“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” says senior author Elizabeth Habermann, Ph.D., scientific director of surgical outcomes research in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”
Since 2000, the number of Americans receiving an opioid prescription and the number of deaths involving prescription opioid overdoses have roughly quadrupled, according to the Centers for Disease Control and Prevention. More than 90 people per day died from a prescription opioid or heroin overdose in 2015.
“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” says co-author Robert Cima, M.D., a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”
In contrast to antibiotics, the Mayo researchers say, there really aren’t evidence-based guidelines for prescribing opioids after surgery.
“That’s the fundamental issue,” Dr. Cima says. “And because pain is very subjective, it makes it challenging.”
The study looked at 7,181 opioid prescriptions following 25 common surgeries from January 2013 to December 2015 at Mayo Clinic campuses in Arizona, Florida and Rochester. In particular, the researchers examined patients who weren’t taking opioids in the 90 days before surgery. Within that group of 5,756 patients, they found the median opioid prescription was equivalent to 50 pills of five-milligram oxycodone. That’s almost twice the amount draft Minnesota state guidelines recommend for a maximum, which is roughly a seven-day supply or about 27 pills of five-milligram oxycodone.
Also, within that group, the prescription varied among the three campuses after adjusting for other factors. The Rochester campus median equaled 40 pills of oxycodone; whereas, the Arizona and Florida campus’ median equaled 50 and 60 pills, respectively.
Because different surgeries require different degrees of pain management, the researchers also compared the opioid prescribing ranges within each of the 25 surgeries. They found a wide variation ─ even after controlling for individual patient factors.
While the researchers say the results show there is room for improvement ─ as is likely the case in most practices that prescribe opioids nationwide ─ the draft Minnesota guidelines aren’t appropriate for all cases. “For some of the procedures, the guideline is probably appropriate and we have an opportunity to reduce the amount prescribed,” says Dr. Habermann. “For some of the more painful procedures, in orthopedics, for example, the draft guideline is likely too low.”
The Mayo Clinic Department of Orthopedic Surgery already has used these data to improve its opioid prescribing practices, developing a tiered approach based on surgical procedure. Other departments plan to follow suit.
For their part in reducing opioid prescriptions, patients must adjust expectations on appropriate levels of pain after surgery, the researchers say.
“We actively support patients, but they also need to be educated that some discomfort is part of the process,” says Dr. Cima. “We want patients to be comfortable enough to function, but taking away all the pain isn’t an appropriate part of recovery.”
The research was funded by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, which analyzes data with the goal of making broad-based quality and efficiency improvements in patient care.
“This work is exactly the purpose of our center,” says Dr. Cima. “We ask questions about our practice, see how we can do better, implement change, and study that change.”
The lead author is Cornelius Thiels, D.O., a general surgery resident in the Mayo Clinic School of Graduate Medical Education.
The other authors ─ all from Mayo Clinic ─ are: