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Challenges in Minimizing Post-Surgical Opioid Use

Challenges in Minimizing Post-Surgical Opioid Use

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Action Points

  • Note that a randomized trial demonstrated that gabapentin was superior to placebo in terms of time to postoperative opioid cessation.
  • A different study found a significant rate of potential overprescription of opioids after surgery.

Gabapentin helped surgical patients stop opioid painkillers sooner in a placebo-controlled trial, although it didn’t speed overall recovery from post-surgical pain, suggesting the drug could play a supporting role in combatting opioid overuse.

Meanwhile, a separate study added to the growing body of evidence that surgery patients are sent home with opioid prescriptions they may not need. In this research, nearly half of patients not needing opioids in the hospital got a prescription at discharge anyway.

Non-Opioid Alternative

In the 422-patient gabapentin study, there was a 24% faster time to opioid cessation (25 days versus 32 with placebo, HR 1.24, 95% CI 1.00-1.54), reported Jennifer Hah, MD, MS, of Stanford University in Palo Alto, California, and collaborators of the Stanford Accelerated Recovery Trial writing in JAMA Surgery.

But patients assigned to the active drug did not achieve pain resolution sooner than the placebo group (84 days for patients to give five consecutive reports of zero average pain at the surgical site, versus 73 days with placebo; HR 1.04, 95% CI 0.82-1.33).

“The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use,” Hah’s group suggested. “Identifying gabapentin as an important adjuvant to promote definitive opioid cessation rather than merely reducing immediate postoperative opioid requirements has important and timely clinical implications in the context of the national epidemic of opioid overdose deaths and addiction.”

Adverse events were about equal in the two study arms (about 1% in both for serious events). Patients discontinued due to sedation or dizziness at similar rates (20.8% placebo versus 25.0% gabapentin, P=0.96).

Study participants were randomized to 10 doses of either placebo or gabapentin. It was intended that 560 patients would be enrolled for 90% power to detect an advantage with the drug, but the trial was stopped early when a planned interim analysis suggested the study groups would have similar times to pain cessation.

By day 90, rates of opioid cessation (90.2% gabapentin versus 88.6% placebo) and pain cessation (56.8% versus 59.6%) didn’t differ significantly.

Of note was that the prescribing of opioids following surgery was not standardized, said Michael Ashburn, MD, MPH, and Lee Fleisher MD, both of University of Pennsylvania in Philadelphia, in an invited commentary.

“While Hah and associates provide an interesting clue to this puzzle, additional work is necessary to determine if gabapentin administration might help in these efforts,” they suggested.

Overprescription?

High rates of potential opioid overprescription in surgical patients at discharge were found at two Boston-area hospitals, according to a separate study in the same journal, with ob/gyn services the worst offenders.

The researchers, led by Eric Chen, MD, PhD, of Boston Medical Center (BMC), conducted a retrospective analysis of postoperative patients there and at Lahey Hospital Medical Center-Burlington Campus (LHMC-B) who were discharged home after staying more than 24 hours in 2014-2016 (n=18,343).

Potential overprescription was noted in patients who had not received opioids in their final 24 inpatient hours, but were nevertheless given an opioid prescription at discharge. Overall, this definition was met in 15.2% of all admissions included in the study, and in 42.9% of procedures after which patients were opioid-free at discharge.

Another 57.9% were still on opioids at discharge and received a prescription; the remainder were not discharged with a prescription.

Among the highest rates for potential overprescription:

  • Obstetrics (74.3% at BMC)
  • Gynecology (72.3% at BMC, 83.5% at LHMC-B)
  • Orthopedics (60.0% at BMC, 65.6% at LHMC-B)
  • Plastic surgery (68.8% at BMC, 57.9% at LHMC-B)

Pediatric surgery was the sole service that avoided any potential overprescription.

“Patients who were overprescribed opioids often underwent longer procedures in our data set (175 vs 95 minutes), a factor that has been previously associated with increased opioid use. In addition, the services with higher rates of potential overprescription (obstetrics and gynecology, general surgery, and orthopedic surgery) are generally associated with more painful operations,” Chen’s group acknowledged.

They suggested that “prescribers who routinely care for patients undergoing more invasive surgical procedures may be more accustomed to regularly prescribing opioids and thus may be less vigilant about identifying patients who are not taking opioids at the time of hospital discharge.”

“Opioid stewardship has been neglected and it is imperative that surgeons take ownership of their role in this epidemic.We suggest a proactive reform in the way surgeons approach pain management,” said Patrick Varley, MD, and Brian Zuckerbraun, MD, both of University of Pittsburgh.

In an invited commentary, they proposed a framework with the acronym REDUCE to achieve just that:

  • Recognize risk: appreciate risk factors for developing dependence, namely male sex, age older than 50 years, and a history of depression or other drug abuse
  • Educate patients: give an idea of what to expect for postoperative pain management
  • Discuss patient expectations and the proposed plan: the goal should not be to be “pain free” but to make it manageable during recovery
  • Use multimodal therapy: to reduce opioid use
  • Controlled prescribing: by creation of procedure-specific guidelines for opioid prescribing, taking into account inpatient opioid use
  • Early referral to pain specialists: to offer adjunctive interventions and supervise a period of weaning off opioids

“In summary, surgical procedures represent a potential gateway to opioid dependence, and surgeons must recognize their role as stewards of safe opioid use. Ongoing education of practicing surgeons and residents in all surgical specialties is necessary,” according to Varley and Zuckerbraun.

Hah, Ashburn, Fleisher, Varley, and Zuckerbraun disclosed no conflicts of interest.

  • Reviewed by
    F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

2017-12-15T16:30:00-0500

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