Opioid Analgesia Use After Ambulatory Surgery: Mismatch

Between Quantities Prescribed and Used

Christopher Shanahan MD MPH, Inga Holmdahl BA, Olivia Gamble BA, Julia Keosaian MPH,

Marc LaRochelle MD, Ziming Xuan ScD, Jane Liebschutz MD MPHBoston Medical Center

Boston University School of Medicine

May 13, 2016Substance Abuse: Opioids

Supported by a grant from the CAREFUSION

Foundation

Prescription Opioid Misuse

• Post surgical overprescribing of opioids may contribute to diversion and addiction1,2

– Post-op patients may not take full prescription3,4

– Leftover medication may be risky because of potential for diversion or abuse

• Day surgery patients self-manage their opioid prescriptions1,2

• Lack of clinical guidelines for day surgery prescribing

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(1) Bateman BT, Choudhry NK. Limiting the Duration of Opioid Prescriptions: Balancing Excessive Prescribing and the Effective Treatment of Pain. JAMA Intern Med. Apr 2016 [Epub before print]. (2) Alam A, et al. Long-term Analgesic Use After Low-Risk Surgery: A Retrospective Cohort Study. Arch Intern Med. Mar 2012;172(5)425-430. (3) Bates C, et.al. Overprescription of Postoperative Narcotics: A Look at Postoperative Pain Medication Delivery, Consumption and Disposal in Urological Practice. J Urol. Feb 2011;185(2):551-555. (4) Rodgers J, et.al. Opioid Consumption Following Outpatient Upper Extremity Surgery. J Hand Surg. 2012;37(4):645-50.

Study Aims

Among a cohort of patients who underwent elective, ambulatory surgery, we sought to study:

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1. Surgeons’ post-operative opioid prescribing patterns

2. Patients’ use of prescribed opioids in post-operative period

3. Patients’ plans for leftover medications

Setting and Design

Setting: – Ambulatory surgery

– Academic safety-net hospital

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Design: – Prospective observational study

Participant Selection

Inclusion Criteria– Aged ≥18 years

– Undergoing elective, ambulatory surgery

– Working phone

– English speaking

Exclusion Criteria– Procedures not expected to require post-operative

pain management (eye surgery, endoscopy, etc.)

– Cancer-related procedures

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Data Collection

Recruitment:– List of upcoming surgeries selected

from EHR– Surgeons signed opt-out letter to

patients– Patient letter included a phone

number for patients to call to “opt out”– Research Assistants called potential

participants (January-August 2015)

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Data Collection7

• 7-10 days post-surgery• Medication-taking (Time Line Follow-Back)• Plans for leftover

medication

Follow-Up SurveyBaseline Survey• ≤1 week prior to surgery• Demographics• Pain (GCPS)• Depression (PHQ-8)• Substance use (CAGE-

AID, AUDIT, & DUDIT)

GCPS: Graded Chronic Pain ScalePHQ-8: Patient Health Questionnaire depression scaleAUDIT: Alcohol Use Disorders Identification TestDUDIT: Drug Use Disorders Identification Test

Aim 1 Methods: Describe Surgeon’s Post-operative Prescribing Patterns• Patient interview within 1 week before day of surgery • Chart review to confirm opioid prescription

– # of tablets– Dosage – Instructions (Sig.)

• Calculate Days Supplied Opioid • Calculate Morphine Equivalent Dose (MED)• Sort patients by Total MED prescribed (Quintiles)

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Aim 1 Methods: Prescription Conversion Calculations

Oxycodone/APAP 5/325 mg

Sig: 1-2 po q4-6 hoursDisp: #30

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Days Prescribed Opioid = Total Pills Dispensed / Max Daily Pills

Total MED Dispensed =Total Mg of Opioid Dispensed / Max Daily Pills

Conversion Factor:1 mg Oxycodone = 1.5 mg Morphine

ExampleTotal Oxycodone mg dispensed: 5 mg x 30 pills = 150mgConvert to Total MED = 1.5 x 150 = 225 MED

ExampleDispensed pills = 30 Max daily pills: 2 q 4 hours = 12 pills/day30 pills/12 pills per day = 2.5 days Prescribed Opioid

Aim 2 Methods: Describe Patient’s Post-Operative Use of Prescribed Opioids

Self-reported use– Patient telephone Interview

within 10 days of day of surgery

– 10-Day Time-Line Follow Back

– # of tablets taken per day

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Aim 3 Methods: Describe Patient’s Plans for Leftover Medications

• Patient telephone interview within 10 days of day of surgery

• Plan for leftover medication• Self-reported, open written responses (TLFB)

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Screened(n=338)

Consented(n=181)

Baseline Complete(n=177)

Follow-Up Complete(n=149)

Patient Selection12

Identified Patients (n=619)

Eligible(n=266)

Could not be reached/ opted out (n=281)

Ineligible (n=72)

Refused(n=85)

Did not Complete Baseline(n=4)

Lost to Follow-Up(n=28)

Baseline Characteristics

N = 149

Mean age (range) 49 (20-81)

Female (%) 53

Hispanic (%) 17

Limiting & Disabling Pain or worse (GCPS) (%) 42

Depression (PHQ-8) (% score ≥ 10/40) 15

Alcohol Risk (AUDIT) (% score ≥ 8/40) 9

Drug Risk (DUDIT) (% score ≥ 2/44) 18

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Follow Up Characteristics

N=149 (%)

Complete or High Pain Relief (7 to 10/10) 68

Moderate Pain Relief (4 to 6/10) 24

Low or No Pain Relief (0 to 3/10) 8

Would have liked more pain treatment (Yes) 22

Took opioids more often than prescribed (Yes) 15

Needed early refill of prescription (Yes) 10

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Total MED Prescribed15

0 1-100 101-200 201-300 >3000%

10%

20%

30%

40%

50%

60%

5% 7%

17%

51%

19%

Total MED Prescribed (mg)N = 149

MED: Mean Taken vs. Mean Leftover16

1-100 101-200 201-300 >3000

100

200

300

400

500

48.6 (61%) 68.6 (46%)125.4 (50%)

213.6 (47%)30.6 (39%)

81.1 (54%)

123.2 (50%)

243.0 (53%)

Meds Taken Meds Leftover

Mea

n M

ED

Total MED Prescribed N = 116

Number of Days Prescribed Opioid 17

9-11 days (4%)

12-14 days (1%)

15-17 days (1%)

N = 149

3-5 days (63%)0-2 days (14%)

6-8 days (17%)

Plans for Leftover Medication

N = 107

Among Participants who endorsed having leftover medication

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Safe Disposal

(34%)

Keep/Store Pills (43%)

Keep Taking Prescription (10%)

Throw Away (7%)

Don’t Know (6%)

Limitations• Study performed at one site only• Convenience sample• Limited number of surgeons per specialty

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Leftover Medication

• The equivalent of 4,049, 5 mg Oxycodone pills were prescribed to this group (30,368 MED)

• 29% of participants took all prescribed medication • Patients used Less than half the medication

prescribed to them– 14,820 MED (49%), the equivalent of 1,976 pills, were

consumed – 15,548 MED (51%), the equivalent of 2,073 pills, were

leftover

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Conclusions: Mismatch between Surgeon Prescribing Practice and

Patient Use of Pain Medication

• Substantially less post-operative opioid pain medication was used than prescribed

• Post-operative opioid pain medication was used for a substantially shorter time period than prescribed

• The percentage of prescribed pain medication not taken by patients was just over 50% for patients prescribed higher Total MED

• Over 50% of patients reported plans to retain unused medications after pain resolution

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Implications: Minimize Mismatch

Steps should be considered to:• Reduce unnecessary ambulatory post-operative opioid

prescribing may be possible by improving: Physician prescribing practices Patient disposal options

• Set realistic expectations for pain management with patients

• Create enhanced systems that facilitate more flexible prescribing for pain management

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Future Directions

Include:• Complete multivariate analysis of patient & surgeon

characteristics that may impact prescribing taking practices & medication taking behaviors

• Review physician prescribing practices in detail

• Develop approaches to provide:• Individualized prescribing feedback to surgeons

• Pre-operative pain management counseling to patients

• Education for safe opioid use & disposal to patients

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Acknowledgements

Collaborators: Inga Holmdahl BA Olivia Gamble BA

Julia Keosaian MPH Marc LaRochelle MD

Ziming Xuan ScD Jane Liebschutz MD MPH

David McAneny MD (Vice Chair Surgery) Gerry Doherty MD (Chief of Surgery Surgery)

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