Opioid Prescribing following Surgery at Three Academic Medical - - PowerPoint PPT Presentation

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Opioid Prescribing following Surgery at Three Academic Medical - - PowerPoint PPT Presentation

Feb 28, 2023 332 likes •450 views

Opioid Prescribing following Surgery at Three Academic Medical Centers: Using Evidence to Improve Practice and Guide Quality Elizabeth Habermann, PhD MPH Mayo Clinic Learning Objective: To understand how one - size fits all

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Elizabeth Habermann, PhD MPH Mayo Clinic

Opioid Prescribing following Surgery at Three Academic Medical Centers: Using Evidence to Improve Practice and Guide Quality

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  • To understand how “one-size fits all” guidelines or legislation on surgery

prescribing may not be appropriate

Learning Objective:

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  • In response to the opioid epidemic, a number of state and federal policymakers

either have implemented or are considering implementing guidelines or legislation to limit opioid prescribing following surgery

  • However, these guidelines do not recognize variations in need by surgical procedure
  • “Prescribe no more opioids than will be needed for initial tissue recovery following more

extensive surgical procedures…

  • “Limit the entire prescription to 200 MME (not 200 MME/day).”

Overview:

https://mn.gov/dhs/assets/2017-opip-overview_tcm1053-320120.pdf

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The Evidence:

(Ann Surg 2017;266;564-573)

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  • Adults undergoing 25 common elective procedures

(2013-2015):

  • Institutional ACS-NSQIP data + prescription data
  • Calculated Oral Morphine Equivalents (OME) and

compared to State of Minnesota draft guidelines of max 200 OME following major surgery

Methods

Procedure Groups

GENERAL SURGERY 1. Lap Cholecystectomy 2. Lap Initial Inguinal Hernia Repair 3. Initial Inguinal Hernia Repair 4. Ventral Hernia Repair GENERAL SURGICAL ONCOLOGY 5. Simple Mastectomy 6. Breast Lumpectomy 7. Ileocecectomy 8. Laparoscopic LAR 9. VATS Wedge Resection ORTHOPEDIC

  • 10. Total Shoulder
  • 11. Total Hip
  • 12. Knee Arthroscopic Meniscectomy
  • 13. Total Knee
  • 14. Rotator Cuff Repair

SPINE

  • 15. Lumbar Laminotomy
  • 16. Lumbar Laminectomy

UROLOGY/GYNECOLOGY

  • 17. Lap Hysterectomy
  • 18. Vaginal Hysterectomy,
  • 19. Lap Nephrectomy
  • 20. Lap Prostatectomy

HEAD & NECK

  • 21. Thyroid Lobectomy
  • 22. Parathyroidectomy
  • 23. Carotid Thromboendarterectomy
  • 24. Parotid Gland Excision
  • 25. Tonsillectomy
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Opioid Naïve Patients

75.2% of patients (n=5,756)

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20 40 60 80 100 120 140 160 180 200 200 400 600 800 1000 1200 1400

Standardized to 5mg Tabs of Oxycodone Prescribed Oral Morphine Equivalents (OME)

Procedure

OME Prescribed in Opioid Naïve Patients

80.9% of opioid naïve patients received > 200 OME (This varied by procedure)

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  • But how much do surgical patients use?
  • Patient survey data from our institution:
  • Median amounts used varied by procedure, from 0 to 400 OME

Data to be presented at the American Surgical Association in April 2018

Utilization data and patient and procedural predictors of high or low opioid consumption will inform institutional prescribing guidelines.

  • Data on patient consumption and pain control is what should drive policy, not a one-size-fits all limit

The Evidence:

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  • Variations by surgical procedure
  • Amount of opioids prescribed at discharge
  • Amount of opioids consumed by surgical patients
  •  need for more procedure-specific policy or guidance

Health Policy Implications:

Procedure

Hydrocodone (Norco)

5 mg tablets

Codeine (Tylenol #3) Oxycodone

30 mg tablets 5 mg tablets

Tramadol

50 mg tablets

Laparoscopic Cholecystectomy 15 10 Laparoscopic Appendectomy 15 10 Inguinal/Femoral Hernia Repair (open/laparoscopic) 15 10 Open Incisional Hernia Repair 40 25 Laparoscopic Colectomy 35 25 Open Colectomy 40 25 Hysterectomy Vaginal 20 15 Laparoscopic & Robotic 30 20 Abdominal 40 25 Wide Local Excision ± Sentinel Lymph Node Biopsy 30 20 Simple Mastectomy ± Sentinel Lymph Node Biopsy 30 20 Lumpectomy ± Sentinel Lymph Node Biopsy 15 10 Breast Biopsy or Sentinel Lymph Node Biopsy 15 10

https://opioidprescribing.info/

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  • There is wide variation and over prescription of opioids to surgical patients
  • State and federal policies have been developed to address overprescription
  • But may not be appropriate for all surgical procedures
  • Institutionally, we have used these data to develop specialty- and procedure-specific guidelines
  • Future policy should consider these differences
  • Next steps:
  • Disseminate evidence to policy makers to reflect procedural and patient variation in

appropriate opioid prescriptions

  • Individualized medicine and pharmacogenomics
  • Continued refinement of best practices and policy

Why This Matters: