BACKGROUND: Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures. STUDY DESIGN: Patients undergoing 6 procedures were offered the opportunity to participate in an opioidsparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small "rescue" opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed. RESULTS:A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 AE 14 vs 59 AE 13 years; p ¼ 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p ¼ 0.014), received larger rescue prescriptions (6 AE 3 vs 4 AE 4 pills; p ¼ 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p ¼ 0.001). There were no other significant differences between opioid users and non-users. CONCLUSIONS: Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures. (J Am Coll Surg 2019;229:316e322. Ó

Objective: The aim of this study was to explore beliefs and behaviors of opioid pain medications among patients undergoing elective surgery. Background: Opioid dependence after surgery is a major contributor to the ongoing opioid epidemic. Recent efforts by surgeons and health systems have sought to improve the education patients receive regarding safe opioid use after surgery; however, little is known about patients’ pre-existing beliefs surrounding opioids. Methods: Semistructured interviews were conducted with patients who underwent 1 of 4 common elective surgical procedures at 1 institution. Patients were specifically asked about their knowledge and beliefs about opioids before surgery and their opinions of opioid-sparing recovery after surgery. Coding was conducted through iterative steps, beginning with an initial cycle of rapid analysis, followed by focused coding, and thematic analysis. Results: Twenty-one patients were interviewed. Three major themes emerged regarding patient opinions about using opioids after surgery. First, there was widespread awareness among patients about opioid medications, and preoperatively, patients had specific intentions about using opioids, often informed by this awareness. Second, patients described a spectrum of opioid related behavior which both aligned and conflicted with preoperative intentions. Third, there was tension among patients about opioid-free postoperative recovery, with patients expressing support, opposition, and emphasis on tailoring recovery to patient needs. Conclusions: Patients undergoing common surgical procedures often arrive at their surgical encounter with strong, pre-formed opinions about opioids. Eliciting these preexisting opinions may help surgeons better counsel patients about safe opioid use after surgery.

This quality improvement study examines the use of a novel reimbursement incentive for surgeons to counsel patients on an opioid-sparing pathway for postoperative pain management.

Background: Larger opioid prescriptions are associated with increased consumption without improvements in pain, and the majority of opioids prescribed go unused. We examined postoperative opioid prescription and use in patients undergoing vascular access surgery, where preoperative opioid exposure is common.Methods: A retrospective analysis was conducted in adult CKD patients who underwent outpatient vascular access surgery. Patients were surveyed by telephone > 2 weeks after surgery to assess pain level and opioid and non-opioid medication use. Results:Of 117 patients contacted, 76 responded (65% response rate), with a median (interquartile range) age of 56 (42-69) years. Sixty-three patients (83%) were prescribed an opioid postoperatively. Respondents were prescribed 60 (38-75) oral morphine equivalents (OMEs) and consumed 0 (0-15) OMEs over 1 day with a pain score of 5 out of 10. Thirtynine patients ( > 50%) used no opioids. There were no differences in postoperative opioid prescribing or use in patients with recent opioid exposure compared to patients without.Patients who underwent arteriovenous fistula (AVF) creation (short surgical incision procedure) were prescribed 60 (38-75) OMEs, compared with 75 (56-111) OMEs for patients who underwent AVF superficialization, AVG, or BVT (long surgical incision procedure; P < 0.01) and consumed 0 (0-15) OMEs compared with 10 (0-43) OMEs, respectively ( P = 0.07). Conclusion:Regardless of preoperative opioid exposure, CKD patients undergoing vascular access surgery consumed fewer opioids than prescribed, with a median of < 10% of opioids used. Therefore, we've reduced our institutional prescribing recommendations to 4 and 6 oxycodone 5mg pills for short and long surgical incision procedures, respectively.

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