Abstract
Surgeons must balance management of acute postoperative pain with opioid stewardship. Patient-centered methods that immediately evaluate pain and opioid consumption can be used to guide prescribing and shared decision-making. To assess the difference between the number of opioid tablets prescribed and the self-reported number of tablets taken as well as self-reported pain intensity and ability to manage pain after orthopedic and urologic procedures with use of an automated text messaging system. This quality improvement study was conducted at a large, urban academic health care system in Pennsylvania. Adult patients (aged ≥18 years) who underwent orthopedic and urologic procedures and received postoperative prescriptions for opioids were included. Data were collected prospectively using automated text messaging until postoperative day 28, from May 1 to December 31, 2019. The primary outcome was the difference between the number of opioid tablets prescribed and the patient-reported number of tablets taken (in oxycodone 5-mg tablet equivalents). Secondary outcomes were self-reported pain intensity (on a scale of 0-10, with 10 being the highest level of pain) and ability to manage pain (on a scale of 0-10, with 10 representing very able to control pain) after orthopedic and urologic procedures. Of the 919 study participants, 742 (80.7%) underwent orthopedic procedures and 177 (19.2%) underwent urologic procedures. Among those who underwent orthopedic procedures, 384 (51.8%) were women, 491 (66.7%) were White, and the median age was 48 years (interquartile range [IQR], 32-61 years); 514 (69.8%) had an outpatient procedure. Among those who underwent urologic procedures, 145 (84.8%) were men, 138 (80.7%) were White, and the median age was 56 years (IQR, 40-67 years); 106 (62%) had an outpatient procedure. The mean (SD) pain score on day 4 after orthopedic procedures was 4.72 (2.54), with a mean (SD) change by day 21 of -0.40 (1.91). The mean (SD) ability to manage pain score on day 4 was 7.32 (2.59), with a mean (SD) change of -0.80 (2.72) by day 21. The mean (SD) pain score on day 4 after urologic procedures was 3.48 (2.43), with a mean (SD) change by day 21 of -1.50 (2.12). The mean (SD) ability to manage pain score on day 4 was 7.34 (2.81), with a mean (SD) change of 0.80 (1.75) by day 14. The median quantity of opioids prescribed for patients who underwent orthopedic procedures was high compared with self-reported consumption (20 tablets [IQR, 15-30 tablets] vs 6 tablets used [IQR, 0-14 tablets]), similar to findings for patients who underwent urologic procedures (7 tablets [IQR, 5-10 tablets] vs 1 tablet used [IQR, 0-4 tablets]). Over the study period, 9452 of 15 581 total tablets prescribed (60.7%) were unused. A total of 589 patients (64.1%) used less than half of the amount prescribed, and 256 patients (27.8%) did not use any opioids (179 [24.1%] who underwent orthopedic procedures and 77 [43.5%] who underwent urologic procedures). In this quality improvement study of adult patients reporting use of opioids after common orthopedic and urologic surgical procedures through a text messaging system, the quantities of opioids prescribed and the quantity consumed differed. Patient-reported data collected through text messaging may support clinicians in tailoring prescriptions and guide shared decision-making to limit excess quantities of prescribed opioids.
Highlights
Management of severe acute pain after surgery may require an opioid as part of an individual’s pain relief regimen[1,2]; clinicians must balance pain management approaches with the risks of opioid use within the context of state policies, which seek to mitigate these risks by limiting prescription of opioids for acute pain.[3,4]
Up to 80% of opioids prescribed for acute pain after surgical procedures are left unused, and excessive quantities of opioids prescribed for acute pain have been associated with conversion to long-term use, overdose, and opioid use disorder.[7,8,9,10,11,12,13]
Despite wide national variability in opioid prescribing for acute pain after orthopedic and urologic surgical procedures, studies documenting patient opioid consumption after these high-volume procedures are limited.[19,20]
Summary
A knowledge gap that has inhibited progress toward matching opioid prescriptions with anticipated patient needs is limited procedure-specific data to guide practitioners. Phone-based survey studies have started to fill this gap but have primarily focused on general surgical procedures and are labor intensive to replicate across the entire spectrum of surgical procedures.[12,13] Despite wide national variability in opioid prescribing for acute pain after orthopedic and urologic surgical procedures, studies documenting patient opioid consumption after these high-volume procedures are limited.[19,20] A learning health system approach[21,22] would inform clinical practice with pragmatic patient-reported data and move toward a system that continually monitors use and informs prescribing. The rapid adoption of digital media (eg, text messaging or mobile surveys) has created scalable means of engaging patients and collecting real-time health data.[23,24,25] Use of this approach for patient-reported pain and opioid use remains understudied
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