For inpatients having general surgery, receiving opioids the day before hospital discharge best predicts postdischarge use, according to a new guideline from Dartmouth University surgeons, published in the November issue of the Journal of the American College of Surgeons.
The guideline will satisfy the at-home opioid needs for 85% of these postsurgical patients: "If no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given to discharge; and if 4 or more pills are given to the day before discharge, then to prescription for 30 opioid pills is given to discharge, "the authors noted.
"We studied six different operations and found that the type of surgery did not affect the number of opioid pills, if we use these guidelines in the future, we expect that the number of pills will decrease by 40%! " senior author Dr. Richard J. Barth, of the Dartmouth-Hitchcock Medical Center in Lebanon.
"The guideline is very easy to apply in routine clinical practice because it is simple and the data on inpatient opioid use the day prior to discharge is obtained from the medical records," said Dr. Barth, who is also a professor of surgery at Dartmouth Geisel School of Medicine in Hanover, New Hampshire.
The researchers reviewed the records of all 333 patients who underwent surgery at their medical center and were discharged to home. After excluding chronic opioid users and patients with complications, they included 234 patients in the analysis.
The authors interviewed the participants by mailed questionnaires and phone surveys. Overall, 85% of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Prescribing 15 opioids… was sufficient for 88% of patients discharged on the first day after surgery.
For patients discharged later than the first day after surgery, the number of opioid pills taken at home was related to the number taken from the day before discharge (P <0.0001) and to patient age (P = 0.006), but not to the type of surgery they have undergone.
On the day before discharge, 41% of patients took no opioids, 33% took one to three pills, and 26% took more than four pills. Of 40 outlier patients who took more pills than the recommended guidelines, 28 responded to phone interviews. Just over half of the respondents said they were using opioids for reasons other than the pain for which they had been prescribed.
"This guideline … will markedly reduce the number of opioid pills prescribed for most patients without compromising the quality of care and will reduce the number of leftovers that could potentially end up in the wrong hands or be abused," commented Dr. Rosenquist, who was not involved in the study.
"I am not surprised by the results. I found this overprescribing very common among surgeons, even among my patients who have known opiate dependence histories and let the surgeon know that," said Dr. Thomas Kosten, of Baylor College of Medicine in Houston. "Guidelines from surgeons themselves based on data are more likely to be followed than guidelines published by government agencies or by addiction treaters."