Evaluation of Policies Limiting Opioid Exposure on Opioid Prescribing and Patient Pain in Opioid-Naive Patients Undergoing Elective Surgery in a Large American Health System

Abstract

ObjectivesOverprescribing to opioid-naive surgical patients substantially contributes to opioid use disorders, which have become increasingly prevalent. Opioid stewardship programs (OSPs) within healthcare settings provide an avenue for introducing interventions to regulate prescribing. This study examined the association of OSP policies limiting exposure on changes in surgery-related opioid prescriptions and patient pain.MethodsWe evaluated policies implemented by an OSP in a large American healthcare system between 2016 and 2018: nonopioid medication during surgery, decrease of available opioid dosage vials in operating rooms, standardization of opioid in-patient practices through electronic health record alerts, and limit to postsurgery opioid supply. Generalized linear mixed effects models examined the association of interventions with outcome changes in 9262 opioid-naive patients undergoing elective surgery. Outcomes were discharge pain, morphine milligram equivalent in the first prescription postsurgery, and opioid prescription refills.ResultsDecreases in all prescription outcomes and discharge pain were observed following onset of OSP interventions (P’s < 0.001). Among individual policies, standardization of in-patient prescribing practices was associated with the strongest decrease in prescribed morphine milligram equivalent. Importantly, there was no evidence of an increase in discharge pain related to any intervention.ConclusionsThis study promotes the potential of OSP formation and policies to reduce opioid prescribing without compromising patient pain. The most effective policy, standardization of in-patient prescribing practices through alerts, suggests that reminding prescribers to re-evaluate the patient’s need is effective in changing behavior. The findings offer considerations for OSP formation and policy implementation across health systems to improve quality and safety in opioid prescribing.

Association between Initial Opioid Prescription and Patient Pain with Continued Opioid Use among Opioid-Naïve Patients Undergoing Elective Surgery in a Large American Health System

“…That said, there is generally a lack of consistent guidelines for opioid prescribing post-surgery, particularly for opioidnaïve patients, with studies utilizing a variety of dosages (e.g., 50-2000 MME) or any dosage to examine the association between dose and later use [18,19,22,25,26]. Whereas 90 MME is considered high-dose prescribing, it is still lower than that examined in some studies, and our study detected a significant difference in the likelihood of a refill between ≤ 90 MME and >90 MME, demonstrating the need for guidelines for opioid-naïve patients [4,7,[18][19][20][21][22]. Additionally, there has been a focus in the literature on opioid prescriptions for chronic or pre-operative pain and the risk of continued use, while surgical patients receive the greatest amount of potent opioids [6,7,10,19,23].…”

“…Alternative non-opioid medications and opioid prescribing protocols may be of use to minimize risks without jeopardizing pain management. To give some examples, a shift to use of ketamine instead of opioids during surgery, a decrease in the availability of opioid dosage vials, EHR notifications to alert prescribers to high doses, and limitations to the duration of post-surgery prescriptions have been shown to be effective at reducing the MME prescribed post-surgery without compromising patient pain [4]. However, in an evaluation of opioid-prescribing practices, such policies did not show an association with fewer refills of opioid prescriptions post-surgery [4].…”

“…To give some examples, a shift to use of ketamine instead of opioids during surgery, a decrease in the availability of opioid dosage vials, EHR notifications to alert prescribers to high doses, and limitations to the duration of post-surgery prescriptions have been shown to be effective at reducing the MME prescribed post-surgery without compromising patient pain [4]. However, in an evaluation of opioid-prescribing practices, such policies did not show an association with fewer refills of opioid prescriptions post-surgery [4]. Notably, refills themselves have been identified as a risk factor for further use over time for the patient or family members [26,29].…”

“…Participants were grouped into three categories: (1) 0 MME (no opioids prescribed), (2) 1-90 MME, and (3) greater than 90 MME prescribed during the first prescription post-surgery. A threshold of >90 MME/day was chosen because it has been used as an indicator of high-dose prescribing and generally recommended against [4,7,[19][20][21]. Additionally, we examined patient-reported pain ratings.…”

“…However, the opioid epidemic has become a major public health concern in recent years, due to the alarming increase in opioid-related deaths [2]. Given the tendency for high doses of opioids to be used to control pain related to surgery, attention has turned to surgeons as a key population for opioid prescribing guidelines to curb the epidemic [3][4][5]. While it is well-established that prescription opioids for chronic pain put patients at risk of continued use, with the dosage of the initial prescription being significant, less is known about patients who are opioid-naïve, without chronic pain, who are first exposed to opioids as a product of elective surgery.…”