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Original Investigation
November 7, 2018

Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Michigan Opioid Prescribing Engagement Network, Ann Arbor
  • 3University of Michigan School of Medicine, Ann Arbor
  • 4Michigan Surgical Quality Collaborative, Ann Arbor
  • 5Department of Anesthesiology, University of Michigan, Ann Arbor
JAMA Surg. 2019;154(1):e184234. doi:10.1001/jamasurg.2018.4234
Key Points

Question  What factors are associated with opioid consumption after surgery?

Findings  In this population-based study of patients undergoing surgery in Michigan, 2392 patients used only 27% of the opioids prescribed to them. Prescription size had the strongest association with opioid consumption after surgery, with patients using an additional 5 pills for every 10 extra pills prescribed.

Meaning  Excessive opioid prescribing is associated with higher opioid consumption after surgery. Using patient-reported opioid consumption will improve postoperative opioid prescribing to better match patient opioid requirements.

Abstract

Importance  There is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption.

Objective  To describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery.

Design, Setting, and Participants  A retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients.

Exposures  Opioid prescription size in the initial postoperative prescription.

Main Outcomes and Measures  Patient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors.

Results  In this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills; P < .001). The quantity of opioid prescribed had the strongest association with patient-reported opioid consumption, with patients using 0.53 more pills (95% CI, 0.40-0.65; P < .001) for every additional pill prescribed. Patient-reported pain in the week after surgery was also significantly associated with consumption but not as strongly as prescription size. Compared with patients reporting no pain, patients used a mean (SD) 9 (1) more pills if they reported moderate pain and 16 (2) more pills if they reported severe pain (P < .001). Other significant risk factors included history of tobacco use, American Society of Anesthesiologists class, age, procedure type, and inpatient surgery status. After adjusting for these risk factors, patients in the lowest quintile of opioid prescribing had significantly lower mean (SD) opioid consumption compared with those in the highest quintile (5 [2] pills vs 37 [3] pills; P < .001).

Conclusions and Relevance  The quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.

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    1 Comment for this article
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    How did we get here?
    Carlos Alvarez, MD |
    I want to congratulate the authors for providing us with very timely data. Many will jump to impugn surgeons for being responsible for the US epidemic of opioid use on the basis of this report, ignoring the fact that the information provided is only now being sought. No one taught me in residency (or medical school, since at the time, we 3rd year students were allowed to carry signed prescriptions to expedite discharges) to write a 30 pill narcotic prescription for postop patients. We were just told to do it. If there had been a study in the 40s to establish this as the right quantity, no one quoted it, and you could not find it on Medline. I would hazard a guess that it was probably Dr. Halsted's preferred number of pills. There is no question that the chief driving factor, as residents, was to avoid getting called after discharge for a refill. You wanted to avoid unhappy patients and attendings at all costs. Early on in my practice, it was relatively easy to come up with the right amount of pills to provide, since we could look at the patient's consumption in the hospital for several days. In some cases, you could even send them home without a prescription, since by day 5 or 10 postop, many reported minimal pain. But then in the 90s, we moved to minimally invasive surgery, early discharges and same day surgery care, and the system did not adjust. We continued to hand out 30 pill prescriptions, even as we were arguing in the literature that MIS was worth pursuing in large part because of decreased patient discomfort.

    The data here allow (compel?) us to cut back on that magic number. But it also points out the fact that some patients need more, and our system is poorly set up to accommodate them. In most states, and pharmacies, a paper prescription is required. It is difficult to understand why narcotic prescriptions remain difficult, if not downright impossible to prescribe electronically. In the era of Prescription Drug Monitoring Programs, electronic prescribing, which at least in theory should be able to check in real time for potential abuse, should not only be allowed, it should be the default.
    CONFLICT OF INTEREST: None Reported
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