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Review
March 11, 2020

Recommendations for the Prescription of Opioids at Discharge After Abdominopelvic Surgery: A Systematic Review

Author Affiliations
  • 1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
  • 3Department of Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
  • 4Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario, Canada
  • 5Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
  • 6Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 7Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
  • 8Department of Surgery, Women’s College Hospital, Toronto, Ontario, Canada
  • 9Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 10Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 11Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
  • 12Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
JAMA Surg. Published online March 11, 2020. doi:10.1001/jamasurg.2019.5875
Key Points

Question  What are current recommendations from clinical practice guidelines and other documents for the prescription of opioids at discharge, appropriate disposal, and prevention of long-term opioid use after abdominopelvic surgery?

Findings  Of 5530 citations screened, 41 full-text documents were included in the systematic review, and 15 clinical practice guidelines were identified. The quality of guidelines included was found to be highly variable; most recommended interventions were not supported by any assessment of evidence, and the amount of prescription opioid recommended varied widely between publications, even for the same procedure.

Meaning  Current guidance for the treatment of postdischarge pain with opioids after abdominopelvic surgery is limited.

Abstract

Importance  The prescription of opioids at discharge after abdominopelvic surgery is variable and often excessive. A lack of guidance for abdominopelvic surgeons may explain the suboptimal nature of current prescribing practices.

Objective  To systematically review existing recommendations on the prescription of opioids at discharge, the appropriate disposal of opioids, and the prevention of chronic postsurgical opioid use after abdominopelvic surgery.

Evidence Review  This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From January 2010 to December 2018, a search of MEDLINE, PsycINFO, HealthSTAR, Embase, and the difficult to locate and unpublished (ie, gray) literature was performed using a peer-reviewed strategy with variations of the terms opioid, surgery, and guideline to identify English-language documents that contained recommendations published by professional societies or health care institutions. The quality of clinical practice guidelines was assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. A descriptive synthesis of results was performed.

Findings  Of 5530 citations screened, 41 full-text documents were included in the systematic review. Fifteen clinical practice guidelines were identified. AGREE II domain scores varied substantially. Identified among the 41 included documents were 98 recommended interventions for the prescription of opioids at discharge, 8 interventions for the disposal of opioids, and 8 interventions for the prevention of chronic postsurgical opioid use. Only 13 of 114 interventions (11.4%) were supported by an assessment of strength or level of evidence, and the amount of opioid recommended after specific abdominopelvic surgical procedures varied widely between guidance documents, even for the same procedure.

Conclusions and Relevance  Current guidance for the prescription of opioids at discharge after abdominopelvic surgery is heterogeneous and rarely supported by evidence. More research is needed on this topic to guide the development of future recommendations.

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