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Recommendations for the Prescription of Opioids at Discharge After Abdominopelvic SurgeryA Systematic Review

Educational Objective To identify current evidence associated with the prescription of opioids at discharge after abdominopelvic surgery, disposal of unused opioids, and the prevention of long-term use after surgery.
1 Credit CME
Key Points

Question  What are current recommendations from clinical practice guidelines and other documents for the prescription of opioids at discharge, appropriate disposal, and prevention of long-term opioid use after abdominopelvic surgery?

Findings  Of 5530 citations screened, 41 full-text documents were included in the systematic review, and 15 clinical practice guidelines were identified. The quality of guidelines included was found to be highly variable; most recommended interventions were not supported by any assessment of evidence, and the amount of prescription opioid recommended varied widely between publications, even for the same procedure.

Meaning  Current guidance for the treatment of postdischarge pain with opioids after abdominopelvic surgery is limited.

Abstract

Importance  The prescription of opioids at discharge after abdominopelvic surgery is variable and often excessive. A lack of guidance for abdominopelvic surgeons may explain the suboptimal nature of current prescribing practices.

Objective  To systematically review existing recommendations on the prescription of opioids at discharge, the appropriate disposal of opioids, and the prevention of chronic postsurgical opioid use after abdominopelvic surgery.

Evidence Review  This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. From January 2010 to December 2018, a search of MEDLINE, PsycINFO, HealthSTAR, Embase, and the difficult to locate and unpublished (ie, gray) literature was performed using a peer-reviewed strategy with variations of the terms opioid, surgery, and guideline to identify English-language documents that contained recommendations published by professional societies or health care institutions. The quality of clinical practice guidelines was assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. A descriptive synthesis of results was performed.

Findings  Of 5530 citations screened, 41 full-text documents were included in the systematic review. Fifteen clinical practice guidelines were identified. AGREE II domain scores varied substantially. Identified among the 41 included documents were 98 recommended interventions for the prescription of opioids at discharge, 8 interventions for the disposal of opioids, and 8 interventions for the prevention of chronic postsurgical opioid use. Only 13 of 114 interventions (11.4%) were supported by an assessment of strength or level of evidence, and the amount of opioid recommended after specific abdominopelvic surgical procedures varied widely between guidance documents, even for the same procedure.

Conclusions and Relevance  Current guidance for the prescription of opioids at discharge after abdominopelvic surgery is heterogeneous and rarely supported by evidence. More research is needed on this topic to guide the development of future recommendations.

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Article Information

Accepted for Publication: November 9, 2019.

Corresponding Author: Nancy N. Baxter, MD, PhD, Department of Surgery, St Michael’s Hospital, 30 Bond St, Room 040-16 Cardinal Carter Wing, Toronto, ON M5B 1W8, Canada (baxtern@smh.ca).

Published Online: March 11, 2020. doi:10.1001/jamasurg.2019.5875

Author Contributions: Dr Zhang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zhang, Dossa, Ladha, Brar, Tricco, Wijeysundera, Clarke, Baxter.

Acquisition, analysis, or interpretation of data: Zhang, Dossa, Arora, Cusimano, Speller, Little, Urbach, Wijeysundera.

Drafting of the manuscript: Zhang.

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

Statistical analysis: Zhang.

Obtained funding: Ladha, Clarke, Baxter.

Administrative, technical, or material support: Zhang, Dossa, Arora, Cusimano, Speller, Little, Urbach.

Supervision: Tricco, Wijeysundera, Clarke, Baxter.

Conflict of Interest Disclosures: Dr Dossa reported receiving grants from the Canadian Institutes of Health Research (CIHR). No other disclosures were reported.

Funding/Support: This study was funded by a CIHR Operating Grant (OCK 156784). Drs Ladha and Clarke are supported in part by Merit Awards from the Department of Anesthesia at the University of Toronto. Dr Tricco is supported by a Tier 2 Canada Research Chair in Knowledge Synthesis. Dr Wijeysundera is supported in part by a New Investigator Award from the CIHR, an Excellence in Research Award from the Department of Anesthesia at the University of Toronto, and the Endowed Chair in Translational Anesthesiology Research at St Michael’s Hospital and University of Toronto.

Role of the Funder/Sponsor: The funding sources 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.

Additional Contributions: Teruko Kishibe, MISt (information specialist at the Scotiabank Health Sciences Library and Li Ka Shing Knowledge Institute, St Michael’s Hospital), designed the standard literature search strategy and conducted the search. Marina Englesakis, MLIS (information specialist at the University Health Network, Toronto), peer-reviewed the search strategy. Jessie McGowan, PhD (University of Ottawa), assisted in designing the gray literature search strategy, and Alissa Epworth (St Michael’s Hospital) conducted the search. They were not compensated for their contributions.

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