Study Advocates Guidelines for Postoperative Pain

By Pat Anson, Editor

Patients recovering from gallbladder surgery need only about a third of the opioid painkillers that are prescribed to them, according to a small new study that could lay the groundwork for new national guidelines on treating postoperative pain.

Researchers at the University of Michigan looked at prescribing data on 170 people who had their gallbladders surgically removed in a laparoscopic cholecystectomy and found that the average patient received an opioid prescription for 250mg morphine equivalent units. That's about 50 pills.

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But when the researchers interviewed 100 of those patients, the amount of opioid medication they actually took after their surgeries averaged only 30mg, or about 6 pills. The remaining pills were often left sitting in their medicine cabinets for years.

"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," says lead author Ryan Howard, MD, a resident in the U-M Department of Surgery who began the study while attending the medical school.

"We've been overprescribing because no one had ever really asked what's the right amount. We knew we could do better."

When U-M surgical leaders heard about the findings, they gave Howard and his colleagues permission to develop a new prescribing guideline that recommended just 15 opioid pills for gallbladder patients.

Five months later, the average prescription for the first 200 patients treated under the guideline dropped by 66 percent -- to 75mg morphine equivalent units. Requests for opioid refills didn't increase, as some had feared, but the percentage of patients getting a prescription for “safer” non-opioid painkillers such as acetaminophen or ibuprofen more than doubled.

Interviews with 86 of the patients who received the smaller prescriptions showed they had the same level of pain control as those treated before -- even though they took fewer opioid painkillers. A new education guide for patients counseled them to take pain medication only as long as they have pain, and to reserve the opioid pills for pain that's not controlled by ibuprofen or acetaminophen.

"Even though the guidelines were a radical departure from their current practice, attending surgeons and residents really embraced them," said U-M researcher Jay Lee, MD. "It was very rewarding to see how effective these guidelines were in reducing excess opioid prescribing."

Researchers estimate that implementing the new guideline has kept more than 13,000 excess opioid pills out of circulation in the year since the rollout began. Their findings were published in JAMA Surgery.

U-M researchers have expanded on their efforts by developing prescribing guidelines for 11 other common surgeries, including hysterectomies and hernia repair. They believe the guidelines could serve “as a template for statewide practice transformation” and could be adopted nationally as well.   

It’s a common misconception that many patients become addicted to opioid medication after surgery. According to a recent national survey, one in ten patients believe they became addicted or dependent on opioids after they started taking them for post-operative pain. But a recent study in Canada found that long term opioid use after surgery is rare, with less than one percent of older adults still taking opioid pain medication a year after major elective surgery.

Another fallacy is that leftover pain medication is often stolen, sold or given away. The DEA says less than one percent of legally prescribed opioids are diverted.

Many patients are dissatisfied with the quality of pain care in hospitals. In a survey of over 1,200 patients by Pain News Network and the International Pain Foundation, 60 percent said their pain was not adequately controlled in a hospital after a surgery or treatment. And over half rated the quality of their hospital pain care as either poor or very poor.