Tag Archives: opioids

Pharmacy

Opioids In Trauma Care: A Suggestion?

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In my last post, I reviewed a paper that showed how disorganized we are at responsibly prescribing and providing instructions for use of opioid pain medications. Today, I’ll look at a paper that attempts to provide a bit more concrete guidance on what to do.

This study was performed at Dartmouth, and consisted of a questionnaire sent to a group of patients who had undergone an inpatient general surgical procedure during a 6-month period. These were not trauma procedures, but included gastric bypass, sleeve gastrectomy, lap or open ventral hernia repair, laparoscopic fundoplication, hepatectomy, lap or open pancreatectomy, and lap, open, or robotic colectomy. The authors specifically looked at opioid use before discharge, length of stay and complications, and opioid prescriptions and refills.

After excluding patients who had preop opioid use or abuse, and those who developed postop complications, there were 234 study patients. Here are the factoids:

  • Overall, 85% patients were given opioid prescriptions, and only 38% of the medication prescribed was taken
  • Patients discharged on postop day 1 had different requirements from those who were discharged later, and were studied separately
  • 88% of patients discharged on day 1 had their opioid needs satisfied by 15 pills
  • For patients discharged after day 1, there was a very strong correlation with home needs and the amount of opioid required on the before discharge
  • 41% of patients took no pills the day prior to discharge, 33% took 1 to 3, and 26% took more than 4
  • Proper disposal of unused meds was extremely variable

Based on this information, the authors calculated that 85% of patients’ home opioid use would be met by using the following guideline:

  • If no pills were used the day prior to discharge, none were prescribed
  • If 1-3 were taken, 15 were prescribed
  • If 4 or more were taken, 30 were prescribed

The authors estimated that, if these guidelines had been followed in the patients reviewed, the number of pills prescribed would have decreased by about 40%.

Bottom line: This is an interesting attempt to answer our questions about opioid use after discharge. Of course, there are limitations in extrapolating this to the trauma population. The pain patterns in patients with fractures, chest trauma, or multiple injuries are very different than those with abdominal general surgical procedures,  especially those performed with a laparoscope  or robot. But it does demonstrate some key concepts:

  • It should be possible to systematize discharge prescribing in a significant number of patients
  • We need to provide guidelines and expectations to our patients to help them minimize their use of opioids after discharge
  • We also need to make sure that our patients know what to do if they run out of medication
  • These guidelines must include safe disposal instructions for unused meds so they can’t be diverted for inappropriate use

I’m looking forward to more papers that help quantify these concepts. In the meantime, I guess I’ll hit the drawing board and start sketching out an interim guideline to tide me over until that happens!

Pharmacy

Opioids In Trauma Care: Some Data

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Yesterday I shared a TED Talk that outlined one person’s experience navigating the system (or lack thereof) for people trying to kick their addiction to medically prescribed narcotics. Today, I’ll share some new data that describes prescribing patterns and patient usage. This information was collected on patients after surgical procedures, not necessarily trauma, so this data may not be completely applicable. But it’s a start.

This paper is from the University of Vermont, and reviewed two datasets regarding opioid prescriptions. The first was a retrospective look at prescriptions written over a one year period after various surgical procedures in either an inpatient or outpatient setting at their center. This was used to design a patient telephone questionnaire containing questions about narcotic prescriptions and how much was used. The survey was administered about 1 week postop for patients having procedures over a 9 month period.

Here are the factoids:

  • Over 10,000 patients were identified in the retrospective arm of the study (!), of which 5100 were orthopedic procedures and 3100 were general surgery
  • 65% of patients were given only narcotic prescriptions on discharge, 24% were give no opioids, 3% were given only a Tramadol prescription, and 8% were given both
  • Residents wrote the vast majority of prescriptions at this academic medical center (63%), with 24% written by advanced practice providers and 13% by the attending surgeon
  • Drugs commonly prescribed in the retrospective data were oxycodone (44%, avg 30 pills), hydromorphone (31%, 25 pills), Tramadol (13%, 50 pills), and hydrocodone (8%, 20 pills)
  • There were considerable variations in prescribing patterns, drugs prescribed, and morphine equivalent doses provided across specialties
  • In the prospective data, the median amount of prescribed narcotic (in morphine equivalents) that was used was only 27%
  • Procedures associated with the highest amount of narcotic use were orthopedic in nature, particularly knee and shoulder operations

Bottom line: There is a huge amount of variability in prescribing patterns at one academic medical center, and this is probably true at most hospitals. There are a number of factors that contribute: the type of prescriber, local customary practices, type of surgery, and many more. Prescribers are not very experienced in predicting patient needs, and patients do not always do a good job communicating their needs to the clinicians.

In the next post, I’ll describe a suggested practice guideline that seeks to bring some sense to this complex topic.

Reference: Post-discharge opioid prescribing and use after common surgical procedures. J Am Coll Surg 226(6):1004-1013, 2018.

Pharmacy, Video

Opioids In Trauma Care: Food For Thought

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Here’s something I ran across during my reading last week. In the “old days”, I used to encourage my trainees to be generous with pain medicine prescriptions for patients being discharged from the hospital. I would routinely send people home with 60, 75, or more pills. I got a hint of the folly of this just a few years ago when I underwent an outpatient procedure (biceps tendon repair).

The orthopedic surgeon prescribed 15 narcotic pain pills for me to take home. I scoffed at the low number, although I didn’t tell him that. But once I got home and the regional block wore off, how many do you think I took? Exactly one. I (safely) disposed of the rest. This prompted me to start rethinking our role in the opioid problem here in the US.

Tomorrow, I’ll write about a recently published paper and guideline for discharge opioid prescriptions. But today, watch the TED talk embedded below. It reveals the inadequacies within our health care system for those who, one way or another, have developed a dependence on these medications. It was an eye-opener for me.