A Third of Post-Surgical Opioids Effective for Gall Bladder Removal Patients
Literally determining that enough is enough, University of Michigan researchers used data from how laparoscopic cholecystectomy patients actually used opioid painkillers to come up with guidelines to reduce prescribing of the narcotics. Here is why they now recommend that patients can do as well with a third of the pills they formerly were prescribed.
ANN ARBOR, MI – Pharmacists often dispense about 50 opioid pills to patients who undergo laparoscopic cholecystectomy. A new study contends that is way too much and provides data to back up that argument.
In fact, the research letter in JAMA Surgery suggests that patients would have similar levels of post-surgical pain even if they were prescribed a third of the opioid painkillers.
As no national guidelines are available on opioid use post-surgery, a study team from the University of Michigan decided to develop one and test it, using a common procedure, gallbladder removal. First, they identified patients who underwent elective laparoscopic cholecystectomy from January 2015 through June 2016 and queried them within 12 months about the number of opioid pills they had used; their use of nonopioid analgesics, i.e. over-the-counter acetaminophen and ibuprofen, and their pain level during the first week after surgery.
All patients in the preintervention group received a prescription for opioids, an average of 250 mg. Those responding to the telephone survey reported a median (IQR) opioid use of 30 mg. More than half of those patients also reported using acetaminophen or ibuprofen along with opioids. Their median pain score was 5.0 on a scale of 0 to 10, researchers note.
That information was used to develop post–laparoscopic cholecystectomy guidelines that recommended prescribing 15 tablets of hydrocodone/acetaminophen, 5/325 mg -- oral morphine equivalent (OME), 75 mg -- or 15 tablets of oxycodone, 5 mg -- OME, 112.5 mg -- plus acetaminophen or ibuprofen, as needed.
The guidelines were introduced to surgical faculty, residents and staff through videos and oral presentations. Post-guidelines, when the median amount of opioid prescribed had been reduced from 250 mg to 75 mg, patients receiving laparoscopic cholecystectomy operations from November 2016 through March 2017 answered the same survey questions as the preintervention group.
Among the patients who had surgery after the guidelines went into effect, only 2.4% requested refills, and median (IQR) postoperative opioid use was significantly reduced from 30 mg to 20 mg but no change in pain score (median, 5.0; IQR, 3.1-6.5) was found.
At the same time, prescriptions for either acetaminophen or ibuprofen increased, with 49% of postintervention patients receiving them, compared to 21% of preintervention patients. The surveys didn't indicate much change in their usage, however.
"Evidence-based prescribing guidelines reduced prescription size by 63% without increasing the need for medication refills, thereby eliminating the excessive prescription of roughly 7000 pills," the researchers write. "Patients also reported using fewer opioids after guideline implementation. This might be explained in part by the anchoring and adjustment heuristic, where the initial prescription size serves as the mental reference point for assessments of change."
"For a long time, there has been no rhyme or reason to surgical opioid prescribing, compared with all the other efforts that have been made to improve surgical care," added first author Ryan Howard, MD, a resident in the U-M Department of Surgery who began the study while attending the U-M Medical School. "We've been overprescribing because no one had ever really asked what's the right amount. We knew we could do better."
Howard estimates that, because of the changes, more than 13,000 excess opioid pills were kept out of circulation in the year since the guidelines were rolled out.