J. Bleicher1, S. M. Stokes1, B. C. Nguyen1, L. C. Huang1,2, B. S. Brooke1, R. E. Glasgow1 1University Of Utah,General Surgery,Salt Lake City, UT, USA 2Huntsman Cancer Institute At The University Of Utah,General Surgery,Salt Lake City, UT, USA
Introduction: As knowledge of the opioid epidemic grows, many have begun to generate guidelines to optimize opioid prescribing. Adherence to blanket guidelines, as opposed to a patient-centered approach to opioid prescribing, may lead to significant problems with over- and under-prescribing of opioids for patients. Patients’ in-hospital narcotic requirements can serve as a valuable way to determine the optimal amount of opioids for discharge. As the first step to developing a patient-centered approach to opioid prescribing, we compared inpatient opioid use during the 24 and 48 hours prior to discharge with the amount of opioids prescribed at discharge.
Methods: We conducted a retrospective observational study at a single academic tertiary center. All patients with CPT codes for Roux-en-Y gastric bypass, distal pancreatectomy, pancreaticoduodenectomy, colectomy, and abdominal wall reconstruction between July 1, 2016 and June 30, 2018 were included. Patients with chronic pain requiring preoperative methadone and fentanyl patches were excluded from the study. The total 24 and 48 hour pre-discharge opioids used, and the discharge prescription, were convered to morphine milligram equivalents (MME). This was converted to daily MME prescribed by dividing the total discharge prescription by 7 days – based on the Centers for Medicare and Medicaid Services recommendations. Spearman’s rank coefficients were used to measure the correlation between inpatient opioid use and discharge prescriptions. We examined the association between 24 and 48 hour inpatient opioid use with the total discharge prescription MME using hierarchical multiple linear regression models (with clustering by procedure and provider) to examine the association between total discharge MME with 24 and 48 hour pre-discharge opioid use.
Results: Of 631 patients who met the inclusion criteria, 53.1% (335/631) received a prescription for daily MME that exceeded their 24 hour opioid requirement. 130 patients (25.1%) required no pain medications within 24 hours of discharge and 66 patients (12.7%) required no pain medications within 48 hours of discharge who still received a discharge prescription. The 24 hour inpatient (r = 0.33) and 48-hour inpatient (r = 0.35) pain requirement showed low correlation with the discharge MME. Increasing length of stay was associated with a higher total MME prescribed at discharge (+10.1 MME/additional hospital day, p < 0.001).
Conclusion: Opioid prescriptions at discharge do not consistently correlate with actual patient opioid requirements. This leads to significant problems with over- and under-prescribing. Systematic and prescriber educational interventions are needed to create a practice of patient-centered opioid prescribing.
