- Email: [email protected]
Decreasing Postoperative Opioid Prescribing through Education
ARTICLE IN PRESS ORIGINAL REPORTS
Decreasing Postoperative Opioid Prescribing through Education Lynn Nguyen, MD, Stacey Bowlds, MD, Christina Munford, MD, Krista Miller, MD, Timothy Finnegan, MD, Eric Clayton, MS, MPH, Murali Ranjani Behara, MD, and Christopher Senkowski, MD, FACS HCA Memorial Savannah, Savannah, Georgia OBJECTIVES: To study how an educational intervention given to surgical residents affected postoperative opioid prescribing. To determine whether decreased opioid prescription amounts increased patients’ rate of refills, emergency department visits, or readmissions.
ABBREVIATIONS: MME, Morphine milligram equivalent
PI, Pre-Intervention group POE, Post-Opioid Education group LOS Length of stay KEY WORDS: opioid prescribing, opioid epidemic, post-
DESIGN: Prospective sequential cohort study.
operative pain, pain control, surgical residency, surgical education
SETTING: Level 1 tertiary care center in Savannah,
COMPETENCIES: Patient Care, Practice-Based Learning
Georgia.
and Improvement, Medical Knowledge, Systems-Based Practice
PARTICIPANTS: Opioid-naive patients who underwent
general surgery (appendectomy, cholecystectomy, colectomy, hernia repair, lumpectomy, and mastectomy) between November 2017 and February 2018. RESULTS: Over a 6 month period, morphine milligram equivalents (MME) prescribed after general surgery per patient was decreased by 21.8% on average, with the largest reductions seen after breast and gallbladder surgeries (38% and 25% respectively). Patients who underwent laparoscopic surgery were prescribed 18.3% fewer MME. There was no significant change in MME prescribed after open abdominal surgery. Smaller prescription amounts were not associated with an increased rate of opioid refills. There was no increase in pain-related calls to clinic offices, emergency department visits, or readmissions for pain. CONCLUSION:
After a single education intervention given to surgical residents, MME prescribed after common general surgeries can be decreased significantly without increasing rates of refills or utilization of care. ( J Surg Ed 000:1 6. Ó 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA-affiliated entity. The views represented in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. Correspondence: Inquiries to Lynn Nguyen MD, 113 Timberline Drive, Savannah, GA 31404; e-mail: [email protected]
BACKGROUND Since pain was declared the fifth vital sign in 1999, there has been a steady increase in opioid prescribing, addiction, and overdose.1 In the United States, 47,600 deaths were attributed to opioid overdose in 2017 alone.1 Consequently, the U.S. Opioid Epidemic was declared a public health emergency and organized efforts to combat opioid abuse with research, health policies, and new pain management strategies began.1 Surgeons prescribe opioids to treat postoperative pain. The number of opioid tablets written after surgery generally exceeds the amount patients require for pain control.2 In a large study published in JAMA in 2017, Nallamothu et al. found that approximately 6% of opioidnaive patients who are prescribed opioids after surgery are still using them 6 months later, well outside the usual period of postoperative pain.3 Recommendations to reduce opioid prescribing after surgery have been published by the Michigan Opioid Prescribing Engagement Network in hopes of reducing opioid use, abuse, and addiction. However, they have been met with resistance by surgeons due to concerns that the patient will run out of tablets, have inadequate pain control, request more refills, and report dissatisfaction with care.4-6 In this prospective study at a tertiary care hospital in Savannah, Georgia, we report reductions in morphine
Journal of Surgical Education © 2019 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2019.11.010
1
ARTICLE IN PRESS milligram equivalents (MME) prescribed by general surgery residents after a single educational intervention on opioid prescribing.
METHODS This is a prospective study on MME prescribed by general surgery residents at a tertiary care hospital before and after an educational intervention. 453 adult patients who underwent cholecystectomy, appendectomy, hernia repair, colectomy, thyroid, or breast cancer surgery by faculty attending at our institution between November 2018 and February 2019 were identified. 28 patients who had a current opioid prescription prior to surgery or were under the care of a pain specialist were excluded from the study. 24 patients who had complications requiring ICU admissions or reoperation were excluded. After applying exclusion criteria, 401 total patients were studied. In the 2 month-long pre-intervention period (PI), residents were instructed to continue their habitual prescribing practices. No new prescribing recommendations were given. The number of tablets prescribed after specific surgeries were recorded to capture and describe preintervention opioid prescribing practices. After PI data was collected, an educational intervention was performed. Residents were given a 20 minute lecture on opioid prescribing which included epidemiologic data on opioid addiction and the increasing rate of opioid-related deaths in the United States. The lecture reviewed and refuted the following common misconceptions held by surgeons that make them reluctant to prescribe fewer tablets: - “If I do not prescribe enough, my patients will run out of opioid tablets.” Vu et al. reported that patients only used 28% of the opioid tablets prescribed after common operations.2 Even after halving initial prescriptions, patients only used 35% of prescribed tablets.4 - “If I write a larger initial prescription, then the patient won’t need a refill.” Waljee et al. reported that refill rates were stable across all initial prescription sizes at approximately 8.67%. Larger initial prescriptions were not associated with a lower rate of refill, but instead trended toward an increased risk of refill within 30 days.5 - “If I do not write a larger prescription, then patients will be dissatisfied with my care.” Lewis and Trafton asked patients to rate their care on a scale of 1-10 30 days after their surgery. He found that more than 80% of patients rated their satisfaction as a 9 or 10 out of 10 across all prescription sizes,6 showing that the amount of opioids prescribed does not affect patient satisfaction.
2
This lecture also provided residents with tips on opioid counseling, the utility of multimodal pain regimens, and useful phrases in managing patients’ expectations of pain. A table with surgery-specific postoperative prescription recommendations that would provide adequate pain control for 88% of patients 1 was distributed in both physical laminated card and electronic formats to the residents for easy reference. Residents were encouraged to follow the recommendations (Table 1) on this card when writing opioid prescriptions but were allowed to deviate from these recommendations for any reason. In addition, a patient counseling program was implemented. Tips on how to use opioids safely were posted in all clinic examination rooms and pre-op preparation rooms for patients to read (Fig. 1). Topics addressed in this document included expectations of pain, risks and side effects of opioids, timing of transition from opioids to over-the-counter analgesics, and instructions for safe disposal of unused tablets. This informational sheet was input into the electronic medical record, included in discharge paperwork, and reviewed by nursing at bedside. After this intervention, prescribing practices were again recorded for 2 months in the Post Opioid Education (POE) period. Data points collected in both the PI and POE periods were patient sex, age, type of surgery, and length of stay (LOS). The primary outcome measures were number of MME prescribed and filled within
TABLE 1. Opioid Prescribing Recommendation Card Procedure
Lap colectomy Open colectomy Ileostomy/colostomy Lap cholecystectomy Lap appendectomy Thyroidectomy Breast biopsy or lumpectomy Lumpectomy with SLN Mastectomy with SLN Mastectomy with ALND
Hydrocodone (Norco) 5 mg Tablets Tylenol #3 30 mg Tablets
Oxycodone (Percocet) 5 mg Tablets
Tramadol 50 mg Tablets
Hydromorphone (Dilaudid) 2 mg Tablets
30 30 40 15 15 10 10
20 20 25 10 10 5 5
15 30 45
10 20 30
Data-based prescribing recommendations from the opioid prescribing engagement network (OPEN) were provided in electronic and laminated hard copy to surgical residents.
Journal of Surgical Education Volume 00 /Number 00 Month 2019
ARTICLE IN PRESS
FIGURE 1. Patient counseling. Opioid counseling sheets were posted in patient care areas and included in discharge paperwork. These points were reviewed with the patient at bedside by surgical residents and nursing staff.
30 days of surgery. In an effort to capture episodes of inadequate pain control, the following events were tracked for 30 days after surgery: calls to the clinic office regarding pain, emergency department visits for pain, readmissions for pain control, and of course opioid prescription refills. These were recorded in both the PI and POE group as pain related events. Data on all opioid prescriptions filled by an individual patient was obtained from the Prescription Drug Monitoring Program (PDMP). At the time of data collection in March 2019, the participants of the PDMP included the Military Health system and the following states: AL, AR, DE, DC, FL, LA, ME, MA, MI, NY, NC, ND, OH, SC, TN, VA, and the District of Columbia. Descriptive statistics were calculated for all variables of interest. The statistical significance of the relationships between the variables was determined via independent samples t-tests, Pearson chi-squared tests,
Journal of Surgical Education Volume 00 /Number 00 Month 2019
general linear modeling, linear regression, and logistic regression, as appropriate. The threshold for declaring statistical significance was set at p < 0.05, and all analyses were performed with the IBM Statistical Package for the Social Sciences software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.).
RESULTS There were 200 patients in the pre-intervention (PI) group and 201 patients in the post-opioid education (POE) group. There was no significant difference between the groups’ age, sex, type of surgery, or hospital LOS (Table 2). Laparoscopic cholecystectomy was the most common operation overall (n = 119, 29.7%), followed by breast surgery (n = 101, 25.2%), hernia
3
ARTICLE IN PRESS
TABLE 2. Descriptive Patient Characteristics PI Group n (%) Sex Male Female Type of surgery Gallbladder Colon Hernia Breast Thyroid Appendix Surgical approach Skin/superficial Laparoscopic Open Abd Age Length of stay
POE Group n (%)
p
71 (35.5%) 129 (64.5%)
65 (32.3%) 136 (67.7%)
0.504
64 (32.0%) 21 (10.5%) 33 (16.5%) 48 (24.0%) 6 (3.0%) 28 (14.0%)
55 (27.4%) 14 (7.0%) 52 (25.9%) 53 (26.4%) 9 (4.5%) 18 (9.0%)
0.096
56 (28.0%) 109 (54.5%) 35 (17.5%) 54.53 (18.61) 1.08 (1.46)
63 (31.3%) 110 (54.7%) 28 (13.9%) 52.51 (18.61) 1.10 (1.38)
0.551 0.278 0.900
Pre-intervention (PI) and Post Opioid Education (POE) patients were not significantly different in regards to sex distribution, type of surgery, surgical approach, age, or length of stay.
surgery (n = 85, 21.2%), appendectomy (n = 46, 11.5%), and colectomy (n = 35, 8.7%). Only 15 thyroid surgeries were performed which was too few for comparative statistical analyses. The most common surgical approach was laparoscopic (n = 219, 54.6%). Overall, 372 (92.8%) of patients were given an opioid prescription upon discharge. In both groups, the median length of stay was one day. There was no difference in the proportion of patients who received an opioid prescription between the 2 groups (POE 95%, PI 91.5%, p = 0.328). Across all procedures, patients in the POE group were prescribed 21.8% fewer MME when compared to the PI group (POE 106.9 vs PI 136.7 MME, p < 0.0005, see Table 2). The greatest decrease in MME prescribed were observed after cholecystectomy (25% fewer MME, POE 103.7 MME vs PI 137.8 MME, p < 0.0005) and breast surgery (38% fewer MME, POE 83.3 MME vs PI 134.9 MME, p < 0.0005, see Fig. 2). Patients who had laparoscopic surgery were prescribed 18.3% less MME in the POE group compared to the PI group (POE 108 MME vs PI 132.2, p < 0.05, see Fig. 3). MME prescribed after open abdominal surgery did not vary significantly when examined independently (POE 149 MME, PI 155.3 MME). Overall, 19.1% of patients who were given a prescription did not fill it. Patients were not less likely to fill their prescriptions after opioid counseling (POE 75% filled vs PI 78% filled, p = 0.479). There was no difference in number of opioid refills within 30 days of surgery between the 2 groups (POE n = 16 patients, 9.5% vs PI n = 19 patients, 8%, p = 0.509).
4
FIGURE 2. Prescribing differences between PI and POE groups by surgery. Significantly less morphine milligram equivalents (MME) were prescribed to patients in gallbladder and breast surgeries in the POE (postopioid intervention) group as compared to the PI (pre-intervention) group (p < 0.005).
One patient in the PI group was readmitted for abdominal pain due to constipation. There were no readmissions for abdominal pain in the POE group. There was no significant increase in pain-related events between the PI and POE groups (p = 0.509, see Table 3). The only factor significantly associated with a pain-related event was number of MME prescribed (OR 1.008 for each additional MME prescribed, p = 0.031, see Fig. 4).
DISCUSSION In this study, a single educational intervention on opioid prescribing was associated with a 21.8% decrease in MME prescribed after surgery. Over 2 months, 5990 fewer MME were prescribed, which is the equivalent of 1198 5 mg hydrocodone tablets. Our results were consistent with other research that suggests that refill rates are constant across initial prescription sizes 5 and that surgeons prescribe more opioids than patients require.4 Since unused opioid tablets are often diverted to nonpatients, smaller prescriptions may have the potential to prevent opioid exposure to opioid-naive members of the community and decrease the abuse of prescription pain medications in the overall population.7 It should be noted that prescribing recommendations were obtained from https://michigan-open.org/prescribing-recommen dations/, accessed on August 23, 2018. Since then, the
Journal of Surgical Education Volume 00 /Number 00 Month 2019
ARTICLE IN PRESS
p = 0.031
FIGURE 4. Number of prescribed MME is associated with increased risk of pain-related event. Number of prescribed MME was associated with an increased risk of pain-related event, with odds ratio (OR) of 1.008 per each additional MME prescribed.
FIGURE 3. Prescribing differences between PI and POE groups by surgical approach. Significantly fewer MME (morphine milligram equivalents) were prescribed to patients after laparoscopic and skin and superficial surgeries in the POE (post-opioid education) group as compared to PI (preintervention) group.
Michigan Opioid Prescribing Engagement Network has released new, lower prescribing recommendations. One advantage of our educational intervention was its focus on refuting common misconceptions that are psychological barriers to prescribing less opioids. Residents adopted new prescribing practices reassured by data that their new practices would not result in an increased
TABLE 3. Association of Variables with Risk of Pain-related Event Continuous Variable
Odds Ratio
Age Length of stay Prescribed MME Categorical variable Sex Opioid education Type of surgery Surgical approach
1.004 1.210 1.008 x2 0.111 0.437 3.445 2.052
p 0.643 0.095 0.031* p 0.739 0.509 0.486 0.358
Patient age, length of stay, sex, opioid education, type of surgery, and surgical approach were not associated with an increased risk of painrelated event. Asterisk indicates that the number of prescribed MME, however, was associated with an increased risk of pain-related event, with odds ratio (OR) of 1.008 per each additional MME prescribed.
Journal of Surgical Education Volume 00 /Number 00 Month 2019
rate of refills or decreased patient satisfaction. Another unique aspect of our lecture was its section of patient counseling, which empowered residents to educate patients on opioid alternatives and involve them in the delivery of their own care. In 2017, Barth et al. reported a significant reduction in opioid prescribing after a lecture-based educational intervention within a surgical department, but to our knowledge our study is the first to describe a residentled, resident-focused educational endeavor to change prescribing habits. Residents may be especially fruitful targets for education and effective instruments for change in the opioid epidemic given the many years of practice they have left in their careers. The use of PDMP data was a strength of this study because it accurately tracked the filling of initial prescriptions and refills written both by providers at our institution and at other institutions in several states. One limitation of this study is its ability to completely capture instances of uncontrolled pain. Sometimes, calls to the clinic office or prescribing attending are not recorded in the EMR, and visits to other care facilities were not tracked. Some patients may have had uncontrolled pain at home but were not captured because they did not initiate an encounter with the care team or obtain a refill opioid prescription. While patient satisfaction has been shown to be stable across opioid prescription sizes in prior studies,6 it was not measured in this study. Future studies should evaluate these patients 6 to 12 months after their surgery to determine if these interventions reduce chronic opioid use in opioid-naive patients who receive a prescription for acute postoperative pain
5
ARTICLE IN PRESS to achieve the ultimate goal of lowering opioid abuse, addiction, and overdose-related death.
CONCLUSION Presenting reduced opioid prescribing recommendations to surgical residents and counseling patients significantly decreases the number of MME prescribed after general surgery without increasing the rate of refill prescriptions or incurring additional healthcare encounters for pain control.
REFERENCES
3. Brummett CM, Waljee JF, Goesling J, et al. New per-
sistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152:e170504. https://doi.org/10.1001/jamasurg.2017.0504. 4. Howard Ryan, Fry Brian, Gunaseelan Vidhya, et al. Asso-
ciation of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019;154: e184234. https://doi.org/10.1001/jamasurg.2018.4234. 5. Sekhri Shaina, Arora Nonie S, Cottrell Hannah, et al.
Probability of opioid prescription refilling after surgery: does initial prescription dose matter? Ann Surg. 2018;268:271–276. https://doi.org/10.1097/ SLA.0000000000002308.
1. What is the U.S.Opioid Epidemic? Retrieved from:
6. Fry Brian T, Lee Jay S, Howard Ryan, et al. Opioid pre-
https://www.hhs.gov/opioids/about-the-epidemic/ index.html.
scribing and patient satisfaction after general surgery. J Am Coll Surg. 2018;227:S158. https://doi.org/ 10.1016/j.jamcollsurg.2018.07.335.
2. Hill Maureen V, Stucke Ryland S, McMahon Michelle L,
Beeman Julia L, Barth Richard J. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg. 2018;267:468–472. https://doi.org/10.1097/SLA.0000000000002198.
6
7. Lewis ET, Cucciare MA, Trafton JA. What do
patients do with unused opioid medications. Clin J Pain. 2014;30:654–662. https://doi.org/10.1097/ 01.ajp.0000435447.96642.f4.
Journal of Surgical Education Volume 00 /Number 00 Month 2019
Decreasing Postoperative Opioid Prescribing through Education Lynn Nguyen, MD, Stacey Bowlds, MD, Christina Munford, MD, Krista Miller, MD, Timothy Finnegan, MD, Eric Clayton, MS, MPH, Murali Ranjani Behara, MD, and Christopher Senkowski, MD, FACS HCA Memorial Savannah, Savannah, Georgia OBJECTIVES: To study how an educational intervention given to surgical residents affected postoperative opioid prescribing. To determine whether decreased opioid prescription amounts increased patients’ rate of refills, emergency department visits, or readmissions.
ABBREVIATIONS: MME, Morphine milligram equivalent
PI, Pre-Intervention group POE, Post-Opioid Education group LOS Length of stay KEY WORDS: opioid prescribing, opioid epidemic, post-
DESIGN: Prospective sequential cohort study.
operative pain, pain control, surgical residency, surgical education
SETTING: Level 1 tertiary care center in Savannah,
COMPETENCIES: Patient Care, Practice-Based Learning
Georgia.
and Improvement, Medical Knowledge, Systems-Based Practice
PARTICIPANTS: Opioid-naive patients who underwent
general surgery (appendectomy, cholecystectomy, colectomy, hernia repair, lumpectomy, and mastectomy) between November 2017 and February 2018. RESULTS: Over a 6 month period, morphine milligram equivalents (MME) prescribed after general surgery per patient was decreased by 21.8% on average, with the largest reductions seen after breast and gallbladder surgeries (38% and 25% respectively). Patients who underwent laparoscopic surgery were prescribed 18.3% fewer MME. There was no significant change in MME prescribed after open abdominal surgery. Smaller prescription amounts were not associated with an increased rate of opioid refills. There was no increase in pain-related calls to clinic offices, emergency department visits, or readmissions for pain. CONCLUSION:
After a single education intervention given to surgical residents, MME prescribed after common general surgeries can be decreased significantly without increasing rates of refills or utilization of care. ( J Surg Ed 000:1 6. Ó 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA-affiliated entity. The views represented in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. Correspondence: Inquiries to Lynn Nguyen MD, 113 Timberline Drive, Savannah, GA 31404; e-mail: [email protected]
BACKGROUND Since pain was declared the fifth vital sign in 1999, there has been a steady increase in opioid prescribing, addiction, and overdose.1 In the United States, 47,600 deaths were attributed to opioid overdose in 2017 alone.1 Consequently, the U.S. Opioid Epidemic was declared a public health emergency and organized efforts to combat opioid abuse with research, health policies, and new pain management strategies began.1 Surgeons prescribe opioids to treat postoperative pain. The number of opioid tablets written after surgery generally exceeds the amount patients require for pain control.2 In a large study published in JAMA in 2017, Nallamothu et al. found that approximately 6% of opioidnaive patients who are prescribed opioids after surgery are still using them 6 months later, well outside the usual period of postoperative pain.3 Recommendations to reduce opioid prescribing after surgery have been published by the Michigan Opioid Prescribing Engagement Network in hopes of reducing opioid use, abuse, and addiction. However, they have been met with resistance by surgeons due to concerns that the patient will run out of tablets, have inadequate pain control, request more refills, and report dissatisfaction with care.4-6 In this prospective study at a tertiary care hospital in Savannah, Georgia, we report reductions in morphine
Journal of Surgical Education © 2019 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2019.11.010
1
ARTICLE IN PRESS milligram equivalents (MME) prescribed by general surgery residents after a single educational intervention on opioid prescribing.
METHODS This is a prospective study on MME prescribed by general surgery residents at a tertiary care hospital before and after an educational intervention. 453 adult patients who underwent cholecystectomy, appendectomy, hernia repair, colectomy, thyroid, or breast cancer surgery by faculty attending at our institution between November 2018 and February 2019 were identified. 28 patients who had a current opioid prescription prior to surgery or were under the care of a pain specialist were excluded from the study. 24 patients who had complications requiring ICU admissions or reoperation were excluded. After applying exclusion criteria, 401 total patients were studied. In the 2 month-long pre-intervention period (PI), residents were instructed to continue their habitual prescribing practices. No new prescribing recommendations were given. The number of tablets prescribed after specific surgeries were recorded to capture and describe preintervention opioid prescribing practices. After PI data was collected, an educational intervention was performed. Residents were given a 20 minute lecture on opioid prescribing which included epidemiologic data on opioid addiction and the increasing rate of opioid-related deaths in the United States. The lecture reviewed and refuted the following common misconceptions held by surgeons that make them reluctant to prescribe fewer tablets: - “If I do not prescribe enough, my patients will run out of opioid tablets.” Vu et al. reported that patients only used 28% of the opioid tablets prescribed after common operations.2 Even after halving initial prescriptions, patients only used 35% of prescribed tablets.4 - “If I write a larger initial prescription, then the patient won’t need a refill.” Waljee et al. reported that refill rates were stable across all initial prescription sizes at approximately 8.67%. Larger initial prescriptions were not associated with a lower rate of refill, but instead trended toward an increased risk of refill within 30 days.5 - “If I do not write a larger prescription, then patients will be dissatisfied with my care.” Lewis and Trafton asked patients to rate their care on a scale of 1-10 30 days after their surgery. He found that more than 80% of patients rated their satisfaction as a 9 or 10 out of 10 across all prescription sizes,6 showing that the amount of opioids prescribed does not affect patient satisfaction.
2
This lecture also provided residents with tips on opioid counseling, the utility of multimodal pain regimens, and useful phrases in managing patients’ expectations of pain. A table with surgery-specific postoperative prescription recommendations that would provide adequate pain control for 88% of patients 1 was distributed in both physical laminated card and electronic formats to the residents for easy reference. Residents were encouraged to follow the recommendations (Table 1) on this card when writing opioid prescriptions but were allowed to deviate from these recommendations for any reason. In addition, a patient counseling program was implemented. Tips on how to use opioids safely were posted in all clinic examination rooms and pre-op preparation rooms for patients to read (Fig. 1). Topics addressed in this document included expectations of pain, risks and side effects of opioids, timing of transition from opioids to over-the-counter analgesics, and instructions for safe disposal of unused tablets. This informational sheet was input into the electronic medical record, included in discharge paperwork, and reviewed by nursing at bedside. After this intervention, prescribing practices were again recorded for 2 months in the Post Opioid Education (POE) period. Data points collected in both the PI and POE periods were patient sex, age, type of surgery, and length of stay (LOS). The primary outcome measures were number of MME prescribed and filled within
TABLE 1. Opioid Prescribing Recommendation Card Procedure
Lap colectomy Open colectomy Ileostomy/colostomy Lap cholecystectomy Lap appendectomy Thyroidectomy Breast biopsy or lumpectomy Lumpectomy with SLN Mastectomy with SLN Mastectomy with ALND
Hydrocodone (Norco) 5 mg Tablets Tylenol #3 30 mg Tablets
Oxycodone (Percocet) 5 mg Tablets
Tramadol 50 mg Tablets
Hydromorphone (Dilaudid) 2 mg Tablets
30 30 40 15 15 10 10
20 20 25 10 10 5 5
15 30 45
10 20 30
Data-based prescribing recommendations from the opioid prescribing engagement network (OPEN) were provided in electronic and laminated hard copy to surgical residents.
Journal of Surgical Education Volume 00 /Number 00 Month 2019
ARTICLE IN PRESS
FIGURE 1. Patient counseling. Opioid counseling sheets were posted in patient care areas and included in discharge paperwork. These points were reviewed with the patient at bedside by surgical residents and nursing staff.
30 days of surgery. In an effort to capture episodes of inadequate pain control, the following events were tracked for 30 days after surgery: calls to the clinic office regarding pain, emergency department visits for pain, readmissions for pain control, and of course opioid prescription refills. These were recorded in both the PI and POE group as pain related events. Data on all opioid prescriptions filled by an individual patient was obtained from the Prescription Drug Monitoring Program (PDMP). At the time of data collection in March 2019, the participants of the PDMP included the Military Health system and the following states: AL, AR, DE, DC, FL, LA, ME, MA, MI, NY, NC, ND, OH, SC, TN, VA, and the District of Columbia. Descriptive statistics were calculated for all variables of interest. The statistical significance of the relationships between the variables was determined via independent samples t-tests, Pearson chi-squared tests,
Journal of Surgical Education Volume 00 /Number 00 Month 2019
general linear modeling, linear regression, and logistic regression, as appropriate. The threshold for declaring statistical significance was set at p < 0.05, and all analyses were performed with the IBM Statistical Package for the Social Sciences software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.).
RESULTS There were 200 patients in the pre-intervention (PI) group and 201 patients in the post-opioid education (POE) group. There was no significant difference between the groups’ age, sex, type of surgery, or hospital LOS (Table 2). Laparoscopic cholecystectomy was the most common operation overall (n = 119, 29.7%), followed by breast surgery (n = 101, 25.2%), hernia
3
ARTICLE IN PRESS
TABLE 2. Descriptive Patient Characteristics PI Group n (%) Sex Male Female Type of surgery Gallbladder Colon Hernia Breast Thyroid Appendix Surgical approach Skin/superficial Laparoscopic Open Abd Age Length of stay
POE Group n (%)
p
71 (35.5%) 129 (64.5%)
65 (32.3%) 136 (67.7%)
0.504
64 (32.0%) 21 (10.5%) 33 (16.5%) 48 (24.0%) 6 (3.0%) 28 (14.0%)
55 (27.4%) 14 (7.0%) 52 (25.9%) 53 (26.4%) 9 (4.5%) 18 (9.0%)
0.096
56 (28.0%) 109 (54.5%) 35 (17.5%) 54.53 (18.61) 1.08 (1.46)
63 (31.3%) 110 (54.7%) 28 (13.9%) 52.51 (18.61) 1.10 (1.38)
0.551 0.278 0.900
Pre-intervention (PI) and Post Opioid Education (POE) patients were not significantly different in regards to sex distribution, type of surgery, surgical approach, age, or length of stay.
surgery (n = 85, 21.2%), appendectomy (n = 46, 11.5%), and colectomy (n = 35, 8.7%). Only 15 thyroid surgeries were performed which was too few for comparative statistical analyses. The most common surgical approach was laparoscopic (n = 219, 54.6%). Overall, 372 (92.8%) of patients were given an opioid prescription upon discharge. In both groups, the median length of stay was one day. There was no difference in the proportion of patients who received an opioid prescription between the 2 groups (POE 95%, PI 91.5%, p = 0.328). Across all procedures, patients in the POE group were prescribed 21.8% fewer MME when compared to the PI group (POE 106.9 vs PI 136.7 MME, p < 0.0005, see Table 2). The greatest decrease in MME prescribed were observed after cholecystectomy (25% fewer MME, POE 103.7 MME vs PI 137.8 MME, p < 0.0005) and breast surgery (38% fewer MME, POE 83.3 MME vs PI 134.9 MME, p < 0.0005, see Fig. 2). Patients who had laparoscopic surgery were prescribed 18.3% less MME in the POE group compared to the PI group (POE 108 MME vs PI 132.2, p < 0.05, see Fig. 3). MME prescribed after open abdominal surgery did not vary significantly when examined independently (POE 149 MME, PI 155.3 MME). Overall, 19.1% of patients who were given a prescription did not fill it. Patients were not less likely to fill their prescriptions after opioid counseling (POE 75% filled vs PI 78% filled, p = 0.479). There was no difference in number of opioid refills within 30 days of surgery between the 2 groups (POE n = 16 patients, 9.5% vs PI n = 19 patients, 8%, p = 0.509).
4
FIGURE 2. Prescribing differences between PI and POE groups by surgery. Significantly less morphine milligram equivalents (MME) were prescribed to patients in gallbladder and breast surgeries in the POE (postopioid intervention) group as compared to the PI (pre-intervention) group (p < 0.005).
One patient in the PI group was readmitted for abdominal pain due to constipation. There were no readmissions for abdominal pain in the POE group. There was no significant increase in pain-related events between the PI and POE groups (p = 0.509, see Table 3). The only factor significantly associated with a pain-related event was number of MME prescribed (OR 1.008 for each additional MME prescribed, p = 0.031, see Fig. 4).
DISCUSSION In this study, a single educational intervention on opioid prescribing was associated with a 21.8% decrease in MME prescribed after surgery. Over 2 months, 5990 fewer MME were prescribed, which is the equivalent of 1198 5 mg hydrocodone tablets. Our results were consistent with other research that suggests that refill rates are constant across initial prescription sizes 5 and that surgeons prescribe more opioids than patients require.4 Since unused opioid tablets are often diverted to nonpatients, smaller prescriptions may have the potential to prevent opioid exposure to opioid-naive members of the community and decrease the abuse of prescription pain medications in the overall population.7 It should be noted that prescribing recommendations were obtained from https://michigan-open.org/prescribing-recommen dations/, accessed on August 23, 2018. Since then, the
Journal of Surgical Education Volume 00 /Number 00 Month 2019
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p = 0.031
FIGURE 4. Number of prescribed MME is associated with increased risk of pain-related event. Number of prescribed MME was associated with an increased risk of pain-related event, with odds ratio (OR) of 1.008 per each additional MME prescribed.
FIGURE 3. Prescribing differences between PI and POE groups by surgical approach. Significantly fewer MME (morphine milligram equivalents) were prescribed to patients after laparoscopic and skin and superficial surgeries in the POE (post-opioid education) group as compared to PI (preintervention) group.
Michigan Opioid Prescribing Engagement Network has released new, lower prescribing recommendations. One advantage of our educational intervention was its focus on refuting common misconceptions that are psychological barriers to prescribing less opioids. Residents adopted new prescribing practices reassured by data that their new practices would not result in an increased
TABLE 3. Association of Variables with Risk of Pain-related Event Continuous Variable
Odds Ratio
Age Length of stay Prescribed MME Categorical variable Sex Opioid education Type of surgery Surgical approach
1.004 1.210 1.008 x2 0.111 0.437 3.445 2.052
p 0.643 0.095 0.031* p 0.739 0.509 0.486 0.358
Patient age, length of stay, sex, opioid education, type of surgery, and surgical approach were not associated with an increased risk of painrelated event. Asterisk indicates that the number of prescribed MME, however, was associated with an increased risk of pain-related event, with odds ratio (OR) of 1.008 per each additional MME prescribed.
Journal of Surgical Education Volume 00 /Number 00 Month 2019
rate of refills or decreased patient satisfaction. Another unique aspect of our lecture was its section of patient counseling, which empowered residents to educate patients on opioid alternatives and involve them in the delivery of their own care. In 2017, Barth et al. reported a significant reduction in opioid prescribing after a lecture-based educational intervention within a surgical department, but to our knowledge our study is the first to describe a residentled, resident-focused educational endeavor to change prescribing habits. Residents may be especially fruitful targets for education and effective instruments for change in the opioid epidemic given the many years of practice they have left in their careers. The use of PDMP data was a strength of this study because it accurately tracked the filling of initial prescriptions and refills written both by providers at our institution and at other institutions in several states. One limitation of this study is its ability to completely capture instances of uncontrolled pain. Sometimes, calls to the clinic office or prescribing attending are not recorded in the EMR, and visits to other care facilities were not tracked. Some patients may have had uncontrolled pain at home but were not captured because they did not initiate an encounter with the care team or obtain a refill opioid prescription. While patient satisfaction has been shown to be stable across opioid prescription sizes in prior studies,6 it was not measured in this study. Future studies should evaluate these patients 6 to 12 months after their surgery to determine if these interventions reduce chronic opioid use in opioid-naive patients who receive a prescription for acute postoperative pain
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ARTICLE IN PRESS to achieve the ultimate goal of lowering opioid abuse, addiction, and overdose-related death.
CONCLUSION Presenting reduced opioid prescribing recommendations to surgical residents and counseling patients significantly decreases the number of MME prescribed after general surgery without increasing the rate of refill prescriptions or incurring additional healthcare encounters for pain control.
REFERENCES
3. Brummett CM, Waljee JF, Goesling J, et al. New per-
sistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152:e170504. https://doi.org/10.1001/jamasurg.2017.0504. 4. Howard Ryan, Fry Brian, Gunaseelan Vidhya, et al. Asso-
ciation of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019;154: e184234. https://doi.org/10.1001/jamasurg.2018.4234. 5. Sekhri Shaina, Arora Nonie S, Cottrell Hannah, et al.
Probability of opioid prescription refilling after surgery: does initial prescription dose matter? Ann Surg. 2018;268:271–276. https://doi.org/10.1097/ SLA.0000000000002308.
1. What is the U.S.Opioid Epidemic? Retrieved from:
6. Fry Brian T, Lee Jay S, Howard Ryan, et al. Opioid pre-
https://www.hhs.gov/opioids/about-the-epidemic/ index.html.
scribing and patient satisfaction after general surgery. J Am Coll Surg. 2018;227:S158. https://doi.org/ 10.1016/j.jamcollsurg.2018.07.335.
2. Hill Maureen V, Stucke Ryland S, McMahon Michelle L,
Beeman Julia L, Barth Richard J. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg. 2018;267:468–472. https://doi.org/10.1097/SLA.0000000000002198.
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7. Lewis ET, Cucciare MA, Trafton JA. What do
patients do with unused opioid medications. Clin J Pain. 2014;30:654–662. https://doi.org/10.1097/ 01.ajp.0000435447.96642.f4.
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