Study shows need for balance in post-surgery opioid prescribing guidelines

To address the opioid epidemic, surgeons have embraced guidelines to reduce the number of opioid pills they prescribe to patients after surgery, and the efforts have helped to significantly reduce the number of opioids in circulation. But new research presented at the virtual American College of Surgeons Clinical Congress 2020 reports that these guidelines may be missing a small group of patients that need a greater level of pain control.

"The key findings of our study are that we were able to successfully reduce how many opioids we were prescribing for patients after operations using evidence-based guidelines, and that the reduction resulted in less unused opioids remaining in our community," said lead study author Cornelius A. Thiels, DO, MBA, a surgical oncology fellow at Memorial Sloan Kettering Cancer Center, New York, and a researcher at Mayo Clinic, Rochester, Minn., where the study was conducted. "But, importantly, that reduction also resulted in the majority of patients being overall still satisfied with their pain control after discharge and not needing more refills than if they were to get more opioids, as would have been the case in the past."

"However," he continued, "the other finding of our research is that there's still additional room to improve in terms of making sure all patients after surgery have their pain well controlled, because we believe there is a small subset of patients who have lower pain scores with the reduced opioid prescribing guidelines."

The researchers evaluated 138 patients who underwent one of 12 elective operations (May to November, 2019) after Mayo Clinic adopted the evidence-based opioid prescribing guidelines in early 2018. The researchers then compared those findings with 603 patients who had the same procedures before the guidelines (from March 2017 to January 2018). None of the patients in the study were taking opioids prior to surgery.

Overall patient-reported pain control, on a scale of zero to 10, was worse post-guideline vs. pre-guideline, 8 vs. 9 (p=0.002; a lower score represents worse pain control). The percentage of patients who were very or somewhat dissatisfied with their pain control more than doubled post-guideline, 9.4 percent vs. 4.2 percent (p=0.04), as did the percentage who said they were not prescribed enough pain medications after discharge, 12.5 percent vs. 4.9 percent (p=0.002). The study involved a 29-question telephone survey conducted an average of 26 days after discharge.

This is a follow-up study to research Dr. Thiels and Mayo colleagues previously published. A study in 2017 established that the majority of patients having elective surgery were overprescribed opioids. The second study a year later reported on the success of guidelines they developed for minimizing post-surgery opioid prescriptions.

The goal of post-surgery pain management today, Dr. Thiels noted, is to employ what clinicians call "multimodal pain control," which is a combination of opioids with non-opioid pain relievers such as ibuprofen, naproxen sodium and acetaminophen.

"But we do know that some patients will still need opioid pain medications after major surgery, and our goal is to give them the exact right amount so that we limit the number of un-used opioids in our community while also making sure we don't reduce it down too far and then leave them in pain," Dr. Thiels said.

Adequate post-surgery pain management is all the more important as more operations move to outpatient surgery centers. "People are going home sooner and sooner, and that's great, but we need to make sure their pain is well controlled after they leave the hospital as well as balancing that issue with the risk of opioid dependence," Dr. Thiels said.

While this study enrolled patients who were not taking opioids at the time of their operation, the postoperative pain management guidelines Dr. Thiels and colleagues use also include recommendations for how to manage patients taking opioids before surgery and who may also be co-managed by a pain medicine specialist.

"There is a small subset of patients who we're not optimally managing yet, and this study confirmed that this is a small number," Dr. Thiels said. "However, I think that's a critically important subset of patients."

The next step for their research is to determine how to best identify patients in advance who may have lower pain scores after discharge with the reduced opioid prescribing guidelines, Dr. Thiels said. "The right answer may be more non-opioid based pain medications, better patient education and setting of expectations, or in some cases patients may actually require slightly more opioid medications, and that is OK," he said.

"But everybody should have their pain appropriately controlled after surgery," he added.