An institutional effort to reduce the amount of opioids prescribed following lumbar surgery
As we all know, opioid addiction in the US has reached epidemic proportions. In 2017 alone, opioids were involved in the overdose deaths of 47,600 people. Many victims of opioid abuse began their journey with physician-prescribed medications that initially were provided for the management of acute or chronic pain. Often the source of this pain is damage to the lumbar spine or a temporary side effect of lumbar spine surgery.
Physicians and medical institutions are actively seeking solutions to lower the risks of opiate addiction. One focus is reducing the amounts of opioids that are initially prescribed for patients in acute pain. Excess opioid medication has the potential to lead to addiction in patients or misuse by family members or others with access to leftover opioid pills.
At Hospital for Special Surgery (HSS) in New York City (ranked Number 1 in orthopedics 2018-19 by U.S. News & World Report), a task force developed a 1-hour educational program on opiate use and misuse, the role of the orthopedic prescriber, multimodal analgesia, and state laws regarding opioid prescription. All opioid prescribers at the institution were mandated to attend the program in person or via an online presentation. A committee composed of spine surgeons, pain management physicians, anesthesiologists, and nurse managers established guidelines for prescribing opioids following spine surgery. These qualitative guidelines, based on individual patients' consumption of opioids while in the hospital, were disseminated throughout the hospital early in 2017.
In the article "An institutional intervention to modify opioid prescribing practices after lumbar spine surgery," published today in the Journal of Neurosurgery: Spine, Francis Lovecchio, MD, and colleagues address the question of whether this intervention—mandatory provider education together with prescription guidelines—could change prescriber behavior, resulting in a lower amount of opioids prescribed at hospital discharge after lumbar surgery.
Lovecchio and colleagues compared opioid prescription data in the electronic medical records of 1177 patients treated by lumbar surgery before the intervention (March 1-November 1, 2016) with similar data in the electronic medical records of 1302 patients treated after the intervention (February 1-October 1, 2017). Because a variety of opioid medications with different strengths had been prescribed, the researchers converted the amount of opioid per prescription into an oral morphine equivalent (OME) to make comparisons possible.
The researchers found a statistically significant reduction in both the mean amount of opioid (629 ± 294 OME pre-intervention vs. 490 ± 245 OME post-intervention, p < 0.001) and the mean number of opioid pills (81 ± 26 pre-intervention vs. 66 ± 22 post-intervention, p < 0.001) prescribed after the intervention. In fact, prescriptions for 81 or more pills decreased from 65.5% to 25.5%. The researchers also found that the rate of refill prescriptions requested by patients within 6 weeks after surgery increased after the intervention; however, the difference was not significant. The researchers take this to suggest that overall pain control was not significantly altered by the reduction in prescribed opioids.
The researchers estimate that in the 8 months following dissemination of the guidelines, "the change in prescribing practices may have saved the dispensing of over 26,000 narcotic pills."
Lovecchio and colleagues show how the intervention at HSS changed prescriber behavior, resulting in a lower amount of prescribed opioids. They suggest that future studies should be undertaken to focus on how these changes in prescriber behavior may affect patient outcomes.
When asked about the importance of the study, Dr. Lovecchio said, "While we have been able to show that qualitative prescribing guidelines work to change prescriber behavior, the most practical solution to overprescribing is to define the 'minimum necessary quantity' of opioid to prescribe for the average patient after a given spine procedure. This will prove challenging, as postoperative opioid consumption likely depends on a complex interplay of biological, psychosocial, and surgery-related factors, and patient expectations. Our group and many others are working toward this end, and I look forward to finding solutions."