Restrictive postop opioids: fewer given, no diff in pain

Another article came out on the feasibility of prescribing fewer opiates post-surgery, this one finding equivalent pain control after gynecologic and abdominal surgery when using an ultra--restrictive opioid prescription protocol (see opioid dec postabdgynsurg jamaopen2018 in dropbox, or .doi:10.1001/jamanetworkopen.2018.5452)

Details:

-- case-control cohort study of 605 surgical patients on an ultra-restrictive opioid prescription protocol (UROPP), from 2017-2018, at a single tertiary care cancer center (Roswell Park Comprehensive Cancer Center). All patients undergoing gynecologic oncology surgery were included

-- mean age 56, 23% laparotomy/45% robotic laparoscopic surgery/32% ambulatory surgery, 87% white/9% African-American, BMI 33, 24% former smokers/18% current smoker/58% non-smoker, diagnosis 55% pre-invasive or benign/45% malignant, length of stay 1.5 days, 8% had prior chronic opioid use

-- number of opioid doses given (IV and oral) 5 in both groups, last pain score at time of discharge 1.7 in both groups (per 0-10 numeric pain scale)

-- UROPP protocol, at discharge:

    -- patients undergoing ambulatory or minimally invasive surgery: a 7 day supply of ibuprofen and acetaminophen. If hospitalized at night and needed more than 5 opioid doses, they were then given 12 tablets of hydrocodone 5mg/acetaminophen 325 mg, or oxycodone 5mg/acetaminophen 325 mg

    -- laparotomy patients: ibuprofen and acetaminophen for 7 days + 12 tablets of hydrocodone/acetaminophen 5/325 or oxycodone/acetaminophen 5/325. If the patient required higher doses of opiates for pain control during the last 24 hours of admission, they were given 24 pills of the opiates

    -- if the patient requested an opioid refill, there were given a 3 day supply of up to 12 pills (assuming no concern for postop complications). No further refills were given without clinical evaluation

-- these 605 cases were compared with 626 matched controls (patients who were treated at the same center with similar procedures and demographics) in the 12 months before this UROPP protocol

--the in-hospital protocol for pain management, ERAS ( enhanced recovery after surgery), involved acetaminophen, gabapentin, and COX-2 inhibitors preop with the addition of regional anesthesia possible for needed, and scheduled acetaminophen and NSAIDs postop.  prn opiates

Results:

-- mean number of opioid tablets given at discharge after laparotomy:

    -- preintervention: 43.6 opioid tablets

    --UROPP: 12.1 opioid tablets, p<0.001 for the intervention

-- laparoscopic or robotic surgery:

    -- preintervention: 38.4 tablets

    -- UROPP: 1.3 tablets

-- ambulatory surgery:

    -- preintervention: 13.9 tablets

    -- UROPP: 0.2 tablets

-- the total perioperative opioid use (including 30 days before surgery, discharge prescriptions, and 30 days after surgery): preintervention 339.4 mg vs 64.3 mg with UROPP, p<0.001

    -- laparotomy cases: 322.2 mg preintervention, decreasing to 91 mg with UROPP

    -- laparoscopic or robotic cases: 266.1 mg preintervention, 7.0 mg with UROPP

    -- ambulatory cases: 90.4 mg preintervention vs 1.5 mg with UROPP

-- refill requests: no difference (16.6% preintervention, 16.5% UROPP)

-- those 8% of the patients who were chronic opioid users had no difference in oral morphine equivalents comparing the preintervention or the post-UROPP timeframes (though there was a drop in opiates prescribed at discharge but this reverted to their baseline opioid use within 30 days after surgery) 

-- mean postoperative visit pain score: no difference (1.4 preintervention, 1.1 UROPP)

-- number of postop complications: no difference (6.7% preintervention, 4.8% UROPP: )

Commentary:

-- CDC estimates that 116 people in the US die per day after an opioid overdose and that 40% of these deaths involve a prescription opioid

-- more than 4.5 million people in the US misuse opioid prescriptions, as of 2015

-- the total economic burden of the opioid crisis in 2015 was measured at $504 billion, or 2.8% of the gross domestic product

-- 48 million people undergo surgical procedures annually, and opioids are the primary modality for managing postop pain

-- some studies suggest that only 28% of the prescribed doses of opioids are actually taken. Seehttp://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html 

-- many hospitals have implemented the ERAS protocol to decrease opioid use of surgery (as done in this hospital), though in most cases there were no guidelines for postdischarge opioid prescribing

-- the UROPP approach does require buy-in by all involved:

    -- the patients need to be educated about the overall protocol and its rationale, the adverse effects of opioid pain medications, and alternative methods of pain control (this was explicitly stated in the current study)

    -- but, unstated, the clinical staff needed to drastically alter their approach to post-hospital care. The on-call system needs to be robust and responsive to patients, allowing them to get access to consultation and opiates as needed. This means that perhaps very overworked clinicians cannot just write a prescription for a lot of opiates just to make sure that the patients are comfortable and the on-call doctors are not disturbed so much. which means that the clinical systems need to change to support this whole approach, and particularly making it easy for the busy clinicians to function efficiently

-- the UROPP program has continued in this hospital since this study, with compliance on the order of 98% by the healthcare professionals and no issues about its sustainability.

-- this was a case-control study comparing a new intervention with historic controls (though the types of patients was similar, given the nature of this hospital), so it is not nearly as robust as an RCT. Also, only women were involved study, limiting its generalizability. And, one cannot generalize from this study to other types of surgery.

-- one observation from the trenches: the problem with opioids seems to be one of “the lost generation”

    --We know from other studies that prescribing opiates has long-term consequences. Kids in 12^thgrade at low risk of addiction and prescribed opiates by clinicians are 3 times as likely to misuse opiates at age 23 ( http://gmodestmedblogs.blogspot.com/2015/10/prescribed-opioids-and-future.html  ). Older patients going to the ED and seeing high-opiate prescribers (vs lower) for similar clinical indications have a 30% increased likelihood of being on longterm opiates (http://gmodestmedblogs.blogspot.com/2018/03/ed-intervention-to-decrease-opioids.html ). 

    --We have made significant strides in decreasing opiate dispensing (eg, seehttp://gmodestmedblogs.blogspot.com/2018/03/ed-intervention-to-decrease-opioids.html ). And there have been collateral benefits in decreasing opiate dependence and mortality. 

    --The hard part is dealing with those already on opiates. There have been impressive advances with opiate maintenance therapy, with many studies done going back to the 1960s showing clear benefit (see NY times article: https://www.nytimes.com/2018/12/29/health/opioid-rehab-abstinence-medication.html?emc=edit_na_20181229&nl=breaking-news&nlid=52966364ing-news&ref=cta , which highlights the importance of long-term opiate maintenance therapy over detox). But, though some patients do get off opiates entirely, many still have opiate use relapses.  

    -- so, it is abundantly clear that these interventions are far from perfect, reach only a subset of those with opioid use disorders, often are complicated by longterm cravings and opiate dependence, and all of their lives have been fundamentally altered by the history of opiate use. That being said, it is remarkable how well buprenorphine/naloxone does in a large subset of patients who are motivated to get off their opioids: it does give many patients their lives back

    --A primary solution for the future, as in this study, is us clinicians avoiding prescribing opiates, whenever possible. As noted in http://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html ),  we are prescribing way too many opioids postop to patients getting a variety of common surgical procedures, only a small fraction of them are actually taken, and many of the leftovers are making their way into the hands of those who become dependent on them (more than ½ of those who misuse prescription opioids get them from a friend or relative)

    --one issue is that patients do need to have realistic pain expectations. for post-op pain, as well as many chronic pains, unfortunately nothing is likely to give complete relief.  meds may help control the pain so as to preserve function, and opiates are sometimes necessary. but many non-opiate meds and non-drug interventions do help some (eg: see 
http://gmodestmedblogs.blogspot.com/2017/06/tai-chi-for-knee-oa-mindfulness-for.html , http://gmodestmedblogs.blogspot.com/2018/03/opioids-not-better-for-chronic.html . These blogs also reference lots of other blogs on non-drug therapies and on the best adjuvant pain meds). and patients really need to understand the risks of opiates to themselves and family/friends, understand that pain in many cases cannot be fully treated but just minimized, and really try to go without opiates whenever possible

So, this study was quite remarkable. There was a lot of patient education in the study explaining the importance of avoiding opiates. That, with this aggressive protocol, led to huge decreases in opioid prescriptions. It should be noted that this was not a draconian study, in that outpatient opiates were titrated to inpatient opiate needs on an individual basis, and there was accessibility to more opiate prescriptions as needed. Despite this, there was no difference in requests for opiate refills, and most notably no difference in pain scores.

geoff

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