Determining the Optimal Length of Opioid Prescriptions

Overprescription of opioids has led to questions about the lengths of post-surgery prescriptions, but new data suggests that there may be an optimal duration.

With the opioid epidemic looming over pain management prescriptions, there exists a fear not only in the over-prescription of these drugs but in the consistency of refilled prescriptions despite physicians best efforts to discourage overuse.

The study, led by Rebecca E Scully (pictured), MD, of the Center for Surgery and Public Health in the Division of Vascular and Endovascular Surgery at Brigham and Women’s Hospital, and Harvard Medical School, examined the possibility of identifying an ideal range of opioid prescription durations to alleviate some of these struggles.

Results showed that the optimal length of opioid prescriptions falls between the early nadir of the refill probability and the observed median prescription length. The data revealed that for general surgery, prescriptions were optimized at 4 to 9 days, women’s health procedures at 4 to 13 days, and musculoskeletal procedures at 6 to 15 days.

The study examined 215140 opioid-naive patients from the Department of Defense Military Health System Data Repository that had undergone 1 of 8 common surgical procedures and were prescribed opioids, from January 1, 2005, to September 30, 2014. The average duration of prescriptions were 4 days for general surgery and women’s health procedures, and 6 days for musculoskeletal procedures.

Median prescription lengths for specific procedures were found to be the following: 4 days (interquartile range [IQR], 3-5 days) for appendectomy, cholecystectomy, and hysterectomy; 5 days (IQR, 3-6 days) for mastectomy and inguinal hernia repair, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy.

Of the total patient population (107588 women, 107552 men; mean age 40.1 years), 19.1% (n=41107) received at least 1 refill prescription. The length of prescriptions with the lowest probability of refill for general surgery prescriptions was 9 days (10.7% chance of refill), 13 days for women’s health surgery (16.8%), and 15 days for musculoskeletal surgery (32.5%).

The authors noted that ideally, the prescription length would provide patients a balance between proper management of pain and the duration of their treatment. According to an accompanying editorial from Selwyn O Rogers, MD, MPH, despite the knowledge of the overprescription of opioids, few to no guidelines exist for the appropriate opioid prescribing methods after surgery.

Describing this issue as an “ongoing crisis,” Rogers also noted that 1 of the biggest issues with opioid-based pain management prescriptions is the misconception of how a patient’s recovery is supposed to go.

“It is key to remember the importance of setting expectations in the interpretation of pain,” Rogers wrote. “Unfortunately, we have reached a point that 100% elimination of pain has become not only the goal but the expectation. If a surgeon allows a patient to expect a pain-free recovery, he or she will see refill requests increase.”

Rogers declared that it is not time consuming to explain to patients the positives to the use of acetaminophen and ibuprofen as well, noting that stronger options should only be explored if adequate management becomes impossible.