Opioids are commonly prescribed for pain relief following inpatient and outpatient surgical procedures. Overprescription of opioids is known to contribute to the opioid epidemic and overdose-related deaths in the United States. Opioid-naïve patients who are prescribed opioids for postoperative pain relief are at 3 to 7% risk of becoming chronic users. Veterans exhibit even higher risk, converting to chronic use at a rate of 8-15%. Disappointingly, 45% of patients who were not taking opioids on the day prior to hospital discharge are still prescribed opioids at discharge. For most surgeries, there are no evidence-based society-level recommendations to guide postoperative opioid prescriptions. Thus, even for the same operation in opioid naïve patients, we have observed that postoperative opioid prescriptions are highly variable across surgeons and across hospitals. Many opioid prescriptions are written for a large quantity of opioid, with vague instructions such as, “take 1-2 tablets every 4-6 hours as needed for pain”. Some patients take very little and are left with a large quantity of unused medication that is hard to safely dispose of and remains dangerously available for unintended use. Other patients take the medication “as directed” – 2 tablets every four hours – consume a large quantity of opioid, and are unsure what to do when the prescription suddenly runs out. These patients are at risk of developing dependency. We want to avoid both scenarios. Clearly, there is an acute need for a rational and standardized approach to prescribing postoperative opioids that delivers satisfactory pain relief, provides useful guidance to patients on how to manage their postoperative opioid use, and minimizes the quantity of opioids prescribed and dispensed into the community. This is in everyone’s best interest – the patient, the health care system, and society.
The specific questions for the project start-up phase are:
At a single, high complexity tertiary care VA medical center, is it possible to develop a “procedure agnostic”, simple, and uniform strategy for prescribing postoperative opioids across all surgical specialties that will:
a. reduce the total amount of opioid released into the community compared to current practice
b. not increase requests for refills
c. not increase emergency room visits, readmissions, or complications, and reduce persistent postoperative opioid use
d. be easily, rapidly, and widely implemented among a diverse group of surgeons with varied interests and motivations.
Success would have a transformative effect on the delivery of surgical postoperative care in the VA and would greatly benefit veterans and society. Success in Phase I will be defined as (1) achieving a protocol adoption rate of at least 50%, (2) achieving at least a 25% reduction in postoperative opioid dispensed, (3) not measurably increasing the rate of ER visits for pain, readmissions, or persistent opioid use. Assuming the Phase I study is successful, our vision is that VISN-wide implementation would be the subject of a Phase II grant application. This would be the next step towards possible national implementation.
In this project we will implement and study a uniform, yet patient specific approach to prescribing postoperative opioids across all surgeries. This has the potential to greatly simplify care and reduce opioids dispensed without sacrificing pain relief.
External Links for this Project
Grant Number: I01HX002946-01
Dimensions for VA
None at this time.
Substance Abuse and Addiction, Other Conditions
Treatment - Observational, TRL - Applied/Translational
Best Practices, Patient Safety, Pharmacology
None at this time.