Quiz: Post-Surgical Opioid Prescribing and Use

Test your clinical knowledge on persistent post-operative opioid use with these 4 questions. Hit submit to see the answers.

The United States continues to be in an opioid epidemic. There are an estimated 2 million people with opioid use disorder (OUD), and overdose deaths related to opioids reached 80,000 in 2021. Tens of billions of dollars are spent annually on related healthcare costs such as medical care and addiction treatment, which in the past directly correlated with the overprescribing of opioids.^1-3

While chronic pain specialists and primary care physicians have been scrutinized for opioid-prescribing practices (leading to the 2016 CDC guideline on Prescribing Opioids for Chronic Pain in 2016 and its 2022 revision), less attention has been drawn to post-operative/post-discharge opioid prescribing practices.⁴

What Is Persistent Post-Operative Opioid Use?

Although definitions for persistent post-operative opioid use (PPOU) vary, it is commonly defined as filling any opioid prescription between 90 and 365 days after surgery. PPOU is common, with meta-analyses pooling incidence rates of over 4% in opioid-naïve patients and higher rates in opioid-experienced patients.^5-7 One very large study (over 300,000 subjects) following veterans in the Veterans Health Administration database for a median of 5.6 years following surgery between 2008 and 2018 found that PPOU was statistically and clinically significantly associated with an increased risk of developing both OUD and overdose.⁸

Consequently, it is important to highlight post-discharge opioid prescribing practices to help curb PPOU when possible, before potentially problematic use or inappropriately treated chronic pain syndromes occur.

Risk factors correlated with the development of PPOU in opioid-naïve patients include those specific to the patient, surgery, and perioperative pain management plan. Patient-specific factors include pre-existing chronic pain, substance use disorders, and mood disorders.^9,10

Many surgical procedures putting patients at risk for PPOU are especially common, such as total knee arthroplasty and Cesarean section. Others include simple mastectomy, open abdominal procedures such as cholecystectomy and appendectomy, and cardiothoracic surgery.^9,11

Heavily prioritizing opioids as part of the perioperative pain management plan rather than a multimodal pain regimen is also associated with PPOU. Unsurprisingly, the dosage and duration of post-operative opioid prescriptions is associated with PPOU as well.^11-14

Surgeons already try to prioritize techniques such as laparoscopic over open when possible, and guidelines have already been published for the anesthesiologist’s management of acute post-operative pain, highlighting the utilization of multimodal pain regimens between different classes of pharmacological analgesics as well as peripheral regional anesthesia.¹⁵ However, large-scale guidelines for improved opioid prescribing post-discharge for surgical patients are generally still lacking, often leading to PPOU.

A systematic review analyzing outpatient use of prescription opioids for varying types of surgeries found that the percentage of prescribed opioids actually taken was only 11% to 58% (with the exception of pediatric spinal fusion patients at 90.1%).¹⁶ Patients who underwent abdominal surgery took fewer than 15 opioid pills, shoulder surgery patients took 35.2 pills but left 20 pills unused, and hand surgery patients averaged more than 16 unused opioid pills.^16-18 Most dermatologic and breast lumpectomy patients took fewer than 5 pills.¹⁶

Looking at spine surgery, whose patients tend to have chronic pain prior to surgery and face a long and painful recovery, opioid use and overuse is particularly common. Opioid use was reported in 53% of these patients prior to surgery and 60% in these patients 3 months after surgery, and 9% of opioid-naïve patients 3 months after surgery.¹⁹ Of patients taking opioids 3 months after their procedures, only 53% endorsed their post-operative opioid use solely for surgery-related pain, while 37% reported it for surgery-related pain in combination with other reasons, and 10% for reasons not related to their surgery. Moreover, 33% of patients reported experiencing withdrawal symptoms, which were significantly associated with a failure to stop taking opioids.¹⁹

Among patients who do not take all of their prescribed opioids, more than 65% keep the excess pills.^16,20 Even among studies analyzing opioid overprescribing for different types of surgery, almost half did not report on planned or completed methods of disposal for the leftover pills, further suggesting that physicians do not appropriately emphasize opioid disposal.¹⁶

A study investigating post-operative opioid prescriptions in shoulder surgery patients found that only 25% of patients were given disposal instructions.¹⁷ When planned disposal methods were reported, studies show that less than 60% of patients planned proper disposal, with some studies demonstrating even less than 5%.¹⁶ As a result, individuals most often report planning to save the unused pills for future use.¹⁷ While patients may not initially plan to divert the remaining pills to family or friends, many end up doing so and spread the increased risk of OUD from themselves to others.²⁰

Although this article centers on post-surgical opioids and PPOU, the first steps toward improved prescribing practices begin before the post-operative stage. Pre-operatively, educating patients on their post-operative recovery and setting proper expectations for their post-operative pain management has been demonstrated to result in decreased opioid prescriptions with reduced opioid consumption – without significant changes to patient satisfaction or refill requests.^21,22

Additionally, checking state prescription drug monitoring programs (PDMPs) to review previous opioid consumption prior to these pre-operative consultations can further tailor the conversation to the individual patient for a more effective discussion.

Perioperatively, Chou et al published guidelines for the management of acute post-operative pain. While it provides 32 recommendations, only four were considered “high-quality evidence.” Those four included multimodal analgesia (and opioid-sparing analgesia if appropriate), including acetaminophen and/or NSAIDs as part of the multimodal regimen, providing peripheral regional anesthesia when applicable, and neuraxial anesthesia for major thoracic and abdominal cases when possible.¹⁵

The Michigan Example

Regarding post-discharge opioid prescriptions, prescribers should work to refine their practices according to procedure-specific, evidence-based guidelines. Multiple studies have proved that opioid-prescribing guidelines decrease opioid prescriptions, opioid consumption, and resulting leftover opioid pills without affecting patient satisfaction.^21,22

One positive example of putting all of these recommendations into practice came out of the University of Michigan. The university’s Michigan Opioid Prescribing Engagement Network (OPEN) applied guidelines to 72 hospitals within the state. Michigan OPEN has provided evidence-based guidelines for acute care opioid prescribing and post-discharge prescribing, as well as educational brochures for patients on topics such as managing pain after surgery and safe storage and disposal of leftover opioids.^23-26 In particular, their post-discharge prescribing recommendations are evidence-based guidelines for specific types of surgery (currently 28) across multiple surgical subspecialties.²⁴

One large study investigated opioid-native patients who underwent one of six common surgeries that Michigan OPEN had published guidelines for, studying nearly 25,000 patients in Michigan and 120,000 patients outside of Michigan. It found that adhering to the OPEN guidelines resulted in statistically and clinically significant reductions in PPOU, from 3.29% to 2.51%, and opioid prescription quantity from 199.5 oral morphine equivalents (OME) to 88.6, both of which were also markedly larger decreases than those found in patients outside of Michigan.²⁷

The United States has been challenged by an opioid epidemic for years, and it has been shown that PPOU is associated with an increased risk of OUD and overdose. Risk factors associated with developing PPOU depend on the individual patient, the surgery, and the pain management plan. Although more physicians are acutely aware of the nationwide problem, many still overprescribe opioids. Such prescribing predisposes patients towards developing PPOU. Further, due to a lack of patient education on proper disposal methods, many individuals do not dispose of their leftover pills and some give them to unprescribed family and friends, putting them at risk of OUD and overdose as well.

The process to prevent PPOU begins pre-operatively by educating the patient on the recovery process and setting pain management expectations. It continues perioperatively and immediately post-operatively with a multimodal pain regimen and the utilization of peripheral regional or neuraxial anesthesia when possible. Finally, it concludes with an evidence-based post-discharge pain protocol dependent on the type of surgery performed.

While there is still a relative scarcity of widely accepted post-discharge prescription guidelines, physicians and hospital systems should look to follow the example of the Michigan OPEN program.

By providing evidence-based guidelines for acute care opioid prescribing, post-discharge prescribing, and educational brochures for patients on topics such as managing pain after surgery and safe storage and disposal of used medications, they have been shown to reduce the number of excessive opioids in circulation and the incidence of post-operative opioid use.