Opioid duration, not dosage, counts after surgery in reducing misuse

Study sheds light on measures that could reduce misuse

Prescription opioid duration—not the dosage—is associated with an increase in opioid misuse among postsurgical patients who were opioid-naive, according to results of a retrospective, observational study published in BMJ. These results suggest that opioid-naive patients who undergo surgery should be prescribed opioids at dosages that control their pain, even if higher doses are needed, but for the shortest duration of time. These measures may reduce misuse of opioids in this patient population.

Brat and colleagues conducted a retrospective cohort study of surgical claims that were linked to medical and pharmacy administrative databases (i.e., Aetna) to determine the effects of varying opioid prescribing patterns after surgery on opioid misuse in opioid-naive patients. More than a million opioid-naive patients undergoing surgery were identified, with 568,612 receiving postoperative opioids. These opioids included any of the following ingredients: codeine, hydrocodone, hydromorphone, morphine, oxycodone, oxymorphone, and tramadol. Opioid-naive patients were defined as those whose total opioid use in the 60 days before surgery was 7 days or less. A code for opioid abuse was identified for 5,906 of these patients.

The researchers noted that each additional opioid refill and additional week of opioid use were associated with an adjusted increase in the rate of misuse of 44% and 19.9%, respectively (i.e., increase in hazard). This duration was more strongly associated with misuse than the opioid dosage.

Recommendations by Michigan OPEN, an organization founded to develop a preventive approach to the opioid epidemic in the state of Michigan, focus on appropriate prescribing of opioids in opioid-naive patients after surgical procedures. The organization has created a chart with the recommended number of tablets for various opioids based on the surgical procedure. The organization has also listed several key counseling pearls for patients, which include setting expectations about postsurgical pain control, setting norms with patients, encouraging the use of nonopioid pain medications (e.g., acetaminophen, NSAIDs) around the clock and use of opioids only for breakthrough pain, and educating patients on appropriate use.

Patients should be informed that some pain is normal and expected and should get better over time. In addition, patients should be told about the average behavior of opioid use (e.g., “half of patients who have this procedure take fewer than 10 to 15 tablets).” Patients should also be reminded that the opioids are to be used to treat the pain associated with their surgical procedure and not for other painful conditions, and that these medications should not be shared with other people.

For the full article, please visit www.pharmacytoday.org for the June 2018 issue of Pharmacy Today.