Expert Panel: Opioid Prescribing Limits Should be Based on Operation Performed

AUGUST 21, 2018
An expert panel of health care providers and patients are recommending that  opioid prescribing limits should be based on the operation performed rather than a blanket approach. The ranges offered for each of 20 common operations generally call for reductions from the current rates of opioid prescription, and the researchers note that patients themselves favor using less of the medications than often prescribed.

In a recently published paper, the researchers, from Johns Hopkins University School of Medicine, explain the process of consensus reached by 30 surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients and pharmacists.

“Prescriptions for pain meds after surgery should be custom tailored to the operation and a patient’s needs and goals, but the hope is that these guidelines will help reset ‘defaults’ that have been dangerously high for too long,” Martin Makary, MD, MPH, a professor of surgery and health policy expert at the Johns Hopkins University School of Medicine and the study’s senior author said in a press release.

The guidelines are already being used to educate Johns Hopkins residents and surgeons and to replace the current e-prescribing defaults that appear in prescribing systems. A second expert panel of dentists has also duplicated the effort for dental procedures.

Johns Hopkins researchers recognized the need for creating a consensus around guidelines for appropriate amounts of opioids. In efforts to develop such detailed guidelines, Makary and his colleagues convened 30 health care professionals from the Johns Hopkins Health System, split into 6 groups: surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients, and pharmacists. Makary provided each panel member with relevant literature on addiction and other risks of opioids.

The panel then reviewed 20 common procedures in the areas of breast surgery, thoracic surgery, orthopaedic surgery and, cardiac surgery, among others such as open hysterectomies and cochlear implants. The panelists were asked to recommend a pain management opioid regimen for each procedure, assuming the patient was an average adult who has not been previously exposed to opioids.

Drafts of the recommendations were shared with all 30 panel members and again during a full panel, in-person meeting 2 weeks later.

During the meeting, researchers asked the panel members to recommend an appropriate  number of pills, each pill equivalent to 5 milligrams of oxycodone, for each procedure for the average adult patient procedure—assuming the patient’s operation was uncomplicated and the patient did not suffer from chronic pain unrelated to the surgery.

Overall, the panel recommended a range from one to 15 opioid tablets for 11 of the 20 procedures, 16 to 20 tablets for 6 of the 20 procedures, and zero tablets for 3 of the 20 procedures.

The panel also recommended that the minimum number listed in the table range for opioid tablets should be 0 and the maximum should be 20.
Overall, patients who had the procedures voted for less opioid pills than the surgeons performing those operations. For example, one patient who underwent a knee scope and one patient discharged after a c-section believed non-opioid alternatives alone were sufficient pain management, whereas others on the panel voted for 10 and 15 opioids to be prescribed, respectively.

Funding for this study was provided by the National Institutes of the Health (5T32CA126607-09) and the Foundation for Anesthesia Education and Research.

Reference
Overton HN, Hanna MN, Bruhn WEE, et al. Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus. J Am Coll Surg. 2018; DOI: https://doi.org/10.1016/j.jamcollsurg.2018.07.659. 
 

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