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Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures

Educational Objective To determine the pattern of opioid prescription after common surgical procedures based on the rate of refills.
1 Credit CME
Key Points

Question  What are the optimal ranges of initial durations of opioid prescriptions in a cohort of opioid-naive patients who have undergone common surgical procedures?

Findings  In this cohort study of 215 140 individuals, the median observed prescription lengths were 4 days for general surgery procedures, 4 days for women’s health procedures, and 6 days for musculoskeletal procedures. The prescription lengths associated with lowest requirement for refill were 9 days for general surgery, 13 days for women’s health, and 15 days for musculoskeletal procedures.

Meaning  The ideal initial prescription duration likely falls between the observed median and the modeled nadir in refill rate.

Abstract

Importance  The overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic; however, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery.

Objectives  To describe patterns of opioid pain medication prescriptions after common surgical procedures and determine the appropriateness of the prescription as indicated by the rate of refills.

Design, Setting, and Participants  The Department of Defense Military Health System Data Repository was used to identify opioid-naive individuals 18 to 64 years of age who had undergone 1 of 8 common surgical procedures between January 1, 2005, and September 30, 2014. The adjusted risk of refilling an opioid prescription based on the number of days of initial prescription was modeled using a generalized additive model with spline smoothing.

Exposures  Length of initial prescription for opioid pain medication.

Main Outcomes and Measures  Need for an additional subsequent prescription for opioid pain medication, or a refill.

Results  Of the 215 140 individuals (107 588 women and 107 552 men; mean [SD] age, 40.1 [12.8] years) who underwent a procedure within the study time frame and received and filled at least 1 prescription for opioid pain medication within 14 days of their index procedure, 41 107 (19.1%) received at least 1 refill prescription. The median prescription lengths were 4 days (interquartile range [IQR], 3-5 days) for appendectomy and cholecystectomy, 5 days (IQR, 3-6 days) for inguinal hernia repair, 4 days (IQR, 3-5 days) for hysterectomy, 5 days (IQR, 3-6 days) for mastectomy, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy. The early nadir in the probability of refill was at an initial prescription of 9 days for general surgery procedures (probability of refill, 10.7%), 13 days for women’s health procedures (probability of refill, 16.8%), and 15 days for musculoskeletal procedures (probability of refill, 32.5%).

Conclusions and Relevance  Ideally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.

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Article Information

Corresponding Author: Louis L. Nguyen, MD, MBA, MPH, Center for Surgery and Public Health, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (llnguyen@bwh.harvard.edu).

Accepted for Publication: May 14, 2017.

Published Online: September 27, 2017. doi:10.1001/jamasurg.2017.3132

Author Contributions: Drs Scully and Nguyen had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Scully, Schoenfeld, Lipsitz, Chaudhary, Koehlmoos, Nguyen.

Acquisition, analysis, or interpretation of data: Scully, Schoenfeld, Jiang, Lipsitz, Learn, Koehlmoos, Haider, Nguyen.

Drafting of the manuscript: Scully, Schoenfeld, Lipsitz, Nguyen.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Scully, Schoenfeld, Jiang, Lipsitz, Chaudhary, Haider.

Obtained funding: Learn, Koehlmoos, Nguyen.

Administrative, technical, or material support: Scully, Schoenfeld, Koehlmoos, Haider.

Study supervision: Schoenfeld, Haider, Nguyen.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was funded by grant HU0001-11-1-0023 (The Comparative Effectiveness and Provider Induced Demand Collaboration [EPIC]: A Clinical and Economic Analysis of Variation in Healthcare) from the Department of Defense/Henry M. Jackson Foundation.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Haider is Deputy Editor of JAMA Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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