Discharge Analgesia After Surgery; Responsive and Responsible Prescribing in the Era of an Opioid Crisis

The current worldwide opioid ‘crisis’ has been well described. Deaths from opioid misuse are now the number one cause of unintentional deaths in the US(1). Doctors have been central to the development of the problem through the overprescribing of opioid medications. Post-surgical discharge overprescribing has been identified as a contributor to the opioid ‘crisis’ and to persistent opioid use in individuals(1-3).

Internal hospital programs focused on opioid reduction and multimodal analgesia use for elective surgery such as ‘fast track’ and Enhanced Recovery After Surgery (ERAS) are now commonplace(4). They aim to improve post-operative recovery and reduce hospital length of stay through the protocolization of elective surgical pathways. Day case surgery has also gained in popularity and these initiatives see patients discharged into the community more quickly with acute pain that often requires opioid analgesia(5, 6). There is a tension between managing pain effectively and reducing the risk of opioid harm.

A recent systematic review by Wetzel and colleagues looking at postsurgical opioid prescribing interventions found evidence for organizational level changes and guidelines in reducing prescribed quantities(7). They also identified a study reducing opioid prescribing to children where patient follow up showed poorly controlled pain in 5.4% of patients(7).

Poorly treated acute pain is a risk factor for the development of persistent pain and ongoing opioid use(8). Guidelines to assist with discharge prescribing may support doctors in decision making to balance this tension by improving patient care and safety.

A literature review was undertaken to evaluate evidence on the impact of postsurgical discharge prescribing guidelines for opioid reduction and pain management. Specific focus was given to evaluating the relevance to the New Zealand context given differences in healthcare systems worldwide.

A formal search of the SCOPUS database using the key words ‘discharge analgesia’ and ‘guidelines’ returned 341 references. A further modified search including ‘New Zealand’ returned 27 references. A purposeful search was made of Australasian journals (NZ Medical Journal, Anaesthesia and Intensive Care and ANZ journal of Surgery) to find NZ specific studies since 2009 including the above terms and any reference to ‘opioid’. Abstracts were reviewed to determine relevance. Editorial and commentary pieces were included to evaluate current perspectives on the topic. In addition, articles were retrieved based on citations in articles reviewed and other relevant references as encountered during reading.

Perioperative exposure to opioids is a risk factor for persistent opioid use with up to 6% of opioid naive surgical patients continuing opioid use beyond 90 days after surgery(9). A retrospective cohort study of over half a million opioid naïve patients showed that just one repeat opioid prescription after surgery increases the risk of persistent opioid use by 40%(8). Each additional week of postoperative opioid use increased the risk of persistent opioid use, and discharge with a large opioid supply also increased the duration of opioid use in patients(8). This finding is supported by a phone survey of women post cesarean section by Bateman and colleagues who found women prescribed more opioids at discharge from hospital used more opioids, independent of their pain scores. They discuss that prescribing large quantities may ‘set expectations’ for pain and analgesic use(10). Giving more opioids after surgery does not appear to mean we are giving better care or even managing pain well. Prescribing more does however leave many patients with an unused supply at home that is available for diversion, misuse and potential harm(8, 10, 11). 40-70% of prescribed opioids in the US go unused after surgery according to one review(1). The problem of opioid overprescribing after surgery is now significant and well established.

Clinical stewardship by both anaesthetists and surgeons in providing solutions for opioid overprescribing was a strong theme identified in the literature(1-3). This acknowledges wider ownership of the problem by these specialists as the initiating opioid prescribers of the perioperative period. The most frequently identified prescribers in the literature however were junior doctors in training(11-13). A lack of education and guidance in pain management and opioid use was frequently mentioned as a factor in overprescribing by junior staff(21, 8, 11). Generational patterns of prescribing quantities based on habit and routines rather than evidence were recognized as widespread among surgeons in particular. Characterized by ‘the way I do it’ or ‘what I have always done’(13). In qualitative interviews with surgical residents, Lee and colleagues showed social influences and beliefs strongly influenced their prescribing behaviours(12). Prescribing large quantities of opioids to keep patients from phoning or returning for pain relief was reported. This was motivated in part by a concern for the patient but also not wanting to be bothered or seen by others to have got things wrong. Not wanting to be out of step with what their colleagues were doing was important to junior doctors. Behaviour change education and prescribing guidelines were developed from themes identified at these interviews. The initiatives were effective in reducing prescribed opioids without an increase in repeat prescriptions(14). A criticism of prescribing guidelines over time however was they ‘had no teeth’ as they were not enforceable and behavior change needed to be maintained through ongoing education(15).

The need for repeat opioid prescription often appears as a surrogate for pain measurement in the literature. The assumption that ongoing pain would require more medication, and therefore repeat prescriptions, is made in several studies reviewed evaluating surgery specific opioid requirements as a guide to discharge prescribing(14, 16, 17). Howard and colleagues additionally incorporated pain scores in their survey of patients following laparoscopic cholecystectomy to determine a procedure specific opioid guideline. On average patients were dispensed 50 opioid tablets at discharge but used only 6 tablets. Their guideline revised practice to a recommended 15 tablets with no reported increase in repeat prescriptions(17). Procedure specific guidance on discharge opioid prescribing holds appeal in its simplicity of a specified number of pills to match a surgery. A consensus prescribing guideline from a US multidisciplinary panel at Johns Hopkins University Hospital for 20 common procedures included patients, surgeons and allied health staff on the panel(13). The patients suggested lower numbers of discharge opioid tablets than the surgeons across all procedures. The authors emphasized the importance of including the patient experience when planning discharge prescribing guidelines.

Inclusion of the patient experience, especially through qualitative studies, does not feature prominently in the literature on discharge opioid prescribing.  Criticism of the ‘numbers of tablets for specific procedures’ approach is made in several commentaries as lacking individualization to the patient(21, 18). The nuancing of tapering opioids after discharge is not contained in a number but requires both patient and prescriber education(21, 19). Broader guidance incorporating patient risk assessment, pain scores, inpatient opioid use and patient preferences are advocated for by several authors(21, 19, 20). An example of this type of guideline from Australia is given by Stewart and colleagues. They recommend a range of opioid quantities for discharge based on patient pain scoring and opioid use in the preceding 24 hours. Their intervention also included education for prescribers to improve practice(15). While opioid prescribing reduced, the effectiveness of pain control and patient experience is absent from their data. The tension between opioid risk, pain management and individualization in planning guidelines is discussed but no solutions advanced.

Developing a prescribing guideline for pain management is more complex than a guideline to simply reduce prescribed opioid quantities. Enhanced Recovery After Surgery protocols for elective surgery are frequently focused on opioid minimization perioperatively to speed functional recovery(4). These protocols are effective at reducing length of hospital stay but typically don’t include discharge prescribing guidance. One study specifically reviewed discharge prescribing pre and post the introduction of an ERAS protocol for colorectal surgery and found an increase in opioid prescribing at discharge. Reduced length of stay in hospital was discussed as a key driver of this(5).  The lack of individualization of care within ERAS protocols around pain management has been identified as both a strength and weakness in separate studies.  Brandal and colleagues recognised the absence of a guideline for discharge prescribing led to high rates of opioid prescription without assessment of patient factors. 70% of patients with low pain scores and low opioid use prior to discharge were still discharged with opioids(6). The undoing of opioid sparing ERAS techniques at discharge by doctors ‘habits’ of prescribing seems like a gap in planning. This point is echoed and expanded in a review which identifies the benefits of ERAS as an opioid reducing care pathway(1). The lack of linkage of these protocols to discharge prescribing, and importantly post-discharge repeat prescribing is highlighted as an opportunity to develop guidance.

The current focus on reducing opioid prescriptions without increasing the quality of patient care is criticized in a commentary by Clarke and Ladha from the Toronto Transitional Pain Service(21). In contrast to much of the literature they disagree with the emphasis on individual prescribers and the emerging ‘blame culture’ around opioid prescribing. Rather than just guidelines they advocate for wider health system and policy changes. The gap between primary care and hospital is particularly highlighted as a deficiency in discharge care planning and opioid prescribing(21). Several other review articles advocate for attention to care planning and transition to primary care but specifics in this area are absent from the wider literature. Advice for patients to seek help with their general practitioner after discharge for pain management is often encouraged but guidance for general practitioners is typically not included within guidelines(15, 19, 22). The experience of both general practitioners and patients after discharge is also not well addressed in the literature.

The differences in healthcare systems worldwide accounts for some variation in the literature reviewed as the US in particular is overrepresented as the ‘home’ of the opioid ‘crisis’(7).  Hospital systems interventions such as reducing the default limits on electronic prescribing programs are described as potentially more effective than prescriber education in the US(22). In New Zealand opioid prescriptions must be handwritten on separate specific forms so this type of intervention is not applicable. Equally it may have helped reduce opioid prescribing at baseline in New Zealand due to the additional steps required to prescribe including accessing the forms from locked storage.

In evaluating the literature from a New Zealand perspective there were few specific references found and evidence for New Zealand opioid discharge prescribing guidelines was absent. A recent commentary in the New Zealand Medical Journal discusses similarities and differences between the US opioid ‘crisis’ and New Zealand. The lack of up to date data on opioid use in New Zealand is highlighted as a concern for health care planning(23). Pharmacy data for New Zealand however shows that opioid prescriptions are increasing and are most frequently initiated in hospital, consistent with the wider literature reviewed(24).

Current evidence shows discharge prescribing guidelines appear effective in reducing prescribed opioid amounts, but there is disagreement as to their efficacy in pain management and role in patient centered care. The patient experience is not at forefront in much of the literature and postsurgical prescribing limits may result in poorly controlled pain which is a risk for the development of persistent pain. Repeat prescribing after surgery has been identified as increasing the risk of persistent opioid use but there is little available evidence to guide the transition from hospital discharge to primary care pain management. Further research exploring the transition of patient care after surgery from hospital into primary care within the New Zealand health system could be used to inform opioid prescribing. Qualitative methodologies would enable better understanding of the experiences of both patients and general practitioners in developing guidelines that are patient and clinician focused.

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