Science in the News
An In-Press Study Describes an Educational Intervention Undertaken in a Cohort of General Surgeons at Dartmouth-Hitchcock Medical Center to Decrease Prescribing of Postoperative Opioid Medications
March 09, 2017
An in-press study1
to be published in the April 2017 issue of Annals of Surgery
describes an educational intervention undertaken in a cohort of general surgeons at Dartmouth-Hitchcock Medical Center to decrease prescribing of postoperative opioid medications. As highlighted in the Washington Post
Dr. Richard J. Barth, chief of general surgery at the medical center, led a research team to first evaluate how many prescription opiates were prescribed at the center for 5 specific outpatient surgeries in 2015 (i.e., 2 types of partial breast surgeries, laparoscopic gallbladder surgery, or open or laparoscopic hernia repair) and how many of the drugs were actually being used by patients. This retrospective survey3
(also to be published in the April issue of Annals of Surgery
) evaluated 642 patient cases; postoperative opioid prescriptions and refill data were tabulated and a phone survey was conducted to determine the number of opioid pills taken by patients. The investigators found wide variation in the number of opiates prescribed to patients undergoing the same operation, for example, the median number of opiates prescribed for patients undergoing laparoscopic gallbladder surgery was 30 (range: 0 to 100). Overall, only 28% of the prescribed pills were taken, but this percentage also varied across procedure type. Fewer than 2% of patients obtained medication refills. Using these data as a basis, the investigators estimated the “ideal number” of pills that would supply the opioid needs of 80% of patients undergoing each operation: partial mastectomy, 5 pills; partial mastectomy with lymph-node biopsy, 10 pills; laparoscopic gallbladder surgery, 15 pills; and 15 pills for both open and laparoscopic hernia surgeries. This would represent a 57% reduction in the total number of opioids prescribed following these surgeries.
The investigators then presented these data and their suggested prescribing guidelines to their institution in April and May 2016 to surgical residents, associate providers, and attending physicians at a Surgery Grand Rounds presentation, 2 General Surgery section meetings, a resident forum and by email.1
This educational component also recommended that prescribers encourage patients to use nonopioid analgesics (i.e., acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDS]) first, and only take opioids for persistent pain. In October 2016, the investigators undertook a similar retrospective case look at the 246 procedures done between June and September 2016 (following education) to determine how many opioids were prescribed, how many were taken, and how many patients required a medication refill. The mean number of opioid pills prescribed for each operation markedly decreased following the educational intervention: partial mastectomy, 19.8 versus 5.1 pills; partial mastectomy with lymph-node biopsy, 23.7 versus 9.6 pills; laparoscopic gallbladder surgery, 35.2 versus 19.4 pills; laparoscopic hernia repair, 33.8 versus 19.3 pills; and open hernia repair, 33.2 versus 18.3 pills (all comparisons p<0.0003). The total number of pills initially prescribed following surgery decreased by 53%; only 1 patient (0.4%) required a refill opioid prescription. Eighty-five percent of patients used either an NSAID and/or acetaminophen for pain management.
The investigators concluded, “By defining postoperative opioid requirements through patient surveys and disseminating operation-specific guidelines for opioid prescribing to surgeons, we were able to decrease the number of opioids initially prescribed by more than half,” and “Decreased initial opioid prescriptions did not result in increased opioid refill prescriptions.”
- Hill MV, Stucke RS, McMahon ML, Beeman JL, Barth RJ, Jr. An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations. Ann Surg 2017.
- Bernstein L. Surgeons were told to stop prescribing so many painkillers. The results were remarkable.: Washington Post. March 7, 2017. Accessed March 8, 2017.
- 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(4):709-14.
Prepared by: Center for Scientific Information, ADA Science Institute
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