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Table 1.  
Characteristics of Opioid-Naive Patients Who Underwent Carpal Tunnel Release, Laparoscopic Cholecystectomy, Inguinal Hernia Repair, or Knee Arthroscopy Surgical Procedures, 2004-2012
Characteristics of Opioid-Naive Patients Who Underwent Carpal Tunnel Release, Laparoscopic Cholecystectomy, Inguinal Hernia Repair, or Knee Arthroscopy Surgical Procedures, 2004-2012
Table 2.  
Total Opioids Prescribed, Mean Daily Dose, and Duration of Prescription for Opioid-Naive Patients Who Filled an Opioid Prescription for Hydrocodone/Acetaminophen or Oxycodone/Acetaminophen Within 7 Days After Surgery (Outpatients) or Hospital Discharge (Inpatients), 2004-2012
Total Opioids Prescribed, Mean Daily Dose, and Duration of Prescription for Opioid-Naive Patients Who Filled an Opioid Prescription for Hydrocodone/Acetaminophen or Oxycodone/Acetaminophen Within 7 Days After Surgery (Outpatients) or Hospital Discharge (Inpatients), 2004-2012
1.
Yokell  MA, Delgado  MK, Zaller  ND, Wang  NE, McGowan  SK, Green  TC.  Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA Intern Med. 2014;174(12):2034-2037.
PubMedArticle
2.
Han  B, Compton  WM, Jones  CM, Cai  R.  Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003-2013. JAMA. 2015;314(14):1468-1478.
PubMedArticle
3.
Strassels  SA, McNicol  E, Suleman  R.  Postoperative pain management: a practical review, part 2. Am J Health Syst Pharm. 2005;62(19):2019-2025.
PubMedArticle
4.
Alam  A, Gomes  T, Zheng  H, Mamdani  MM, Juurlink  DN, Bell  CM.  Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-430.
PubMedArticle
6.
University of North Carolina at Chapel Hill School of Medicine. Opiate equianalgesic dosing chart. https://www.med.unc.edu/aging/fellowship/current/curriculum/palliative-care/UNC%20Equianalgesic%20Card%20-Dec2009.pdf. Accessed February 16, 2016.
Research Letter
April 19, 2016

Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012

Author Affiliations
  • 1Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 2Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 3Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 4Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA. 2016;315(15):1654-1657. doi:10.1001/jama.2016.0130

Adverse events related to opioid analgesics are common.1,2 Although opioids represent a component of pain treatment regimens following low-risk surgery,3,4 few data exist regarding patterns of postoperative opioid prescribing over time. We assessed trends in the amount of hydrocodone/acetaminophen and oxycodone/acetaminophen prescribed, 2 opioids commonly used for postoperative pain management.

Methods

The University of Pennsylvania determined this research was exempt from review. We identified patients from the Clinformatics Data Mart Database (OptumInsight),5 including health care encounters of approximately 14 million primarily commercially insured patients. Adults in the database tend to be younger and from the South compared with the US population. The database includes pharmacy and medical claims with data on services and procedures.

The sample included opioid-naive adults (age, 18-64 y) who underwent 1 or more of 4 low-risk surgical procedures in 2004, 2008, or 2012: carpal tunnel release, laparoscopic cholecystectomy, inguinal hernia repair, or knee arthroscopy. Patients who filled any opioid prescription in the 6 months before surgery were excluded. We assessed the proportion of patients who filled any opioid prescription (and specifically hydrocodone/acetaminophen or oxycodone/acetaminophen) in the 7 days after hospital discharge (inpatients) or after the procedure date (outpatients).

For patients who filled a prescription for hydrocodone/acetaminophen or oxycodone/acetaminophen, we calculated morphine equivalents dispensed using a standard conversion table.6 We calculated the mean duration of prescriptions, daily morphine equivalent dose, and total morphine equivalents across the procedures and over time. We assessed trends using linear regression, adjusting for age, sex, inpatient/outpatient procedure, and region. Two-sided P values less than .05 were considered statistically significant; SAS (SAS Institute), version 9.3, was used.

Results

Characteristics of opioid-naive patients who underwent a low-risk surgical procedure (N = 155 297) changed over time, becoming more likely to be older and male and less likely to have inpatient surgery. Within 7 days, 80.0% filled a prescription for any opioid, and 86.4% of these prescriptions were for hydrocodone/acetaminophen or oxycodone/acetaminophen (Table 1). The proportion filling a prescription for hydrocodone/acetaminophen or oxycodone/acetaminophen varied across surgical procedures from 59.7% (carpal tunnel release) to 75.5% (inguinal hernia repair). The proportions of patients filling prescriptions for any opioid and for hydrocodone/acetaminophen and oxycodone/acetaminophen increased over time for all surgical procedures (Table 1).

Among patients filling a prescription for hydrocodone/acetaminophen or oxycodone/acetaminophen, the mean morphine equivalents dispensed ranged from 203.0 (95% CI, 202.1-204.0) for laparoscopic cholecystectomy to 268.8 (95% CI, 267.6-270.0) for knee arthroscopy (Table 2). The mean morphine equivalents dispensed increased over time for all procedures: adjusted increase from 2004 through 2012, 29.71 (95% CI, 28.08-31.35; P < .001). The adjusted increase was highest for knee arthroscopy: 45.16 morphine equivalents (95% CI, 42.26-48.07; P < .001). This increase was driven by an increase in the mean daily dose prescribed, with little change in the duration of prescriptions (Table 2).

Discussion

In this cohort, 70% of opioid-naive patients who underwent low-risk surgical procedures filled a prescription for hydrocodone/acetaminophen or oxycodone/acetaminophen within 7 days after discharge or the procedure date. The mean morphine equivalent dose increased over time for all procedures examined, with an increase of 18% (potency equivalent to an additional 45 mg of morphine) for patients undergoing knee arthroscopy, driven by a change in the mean daily dose. Because the cohort was restricted to opioid-naive individuals, these changes are unlikely to represent an appropriate response by prescribing physicians to increasing rates of opioid tolerance over time within the population. Possible explanations include an increased focus on pain treatment or an increasing reliance on opioids for postoperative pain relief vs alternative therapies.

Limitations include restriction to 4 surgical procedures; lack of data after 2012, as further changes in prescribing practices could have occurred; use of data that may not be generalizable; and an inability to determine which patients received a prescription that they did not fill. Details regarding source data for the database were provided to us by the vendor in working documents; there may be uncertainty regarding the validity, completeness, and accuracy of the data. Further research should assess the contribution of postoperative opioid prescribing practices to the epidemic of prescription opioid-related abuse.

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Article Information
Section Editor: Jody W. Zylke, MD, Deputy Editor.

Corresponding Author: Hannah Wunsch, MD, MSc, Department of Critical Care Medicine, Sunnybrook Hospital, 2075 Bayview Ave, Room D1.08, Toronto, ON M4N 3M5, Canada (hannah.wunsch@sunnybrook.ca).

Published Online: March 15, 2016. doi:10.1001/jama.2016.0130.

Author Contributions: Dr Neuman and Ms Passarella had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Wunsch, Wijeysundera, Neuman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wunsch, Neuman.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work is supported in part by a New Investigator Award from the Canadian Institutes of Health Research (Dr Wijeysundera) and a Merit Award from the Department of Anesthesia at the University of Toronto (Dr Wijeysundera).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. OptumInsight approved the manuscript specifically for accuracy of information related to Clinformatics Data Mart Database.

References
1.
Yokell  MA, Delgado  MK, Zaller  ND, Wang  NE, McGowan  SK, Green  TC.  Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA Intern Med. 2014;174(12):2034-2037.
PubMedArticle
2.
Han  B, Compton  WM, Jones  CM, Cai  R.  Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003-2013. JAMA. 2015;314(14):1468-1478.
PubMedArticle
3.
Strassels  SA, McNicol  E, Suleman  R.  Postoperative pain management: a practical review, part 2. Am J Health Syst Pharm. 2005;62(19):2019-2025.
PubMedArticle
4.
Alam  A, Gomes  T, Zheng  H, Mamdani  MM, Juurlink  DN, Bell  CM.  Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-430.
PubMedArticle
6.
University of North Carolina at Chapel Hill School of Medicine. Opiate equianalgesic dosing chart. https://www.med.unc.edu/aging/fellowship/current/curriculum/palliative-care/UNC%20Equianalgesic%20Card%20-Dec2009.pdf. Accessed February 16, 2016.
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