Wide Variations in Opioid Prescribing Practices for Surgical Procedures

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A total of 92.5% of patients undergoing surgery in an acute care surgery service received a prescription for opioids upon discharge, with oxycodone being the most commonly prescribed opioid.
A total of 92.5% of patients undergoing surgery in an acute care surgery service received a prescription for opioids upon discharge, with oxycodone being the most commonly prescribed opioid.

Wide variation in opioid prescribing exists in single-hospital systems, as well as within a single surgical service, with physicians prescribing more opioids than nurse practitioners, according to a study published in Surgery.

A team of investigators from the Division of Trauma, Emergency Surgery & Surgical Critical Care at Massachusetts General Hospital and Harvard Medical School sought to analyze the variation in opioid prescribing within the 3 most common surgical procedures performed in their medical institution: laparoscopic appendectomy (LapAppy), laparoscopic cholecystectomy (LapChole), and open inguinal hernia repair (InHR).

The researchers reviewed their institutional prescribing pharmacy database to identify the following: 1) recorded medical history of opioid abuse; 2) history of opioid intake or prescription 3 months prior to the surgical procedure; 3) the number of opioid pills prescribed upon discharge; 4) direction by a physician or prescription to take alternative nonopioid pain medication; and 5) the need for opioid prescription refills 3 months after the surgical procedure.

Between October 2016 and March 2017, 255 patients (mean age, 47.5 years, 52.1% women) underwent 1 of the 3 procedures (43.5% LapAppy, 44.3% LapChole, and 12.1% InHR). Mean duration of hospital stay was 3.4 days, and 11.4% of patients had a history of opioid use. A prescription for opioid pain relievers was provided to 92.5% of patients upon discharge; 70.9% of patients were instructed to use or were prescribed nonopioid medications. Oxycodone was the most commonly prescribed opioid (93.4%).

The number of pills prescribed per patient ranged between 0 and 75, with the mean number of pills prescribed as follows: LapAppy, 17.4; LapChole, 17.1; and InHR, 20.9.  The oral morphine equivalent (OME) ranged from 0 to 600 mg, with the mean OME per procedure as follows: LapAppy, 136.3 mg; LapChole, 140.1 mg; and InHR, 155 mg). The number of pills with their corresponding OME was higher for patients with a preoperative history of opioid use vs those without (21.1 vs 17.3 and 180.3 vs 135.1, respectively). Hospital resident physicians prescribed more opioids than NPs for all 3 procedures: LapAppy (mean OME 147.7 vs 105.5), LapChole (156.4 vs 112.4), and InHR (176.1 vs 45). No patients in the cohort needed an opioid refill.

“Even within a single surgical service of a single institution, and with a relatively homogenous patient population undergoing the same type of surgical interventions, wide variation in opioid prescribing patterns was observed, and underutilization of alternative pain medications was noted,” the authors concluded. “…Our findings raise serious concerns regarding opioid overprescribing in surgery and suggest that standardization of pain management strategies [is] needed.” 

Reference

Eid AI, DePesa C, Nordestgaard AT, et al. Variation of opioid prescribing patterns among patients undergoing similar surgery on the same acute care surgery service of the same institution: time for standardization? [published online July 23, 2018].  Surgery. doi: 10.1016/j.surg.2018.05.047

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