Excess Opioids Research Articles

An Evaluation of the Effect of Catheter-Directed Continuous Infusion of Local Anesthetic by Elastomeric Pump on Opioid Usage Following Donor Kidney Nephrectomy.

Postoperative pain management following donor nephrectomy can prove challenging for immediate discharge on postoperative day 1 or 2. Although the standard for pain control is utilization of opioids, this increases the risk of postoperative ileus and, if continued inappropriately, increases excess opioids circulating in the community. One strategy that proposes to limit postoperative opioids in kidney donors is the continuous infusion of local anesthetics (CILA), though the effect on patient outcomes is unclear. The purpose of this study was to evaluate the effectiveness of postoperative CILA to decrease opioid usage in kidney donors who undergo laparoscopic nephrectomy. A retrospective analysis was conducted of kidney donors who underwent laparoscopic nephrectomy and received CILA (CILA group) compared with kidney donors who received standard-of-care (SOC) postoperative analgesia. The primary outcome was the mean total oral morphine equivalents (OMEs) administered following surgery. A total of 176 kidney donors were evaluated, 88 in each group. The mean OME administered in the CILA group was significantly higher than in the SOC group: 194.8 versus 133.5 mg (P = 0.003). Mean total postoperative administration of acetaminophen was also increased in the CILA group: 3736.9 versus 2611.6 mg (P = 0.0041). Mean length of stay following surgery was higher in the kidney donors who received CILA, whereas return to bowel function, time to ambulation, and pain scores were not significantly different. This report demonstrated that CILA is not an effective modality to reduce opioid utilization or improve recovery in kidney donors following laparoscopic nephrectomy.

Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage

BackgroundKidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills. Materials and MethodsA historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected. Results270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02). ConclusionsA protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.

Effect of drug disposal bag provision on families’ disposal of children’s unused opioids

ObjectiveOne strategy to combat opioid misuse is to remove excess opioids from circulation by providing patients with drug disposal products that enable the safe disposal of opioids. We aimed to evaluate opioid use and disposal of unused opioids among children and young adults before and after pharmacy staff at our institution began to provide patients and families filling opioid prescriptions with a drug disposal bag. MethodsWe performed a prospective pre-post cohort study of patients who filled an opioid prescription in May-August 2019 at the outpatient pharmacies of a large tertiary children’s hospital. Patients and caregivers were enrolled at the time the opioids were dispensed. During the first half of the study period, standard opioid-related education was offered by pharmacy staff. During the second half of the study period, standard education was offered, and a drug disposal bag and instructions on its use were provided when the opioids were dispensed. A follow-up survey to assess opioid use and disposal was completed online or by telephone 4-7 weeks after the opioids were dispensed. ResultsA total of 215 participants were enrolled; 117 received a drug disposal bag and 98 did not. Of those, 68% of the participants completed a follow-up survey. In both groups, the median patient age was 11 years, and most patients had been prescribed opioids after a procedure. More than 70% had opioids leftover after they had stopped taking them, and this did not vary by group. However, among families with leftover opioids, the receipt of a drug disposal bag was associated with a higher likelihood of disposal of the unused opioids (71.7% vs. 52.1%, P = 0.04). ConclusionProviding a drug disposal bag to families of children receiving opioids increases the likelihood of excess opioid disposal. Greater availability of drug disposal products can complement prescribing reduction efforts aimed at decreasing prescription opioid misuse.

Opioid Prescribing and Use Following Common Plastic Surgery Procedures

BACKGROUND: Overprescribing of opioids has become a topic of interest given the potential adverse outcomes associated with their use. Excess prescribing of opioids has been shown to have individual and societal impacts such as addiction, dependence, and misuse. Opioids are frequently prescribed for analgesia following plastic surgery procedures. This study aims to investigate prescribing patterns and explores self-reported patient experiences with opioid use, pain control and disposal of unused tablets following common hand and breast surgeries. METHODS: Patients undergoing 5 common predetermined breast procedures and 6 common hand procedures in a specified 14-week period were identified by billing code through health information services. Sixty-two hand procedures 46 breast procedures were identified. Collaboration with opioid monitoring services of the Nova Scotia Provincial Monitoring Program (NSPMP) allowed for data surrounding prescription filling rates, drug type, dose and tablets dispensed. Additionally, all patients were contacted to participate in a structured telephone interview surrounding prescription awareness, pain control, and disposal of excess medication. RESULTS: 55.4% and 41.6% of patients received and filled an opioid prescription following a hand or breast procedure, respectively. Hydromorphone was the most commonly prescribed narcotic for both hand and breast procedures. Average number of opioid tablets dispensed following hand and breast procedures was 36.1 and 31.9, respectively. Forty-eight percent and fifty-two percent of hand and breast patients completed phone interviews. 4.2% of breast patients required an opioid refill, whereas no hand patients did. Seventy-three percent of hand 75% of breast patients used at least one over-counter analgesic, most common being acetaminophen alone. Average self-reported pain score and total pain period was not significantly different between those using opioids and those not for both hand and breast procedures. 6.7% and 23.1% of patients report returning excess narcotics to pharmacy, whereas the majority report still having or self-disposing excess tablets. CONCLUSIONS: Opioid prescriptions are frequent following the procedures studied. In general, opioids appear to be prescribed in excess as denoted by self-report low prescription usage, statistically insignificant differences in pain for those using and not using opioids and low refill rates. Additionally, the majority of unused opioids were noted to be still at home or disposed of inappropriately. Taken together, this study suggests a role for reviewing opioid prescribing patterns for common hand and breast procedures to reduce contributions of excess opioids to an ongoing opioid epidemic.

A Simple Brochure Improves Disposal of Unused Opioids: An Observational Cross-Sectional Study.

We evaluated the effectiveness of a simple, low-cost educational brochure in improving disposal rates of unused opioids after outpatient upper extremity surgery. This cross-sectional study enrolled eligible adult patients from a peripheral nerve clinic between November 2017 and September 2018. Patients either received or did not receive the educational brochure, which outlined a simple method to dispose of unused opioids and completed a survey at 2 weeks after surgery. We compared the proportion of patients who disposed of unused opioids after surgery between the group that had received the brochure and the group that had not. Categorical data were analyzed with χ2 test, proportions data with binomial tests, and numerical data with Mann-Whitney U test, all with a significance level of P < .05. There were 339 survey respondents. Nineteen patients who did not meet inclusion criteria were excluded. Of the 320 remaining patients, 139 received the brochure and 181 did not. An additional 55 patients were excluded due to preoperative opioid use. Overall, 35.3% of recipients and 38.3% of those who did not receive the brochure used all of their prescribed opioid medication (P = .625; confidence interval = -14.6%-8.8%). Among patients with unused opioid medication, a significantly higher proportion of brochure recipients disposed of the medicine compared with those who did not receive the brochure (46.7% vs 19.6%, P < .001). Distribution of an educational brochure significantly improved disposal of unused opioids after surgery. This easily implemented intervention can improve disposal of unused opioids and ultimately decrease excess opioids available for diverted use in the community.

Patient Opioid Requirements Are Often Far Less Than Their Discharge Prescription After Orthopaedic Surgery: the Results of a Prospective Multicenter Survey.

Evidence-based, procedure-specific guidelines for opioid prescribing after orthopaedic surgery are urgently needed to standardize care and minimize excess opioids. We developed a prospective, multicenter survey study conducted from March 2017 to January 2018 including 7 common elective orthopaedic surgical procedures (total knee arthroplasty, total hip arthroplasty, lumbar fusion, lumbar laminectomy, rotator cuff repair, arthroscopic meniscectomy, and carpal tunnel release). Phone surveys were conducted between 21 and 35 days postoperatively. We aimed to document both the amount and length of time patients consumed opioid medications to inform further improvements in opioid management and prescribing. Among the 919 orthopaedic patients who completed the survey, 94.3% received opioids at discharge with a median of 388 oral morphine equivalents (OMEs) (interquartile range [IQR] 225 to 675). A median of 128 (IQR 23 to 360) OME were consumed with 77% of patients having leftover opioids. Sixty percent of prescribed opioids were unused; 18.2% of patients used no opioids, and 34.7% required <50 OME. In comparison to departmental guidelines, 50.2% of patients consumed <50% of the recommended prescription maximum per procedure. Most patients used far fewer opioids after orthopaedic surgery than prescribed. These data have informed further improvement of our opioid prescription guidelines to more precisely align with anticipated procedure- and patient-specific requirements.

ELIMINATING PATIENT CONTROLLED ANALGESIA REDUCES OPIOID USE IN RENAL TRANSPLANT RECIPIENTS

Introduction: Six percent of opioid-naïve patients develop opioid dependence post-operatively. Renal transplant recipients who fill opioid prescriptions for more than 90 days post-operatively are at increased risk for graft failure and death. We implemented a protocol in our renal transplant recipients that eliminated opioid patient-controlled analgesia (PCA) and included a multi-modal non-opioid regimen. The purpose of this study was to examine the impact of PCA elimination on opioid requirements at discharge in renal transplant recipients. Materials and Methods: We reviewed adult renal transplant recipients for the three months prior to, and following, implementation of the protocol. Patients with an intra-abdominal transplant, a simultaneous pancreas-renal transplant, or a history of chronic pain were excluded. The number of opioid pills prescribed on the day prior to discharge were categorized as A) 0, B) 1-3, and C) 4. Discharge opioid prescriptions were then evaluated based on a recent recommendation that group A receive 0 pills, group B 15 pills, and group C 30 pills, to satisfy the outpatient pain needs of 85% of patients. Pre- and post- metrics were compared using independent t-tests and Chi squared tests. Results and Discussion: 150 recipients were included (79 pre-intervention, 71 post; 51% male).PCA use decreased significantly (95.8% vs. 19%, p<0.001). PCAs were associated with increased OMEs prescribed at discharge (84.3 vs. 68.5, p=0.14). Post-intervention, gabapentin, topical lidocaine, and acetaminophen increased significantly (7% to 73%, 6% to 68%, 72% to 94%, respectively).Of patients requiring no opioids on the day prior to discharge, 51.5% of pre- and 35.5% of post- were prescribed excess opioids at discharge.Of patients prescribed 1-3 pills on the day prior to discharge, 24.2% of pre- and 25.8% of post patients were prescribed excessive opioids at discharge.Conclusion: A multidisciplinary approach to developing an opioid-reducing protocol significantly decreased the use of PCAs and increased the use of non-opioid adjunct medications in renal transplant recipients. Eliminating PCAs trended towards a decreased amount of opioids prescribed at discharge. Excess opioids at discharge remains a problem. While we implemented a systems-based intervention to eliminate inpatient PCA prescription, we failed to adequately communicate the ultimate goal of decreasing opioids prescribed at discharge. Changing prescriber behavior requires specific interventions targeting all the metrics of interest. Following this study, we sought to protocolize both inpatient and discharge opioid prescribing wherein all patients, regardless of how many opioids received while inpatient, receive 10 opioid pills at discharge. After a three-month pilot, we plan to analyze the number of refills needed to evaluate whether this opioid-sparing approach at discharge leads to sufficient pain control in the short post-operative term. Transplant surgery nursing staff, pharmacists, and clinical providers.

Implementing an opioid reduction protocol in renal transplant recipients

BackgroundSix percent of opioid-naïve patients develop opioid dependence post-operatively. We implemented a protocol in our renal transplant recipients that eliminated opioid patient-controlled analgesia (PCA) and included a multi-modal non-opioid regimen. The purpose of this study was to examine the impact of PCA elimination on opioid requirements at discharge in renal transplant recipients. MethodsWe reviewed adult renal transplant recipients for the three months prior to, and following, the protocol’s implementation. Patients with an intra-abdominal transplant, pancreas-renal transplant, or chronic pain were excluded. The number of opioid pills prescribed on the day prior to discharge were categorized as A) 0, B) 1–3, and C) ≥4. Discharge opioid prescriptions were then evaluated based on a recent recommendation that group A receive 0 pills, group B 15 pills, and group C 30 pills, to satisfy the outpatient pain needs of 85% of patients. Pre- and post-intervention metrics were compared using independent t-tests and Chi squared tests. Results150 recipients were included (79 pre-intervention, 71 post; 51% male). PCA use decreased significantly (81% vs. 4.2%, p < 0.001). Post-intervention, gabapentin, topical lidocaine, and acetaminophen increased significantly (6.3%–69%, p < 0.001, 5.1%–66.2%, p < 0.001, 73.4%–93% respectively, p = 0.003.) PCA use did not impact the amount of opioids prescribed at discharge (median 75 OMEs in both groups). Of patients requiring no opioids on the day prior to discharge regardless of PCA use, 51.5% of pre- and 35.5% of post- were prescribed excess opioids at discharge. Of patients prescribed 1–3 pills on the day prior to discharge regardless of PCA use, 24.2% of pre- and 25.8% of post patients were prescribed excessive opioids at discharge. ConclusionsA multidisciplinary approach to developing an opioid-reducing protocol significantly decreased the use of PCAs and increased the use of non-opioid adjunct medications in renal transplant recipients. Patients continued to be prescribed excess opioids at discharge compared to inpatient opioid use the day prior to discharge. Ongoing communication with all providers caring for renal transplant recipients and protocolization of the different stages of a patient’s post-operative hospitalization are crucial.

A quality improvement approach to reduce opioids prescribed at a pediatric institution

Introduction: The United States is in the midst of an opioid epidemic and the pediatric population is vulnerable to prescription opioid misuse and overdose. There is a mismatch between the amount of opioids needed to treat pediatric acute pain and leftover opioids account for a substantial source available for unintentional overdose by young children and misuse among adolescents. It is imperative that providers seek to decrease the amount of excess opioids prescribed, while still providing adequate pain control. A quality improvement approach was taken at our pediatric institution to decrease excess opioid prescribing. …

Analgesic prescribing habits and patterns of Canadian chief urology residents: A national survey.

Prior studies have identified significant knowledge gaps in acute and chronic pain management among graduating urology residents as of five years ago. Since then, there has been increasing awareness of the impact of excessive opioid prescribing on long-term narcotic use and development of adverse narcotic-related events. However, it is unclear whether the attitudes and experience of graduating urology residents have changed. We set out to evaluate the attitudes and experience of graduating urology residents in prescribing opioid/non-opioid analgesia for acute (AP), chronic non-cancer (CnC), and chronic cancer (CC) pain. Graduating urology residents were surveyed at a review course in 2018. The survey consisted of open-ended and close-ended five-point Likert scale questions. Descriptive statistics, Mann-Whitney U-test, and Student's t-test were performed. A total of 32 postgraduate year-5 (PGY5) urology residents completed our survey (92% response rate). The vast majority agreed that formal training in managing AP/CnC/CC is valuable (91/78/81%). Most find their training in CnC/CC management to be inadequate and are unaware of any opioid prescribing guidelines; 66% never counsel patients on how to dispose of excess opioids. In general, 88% are comfortable prescribing opioids, whereas most are very uncomfortable prescribing cannabis or antidepressants (100% and 78%, respectively). Residents reported the acute pain service as the highest-rated resource for information, and dedicated textbooks the least. This survey demonstrated that experience in pain management remains variable among urology residents. Knowledge gaps remain, particularly in the management of CC/CnC pain.

Opioid Prescribing and Use in Ambulatory Otolaryngology.

The objective of this study was to evaluate surgeon-prescribing patterns and opioid use for patients undergoing common otolaryngology surgeries. We hypothesized that there was little consistency across surgeons in prescribing patterns and that surgeons prescribed significantly more opioids than consumed by patients. E-mail-based surveys were sent to all postoperative patients across a 23-hospital system. The survey assessed quantity of opioids consumed postoperatively, patient-reported pain control, and methods of opioid disposal. We compared patient-reported opioid consumption to opioids prescribed based on data in the electronic data warehouse. There was wide variation in prescribing between providers both in the quantity and type of opioids prescribed. Patients used significantly less opioids than they were prescribed (10 vs. 30 tablets, P < 0.001) for both opioid-exposed and opioid-naïve patients. More than 75% of patients had excess opioids remaining. Opioids are consistently overprescribed following ambulatory head and neck surgery. Otolaryngologists have an important role in the setting of the national opioid epidemic and should be involved in efforts to reduce excess opioids in their community. 4 Laryngoscope, 130: 1913-1921, 2020.

Prescription patterns and opioid usage in sinonasal surgery.

Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery. All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills. Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used <50% and 36.1% used >50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates. Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.

1452 Development of a Postoperative Opioid Prescription Practice Algorithm for Benign Gynecologic Surgery (POPP Algorithm)

Study Objective To determine if gynecologic surgery patients have satisfactory postoperative pain control when the POPP algorithm is used to guide the quantity of opioid medication prescribed. The secondary aim is to see if this algorithm leads to less opioid tablets prescribed after gynecologic surgery compared to past opioid prescription records. Design Prospective observational study, with a secondary comparison to a de-identified, retrospective dataset Setting A large military medical center Patients or Participants Women ≥18 years-old undergoing benign gynecologic surgery Interventions Using existing data on opioid use after gynecologic surgery, we developed a simple algorithm to guide physicians in their opioid prescribing practices. Using the algorithm, the physician prescribes a set quantity of opioids, accounting for the type of surgery performed and the presence of certain patient characteristics. Patient demographic and background information are collected, both from a brief survey and the medical record. The researcher contacts patients 2 weeks post-operatively to conduct a brief survey to determine postoperative pain satisfaction and the quantity of opioid tablets remaining. Measurements and Main Results Upon study completion, data analysis will determine if the algorithm provided patients with adequate opioid medication by looking at the number of patients that required refills, the median number of tablets consumed after each procedure type, correlation of opioid use with other factors, and patient perception of pain control. We will compare quantity of opioids prescribed using the POPP algorithm to the quantity prescribed to a retrospective cohort of similar patients. We will adjust generalized linear models using patient and surgical co-variates to identify if algorithm prescribing is significantly lower than non-algorithm prescribing. Conclusion Preliminary data demonstrates the POPP algorithm, when used for patients undergoing benign gynecologic surgery, results in satisfactory postoperative pain control, an adequate quantity of opioid medication for most patients, and less excess opioids dispensed.

Description and Impact of a Comprehensive Multispecialty Multidisciplinary Intervention to Decrease Opioid Prescribing in Surgery.

Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in surgery. A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge [median oral morphine equivalent (OME)] were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied. A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative. We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.

Home Disposal Kits for Leftover Opioid Medications After Surgery: Do They Work?

BackgroundPostoperative overprescribing is common, and many patients will have excess medications. An effective method to encourage disposal is lacking. We hypothesized that a convenient home disposal kit will result in more appropriate disposal of excess opioids. Materials and methodsWe conducted a single-center prospective observational pilot study to evaluate the effectiveness of a postoperative opioid disposal kit. Patients in the intervention group received an opioid disposal kit and educational handout before discharge from the hospital. At the first follow-up visit, patients completed a survey in which they reported the remaining amount of pain medications from their original prescription and their plan for the excess medication. Patients were asked about risk factors for chronic opioid use. We used multivariable Poisson regression to identify independent factors associated with an increased likelihood of appropriate opioid disposal. ResultsThe survey was offered to 904 patients with a response rate of 91.7%. After excluding those with missing data, 571 patients were included in the study. Overall, 83 (14.5%) patients never filled an opioid prescription, and 286 (60.0%) patients had tablets remaining at the time of the follow-up visit. Among those with tablets remaining, 52 received a home disposal kit, whereas 234 patients with tablets remaining did not. Patients who received the kit were more likely to dispose of opioid medications (54.9% versus 34.8%, relative risk = 1.8, 95% CI 1.3-2.5). No confounders were identified during multivariable analysis that increased a patient's likelihood of disposing excess medications. ConclusionsThe provision of a convenient home disposal kit postoperatively increased patient-reported opioid disposal.

Improving Care of Children and Young Adults after ACL Surgery: Implementation of Best Practice

Opioid overprescribing after surgery and lack of knowledge about proper disposal of excess opioids may contribute to opioid misuse and overdose through medication availability. A recent study of adolescents and young adults (AYA) following anterior cruciate ligament (ACL) reconstruction (Taylor, Killilea, Dugan-Frost, & Solodiuk, 2017) reported that patients (N=100) used only 36% of prescribed oxycodone and 30 tablets of 5mg oxycodone would be adequate for most. Alarmingly, 65% of patients/families reported not knowing what to do with the remaining oxycodone tablets.

Optimizing Discharge Opioid Prescribing Practices After Mastectomy With Immediate Reconstruction.

A quality improvement initiative was conducted to provide guidelines for opioid prescribing following mastectomy with immediate reconstruction. Patients undergoing mastectomy with concurrent tissue expander reconstruction were surveyed at their first postoperative visit to determine use of pain medication, satisfaction, and refill rates. Opioid prescriptions were converted to total oral morphine milligram equivalents (MMEs). Guidelines for postdischarge prescriptions were developed. During phase I, 16 patients were surveyed to determine baseline prescribed MMEs and rate of satisfaction. A guideline was subsequently developed to standardize postdischarge prescribing (550 MMEs prescribed average risk vs 900 MMEs high risk), and the survey was repeated (phase II). Median 210 MMEs were used. Of the 23 patients, 1 required a refill, 83% were highly satisfied, and 77% of opioids were unused. Guidelines were further revised to limit prescribed opioids (290 MME average risk vs 450 MME high risk), and the survey was repeated (phase III). A median of 118 MMEs was used. Of the 22 patients, 5 required refills, 73% were highly satisfied, and 53% of opioids were unused. Phase IV included 27 patients. A median of 98 MMEs was used. Two patients required refills, 93% were highly satisfied, and 58% of opioids were unused. Our finding showed that there is significant overprescription of opioids after elective breast surgery. Practice guidelines can reduce the amount of opioids prescribed. Reducing excess opioids available in the community is a noble goal; however, it must be done cautiously, as decreased patient satisfaction can be an unintended consequence.

Prescription vs. consumption: Opioid overprescription to children after common surgical procedures

BackgroundIn the setting of a national opioid epidemic there are concerns about routine overprescription of opioids postoperatively in both children and adults, which introduces excess opioids into the community. PurposeWe sought to examine current opioid prescribing practices by surgeons and consumption of prescribed opioids by pediatric surgical patients following discharge. MethodsStarting in January 2017 we began an emailed survey for all postoperative patients in a 23-hospital system about the opioids they were prescribed and consumed following discharge. They were then asked if their pain was controlled. Responses of pediatric patients (age 10–18) were examined. FindingsData from 277 patients were analyzed. After surgical procedures, patients were prescribed significantly more opioids (given in hydrocodone 5 mg equivalents) than they consumed: for appendectomy (median 10 vs. 2) cholecystectomy (12 vs. 5), hernia repair (20 vs. 14), tonsillectomy (30 vs. 17), sinus surgery (30 vs. 5), septoplasty (27 vs. 9.5), knee arthroscopy (30 vs. 12.5), open reduction and internal fixation (ORIF) of the hand and wrist (20 vs. 8.5), and ORIF of the foot and ankle (27 vs. 13.5). The majority (84%) of patients agreed or strongly agreed with the statement that their pain was controlled. Of patients with excess opioids, 64% reported keeping them in their home. ConclusionsProviders prescribed more opioid tablets than were used by patients. Despite using fewer tablets, patients reported good pain control. Current prescribing practices contribute to excess opioids in the community and represent an opportunity to alter the current epidemic. Level of evidenceIII.

A430 - “Right Size Prescribing” Through Statistical Analysis & Bariatric Surgical Patients’ e-Feedback to Prevent Prescription Opioid Misuse and Related Overdose Deaths

Background: From 1999 to 2016, more than 200,000 people died in the U.S. from overdoses related to prescription opioids. Overdose deaths involving prescription opioids were five times higher in 2016 than 1999 as reported by The Centers for Disease Control and Prevention. Utah is one of 22 states where the overdose rate is higher than the national average. Intermountain Healthcare is a 23-facility healthcare system (including 3 comprehensive, accredited, bariatric centers) based in Salt Lake City, UT with an organizational mission to help people live the healthiest lives possible. In 2016-2017 Intermountain established opioid reduction as a system priority and leadership teams were tasked with reducing opioid prescribing by 40% by 2019. In support of the initiative Intermountain's Surgical Services Clinical Program rolled out a quality improvement project to determine the variability of opioid prescribing practices for bariatric surgical procedures. This project includes distributing surveys to bariatric patients to obtain self-reported feedback about their pain medications (e.g. amount consumed, disposition of unused medications). A dashboard was created from the survey data showing prescribing trends, patient consumption trends and disposal of excess opioids. Data shows the median consumption of opioids is about a third of what is prescribed. Providing recommendations to physicians concerning ideal “right size” prescribing for bariatric surgeries is key to our efforts to prevent prescription opioid misuse and to reduce overdose deaths among our patient population.

Opioid use after laparoscopic hysterectomy: prescriptions, patient use, and a predictive calculator

In the setting of America's opioid epidemic, judicious postoperative opioid prescribing is important. Gynecologists lack standard guidelines about postoperative opioid prescriptions. The objectives of the study were to describe opioid prescribing practices by a group of minimally invasive gynecologic surgeons, to measure postoperative opioid use after minimally invasive hysterectomy, and to identify preoperative factors that could predict whether a patient will be a low or high postoperative opioid user. This was a prospective survey-based study including 125 women undergoing laparoscopic hysterectomy for benign indications at 2 community teaching hospitals. Patients were preoperatively surveyed about demographics, past medical history, and current and expected pain scores and were screened for anxiety, depression, and pain catastrophizing. At 1 and 2 weeks after surgery, patients were surveyed about their pain and pain medication use. Ninety-eight percent of patients were prescribed an opioid for acute postoperative pain. The median opioid prescription was for 150 morphine milligram equivalents, equivalent to 20 tablets of oxycodone 5 mg, while median patient postoperative use was 37.5 morphine milligram equivalents, equivalent to 5 tablets of oxycodone 5 mg. Ninety percent of patients had leftover opioids at 2 weeks after surgery, and most leftover opioids were stored in an unsecure location. Preoperative factors that were most strongly correlated with postoperative opioid use included a history of chronic pelvic pain or endometriosis, preoperative opioid use, anxiety, depression, pain catastrophizing, preoperative pain score, anticipated postoperative pain score, and anticipated postoperative pain medication needs. A predictive calculator was developed based on these factors to help identify patients who are likely to be a high opioid user (defined as taking greater than 112.5 morphine milligram equivalents) or a low opioid user (defined as taking 37.5 morphine milligram equivalents or less). On average, surgeons prescribed 4 times the amount of opioids than was needed for patients undergoing laparoscopic hysterectomy for acute postoperative pain control. Individualizing patients' opioid prescriptions based on preoperative risk factors could help reduce excess prescription opioids.