How long is too long for opioids?


prescription pad doctor

With overprescription rife, what is the optimal length for opioid scripts post surgery, and how can pharmacists help?

According to recent US data, the majority of patients undergoing common elective surgical procedures are overprescribed opioids, while significant prescribing variation exists among doctors.

For example, a 2017 paper in the Annals of Surgery found that of nearly 8000 patients, 94% received opioid prescriptions at discharge, with a refill rate among opioid-naïve patients of 16%.

There is a dearth of evidence-based prescribing practices for post-surgical patients, the authors conclude.

In response to the lack of guidelines, researchers from the Brigham and Women’s School Hospital and Harvard Medical School, among others, have set out to identify the safest and most effective length for opioid prescriptions.

“The overprescription of pain medications has been implicated as the driver of the burgeoning opioid epidemic,” write the authors in JAMA Surgery.

“However few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery.”

They studied more than 200,000 adults who underwent a procedure within a 13-year timeframe and received/filled at least one prescription for opioid pain medication.

About 19% of these received at least one refill prescription.

Researchers found the optimal length of opioid prescription depended on the surgery:

  • Four to nine days for general surgery procedures;
  • Four to 13 days for women’s health procedures; and
  • Six to 15 days for musculoskeletal procedures.

“Ideally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment,” say the authors.

Treatment should be minimised due to the potential for medical complications including dependency, they add.

“Further work is needed to better identify the 10%-30% of patients who will require more intensive pain management, to better tailor postoperative pain regiments to these individuals.”

Meanwhile, Australian data shows pharmacist involvement in prescribing within surgical inpatient wards leads to reduced supply of oxycodone on discharge.

Prior to intervention, which involved doctor prescribing followed by pharmacist review, 75.6% of patients were prescribed oxycodone while 60.3% were supplied with the drug following review by a ward pharmacist.

The median amount prescribed and supplied was 100mg/patient.

However after intervention, in which prescriptions were prepared by a pharmacist in consultation with hospital doctors – again followed by ward pharmacist review – 68.6% of patients were prescribed oxycodone, and 57.8% were supplied.

The median amount prescribed and supplied was halved to 50mg/patient.

While ward pharmacist review of doctor-prepared prescriptions reduced the proportion of patients who were supplied oxycodone, pharmacist involvement in the prescribing process also led to a significant reduction in the amount of oxycodone being supplied.

The study, led by the Pharmacy Department of Austin Health in Victoria, shows the pharmacist assistance in preparing discharge prescriptions can help in the fight against opioid dependency due to overprescription.

References

Cornelius et al. 2017, ‘Wide variation and overprescription of opioids after elective surgery, Annals of Surgery, doi: 10.1097/SLA.0000000000002365

Scully, R et al. 2017, ‘Defining optimal length of opioid pain medication prescription after common surgical procedures’, JAMA Surgery, doi: 10.1001/jamasurg.2017.3132

Tran, et al. 2017, ‘Impact of pharmacists assisting with prescribing and undertaking medication review on oxycodone prescribing and supply for patients discharged from surgical wards’, Journal of Clinical Pharmacy and Therapeutics, doi: 10.1111/jcpt.12540

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