A. S. Chiu1, M. Freedman-Weiss1, P. Yoo1 1Yale University School Of Medicine,Surgery,New Haven, CT, USA
Introduction: Surgeons almost universally prescribe opioids postoperatively for analgesia, and often do so in far excess of what is needed—leaving unused pills susceptible to diversion and abuse. However, surgeons also have the opportunity to help offset the opioid epidemic by leading with practice changes. We sought to decrease the amount of opioid prescribed postoperatively through a multifaceted program.
Methods: Starting in the academic year 2016, an initiative to reduce over-prescribing of postoperative opioids was introduced at a single academic center. Based on the results of a needs assessment survey, this multi-pronged program included: resident education on postoperative analgesia and opioid prescribing, a grand rounds on the opioid epidemic, a change of the default number of opioid pills in an electronic medical record, and the distribution of a postoperative analgesic guideline with recommended doses.
The amount of opioid prescribed postoperatively between July 2016 and July 2018 was collected for the five most common short stay general surgery procedures (laparoscopic appendectomy, laparoscopic cholecystectomy, partial mastectomy, and laparoscopic and open inguinal hernia repair). Patients discharged after 48 hours were excluded to avoid confounding of complex hospital stays. To compare different opioids, prescriptions were converted to Morphine Milligram Equivalents (MME). Linear regression was used to evaluate prescribing over time and controlled for patient age, gender, race, insurance, and operation.
Results: There were a total of 6,109 qualifying operations over this 24-month period, including 2,071 laparoscopic cholecystectomies, 1,541 partial mastectomies, 1,404 inguinal hernia repairs (614 open and 790 laparoscopic), and 1,093 laparoscopic appendectomies. The population was predominately female (60.5%), Caucasian (71.0%), and privately insured (54.4%).
The mean opioid dose prescribed during this time was 168.5 MME (SD 102.5). The monthly average steadily declined over time (Figure 1); during the first 3 months, the average postoperative opioid prescription was 196.3 MME compared to 106.3 MME (p<0.01) in the final 3 months. This difference over a 2-year period is the equivalent of 12 pills of 5mg of oxycodone per prescription. Multivariable regression demonstrated a 4.4 MME (95%CI -5.0 to -3.6) decrease in average opioid prescription per month.
Conclusion: A dedicated and comprehensive program aimed at eliminating the over-prescription of opioids by surgeons reduced the amount of postoperative opioid prescribed by nearly half. Surgeons must acknowledge both their role in the societal problem of opioid abuse and their ability to deliver sustained and reproducible improvements.
