Opioid Prescriptions After Hemorrhoidectomy

Abstract

BACKGROUND: Hemorrhoids cause more than 4 million ambulatory care visits in the United States annually, and hemorrhoidectomy is associated with significant postoperative pain. There are currently no evidence-based opioid-prescribing guidelines for hemorrhoidectomy patients. OBJECTIVE: The purpose of this study was to investigate patterns of opioid prescribing and to identify factors associated with opioid refill after hemorrhoidectomy. DESIGN: This was a retrospective database review. SETTINGS: The study was conducted using the Department of Defense Military Health System Data Repository (2006–2014). PATIENTS: Opioid-naïve patients aged 18 to 64 years enrolled in TRICARE insurance who underwent surgical hemorrhoidectomy were included in this study. MAIN OUTCOME MEASURES: We measured patterns of opioid prescriptions and predictors of a second opioid prescription within 2 weeks of the end date for the first prescription after hemorrhoidectomy. RESULTS: A total of 6294 patients were included; 5536 (88.0%) filled an initial opioid prescription with a median 5-day supply, and 1820 (32.9%) required an opioid refill. The modeled risk of refill based on initial prescription supply ranged from a high of 39.2% risk with an initial prescription of 1-day supply to an early nadir (26.1% risk of refill) with an initial 10-day supply. A variety of sociodemographic and clinical characteristics influenced the likelihood of opioid refill, including black race (OR = 0.75 (95% CI, 0.62–0.89)), history of substance abuse (OR = 3.26 (95% CI, 1.37–7.34)), and length of index opioid prescription (4–6 d, OR = 0.83 (95% CI, 0.72–0.96) or ≥7 d, OR = 0.67 (95% CI, 0.57–0.78) vs 1–3 d). LIMITATIONS: Variables assessed were limited because of the use of claims-based data. CONCLUSIONS: There is wide variability in the length of prescription opioid use after hemorrhoidectomy. Approximately one third of patients require a second prescription in the immediate postoperative period. The optimal duration appears to be between a 5- and 10-day supply. Clinicians may be able to more efficiently discharge patients with adequate analgesia while minimizing the potential for excess supply. See Video Abstract at http://links.lww.com/DCR/B112. PRESCRIPCIÓN DE MÉDICAMENTOS OPIOIDES DESPUÉS DE HEMORROIDECTOMÍA ANTECEDENTES: Las afecciones hemorroidarias ocasionan anualmente más de cuatro millones de consultas ambulatorias en los Estados Unidos. La hemorroidectomía esta asociada con dolor postoperatorio muy significativo. Actualmente no existen pautas claras para la prescripción de medicamentos opioides después de hemorroidectomía, basada en la evidencia. OBJETIVO: Investigar los patrones de prescripción de medicamentos opioides e identificar los factores asociados con la acumulación de dichos opioides después de una hemorroidectomía. DISEÑO: Revisión retrospectiva de una base de datos. CONFIGURACIÓN: Almacén de datos del Sistema de Salud militar del Departamento de Defensa de los Estados Unidos de América (2006-2014). PACIENTES: Todos aquellos sometidos a hemorroidectomía quirúrgica, sin tratamiento opiode previo, comprendiodos entre 18-64 años y beneficiarios de seguro TRICARE. PRINCIPALES RESULTADOS: Patrones de prescripción de recetas de opioides, predictores de una segunda receta de opioides dentro las dos semanas posteriores a la fecha de finalización de la primera receta después de la hemorroidectomía. RESULTADOS: 6.294 pacientes fueron incluidos en el estudio. 5.536 (88,0%) completaron una receta inicial de opioides con un suministro promedio de cinco días, y 1.820 (32,9%) pacientes requirieron reabastecerse de opioides. El riesgo modelado de reabastecimiento de opiodes basado en el suministro de la prescripción inicial, varió desde un alto riesgo (39.2%) con una prescripción inicial de suministro por día, hasta un acmé temprano (26.1% de riesgo de reabastecimiento) con un suministro inicial de 10 días. Una gran variedad de características socio-demográficas y clínicas influyeron en la probabilidad del reabastecimeinto de los opioides, incluida la raza negra (OR 0.75, intervalo de confianza (IC) del 95% (0.62, 0.89)), los antecedentes de abuso de substancias (OR 3.26, IC del 95% (1.37, 7.34)) y la duración del índice de la prescripción de opioides (4-6 días (OR 0.83, IC 95% (0.72, 0.96)), o 7 días o más (OR 0.67, IC 95% (0.57, 0,78)) comparados a 1-3 días. LIMITACIONES: Las variables analizadas fueron limitadas debido al uso de datos basados en reclamos. CONCLUSIONES: Existe una gran variabilidad en la duración del uso de opioides recetados después de hemorroidectomía. Aproximadamente un tercio de los pacientes requieren una segunda prescripción en el postoperatorio inmediato. La duración óptima parece estar entre un suministro de cinco y 10 días. Los médicos pueden dar de alta de manera más eficiente a los pacientes con analgesia adecuada y minimizar el potencial de exceso de suministro. Consulte Video Resumen en http://links.lww.com/DCR/B112. (Traducción—Dr. Xavier Delgadillo)

A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use

“…30 They found 88% filled an initial opioid prescription and 32.9% required a refill; longer length of the index opioid prescription was the only modifiable associated with the second prescription. 30 Though not controlled studies, these works support the need to reduce opioid prescribing for outpatient anorectal operations.…”

Hemorrhoids

“…No formal guidelines exist to inform clinicians on appropriate prescribing of narcotics after hemorrhoidectomy, although a recent study of over 6200 patients in a claims database determined that a 5-to 10-day prescription is optimal for most patients, noting there was over threefold increased odds of needing a prescription refill in patients with history of opioid use. One of the major limitations of the study was that it could not determine the number of pills or type of narcotic prescribed [73]. A more recent retrospective single-institution study of 77 patients who underwent ambulatory excisional hemorrhoidectomy evaluated postoperative opioid usage to create a prospective prescribing guideline.…”

Efficacy and safety of pudendal nerve block for postoperative analgesia of hemorrhoids: a systematic review of 7 randomized controlled trials

“…There are many analgesia methods after hemorrhoidectomy, such as medication of analgesics [e.g., opioid analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs)], somatosensory stimulation treatments and narcotic analgesia (3)(4)(5). Analgesics are often effective, whilst their side effects should not be neglected.…”