EXECUTIVE SUMMARY

Opioid overdoses surged during the COVID-19 pandemic, a problem surgery professionals can help solve by paying greater attention to prescription opioid misuse and abuse.

  • Opioid stewardship should include education and outreach to encourage patients to properly dispose of unused pills.
  • Patients should be offered information on various ways to safely dispose of unused pills, including medication disposal drop boxes placed at convenient locations.
  • Evidence shows surgeons can reduce the number of pills prescribed, and patients still will report satisfaction with their pain control.

More than 81,000 people died of drug overdoses between summer 2019 and spring 2020. It was the highest number of overdose deaths ever recorded within 12 months, according to the CDC.1

The biggest drivers of death were synthetic opioids; use of these jumped 38.4% in this period. Federal officials attributed the high number of deaths to the COVID-19 pandemic’s disruption of daily life.1

Surgery professionals and the rest of the healthcare industry have been working on this problem for several years, trying everything from alternative pain management to prescribing fewer pills.

As the authors of a recent study noted, opioid stewardship continues after an operation and after the patient’s pain has improved.

These researchers created guidelines that outline how surgeons can prescribe opioids in a way that spares excess but meets patients’ needs. Further, the guidelines also describe a successful strategy to reduce diversion of unused pills.2

To start, investigators examined previous research on the variability in opioid prescriptions for common general surgical procedures. For example, one research group discovered patients’ needs for opioids could have been met with 43% of the actual number of pills prescribed; 70% of prescribed pills were never taken.3

The authors theorized overprescribing likely occurred because providers might have perceived some patients needed more opioids than others. Also, this might happen because of variances from practice to practice in policies regarding the number of pills a clinician is allowed to prescribe at once.

Richard J. Barth, Jr., MD, FACS, professor of surgery at Dartmouth and section chief of general surgery at Dartmouth-Hitchcock Medical Center, is a co-author of the guidelines produced this year and worked on some of the other investigations that went into building those guidelines.

After considering the literature, Barth and colleagues theorized if a patient did not take any opioids the day before discharge, then he or she did not need any opioids at home. Conversely, if the patient needed four or more opioid pills the day before discharge, then he or she could be sent home with a prescription for many pills.4

Validating the Theory

To try this idea in practice, Barth and colleagues enrolled 229 patients admitted for 48 hours or longer after elective surgery. Procedure types were gynecologic, colorectal, thoracic, and urologic.

When patients were discharged, they received prescriptions for nonopioids and opioids based on their consumption of the latter one day before discharge. If patients took zero oral morphine milligram equivalents (MME) one day before discharge, then they received five 5-mg oxycodone pill-equivalents.

If patients used one to 29 MME, then they received 15 5-mg oxycodone pill-equivalents. If patients took 30 or more MME, then they received 30 5-mg oxycodone pill-equivalents.

Overall, 213 of 229 patients reported they were satisfied with how they could manage their pain. Satisfaction was especially high among low-level opioid users (95% of subjects used nonopioid analgesics).

Here, it is important for surgeons to play a central role. Set pain expectations for patients (i.e., there likely never will be zero pain; at least a little pain should be expected). When it comes to prescribing nonopioid alternatives, don’t just make the recommendation; write the actual prescription.

“When I see a patient, even before the surgery, I set their expectations for what they need after the surgery,” Barth says. “I discuss how we’ll manage their pain in the hospital and explain to them that if they are not taking opioids in the hospital, then we’ll send them home without opioids.”

Although many of the 229 patients underwent serious surgery, Barth says this approach is generalizable across many different operation types. For example, Barth, working with other researchers, established recommendations for opioid prescriptions after outpatient surgeries, including orthopedic and oral maxillofacial procedures, in which overprescription was common. Following those guidelines led to a 53% reduction in opioid pills prescribed.3,4

Preventing Misuse, Waste

Researchers also worked with these 229 patients to improve proper disposal of unused opioids. They used four tactics:

Education. This could be a quick conversation on the day of discharge. It would include information on the risks of driving while on the medication.

Automated phone calls. When the call went out to remind patients of follow-up appointments, there also was a request for patients to bring any unused pills to the appointment.

For those who wanted to dispose of pills before an appointment, these calls provided information about FDA-approved methods for doing so (e.g., crush the pills, mix with kitty litter or coal, place in charcoal containers, and drop off at a pharmacy or fire station).

Drop-off box. Researchers designated a specific box where these patients could leave unused pills.

Questionnaire. Patients completed a survey about what they did with their opioid pills. They were encouraged to be responsible for any unused pills.

The questionnaire also made it possible for researchers to get to the root of why patients wanted to keep pills (e.g., “I want to save a few pills in case I feel pain again later.”).

A main point providers should emphasize to patients is that leftover opioid pills can be a gateway drug to a younger population. “You may not think it’s irresponsible for yourself, but it can be a gateway for someone else, and saying that usually encouraged people to do the right thing,” says Eleah D. Porter, MD, a surgery resident at Dartmouth-Hitchcock who worked with Barth and colleagues on the guidelines. “We also would say that this is an addictive drug. If they need an opioid, they may be at risk of being addicted, so they should see a doctor.”

“It’s also important for a surgeon, when they’re seeing patients back in the office, to ask patients about what they’ve done with their opioids and whether or not they have disposed of them,” Barth adds. “This is like checking with the patient on their bleeding or something else from the surgery.”

These four tactics paid dividends. A total of 138 patients did not use all the pills prescribed; 114 used an FDA-appropriate disposal method, and 58 used the drop box. Out of about 2,600 total pills dispensed, patients only kept 187.2

“The drop box in a pharmacy near our offices made it easy and nonjudgmental to drop off excess opioids,” Barth says. “A lot of patients know they can drop off [opioids] at police departments, but they may not feel comfortable dropping off the pills there. Dropping them off at the pharmacy makes it very easy and doesn’t have stigma associated with it at all.”

Changing Practice Habits

This research has helped change post-surgery prescribing of pain medication at Dartmouth-Hitchcock. “We’ve continued to manage opioids as they were managed on the study,” Barth reports.

These changes and other opioid-sparing tactics represent a serious practice shift from just six years ago. “When I started in 2015, you wouldn’t blink an eye to prescribe copious amounts of opioids,” Porter says. “By doing this prospective trial, we are saying to the skeptics that it’s better than we thought, and we’re not getting calls for [opioid] refills, and people are using less than they were.”

Surgeons are walking into their practices with a completely different mindset about opioid prescribing after operations.

“We’re showing that with some good research, dedication, and public interest, we can change our practice and eliminate the opportunity for surgeons to contribute to the opioid crisis,” Barth says. “We want to make sure our study results are disseminated to others so they can incorporate these changes, which are pretty easily incorporated into practice and can change the way opioids are prescribed when people are discharged from surgery.”

As a training surgeon, Porter says this work has evolved her practice and how she views her own responsibility.

“It’s completely changed how I’ll approach opioids as a surgeon,” she says. “It’s my responsibility as a surgeon to make sure the opioid pills are properly disposed of as leftovers, and we can treat pain, but also can do it in a safe manner that will be the standard of care going forward.” 

REFERENCES

  1. Centers for Disease Control and Prevention. Overdose deaths accelerating during COVID-19. Dec. 17, 2020.
  2. Porter ED, Bessen SY, Molloy IB, et al. Guidelines for patient-centered opioid prescribing and optimal FDA-compliant disposal of excess pills after inpatient operation: Prospective clinical trial. J Am Coll Surg 2021; Jan 30;S1072-7515(21)00056-9. doi: 10.1016/j.jamcollsurg.2020.12.057. [Online ahead of print].
  3. Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg 2017;265:709-714.
  4. Hill MV, Stucke RS, Billmeier SE, et al. Guideline for discharge opioid prescriptions after inpatient general surgical procedures. J Am Coll Surg 2018;226:996-1003.