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Opioid Prescriptions Not Optimized for Post-Surgical Pain

July 13, 2017
In a review of patient opioid use following surgery, only about 10% of patients reported needing the full amount of pills prescribed, raising the need to address the stockpile of unused pain medication.

With Mark C. Bicket, MD 

In anticipation of surgery, nearly all patients were prescribed an opioid to manage their pain following the procedure, yet the vast majority (92%) reported unused medication, including many who didn't even fill the prescription,1 according to a systematic review conducted by researchers at the Johns Hopkins School of Medicine, in Baltimore, Maryland.

Of the patients who filled their prescription, nearly 3/4 reported having leftover pills,1 based on findings published in the Journal of Opioid Management.

“We defined our primary outcome, opioid over-supply, as the number of patients with either filled prescriptions with unused opioids or unfilled opioid prescriptions,” said lead author Mark C. Bicket, MD, assistant professor of anesthesiology and critical care at Johns Hopkins Medicine in Baltimore, Maryland.

Opioids Over-Prescribed for Post-Surgery Pain

Patient Behaviors Reflect Opioid Underuse  

To gain insight on opioid use among post-surgical patients, the researchers conducted a search of 3 databases (PubMed, EMBASE, and Cochrane Central Register of Controlled Trials), for prescription use of opioids following surgery. 

Six studies met the criteria—adults (population), opioids (intervention), surgery/procedure (intervention), and medication use and prescription (outcome; eMethods).1 The data was recent, with 4 studies having been published in 2016, and 2 appearing in 2013.

Of the 810 patients identified as having met the criteria for participation, the authors found that 67% and 92% of patients reported unused medications, while 42 to 71% of the patients indicated that no medication was taken at all following surgery.1

The data was extracted by type of surgery, with 7 procedures reflected across the studies, including cesarean section, thoracic, urology, dermatology, general, dental and orthopedic.

Overprescribing Leaves a Stockpile of Opioids

“The amount of unused opioids after surgery suggests that prescriptions for pain medication are not fully optimized for individual patients,” said Dr. Bicker. "Opioids, if not used or properly disposed of, may contribute to the non-medical use of opioids."

Since the vast majority of patients limited or avoided any the use of their prescribed medication, concern about safe storage of unused pills was also examined from data available from 2 of the studies, he said.

The combination of unfilled prescriptions, unused opioids, inadequate storage practices, and the need for local disposal sites,1 are some of the ways the authors offered to reverse the likely diversion of opioids beyond the patient's post-surgical pain.

“Clearly, most patients require fewer opioids after surgery than prescribed by surgeons to address post-surgical pain, Dr. Bicket told Practical Pain Management.

Several factors may have influenced the manner in which patients reported unused medications but pain intensity and psychological profile appeared as primary factors to inform post-surgical analgesic use.1

Creating a Process for Unused Pills  

With regard to the remaining pills, patients reported a very low rate of intended disposal of unused medication, with no more than 9% of patients following an FDA-recommended disposal method.1

As such, opioids prescribed for post-surgical patients represent a huge reservoir of pain medications available for uses other than those intended, according to the authors.

In addition to time and convenience, reasons patients cited for not following through on proper disposal practices were cost (once it’s paid for, it's theirs) and a perceived need for opioids should the pain return in the future.

The authors suggested looking at the Canadian model for managing unused mediations including a national prescription drug drop-off day, federally sanctioned drug take-back days, and community collection programs. Pharmacies and hospital dispensaries are obvious drivers for collection of used opioids, as well.1

Finding a More Effective Way Forward

We recommend a “data-driven” approach to prescribing when studying a number of opioids that the average patient uses after a surgery, said Dr. Bicket. Studies are starting to seek an answer to this question, and we are working on this question now, as well, he added.

Based on prior research and clinical experience, we know that a number of opioids needed depends on a combination of characteristics. For example, patients who use opioids before surgery are more like to need more opioid after surgery. The number of opioids may also depend on whether a person uses non-opioid pain medication, such as acetaminophen (Tylenol) and non-steroidal anti-inflammatory medications (such as ibuprofen).

“Studies that work to determine how much opioids the average person uses need to take these factors into account when determining the amount to recommend after surgery,” Dr. Bicker told Practical Pain Management.

For future research, the authors pointed out several limitations to their study.1 The data overall was deemed of intermediate methodological quality with missing data that is usually expected from cross-sectional and cohort studies, and no consistency in the methods used to have patients complete questionnaires. 

Also, some of the studies failed to ascertain any history of opioid use prior to the current surgery, and only 7 surgical procedures were reflected across the studies.1

“This study makes the case that postsurgical opioid-prescribing deserves attention, too,” said Dr.Bicker, “Before surgery, [practitioners] should discuss expectations about pain levels and the number of pills to be prescribed. “

Topics such as how to store the pills safely and where to dispose of them at the conclusion of therapy should be mentioned before as well as after the procedure, he added.

As such, they were not able to estimate leftover morphine equivalents for these patients, since this information was not reported in any of the studies examined, or examine more granular data regarding unused opioid pill counts to determine a consistent, clinically relevant definition of unused opioids.1

Last updated on: July 19, 2017
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