Rise in post-surgical opioid prescriping raises concerns, elicits new US guideline

by Bruce Sylvester: Patients who have undergone common surgeries are receiving opioid painkillers at an increasing rate, researchers reported on March 18, 2016 in JAMA/Journal of the American Medical Association.

“These data show us a concerning trend,” said lead author, Mark Neuman, MD, MSc, assistant professor of Anesthesiology and Critical Care and director of the The University of Pennsylvania’s Penn Center for Perioperative Outcomes Research and Transformation in Philadelphia, Pennsylvania.

As background, the researchers noted that about 2.1 million Americans suffer from substance use disorders related to prescription opioid pain relievers, and approximately 467,000 Americans are addicted to heroin.

In the new study, the researchers analyzed insurance claims from 2004 through 2012 for 155,297 adults undergoing four common outpatient surgeries — carpal tunnel repair, laparoscopic gall bladder removal, some minimally invasive knee surgeries, and hernia repair.

They found that for patients  who had not received an opioid prescription in the six months prior to surgery, four out of every five filled a prescription for an opioid pain medication within seven days after surgery. They also found that the percentage of subjects who got opioid drug prescriptions post-surgically increased for all four surgical procedures from 2004 – 2012.

Most significantly, the average amount of opioid medication given post-surgically also increased between 2004 and 2012, and for all procedures. For example, subjects who had undergone knee arthroscopy  had a greater than 18 percent increase in the average total amount of post-surgical opioid use, driven by an increase  in the average daily dose.

Neuman said, “The growth we observe over time in opioid prescribing after surgery occurs against the backdrop of a major public health crisis of prescription opioid abuse. Additional work is needed to understand how postoperative opioid prescribing patterns might play into this epidemic, and to define better strategies for treating postoperative pain safely and effectively in the future.”

In the same issue of JAMA, a major new guideline from the (US) Centers for Disease Control and Prevention (CDC)  calls upon physicians to avoid over-prescription of opioids for surgical patients and other patients with painful conditions.

The new guideline addresses pain management outside of active cancer treatment, palliative care, and end-of-life care. It recommends non-opioid therapy for chronic pain, emphasizing that opioids be used only when  the benefits for pain and function are expected to outweigh the risks.

The guideline also recommends that physicians establish treatment goals before prescribing opioids and address how opioid therapy can be discontinued if benefits do not outweigh risks.

Finally, the guideline recommends use of  the lowest effective opioid dosing, with ongoing reassessment of benefits and risks in relationship to dose increases, as well as evaluation every three months of the benefits and harms of continued opioid therapy.