Interventions Needed for Postoperative Opioids Prescribing

There is an urgent need for the US healthcare system to adopt a coordinated, evidence-based framework to reduce the over-prescription of opioids post-surgery, say the authors of a new literature review.

After being prescribed opioids after surgery, some patients convert to chronic opioid use or experience adverse events. In addition, knowledge gaps regarding opioid prescribing in the context of surgery raise questions such as how many opioids to prescribe to patients and how to optimize pain management for patients after discharge from surgery, the authors write in the paper published in the American Journal of Health-System Pharmacy.

“The severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the US, writes Suzanne Nesbit, PharmD, one of the authors and a clinical specialist in pain management and palliative care at the Johns Hopkins Hospital  Department of Pharmacy.

Well-meaning clinicians wishing to reduce pain and accelerate a patient’s recovery after surgery have facilitated the oversupply of post-operative opioids, the researchers write.

Excessive post-surgical opioid use can be curbed through multiple approaches, including greater use of non-opioid analgesics such as combinations of nonsteroidal anti-inflammatory drugs (NSAIDs such as Advil and aspirin) and acetaminophen (Tylenol), and a wide variety of non-pharmacological techniques ranging from ice, heat, and exercise to various forms of behavioral therapy.

“Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient,” Nesbit and colleagues write.

The researchers reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts. 

They found that opioid prescribing and pain treatment after discharge from surgery broadly consists of three key interacting perspectives: the patient, the perioperative team, and the pharmacist. “The attitudes and beliefs of the perioperative team were found to greatly impact patient expectations and increase the adoption of non-opioid and non-pharmacological treatments,” ASHP writes about the article on its web site.

Pharmacists play a key role in optimizing pain management and opioid prescribing in several key ways, the authors write. “As the public health crisis evolves, patients and perioperative teams benefit greatly from the expertise and involvement of pharmacists,” the researchers write.

Pharmacists’ activities include promoting access to opioid safety initiatives such as naloxone to reverse overdose, checking state prescription drug monitoring programs to prevent overlapping opioid prescriptions, and using partial fills upon discharge to reduce days of post-operative treatment and prevent the dangerous diversion of opioids to other household members,” ASHP writes.

The literature review suggested the value of managing patient expectations about post-surgery pain, providing partial fills of opioid prescriptions upon discharge, educating patients about safe storage and disposal, and identifying patient history of opioid exposure as well as genetic influences on individual patient’s response to the drugs.

Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that "contributes to the most pressing public health crisis of our time,” the authors write.