Abstract

While the 2016 US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain was not intended to address postoperative pain management, observers have noted the potential for the guideline to have affected postoperative opioid prescribing. To assess changes in postoperative opioid dispensing after vs before the CDC guideline release in March 2016. This cross-sectional study included 361 556 opioid-naive patients who received 1 of 8 common surgical procedures between March 16, 2014, and March 15, 2018. Data were retrieved from a private insurance database, and a retrospective interrupted time series analysis was conducted. Data analysis was conducted from March 2014 to April 2018. Outcomes were measured before and after release of the 2016 CDC guideline. The primary outcome was the total amount of opioid dispensed in the first prescription filled within 7 days following surgery in morphine milligram equivalents (MMEs); secondary outcomes included the total amount of opioids prescribed and the incidence of any opioid refilled within 30 days after surgery. To characterize absolute opioid dispensing levels, the amount dispensed in initial prescriptions was compared with available procedure-specific recommendations. The sample included 361 556 opioid-naive patients undergoing 8 general and orthopedic surgical procedures; 164 009 (45.4%) were male patients, and the median (interquartile range) age of the sample was 58 (45 to 69) years. The total amount of opioids dispensed in the first prescription after surgery decreased in the 2 years following the CDC guideline release, compared with an increasing trend in the 2 years prior (prerelease trend: 1.43 MME/month; 95% CI, 0.62 to 2.24 MME/month; P = .001; postrelease trend: -2.18 MME/month; 95% CI, -3.01 to -1.35 MME/month; P < .001; trend change: -3.61 MME/month; 95% CI, -4.87 to -2.35 MME/month; P < .001). Changes in initial dispensing amount trends were greatest for patients undergoing hip or knee replacement (-8.64 MME/month; 95% CI, -11.68 to -5.60 MME/month; P < .001). Minimal changes were observed in rates of refills over time (net change: 0.14% per month; 95% CI, 0.06% to 0.23% per month; P = .001). Absolute amounts prescribed remained high throughout the period, with nearly half of patients (47.7%; 95% CI, 47.4%-47.9%) treated in the postguideline period receiving at least twice the initial opioid dose anticipated to treat postoperative pain based on available procedure-specific recommendations. In this study, opioid dispensing after surgery decreased substantially after the 2016 CDC guideline release, compared with an increasing trend during the 2 years prior. Absolute amounts prescribed for surgery remained high during the study period, supporting the need for further efforts to improve postoperative pain management.

Highlights

  • Opioids are overprescribed after surgery,[1,2] potentially leading to diversion[3,4] and other adverse outcomes.[5,6] In March 2016, the US Centers for Disease Control and Prevention (CDC) released a guideline for opioid prescribing for chronic pain.[7]

  • Absolute amounts prescribed for surgery remained high during the study period, supporting the need for further efforts to improve postoperative pain management

  • The release of the guideline was associated with an acceleration of declining trends in per capita outpatient all-indication opioid dispensing among US patients[10]; potential unintended consequences on opioid prescribing for postoperative pain have not been quantified

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Summary

Introduction

Opioids are overprescribed after surgery,[1,2] potentially leading to diversion[3,4] and other adverse outcomes.[5,6] In March 2016, the US Centers for Disease Control and Prevention (CDC) released a guideline for opioid prescribing for chronic pain.[7] While this guideline primarily focused on chronic pain treatment, they encouraged clinicians to use the lowest effective dosage when prescribing opioids for acute pain treatment and not to prescribe opioids in quantities greater than needed for the expected severity and duration of pain.[7]. Multiple commentators have reported application beyond the scope of the original guideline, including to acute pain after surgery.[8,9] The release of the guideline was associated with an acceleration of declining trends in per capita outpatient all-indication opioid dispensing among US patients[10]; potential unintended consequences on opioid prescribing for postoperative pain have not been quantified

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