G. Brat1, D. Agniel2, A. Beam2, N. Palmer2, B. Yorkgitis1, M. Homer2, A. Salim1, I. Kohane2 1Brigham And Women’s Hospital,Trauma, Burns, And Critical Care,Boston, MA, USA 2Harvard School Of Medicine,Department Of Bioinformatics,Brookline, MA, USA
Introduction:
Age-adjusted opioid overdose rates now rank as the leading cause of unintentional injury-related death. Significant national, state, and hospital guidelines have been published to curb this epidemic. Despite these attempts, few documents are specifically focused on post-surgical patients. These patients receive post-discharge opioids between 50-80% their visits, nearly 4 times more often than their non-surgical counterparts. In this study, we hoped to explore the epidemiological change in prescribing patterns of surgical specialties and if such changes have translated into reduced rates of abuse.
Methods:
We used a de-identified administrative claims database of >70 million patients covered at a commercial managed healthcare company to identify individuals with health insurance coverage between 2008 and 2016 who underwent surgery. Our inclusion criteria were 1) 6 months of pre- and 1 year of post-surgical coverage, 2) 60 days of pre- and 90 days of post-surgical prescription drug coverage, and 3) no pre-surgical opioid or abuse exposure. We used previously described ICD-9 codes to identify pre- and post-surgical opioid abuse. A subset of 23 surgeries and their associated CPT codes, as defined by NSQIP, were used to categorize specialties. Post-discharge opioid use was collated from pharmacy data using total morphine equivalents (MME) prescribed divided by the total days prescribed, adjusted for overlap. Multivariable logistic regression was used to quantify the effect of year in changing surgical abuse rates independent of surgery.
Results:
Of the 1,000,309 narcotic naïve patients who met criteria, 1,913 (0.19%) developed an abuse or overdose code within 1 year. Figure A shows the trends in dose and duration by specialty and over time. From 2008 to 2014, median MME/day fell from 56.2 to 50. Specialties generally followed this same pattern–with vascular and urological surgical specialties making the greatest changes in dosing. However, these efforts did not translate into changes in outcome. Despite significant reductions in rates of opioid prescription over time, abuse rates increased (Figure B) from 202.1 to 297.4 per 100K patient-years. An adjusted model showed that progressive years were an independent risk factor for overdose and abuse.
Conclusion:
Physicians struggle to appropriately dose post-discharge opioids while addressing the very real needs of post-operative acute pain. Our data suggests that surgical specialties have generally behaved in similar ways to reduce their prescribed doses. Despite these small changes, abuse rates continue to rise. Successful interventions in surgery must move beyond dose changes to succeed.
