Abstract
Purpose: Nonmedical use of prescription opioids continues to be a public health crisis in the United States that disproportionately affects rural communities with diversion of pills from friends and family being the most common source. The primary goal of the study was to identify current opioid prescription practices, and to assess the discrepancy in amount of opioids prescribed by surgeons versus the amount needed post-operatively by patients. Patient factors that may influence postoperative analgesia needs and their management of leftover prescription opioids were also evaluated
Methods: Patients ≥18 years-of-age who underwent a surgery between July and December 2018 by the subspecialty departments of Acute Care and General Surgery at a tertiary care facility in the rural Midwest were surveyed at their first post-operative visit to assess their postoperative analgesic needs. Resident and attending surgeons in the above departments were also surveyed to identify different factors that influenced their narcotic prescription practices.
Results: Surveys from 252 patients, 12 attending surgeons, and 14 general surgery residents met inclusion criteria. Of patients who received a narcotic prescription, 19.9% did not fill their prescription, 64.1% of whom were >60 years old, and 72.1% resided within an hour of the hospital. Average reported prescription size was 11–40 pills; however, most used more than 5 pills regardless of the type of operation (P=0.59) and history of chronic pain (P=0.07). Inability to call in narcotic prescriptions and patients’ distance from care influenced providers’ prescription practices, with 77.9% of resident physicians and 68.3% of attending surgeons stating they would prescribe fewer if given the ability to call in a narcotic prescription.
Conclusions: Regardless of the operation complexity, a majority of patients required fewer than five opioid pills after discharge and would be willing to return leftover pills. Development of opioid stewardship programs within the healthcare sector may reduce the number of opioids available for diversion and misuse.
Prescription opioid misuse and abuse is a major public health concern in the United States, with an average of approximately 11.8 million persons ≥12 years-of-age reportedly misusing prescription opioids over the past year.1,2 From 2004 to 2011, emergency department visits linked to prescription narcotic use increased by an estimated 153%,3 and it is estimated that prescription opioid overdoses have resulted in approximately 15,000 deaths since 2008.4 In 2011, the Centers for Disease Control and Prevention estimated the direct health care costs related to nonmedical use of prescription opioids nationwide was $72.5 billion annually.5 Prevalent prescription opioid use has also contributed to the development of secondary and tertiary epidemics of heroin and fentanyl, though we recognize that other factors are involved in these use cases.6,7
According to a 2014 report published in the American Journal of Public Health8 the prevalence of opioid-related deaths and poisoning has increased at a rate greater than three-fold in nonmetropolitan counties compared to metropolitan counties, though recent trends indicate a shift toward increased risk of opioid-related deaths in urban counties with the exception of natural and semisynthetic opioids.9 However, the adverse impacts of opioid abuse are still prevalent in rural counties, as these areas have fewer resources available for substance abuse treatment.10 Proposed contributing factors to the disproportionate impact of the opioid epidemic in rural areas prior to 2017 include a greater number of opioid prescriptions, stronger social networks, demographic changes, and increased economic pressure.8 Diverting legitimately obtained opioids for nonmedical use is a major source for individuals struggling with substance abuse, as the National Survey on Drug Use and Health reported in 2016 that 53% of individuals who misused prescription opioids obtained them from a friend or a relative, and 37.5% obtained them from a health care provider, while only 6% of individuals obtained opioids from drug dealers or other strangers.2
In light of the current opioid epidemic, there have been several endeavors to reduce excessive prescription of opioids post-operatively. To gain a better understanding of patients’ analgesia needs after common surgical procedures and identify trends in provider prescribing practices for our rural population, we surveyed patients and the corresponding residents and attending surgeons assigned to their care. Discrepancies in the amount of opioids prescribed by surgeons versus the amount used post-operatively by patients after discharge from care were compared, and patient knowledge of safe medication disposal practices was evaluated in the context of the degree of surgeon involvement in management of leftover pills. Factors influencing prescription practices of surveyed providers were identified. Patients’ willingness to dispose or return excess pills was also measured. Results from this study are guiding ongoing opioid stewardship efforts at the system level and may be of value to other rural healthcare organizations.
Methods
Study Design
We used a prospective survey-based approach to identify trends in post-operative opioid use by patients and the providers who care for them. Prescribing practices among residents and attending surgeons were evaluated and compared with patients’ reported use of opioids post-operatively after discharge. Patient knowledge and awareness of safe medication disposal practices was also evaluated in the context of provider education. Institutional Review Board approval was obtained prior to survey dissemination.
Target Population
Adult patients (?18 years-of-age) who underwent surgery in the General Surgery and Acute Care Surgery departments of a rural tertiary care facility in the Midwest between the months of July and December 2018 as well as the resident(s) and attending surgeon assigned to their care were recruited for survey participation. Patients who received follow up care at other facilities in our system or with incomplete survey responses specifically patient demographic information, type of surgery, and prescription use were excluded.
Data Collection
From July to December 2018, eligible patients ≥18 years-of-age who underwent surgery in the General Surgery and Acute Care Surgery groups at our institution were consented for participation and received a de-identified voluntary survey (Appendix 1, available online) at their first postoperative follow-up visit. The initial survey focused on identifying the different factors that may influence a patient’s postoperative analgesia needs such as demographics, distance from care, type of surgery, patient’s perception of pain tolerance, and postoperative use of non-narcotic pain medications. Patients were also asked about their usage of the provided prescription opioid, need for refill, and incentives to return leftover pills, as well as their knowledge of safe disposal options. We performed an interim analysis of the data obtained from the first 129 survey responses and subsequently modified the survey to subcategorize the type of surgery as elective or urgent and evaluate whether patient analgesic needs differed by the size of the surgical field (ie, laparoscopic, robotic, or open surgery). Surgeries classified under the ‘other abdominal’ group included patients who underwent any abdominal operations other than those listed and ranged in complexity from minimally invasive bariatric surgery to open pancreaticoduodenectomy.
A de-identified survey was also provided to the residents and providers involved in the patients’ surgical care and follow up during the 5-month period (Appendix 2, available online). Similar to the patient-based survey, residents and providersidentify the factors with the greatest contribution to patient analgesic needs. The Wilcoxon rank sum test and Kruskal-Wallis test were used to compare continuous variables. Fisher’s exact test was used to compare two categorical variables, while the Pearson chi-square test was used when were queried on the factors that influenced their prescribing practices with respect to opioid pain medications, specifically patient access to care and inability to call in a narcotic prescription. Survey items also focused on evaluating the provider’s role in educating patients about postoperative pain management and disposal of leftover prescription opioids.
Statistical Analysis
Descriptive statistics of patients, residents, and attending surgeons were generated to characterize the surveyed populations. Univariate Student’s t test was used to compare responses between residents and attending surgeons, while multivariate logistic regression was used to comparing greater categorical variables (eg, distance from care). Data were analyzed with statistical software package SAS, version 9.4.
Results
Patient Perspective
Between July 2018 and December 2018, survey responses were obtained from 252 patients that met inclusion criteria (Table 1). Of the surveyed respondents, 82.4% received an opioid prescription at discharge, and 19.9% did not fill their prescription. Patients who did not fill their prescription were generally older (64.1% of the population were >60 years of age, P=0.011), lived within an hour of the institution (72.1%, P=0.27), and underwent an abdominal surgery (23.1% underwent an appendectomy, 23.1% cholecystectomy, and 28.3% ‘other abdominal’ surgery) compared to patients who filled their prescription. The ‘other abdominal’ surgery category included other foregut, midgut, and hindgut surgeries, including minimally invasive bariatric procedures to more complex surgeries such as open Whipple and esophagectomies.
Patient cohort characteristics
A multivariate analysis was performed to evaluate patient reported opioid prescription size provided at discharge compared to reported usage (Figure 1). A majority of patients were prescribed between 11-40 pills at discharge for all operative categories except skin and soft tissue, who reportedly received ≤5 (P=0.02). Regardless of surgery type, most patients reported requiring ≤5 pills after discharge from inpatient recovery or same day surgery for their respective procedures (P=0.59). Similar results were noted for the 49 patients who reported being on a chronic opioid regimen prior to surgery; 47.4% reported requiring ≤5 pills, and 31.6% took Even for patients on a long-term opioid regimen, a majority of the patient population did not require a refill (91.4% vs 83.7%, P=0.159).
Postoperative opioid prescription size vs. patient requirements after discharge
To assess the effects of patient demographics, including age, gender, distance from care, pain perception, and knowledge of postoperative opioid use and disposal, additional multivariate analyses were performed. Among age groups, more patients >60 years required ≤5 opioid pills for pain management (62.1%), while 20.7% required between 6-10 pills; comparatively, 46.6% of patients <60 years of age required ≤5 pills, and 22.4% required 11-20 pills (P=0.042). No significant difference was noted in postoperative narcotic analgesic needs of males or females (52.3% vs 54.2% requiring ≤5 pills (P=0.081)). However, patients who reported concern for surgical pain prior to surgery tended to use more pills for pain management than patients who did not voice this concern (P=0.03); of this group, 44.4% required ≤5 pills, 21% 6-10 pills, and 20.2% 11-20 pills vs 67.1%, 14.5%, and 11.8% for ≤5, 6-10, and 11-20 pills, respectively.
Of the patients who filled a prescription for post-operative opioids, 85.1% had leftover pills, though only 9.9% disposed of them via safe drop-off bins. However, 70.8% of patients surveyed were willing to return leftover pills. Of those individuals who expressed reluctance to return their leftover prescription, 49.7% cited a concern for pain recurrence.
Physician Perspective
In July 2018, a total of 12 attending surgeons and 14 General Surgery residents were surveyed about their current prescription practices in both the inpatient and outpatient setting (Table 2). Of the opioids available for prescription at our institution, oxycodone was the most commonly prescribed opioid. A majority of the surveyed providers (50% attending surgeon and 57% residents, P=0.443) prescribed between 21-40 pills to patients at the time of discharge after recovery from inpatient surgeries, and the typical prescription size provided after an outpatient surgery was 11-20 pills, as reported by 33% attending surgeons and 64% residents. However, 33% of attending surgeons also prescribed 21-40 pills. Though 42.9% of residents prescribed more opioids to patients with chronic pain, and a majority of attending surgeons (72.7%) did not alter their prescription practices for this patient population, the differences were not statistically significant (P=0.131).11-20 pills (P=0.072).
Opioid prescribing patterns
When providers were asked if they believed they prescribed more than the patient’s needs, on a Likert scale of 0 to 100, a median score of 62.5 (SD 1.6) and 69.3 (SD 15.9) were reported by attending surgeons and residents, respectively. Using a similar scale, inability to call in a narcotic prescription (median: 75± 32.3 vs 85±25.3, P =0.442) and distance from the treating hospital (median: 70±26.5 vs 65±22.5, P=0.698) influenced the prescribing habits of attending surgeons and residents, respectively, though the results were not statistically significant. Furthermore, a majority of residents believed they prescribed more pills due to their concern that their attending surgeons would be called to approve a refill (median 80±25.3). When asked whether logistical considerations influenced their clinical decision making with respect to post-operative opioid use, 77.9% residents and 68.3% attending surgeons reported they would prescribe fewer pills if they had the ability to call in narcotic prescriptions. While most providers asked patients about postoperative pain at follow up, only 27% of attending surgeons and 7% of residents reportedly inquired about leftover pills, and only 14% of residents educated patients on safe disposal of leftover pills. None of the surveyed attending surgeons discussed safe disposal options for excess opioid medications with patients.
Discussion
Although provided with a prescription for opioids, 19.9% of patients surveyed did not fill their narcotic prescription. Of those who filled their prescription, a majority of patients used ≤5 pills after discharge, despite the complexity of the operation. While most surveyed patients used opioids postoperatively, of those who did not receive or fill a prescription, a majority were older and lived closer to the hospital. No statistically significant increase in opioid needs were noted in chronic pain patients to treat acute postoperative pain, which suggests that patients on a long-term opioid regimen for chronic pain do not require additional opioids to manage surgical pain. Similarly, gender did not significantly affect postoperative opioid usage. However, there was a tendency toward increased opioid usage in patients who were apprehensive about post-operative pain.
In a retrospective study by Brummett et al,7 approximately 6% of opioid naïve patients continued to use opioids 90 days after surgery. The rate of persistent use of opioids was similar between those who underwent minor and major operations; however, among other comorbidities, history of substance abuse (tobacco and alcohol) and mental health disorders (anxiety and depression) were found to be independent risk factors for long-term opioid use.7 These results highlight the importance of providing pre-operative patient counseling to manage patient expectations and indicate patients who may be at risk for long-term opioid use. Since 85.1% of our surveyed population had leftover narcotic pills, and there is no significant difference in opioid analgesic needs among patients with a history of chronic pain, providers in the General Surgery subspecialty and Acute Care Surgery departments can decrease the amount of post-operative opioids prescribed while still adequately managing pain. Because <10% of patients returned leftover pills via safe drop off bins, we recommend providers educate patients on safe disposal practices for unused opioid medications. The importance of patient education was highlighted in a prospective study by Rose et al,8 who reported improvements in proper disposal of prescription opioids from 5% to 27% when patients received an educational pamphlet on safe medication disposal practices.
Though patients were commonly prescribed 11-40 pills after a General Surgery operation at our institution at study onset, upon reviewing our institution performance report provided by the Surgical Collaborative of Wisconsin in 2018, we noted that our health care system providers prescribed a median of 20 oxycodone pills after a laparoscopic cholecystectomy compared to a median of 30 pills prescribed by providers in all Wisconsin hospitals. This prescription practice was more than double the procedure-specific prescribing recommendations developed by Michigan Opioid Prescribing Engagement Network (OPEN) of 0-10 pills.5 After presenting the results of our interim analysis, there was an overall decrease in the amount of opioids prescribed; however, opioid prescriptions continued to be higher than patient needs. Both physician and patient factors that could potentially influence prescription size were evaluated with particular consideration of our rural population. Inability to call in narcotic prescriptions and patients’ distance from care influenced prescription practices in the surveyed providers and corresponded to a higher number of pills prescribed for post-operative pain management, though the results were not statistically significant.
Though not evaluated in this study, two additional factors that warrant additional study is the impact of the Comprehensive Addiction and Recovery Act and implementation of evaluating the Electronic Prescription for Controlled Substances (EPCS) in Wisconsin on prescribing practices of rural general surgeons. In response to the opioid crisis, the Comprehensive Addiction and Recovery Act was passed in 2016 with the intention to decrease the amount of leftover pills available for potential diversion. This act allows pharmacies to supply partial fills of schedule II medications up to 30 days from the date of prescription upon request by either the prescriber or patient. Furthermore, a provider may also provide partial fills with a verbal prescription to the pharmacist in an emergency situation.6 Creating a multicenter database to assess patients’ analgesic needs after different operations, implementing improved procedures for narcotic prescription call in, and increased patient education regarding the proper handling and disposal of leftover pills may help guide prescribing recommendations and narcotic recovery across different populations in the rural General Surgery setting.
Though we report some novel associations between patient analgesic needs, surgical complexity, and history of chronic pain, this study has some noteworthy limitations. Firstly, the study was a single-institution study, which limits its generalizability to patients outside of our institution. Secondly, due to classification and grouping of some of the operations, for example, subcategorizing ‘other abdominal’ surgeries, may artificially increase or decrease the amount of opioids prescribed by surgery type. Reclassification may be necessary to enhance the reproducibility and applicability of these results to other health care systems. Furthermore, opioid prescription and usage was evaluated from the patient’s perspective upon the time of discharge, either from same day surgery or after inpatient recovery, which does not adequately capture opioid use in the inpatient setting. Lastly, patient surveys were subject to recall, voluntary, and information bias. This was especially evident when looking at elective versus urgent/emergent operations (example, patients reporting their scheduled oncologic surgery as urgent/emergent). This misclassification bias could be mitigated in future studies by allocating a specific non-personal health information code to a specific patient to permit accurate abstraction of objective data from the electronic medical record.
Conclusion
Regardless of operation complexity, a majority of patients required ≤5 opioid pills for postoperative pain control and would be willing to return leftover pills. This information has changed prescription habits at our institution and spurred additional quality improvement initiatives for opioid use. Tailoring prescription practices to match patients’ postoperative pain control needs as well as educating patients about safe disposal of leftover pills can reduce the excess opioids circulating in the community and potentially reduce the incidence of adverse post-operative events related to opioid use. Additional options to improve opioid use in rural General Surgery departments may include permitting providers to approve partial filling of prescriptions and implementation of a two-factor authentication EPCS to track prescribing practices and limit opioid prescription size while still offering providers the flexibility to address the analgesic needs of patients in rural/remote regions.
Acknowledgements
The authors gratefully acknowledge Emily A. Andreae, PhD, for manuscript editing assistance and the medical assistants in the departments of General Surgery and Acute Care Surgery at Marshfield Medical Center for their assistance in disseminating the surveys.
Footnotes
Disclosure: This work was presented at the 2018 Wisconsin Surgical Society Annual Conference in Kohler, WI; the 2019 Marshfield Clinic Health System Resident Medical Education Day; and at the October 2019 American College of Surgeons Conference in San Francisco, CA. The authors have indicated they have no potential conflicts of interest or financial relationships relevant to this article to disclose.
- Received October 7, 2020.
- Accepted December 29, 2021.
References
- 1.↵Lipari RN, Van Horn SL, Hughes A, Williams M. State and substate estimates of nonmedical use of prescription pain relievers from the 2012–2014 National Surveys on Drug Use and Health. The CBHSQ Report: July 13, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD. Available at: www.samhsa.gov/data/sites/default/files/report_3187/ShortReport-3187.html. Accessed March 26, 2020.
- 2.↵Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374:154-163.
- 3.↵Keyes KM, Cerdá M, Brady JE, Haven JR, Galea S. Understanding the rural–urban differences in nonmedical prescription opioid use and abuse in the United States. Am J Public Health. 2013;104:e52-e59.
- 4.↵Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD; Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration: 2017. Available at: www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm. Accessed March 26, 2020.
- 5.↵Michigan OPEN (Opioid Prescribing Engagement Network). Prescribing Recommendations. Michigan Department of Health and Human Services, Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships, and the Institute for Healthcare Policy and Innovation (IHPI) at the University of Michigan. Available at: michigan-open.org/prescribing-recommendations. Accessed March 26, 2020.
- 6.↵Arnold J. Dispensing Controlled Substances for Narcotic Drug Treatment. Diversion Control Division. Dallas, TX; National Conference-Drug Enforcement Administration: 2017. Available at: www.deadiversion.usdoj.gov/. Accessed March 26, 2020.
- 7.↵Brummett CM, Waljee JF, Goesling J, Moser S, New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152:e170504.
- 8.↵Rose P, Sakai J, Argue R, Froehlich K, Tang R. Opioid information pamphlet increases postoperative opioid disposal rates: a before versus after quality improvement study. Can J Anaesth. 2016;63:31-37.
- 9.↵Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD.
- 10.↵Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD; National Center for Health Statistics: 2011.
- 11.Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999--2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
- 12.Ciccarone D. The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019;71:183-188.
- 13.Paulozzi LJ, Xi Y. Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiol Drug Saf. 2008;17:997-1005.
- 14.Jones EB. Medication-Assisted Opioid Treatment Prescribers in Federally Qualified Health Centers: Capacity Lags in Rural Areas. J Rural Health. 2018;34:14-22.
