B. Nguyen1, S. Stokes1, J. Bleicher1, R. Glasgow1,2, B. S. Brooke1, L. C. Huang1,2 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:
The quantity and duration of opioid use after surgery has increased over the past several decades. Recent published guidelines specify an optimal amount of opioid medication to be prescribed following a given operation to minimize excess prescribing by surgeons. We sought to determine historical adherence to these current guidelines.
Methods:
We performed a retrospective, observational study analyzing discharge opioid prescriptions following common inpatient and outpatient general surgery procedures at a tertiary academic medical center from 2014 to 2018. All adult patients who underwent cholecystectomy, inguinal hernia repair, appendectomy, mastectomy, umbilical hernia repair, and ventral hernia repair were included. Patient and provider-level demographics were recorded. Morphine milligram equivalents (MME) were calculated from discharge prescriptions. These prescriptions were then classified as appropriate or inappropriate based on the maximum recommended amount as determined by Michigan-OPEN, Dartmouth-Hitchcock, and Hopkins Surgical Opioid Guidelines. The opioid guideline adherence was then analyzed using hierarchical, multivariable logistic regression, adjusting for patient and provider-level covariates.
Results:
There were 4,500 patients included in the study. Opioid prescriptions were written by 775 (17%) junior residents (PGY1-2); 1,488 (33%) senior residents (PGY3-5); 864 (19%) advanced practice clinicians (e.g., nurse practitioners and physician assistants); and 1,373 (31%) attending surgeons. The median MME prescribed for laparoscopic cholecystectomy was 30 (IQR [20-45]). The median MME prescribed for open inguinal hernia repair was 30 (IQR [20-45]). The overall rate of guideline adherence was 12.6%. Advanced practice clinicians (APC) were most likely to follow guidelines (22%), followed by senior residents (12%), junior residents (11%), and attending providers (8%). After adjustment for patient characteristics with multivariable logistic regression, junior residents (OR 2.88, 95% CI 1.99-4.16), senior residents (3.01, 95% CI 2.22-4.08), and advanced practitioners (OR 5.87, 95% CI 4.23-8.15) had higher odds of following guidelines as compared to attending providers. Prescriptions in excess of current inpatient and outpatient guidelines led to the distribution of the equivalent of 79,947 five mg hydrocodone tablets over a four-year time period.
Conclusion:
Historical adherence to current opioid prescribing guidelines is low, particularly by attendings surgeons. In order to adapt to the recommendations, further research is needed to determine the most effective method to change prescribing practices.