Surgeons could prescribe fewer opioid tablets than they currently are after inguinal hernia repair, a study found.
In a prospective, observational study, more than half the patients who underwent an elective inguinal herniorrhaphy under local anesthesia with intravenous sedation used no opioids at all, and most used fewer than the prescribed tablets, Konstantinos Mylonas, MD, from the Department of Surgery at Massachusetts General Hospital, Boston, and colleagues report in an article published online August 1 in Surgery.
“The implication of our study is that, even though surgeons have been careful to limit the number of opioid tablets that we prescribe following operations, we may still be prescribing more medication than is actually needed by our patients,” senior author Peter Masiakos, MD, from the Department of Pediatric Surgery, MassGeneral Hospital for Children, said in a news release. “While these results need to be replicated in other practices and institutions, we have initiated a change in our prescribing practices in light of these findings.”
The researchers evaluated patient experience with their own opioid prescribing practices after hernia repair. They included 185 adult patients of a single surgeon who were undergoing elective repair for primary or recurrent inguinal hernia between October 1, 2015, and September 30, 2016. Most of the patients were men, and most of the hernias were primary and unilateral, the authors report. More than half the patients were aged 60 years or older.
All patients received a prescription for 10 hydrocodone 5 mg/acetaminophen 325 mg tablets but were counseled to use them only if nonopioid analgesics could not control their pain. At their 2- to 3-week postoperative visit, participating patients completed a hernia surgery-specific Patient Reported Outcomes Measurement Information System survey about their pain experience and analgesic use.
Of the 185 patients, 159 (85.9%) used four or fewer opioid tablets, and 110 (59.5%) reported they used none of the opioid. Thirteen patients (7%) reported needing nine or more of the opioid tablets for pain relief, but none of the patients took the opioid drug within a week of their postoperative visit, the authors report.
Although five patients continued to have persistent groin pain, defined as a visual analog score of 4 or higher, at the time of their postoperative visit, none of those patients reported using opioids to treat their discomfort, the authors write.
The researchers also looked at when patients returned to activities of daily living (ADL) and work, and the degree to which their pain or opioid use influenced this. By the time of their postoperative appointment, 123 patients (66.5%) reported that pain did not interfere with their ADL, 42 (22.7%) reported only slightly restricted activities, and 5 (2.7%) reported pain affected their ADL substantially. “[H]owever, no patient was unable to engage in their daily activities, and none was using opioids at this time point,” the authors write.
Employment status did exert some influence on opioid use, in that patients who were employed at the time of their operation were more likely to take opioid postoperative analgesics (P = .049), the authors write.
Compared with patients who took opioid analgesics, patients who did not take any had less maximum pain (P < .001) and persistent groin pain (P = .037) by the time of their postoperative visit, the authors state. Further, those who did not use opioids reported less interference with ADL (P = .012) and fun activities.
Patients’ self-reports of postoperative pain showed no difference in average pain levels between patients who did and did not use opioids. However, in linear regression analysis, both unadjusted and adjusted for patient sex and recurrent hernias, patients with greater maximum pain levels took more opioids.
Of note, by only prescribing 10 opioid tablets, the researchers’ intention was to limit opioid prescribing. “We found that prescribing 4 opioid tablets would be enough to fulfill the postoperative analgesia requirements of ≈86% of our patients,” they write, noting that with the 10-tablet limit, “we still provided our patients with 150% more opioid tablets than the majority of patients actually needed.”
This finding is consistent with existing research. “Several studies in a variety of other surgical disciplines also have indicated that well-intentioned surgeons may be overprescribing opioid analgesics,” the authors write.
Decreasing the number of opioid analgesics prescribed after inguinal hernia repair could have far-reaching implications, the researchers explain. Approximately 750,000 inguinal hernia repairs are conducted each year in the United States. Lowering the number of opioid tablets prescribed from 30 to four would reduce the number of opioid tablets dispensed each year from 22.5 million to 3 million, and make approximately 20 million fewer tablets “available for potential diversion and abuse or as a stimulus for the start of opioid dependency,” each year, the researchers explain.
To address the opioid public health crisis and reduce the availability of unused opioids, as recently reported by Medscape Medical News, it is imperative for researchers and clinicians to understand the actual analgesia needs of patients who undergo common operative procedures, the authors stress.
“Recent attempts to modify the opioid prescribing habits of surgeons by recommending an ideal number of 15 tablets for inguinal hernia repairs are well meaning but also might cause clinicians to overprescribe opioids by ≈300%,” they continue. The 15-tablet recommendation is derived from studies with low patient response rates. “We think that utilizing accurate patient data to define postoperative analgesic needs is important as we attempt to improve our practices,” the authors write.
“The results of our study have allowed us to modify our opioid-prescribing practice by administering even fewer tablets,” the authors state, noting that the findings also suggest that such a change would not leave patients vulnerable to a greater amount of postoperative pain.
“[W]e encourage others to validate these findings for elective hernia operation in their own practice and to similarly evaluate patient opioid use for other operative procedures as well,” the authors conclude. “Such an approach could further decrease the number of patients who become long-term opioid users and limit the amount of excess opioid tablets available for diversion and abuse by others.”
The authors have disclosed no relevant financial relationships.
Surgery. Published online August 1, 2017. Abstract
For more news, join us on Facebook and Twitter
Tidak ada komentar:
Posting Komentar