consumption compared with those in the highest quintile (3 vs 5 pills; P < .001).

-- These results were not limited to a single institution within this collaborative, but was widespread across many hospitals.

Commentary:

-- there were a few significant findings in this study:

    -- for all of these common surgeries, the degree of opiate prescribing far outweighed the actual quantity taken, though 22% did take their full allotment (no granular data on why: persistent otherwise uncontrollable pain?? thinking they should to avoid potential pain?? just following doctors' orders??)

     -- but in this nine-month study in one area of the country, tens of thousands of opioid pills were left over

     -- there was no clear relationship between the type of surgery and number of opiates prescribed (e.g., laparoscopic colectomy was the same as open colectomy, though almost twice as many pills were taken for an open colectomy)

    -- and, the finding that the more opiates given, the more taken (though still plenty leftover), a relationship that was stronger than post-op reported pain, suggests that there is some psychological compulsion to take more if you have more to take; perhaps sort-of-like patients trying to lose weight eat more if they have a larger plate size????

-- other studies have found the following, which reinforce the importance of reducing leftover opiates:

    -- up to 92% of patients have leftover opioids after common operations

    -- more than half of the 3.8 million Americans who misuse prescription opioids get them from a friend or relative; this was much more common than either “doctor shopping” or through illicit sources

    -- many heroin users get their 1^st opioids from a prescription that is not their own

    -- single institution studies have found lower opioid prescription amounts can be achieved by matching postoperative prescription size to patients’ opioid need postoperatively. One study done by the current authors found a 63% reduction opioid prescriptions by doing this in patients getting a laparoscopic cholecystectomy

-- as a related issue, a recent study found that the length of opiate prescribing post-op was more related to future "opioid misuse" (ie: opioid dependence, abuse or overdose, per ICD codes) than the dose prescribed.see http://gmodestmedblogs.blogspot.com/2018/01/post-op-surgery-opiates-and-subsequent.html  , which also references other blogs finding that patients in several acute pain situations (eg kidney stones, ED visits for acute pain) did as well with NSAIDs as opiates.

-- http://gmodestmedblogs.blogspot.com/2017/02/opiate-prescribing-in-elderly-and.html has an interesting/pretty powerful retrospective study in older patients naive to opiates (mean age 69) finding that those seeing high-intensity opiate prescribing ED physicians vs low-intensity ones for similar clinical conditions had a 30% increased likelihood of long-term use of opiates, with no evident difference in presentation or pain

-- this Michigan study did find (not so surprisingly) that some procedures led to fewer opiates taken than others: more with open than laparascopic procedures, thyroidectomy led to many fewer opiates taken (median of 1 tablet, but 1 patient did take them all....)

-- this was a retrospective study with limited granular patient data. for example, no data on whether patients were taking opiates pre-op, no info on how much pain the patients had pre-op or post-op, no breakdown by specific comorbidities (just ASA class), no data on psych status or even propensity to addiction (though it was interesting that smokers needed more meds), etc...

so, a pretty interesting study.

--it seems clear that a goal is to decrease the huge number of unneeded prescribed opiates. this does seem to lead to others taking them with the pretty high risk of collateral addiction

--we all seem to have different pain thresholds (mu-receptor variants? psychological states?) and some patients do need more opiates than others to get an adequate pain response. this is obscured by the reductionism of the few studies done (ie, the fact that NSAIDs seem to work as well as opiates for kidney stones in the aggregate does not mean that this is true for each individual)

--to me, there are a few intriguing ideas based on this and other studies: the idea of tailoring post-op opiate prescriptions to the need for the individual's actual post-op opiate need. or just starting with non-opiates and stepping-up cautiously to opiates only as needed. or giving a pretty limited supply of opiates with the option of another prescription if needed. and all of this with the clear message to the patient that opiates really can be addictive. And the above ED study finding that older patients getting opiates by high-opiate prescribing MDs were much more likely to be taking opiates chronically a year later is quite telling…