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Table 1.  
Patient Demographics and Comorbidities
Patient Demographics and Comorbidities
Table 2.  
Opioid Utilization and Adverse Effects Following Surgery
Opioid Utilization and Adverse Effects Following Surgery
1.
Schroeder  AR, Dehghan  M, Newman  TB, Bentley  JP, Park  KT.  Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse.  JAMA Intern Med. 2019;179(2):145-152. doi:10.1001/jamainternmed.2018.5419PubMedGoogle ScholarCrossref
2.
Chiu  AS, Jean  RA, Hoag  JR, Freedman-Weiss  M, Healy  JM, Pei  KY.  Association of lowering default pill counts in electronic medical record systems with postoperative opioid prescribing.  JAMA Surg. 2018;153(11):1012-1019. doi:10.1001/jamasurg.2018.2083PubMedGoogle ScholarCrossref
3.
Syed  UAM, Aleem  AW, Wowkanech  C,  et al.  Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.  J Shoulder Elbow Surg. 2018;27(6):962-967. doi:10.1016/j.jse.2018.02.039PubMedGoogle ScholarCrossref
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Research Letter
June 25, 2019

Association Between Quantity of Opioids Prescribed After Surgery or Preoperative Opioid Use Education With Opioid Consumption

Author Affiliations
  • 1Emory University School of Medicine, Atlanta, Georgia
  • 2Department of Orthopaedic Surgery, University of Florida College of Medicine, Jacksonville
  • 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
  • 4Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
JAMA. 2019;321(24):2465-2467. doi:10.1001/jama.2019.6125

Prescribing a greater quantity of opioids than needed after surgery has been associated with the development of addiction.1 Lowering default opioid prescription quantities in an electronic medical record system has been shown to reduce the amount of opioids prescribed after surgery.2 However, the effect of reduced prescription quantities on actual patient opioid consumption remains undetermined. Additionally, patient education may also play a role in decreasing excess postoperative opioid use.3 We assessed whether reducing the number of opioid tablets prescribed would decrease postoperative opioid consumption, and whether preoperative opioid use education would further reduce the amount taken.

Methods

All data were collected prospectively from adolescent and adult patients undergoing anterior cruciate ligament reconstruction at a single academic ambulatory surgery center as part of a quality improvement initiative. Institutional review board approval was obtained for the quality improvement initiative and the need for informed consent was waived. At the clinic visit occurring in the third postoperative week, patients completed a survey describing opioid tablets consumed, days of postoperative opioid use, and opioid-related adverse effects. Refills within 2 months were obtained from electronic medical records and the state prescription drug monitoring program.

Patients were nonrandomly separated into 3 cohorts based on the date of surgery. Patients undergoing surgery between December 2016 and July 2017 were given 50 tablets of Percocet (7.5-mg oxycodone/325-mg acetaminophen; 1-2 tablets every 4-6 hours as needed). Patients undergoing surgery between August 2017 and February 2018 were given 30 tablets. From March 2018 to September 2018, scripted opioid use education was given to a cohort of patients receiving 30 tablets. The educational session, which outlined appropriate opioid use and alternative pain control strategies, was delivered by athletic trainers at the preoperative clinic visit and the surgeon in the preoperative holding area and reinforced by nursing staff in the postoperative holding area. There were no changes in patient selection for surgery, personnel, surgical technique or materials, or anesthesia and postoperative rehabilitation protocols during these periods.

The number of opioid tablets taken and the days of opioid use were compared between the 50- and 30-tablet (no education) groups and between the 30-tablet groups (no education vs education). Differences in categorical variables were assessed with χ2 or Fischer exact tests. t Tests or Wilcoxon rank-sum tests were used to compare parametric and nonparametric continuous data. A 2-sided P < .05 was considered statistically significant. Analysis was performed with SPSS.

Results

The response rate was 98%. Of the 264 patients in the study, 109 received 50 tablets, 77 received 30 tablets and no education, and 78 received 30 tablets and education. The mean age was 25 years and 49% were male. There were no significant differences in patient demographics between cohorts (Table 1).

Patients receiving 50 tablets consumed a mean of 25.4 tablets, while those given 30 tablets and no education consumed a mean of 15.6 tablets (difference, 9.8 [95% CI, 6.2-13.5] tablets; P < .001). Patients receiving 50 tablets took opioids for a significantly greater number of postoperative days compared with those receiving 30 tablets and no education (5.8 vs 4.5 days; difference, 1.2 [95% CI, 0.09-2.4] days) (Table 2).

Patients receiving 30 tablets and preoperative education consumed a mean of 12.4 tablets (difference compared with 30 tablets and no education, 3.2 [95% CI, 0.6-5.7] tablets; P = .02). Patients receiving education took opioids for significantly fewer postoperative days (4.5 vs 3.5 days; difference, 1.0 [95% CI, 0.2-1.9] days) (Table 2).

Rates of self-reported constipation and fatigue were lower in the cohorts receiving 30 tablets compared with the 50-tablet cohort. There was no difference in medication refills among cohorts (Table 2).

Discussion

Prescribing fewer tablets was associated with lower postoperative opioid consumption following anterior cruciate ligament reconstruction. Education was associated with lower duration and quantity of postoperative opioid use. An effort to conserve medication and make the prescription last may be the psychological mechanism driving these results.

Because the study was survey based, recall bias is a potential limitation. Furthermore, this study was limited to a single procedure at a single site, the patient cohort was young, and patients were not randomized, raising the possibility of selection bias.

In this study, half of prescribed opioids were consumed in each group, suggesting that prescribing even less might further reduce opioid use. Further investigation should evaluate whether similar opioid stewardship and education protocols would be successful in other patient populations.

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

Accepted for Publication: April 22, 2019.

Corresponding Author: John Xerogeanes, MD, Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park S, Ste 2000, Atlanta, GA 30029 (jxeroge@emory.edu).

Author Contributions: Mr Farley and Dr Xerogeanes 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.

Concept and design: All authors.

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

Drafting of the manuscript: Farley, Anastasio, Kumar, Premkumar, Gottschalk.

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

Statistical analysis: Farley, Anastasio, Kumar, Premkumar, Gottschalk.

Administrative, technical, or material support: Farley, Anastasio, Kumar, Premkumar, Xerogeanes.

Supervision: Kumar, Premkumar, Gottschalk, Xerogeanes.

Conflict of Interest Disclosures: Dr Xerogeanes reported receiving personal fees from Arthrex and stock options from Trice. No other disclosures were reported.

References
1.
Schroeder  AR, Dehghan  M, Newman  TB, Bentley  JP, Park  KT.  Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse.  JAMA Intern Med. 2019;179(2):145-152. doi:10.1001/jamainternmed.2018.5419PubMedGoogle ScholarCrossref
2.
Chiu  AS, Jean  RA, Hoag  JR, Freedman-Weiss  M, Healy  JM, Pei  KY.  Association of lowering default pill counts in electronic medical record systems with postoperative opioid prescribing.  JAMA Surg. 2018;153(11):1012-1019. doi:10.1001/jamasurg.2018.2083PubMedGoogle ScholarCrossref
3.
Syed  UAM, Aleem  AW, Wowkanech  C,  et al.  Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.  J Shoulder Elbow Surg. 2018;27(6):962-967. doi:10.1016/j.jse.2018.02.039PubMedGoogle ScholarCrossref
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