Determining duration: How long to prescribe postoperative opioids

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In the outpatient pain management setting, few guidelines exist

In September, JAMA Surgery published online evidence-based recommendations for optimizing the duration of opioid treatment for pain following common surgical procedures. The authors proposed that opioid prescriptions postsurgery should balance adequate pain management against the duration of treatment and offered guidance for determining the appropriate length of opioid prescriptions.

Standardizing the length of time patients will require postsurgical pain control poses several challenging considerations confounded by inherent subjectivity. Aside from classifying pain into nociceptive, neuropathic, and inflammatory types, descriptions of patients’ sensations vary widely. Some report sharp, itching, burning, or throbbing pain, while others report dull, itching, burning, or radiating pain. These symptoms can occur in patterns that may be persistent, intermittent, or brought about by certain stimuli.

To make matters even less clear, in the setting of postoperative, outpatient pain management, few guidelines exist.

“With so much individual variability in the perception and modulation of pain, as well as the complexity of potential underlying opioid tolerance and hyperalgesia, it is difficult to create an evidence-based, one-size-fits-all approach to opioid prescribing postoperatively,” said Stephanie Abel, PharmD, BCPS, palliative medicine clinical pharmacy specialist at the Ohio State University Wexner Medical Center James Cancer Hospital.

Study fundamentals

Using the Department of Defense Military Health System Data Repository, the study enrolled opioid-naive individuals ranging from 18 to 64 years of age who had undergone one of eight common surgical procedures between 2006 and 2014.

Dispensing of refills for postsurgical opioid prescriptions served as the main outcome measure. Comparing refills with the number of days written for initial prescriptions identified which durations of initial prescriptions held the most adjusted risk for requiring refills on opioid prescriptions. The initial prescription duration associated with the lowest risk of refill served as the low point.

Of 215,140 individuals who received and filled at least one prescription for an opioid pain medication within 14 days of a procedure, 19.1% received at least one refill. The optimal length of opioid prescriptions was said to lie between the observed median prescription length and the early low point. As it resulted, this measured in at 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.

“I think this article is a great start regarding optimal lengths of opioid prescriptions and does align with previous articles on the subject,” said Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE, palliative care clinical pharmacy specialist at the University of Pittsburgh Medical Center Palliative and Supportive Institute and assistant professor at the School of Pharmacy. “Any effort to reduce potentially unnecessary opioid use is welcomed.”

Practice pearls

Through early interventions and diligent follow-up, clinicians can mitigate opioid prescribing from the start and ensure safe and proper use of these medications. When possible, include a pain management assessment in the preoperative appointment for elective procedures.

Prior to surgery, the interdisciplinary team should discuss with the patient any expectations the patient may have about pain and for how long opioids or other medications will be prescribed postoperatively. “This creates an environment of shared decision making and accountability prior to the event,” explained Pruskowski. “Unfortunately, complete pain elimination has become an expectation of many patients, which is not only unrealistic but dangerous. If the interdisciplinary team allows for the expectation, the patient may expect additional opioid refills.”

To improve overall prescribing and use of opioids for postsurgical pain control, clinicians must adopt good practice habits. Abel recommended that clinicians “optimize multimodal analgesia whenever possible, become familiar with opioid calculations and equianalgesic conversions in [their] patient population to avoid errors, and familiarize [themselves] with opioid-induced hyperalgesia and strategies for tapering opioids.” Some pharmacy lead interventions often include pain comfort menus, patient-controlled analgesia dose sevicing, pain stewardship, and pharmacist liaison pain servicing.

By evaluating ongoing data, helping patients make informed decisions early on, and committing to conservative pain management practices, opioids may be used safely and appropriately in postoperative settings. 

For the full article, please visit www.pharmacytoday.org for the December 2017 issue of Pharmacy Today.

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