opioids: very high rate of prescriptions postop in US, and pedi issues

 2 articles just came out from the same group assessing opiate prescribing patterns post-surgery, comparing the US to the rest of the world, finding alarmingly high rate of opiate prescriptions in the US (see opiates postop more in US annsurg2020 in dropbox, or doi.org/10.1097/SLA.0000000000004225 ) 

 

Details: 

--4690 patients from the International Patterns of Opioid Prescribing study, all >16yo getting appendectomy, cholecystectomy, or inguinal hernia repair, in 14 hospitals from 8 countries over a 6-month period in 2016-2017

--mean age 49, 47% female, 4% had opioid use history (19% US/1% non-US), hospital length of stay (LOS) 2.7 days US/4.4 days non-US, emergent procedures 75% US/42% non-US

--postop adverse events 9% US vs 3% non-US

--mean BMI 30 in US/25 non-US, current or former smokers 29% US/18% non-US, re-operation within 14 days for a problem related to initial condition 2% US/1% non-US, readmission within 30 days 8% US vs 1% non-US

--43% of patients were asked about their pain level upon discharge (similar US/non-US): see the second article below

Results: 

--median number of opioid pills and OME (oral morphine equivalents): 

    --US: 20 pills (0-135) and 150 OME (0-1680) mg 

    --non-US: 0 pills (0-50) and 0 OME (0-600) mg 

        --both with p <0.001 

--mean number of opioid pills and OME: 

    -- US: 23.1 pills (+/- 13.9) and 183.5 OME (+/-133.7) mg 

    -- non-US: 0.8 pills (+/-3.9) and 4.6 OME (27.7) mg 

        --both number of pills and OME with p <0.001 for difference 

--opioid prescription refill rates: 

    -- US: 4.7% 

    -- non-US: 1.0% 

        -- p <0.001 

--these difference in opioid prescribing were similarly different in relevant sub-analyses:

    --those without intra-op or post-op complications: US vs non-US: 23.4 vs 0.7 pills and OME 183 vs 4

    --those without previous opioid use history: US vs non-US: 22.5 vs 0.8 pills and OME 173 vs 4

    --those not undergoing emergency surgery: US vs non-US: 22.2 vs 1 pill and OME 168 vs 6

--also, the variation in US prescribing patterns varied significantly within the US vs the non-US countries assessed [variations tend to be more pronounced when one cohort has so many more events than the other]

 

Commentary: 

--this study found that for similar surgical procedures, the US dramatically/alarmingly outpaced other countries in opioid prescriptions post-discharge

--the other huge epidemic in the US (ie, there is one besides Covid) is for opiates: 65,000 deaths in 2016 from drug overdoses, mostly from opiates (though there are also the huge personal and societal problems associated with opioid use disorder, OUD)

--the US (with <5% of the world's population) consumes >80% of opioids.

--surgeons are responsible for 10% of all opioids prescribed in the US

--the causes of the overprescribing in the US is likely multifactorial, including the perverse false advertising by Purdue and other pharmaceuticals (and, as per prior blogs, Purdue bought their way into establishing pain as the 5^th vital sign, and the Institute of Medicine, Joint Commission on the Accreditation of Healthcare Organizations, and American Pain Society were convinced (?hoodwinked) into a strong proclamation that pain was being undertreated and that clinicians needed to treat pain much more aggressively…) 

--and, there are likely cultural issues: US patients may expect to have much less pain than people in other countries, perhaps leading clinicians to treat pain more aggressively (either because patients are more demanding for much greater pain control, or because clinicians feel that's what patients want, or perhaps that giving patients opioids will decrease the number of subsequent phone calls for more/stronger meds...

--and several studies have found increased complications with more opiates prescribed post-discharge: more likely to request refills in the next 7 days, increased risk of future chronic opioid use, more post-op complications (thromboembolic events, infections, GI complications, hospital LOS)

a few comments on kids:

-- http://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html : a study finding that only a small fraction of opiate pills were actually consumed after an array of different surgeries (and more than ½ of Americans who misuse opiates get them from a friend or relative, often from left-over pills in the cabinet, per the CDC) 

    --and a recent article confirmed the high percentage of adolescents and others becoming addicted to opiates through left-over, unused drugs at home (see opioid use in parents and misuse in adol jamaopen2021 in dropbox) or doi:10.1001/jamanetworkopen.2020.31073:

        --15,200 parent-adolescent dyads from the 2015-17 National Survey on Drug Use and Health [similar time interval to the current study]

        --parental opioid use from medical prescriptions was associated with adolescent prescription opioid medical use: adjusted odds ratio [aOR], 1.28; (1.06-1.53) and misuse (aOR, 1.53, (1.07-2.25), whereas parental misuse was not.

        --parental stimulant use from medical prescriptions was associated with adolescent medical prescription opioid use: aOR, 1.40 (1.02-1.91)

        --adolescent opioid misuse was also associated with: parental marijuana use, with aOR, 1.84 (1.13-2.99); parent-adolescent conflict, with aOR, 1.26 (1.05-1.52), and adolescent depression, with aOR, 1.75 (1.26-2.44)

    --further, a multidisciplinary expert panel recently published guidelines for analgesia postop in kids, noting the dangers of future opioid misuse/dependence/diversion; and that many procedures have evidence of opioid-free recovery (hernia repair, soft tissue excisions, myringotomy, circumcision, operative burn debridement, ACL repair, hip or femoral surgery;  with lesser degrees of evidence suggesting nonopioid analgesia for appendectomy, tonsillectomy, and hypospadias repair). see opioid prescribing kids postop guidelines jamasurg2020in dropbox or doi:10.1001/jamasurg.2020.5045)

-- http://gmodestmedblogs.blogspot.com/2015/10/prescribed-opioids-and-future.html: finding that prescribed opiates in 12^thgraders is associated with future misuse at age 23, even in those who had a very low prior likelihood for using illicit drugs 

other relevant blogs:

-- http://gmodestmedblogs.blogspot.com/2019/01/restrictive-postop-opioids-fewer-given.html : a study of 605 patients on an ultra-restrictive opioid prescription protocol for gynecologic and abdominal surgery in a cancer center finding equivalent pain control compared to historical controls (eg, giving 12 vs 44 tabs for laparotomy; 1 vs 38 for laparoscopic surgery). this study did titrate opioids to patient-reported pain control in the hospital, as seems to happen more often in non-US hospitals (see second article below)

-- http://gmodestmedblogs.blogspot.com/2017/02/opiate-prescribing-in-elderly-and.html : 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 prescribers for similar clinical conditions had a 30% increased likelihood of long-term use of opiates, with no evident difference in their ED presentation or pain level

-- http://gmodestmedblogs.blogspot.com/2019/05/portugal-approach-to-oud-trends-in.html . the other side of the equation: Portugal had a huge opiate problem, but decriminalizing it in 2001 led to a dramatic drop in overdoses, HIV and hepatitis infections, and drug-related crime 

-- http://gmodestmedblogs.blogspot.com/2018/03/opioids-not-better-for-chronic.html . patients with moderate-to-severe chronic back, hip, or knee OA did as well with non-opiates as opiates 

--all of these blogs have reference to other blogs on opiates do as well with non-opiate and non-pharmacologic pain management

limitations of the study:

--no specific data on patient satisfaction overall, or pain control (though above blogs do include studies finding no difference in either patient satisfaction or pain control)

--the longer LOS in the non-US hospitals might have allowed for less need for opiates by the time of discharge

--data for the above study was from 2016-17, and already very strong steps have been taken in many hospitals, EDs, dental offices, etc to decrease the use of opiates (see data at end of this blog)

 

So, way too many opiates prescribed post-op, which leads to several issues: 

--excess pills at home in the medicine cabinet are associated with misuse by relatives/friends 

--too many opiates taken by patients increase the likelihood of subsequent opioid taking, even in elderly naïve to opiates and in kids with a low pretest probability of using opiates later in life

--we in primary care can help alleviate this problem by a few things: 

    --ask the surgeons to prescribe opiates only if essential and with limited quantities (and feel free to send them the blog http://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html )

    --ask the patient to bring in all unused opiates for disposal, and not leave them around in the medicine cabinet 

    --advise the patient to resist getting opiates for many procedures/problems (and there are pretty strong data that NSAIDs are as good as opiates for kidney stones, the vast majority of dental procedures do not require opiates, and per http://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html many seemingly big surgeries led to almost no opiates actually needed/ taken when prescribed

-------------------

this related study compared patient-reported pain severity at hospital discharge with opiate prescribing, finding perhaps even more striking differences between the US and non-US sites (see opiates postop more in US jacs2020 in dropbox, or doi.org/10.1016/j.jamcollsurg.2020.08.771 

Details:

-- setting as above, a post-hoc analysis of those hospitals assessing pain at the time of patient discharge for the same surgeries as in the first article.

    --but only 43% of the hospitals in the above study had the appropriate data to analyze, so this study included only 12 hospitals from 7 countries

-- pain severity was assessed by a 0 to 10 visual analog scale before hospital discharge

-- patients were stratified into the following groups based on pain severity: none, mild (1 to 3), moderate (4 to 6) and severe (7 to 10)

-- 2024 patients were included

-- mean age 47, 48% female, BMI normal 75%/underweight 2%/obese 20%, current smoker 15%, prehospital opioid use 8%

-- procedures: open appendectomy 15%, lap appendectomy 15%, lap cholecystectomy 40%, open hernia repair 11%, lap hernia repair 14%

-- hospital LOS 4 days, hospital readmission in 30 days 5%

-- the number of US patients included the study was 298, non-US 1726 

 

Results:

--overall no pain reported in 43%, mild pain in 38%, moderate pain in 12%, and severe pain in 7%

--85% of patients were prescribed non-opioid analgesics at discharge for all pain categories

--increasing pain was found in younger patients, those with history of opioid use before admission, those getting emergency procedures, those with postop complications, those in the ICU or those readmitted within 30 days of discharge

-- in those with no pain at discharge, percent prescribed opioids:

    -- US: 83%

    -- non-US patients: 9%

        -- statistically significant, at p <0.001

-- across the 4 pain groups noted above, the number of opioid prescriptions, number of pills, and oral morphine equivalents prescribed::

    -- US: no statistically significant relationship with pain severity

    --non-US patients: incrementally more opiates given as pain severity progressed from no pain to severe, all with p <0.05

-- comparing the US with non-US patients, per category of pain and hospital discharge, percent given opioids:

    -- no pain: 83% vs 9% (number of pills given 20 vs 1)

    -- mild pain: 92% vs 7% (number of pills given 22 vs 2)

    -- moderate pain: 93% vs 19% (number of pills given 24 vs 2)

    -- severe pain: 94% vs 26% (number of pills given 27 vs 3)

-- number of opiate refills, US vs non-US patients:

    -- no pain: 3 vs 0

    -- mild pain: 3 vs 1

    -- moderate pain: 7 vs 0

    -- severe pain: 8 vs 0

-- these results were similar after adjusting for preoperative, intraoperative, and postoperative characteristics

 

Commentary:

--so, again pretty striking differences. of note, in the US there were lots of opiates prescribed independent of the pain scores of the patient at discharge (with the pretty shocking finding of 83% getting opiates even with no pain!!)

--similar findings from other studies in patients with hip or ankle fractures: 77% and 82% respectively got opioids in the US, vs 0% and 6% in a Dutch hospital; or with head and neck surgery: US 87% vs Hong Kong <1%

--another example of opioid overprescribing: US dentists prescribe many more and stronger opiates than in the UK see http://gmodestmedblogs.blogspot.com/2019/05/opiate-scripts-by-dentists-us-vs-england.html )

    --in one study of adolescents and young adults, 15% of ED visits were associated with an opioid prescription, though close to 60% for dental disorders (see https://www.cdc.gov/acute-pain/dental-pain/index.html )

    --the American Dental Association tried to decrease opiate prescribing, including by highlighting 5 systematic reviews showing that ibuprofen 400 mg plus acetaminophen 1000mg was superior to any opiate-containing medication. unfortunately, despite their argument against opiates, their conclusion to the dentists was the rather lackluster "consider NSAIDs as first line therapy"

--an interesting study in the Netherlands found a large discordance between patient-reported pain and guidelines for management: the guidelines suggested that a numerical pain score >3-4 (from 0 to 10) should lead to opiates for pain controol, but a majority of patients did not want opiates unless the score were 8 or higher (see opioids postop pt pain score diff from guidelines painpract2015 in dropbox or DOI. 10.1111/papr.12217

limitations:

--only 43% of the hospitals in the first study had the appropriate data on pain at discharge, so the actual results here may distort the full picture [though, it is pretty striking that more than half the hospitals did not record pain scores at discharge...]

so, a real eye-opener:

--the US so dramatically exceeds non-US surgeons in opiate prescribing

--the brightish light is that through pretty consistent efforts by the various medical/dental societies and many medical schools/academic hospitals, the number of opiate prescriptions has decreased dramatically. per the CDC (https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html )

    --highest time ever was 2012, with 255,207,954 opioid scripts at 81.2 scripts per 100/person-yrs (sort of like 1 script for everyone.....)

    --this level stayed about the same til 2014: 240,993,021 scripts at 75.6/100 person-yrs

    --2015: 226,819,924, at 70.6/100 person-yrs

    --2016: 214,881,622, 66.5/100 person-yrs

    --2017: 191,909,384, 59.0/100 person-yrs

    --2018:168,158,611, 51.4/100 person-yrs

    --2019: 153,260,450, 46.7/100 person-yrs (down to 1 script for every 2 people: much better, but still a tad on the high side....)

bottom line: we really need aggressive national leadership to substantially decrease opiate prescriptions and their myriad collateral damages (OUD, relatives getting unused scripts and their developing OUD, huge personal/social disruptions from OUD, etc). and this leadership needs to be at least as aggressive as the Institute of Medicine etc was in the past in proclaiming that we clinicians are undertreating pain and need to use stronger pain meds.....

geoff

 

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