Decrease in Postoperative Opioid Dispensing Associated With CDC Guidelines

Tori N. Sutherland, MD, MPH

Research has shown that opioids are overprescribed after surgery, which may lead to diversion or other adverse outcomes, including opioid-induced constipation.

After the 2016 Centers for Disease Control and Prevention (CDC) guideline for opioid prescription for chronic pain was published, experts have noted the potential for the guide to affect postoperative opioid prescribing.

Investigators, led by Tori N. Sutherland, MD, MPH, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, found the guidelines had associations with clinically relevant changes in opioid prescription patterns after surgery including decreases in prescription rates.

Study

The team performed a cross-sectional study to assess the association of the 2016 CDC opioid prescribing guideline with postoperative opioid dispensing 2 years before and after publication.

They followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline checklist for observational studies.

Data was collected from the Clinformatics Data Mart Database. The study sample included patients ≥18 years with a claim for any of 8 general and orthopedic surgical procedures from March 2014 – March 2018.

Exclusions included patients who did not fill an opioid prescription within the first 7 days of surgery, patients with claims for more than 1 eligible procedure on the same day, and those who did not have 90 days of continuous enrollment prior to procedure and 30 days after.

The sample was restricted to include patients with no fulfilled opioid prescriptions 90 days prior to surgery to capture new opioid prescriptions, rather than refills for established chronic pain.

Primary outcomes included the total amount of opioid dispensed in first prescription filled within 7 days of surgery or hospital discharge, measured in morphine milligram equivalents (MMEs).

Further, secondary outcomes included total opioids dispensed across all filled prescriptions in MME within 30 days after surgery or discharge, and percentage of patients receiving an opioid refill within 30 days after surgery.

Results

The study included 361,556 opioid-naïve patients who underwent 8 general and orthopedic surgical procedures between March 2014 – March 2018.

Of the total, 45.4% (164,009) were male and median age was 58 years.

Prior to CDC guideline release, the mean amount of opioid for first-filled prescriptions dispensed increased from 301 MME (95% CI, 295 – 307 MME) to 325 MME (95% CI, 319 – 331 MME).

Following guideline release, the mean amount of opioid received in the first filled prescription decreased from 316 MME (95% CI, 311 – 322 MME) to 266 MME (95% CI, 260 – 271 MME).

Investigators noted the total amount of opioid dispensed in the first prescription after surgery in 2 years following CDC guideline release, in comparison to an increasing trend in the prior 2 years.

They found the prerelease trend was 1.43 MME/month (95% CI, 0.62 – 2.24 MME/month, P = .001), while the post release trend was -2.18 MME/month (95% CI, -3.01 to -1.35 MME/month, P <.001.

The overall trend change noted was -3.61 MME/month (95% CI, -4.87 to -2.35 MME/month, P <.001).

In addition, the changes in initial dispensing trends were found to be greatest for patients undergoing hip or knee replacement at -8.64 MME/month (95% CI, -11.68 to -5.60 MME/month, P < .001).

The team observed minimal changes in rates of refill at 0.14% per month (95% CI, 0.06% - 0.23% per month, P = .001).

Then, the team found absolute amounts prescribed remained high, with 47.7% (95% CI, 47.4% - 47.9%) of patients treated in post-guideline period receiving 2 times the initial opioid dose based on available recommendations.

Conclusion

The investigators concluded that opioid dispensing after surgery had a substantial decrease after the release of the 2016 CDC guidelines, in comparison to an observed trend during the 2 years prior.

“Concurrently, our observation of high opioid amounts dispensed relative to recommendations indicates ongoing opportunities to improve pain treatment after surgery and the potential need for additional policy and clinical interventions to transform care,” investigators wrote.

The study, “Association of the 2016 US Centers for Disease Control and Prevention Opioid Prescribing Guideline with Changes in Opioid Dispensing After Surgery,” was published online in JAMA Network Open.