Tag: post-surgery

Categories : Pain ManagementTags :

Patients Are Now Getting Fewer Post-op Opioids, but Decline is Slowing

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Post-surgery pain relief has shifted away from opioid-containing medications over the past seven years, but the downward trend has slowed since 2020, a new University of Michigan study shows.

Overall, the rate of surgery-related opioid prescriptions dropped by 36% from 2016 to the end of 2022, and the average amount of opioids in those prescriptions dropped by 46%, the study of pharmacy data finds.

That combination of declines means that the total amount of opioids dispensed to surgical patients in late 2022 was 66% lower compared with early 2016, according to the findings published in JAMA Network Open.

But the rate of decline was much faster before the pandemic, the researchers report after comparing surgical opioid patterns before and after 2020.

That’s even after they took into account the unusual circumstances of spring 2020, when most elective surgery temporarily stopped to free up hospital capacity for COVID-19 patients and reduce unnecessary exposure to the SARS-CoV-2 virus.

Even with the overall declines, American surgery patients in late 2022 still received the equivalent of 44 5-milligram pills of hydrocodone from pharmacies after their operations on average.

That’s far higher than what patients need for most procedures.

“These data suggest surgical teams have substantially reduced opioid prescribing, but also suggest that efforts to right-size opioid prescriptions after surgery must continue,” said Kao-Ping Chua, M.D., Ph.D., the senior author of the new study and an assistant professor of pediatrics at U-M. He worked with first author and former U-M research assistant Jason Zhang, who is now in medical school at Northwestern University.

The researchers also find that some types of surgeons have reduced the amount of opioids dispensed to patients more than others.

For instance, reductions were particularly large in cardiothoracic surgery and ophthalmology.

Orthopedic surgeons still account for more than half of all surgical opioids dispensed to American patients, even as the rate and size of prescriptions filled by their patients dropped.

Right-sizing prescribing

The authors note that surgeons should not strive to eliminate opioid prescribing altogether.

“The goal should be to ensure that opioids are only prescribed when necessary, and that the amount of opioids prescribed matches the amount that patients need,” said Zhang.

“Achieving these goals could help reduce the risk of opioid misuse, persistent opioid use, and diversion of pills to other people besides the patient.”

The potential for accidental exposure to opioids by others in the household, and interactions between opioids and other substances including alcohol and prescription drugs, are other reasons to focus on non-opioid surgical pain care.

Chua and colleagues have studied procedure-related opioid prescribing multiple times, including a recent study showing that the reduction in the rate of dental opioid prescribing has similarly slowed in recent years.

Surgical organisations and the Centers for Disease Control and Prevention have advised surgeons to rely less on opioid-based acute pain relief for their patients since the mid-2010s.

But no studies have examined surgical opioid prescribing trends using pandemic-era data.

The new study is based on data from a company called IQVIA that tracks prescriptions dispensed at 92% of US pharmacies.

Source: Michigan Medicine – University of Michigan

Categories : Pain Management Surgeries & ProceduresTags :

No Increase in Post-surgical Pain Seen with Opioid Limits

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Concerns that surgery patients would have a more difficult recovery if their doctors had to abide by a five-day limit on opioid pain medication prescriptions did not play out as expected, finds a study published in JAMA Health Forum.

Instead, the University of Michigan-led researchers found that , after the largest insurer in that US state put the limit in place, patient-reported pain levels and satisfaction didn’t change at all for adults who had their appendix or gallbladder removed, a hernia repaired, a hysterectomy or other common operations.

At the same time, the amount of opioid pain medication patients covered by that insurer received dropped immediately after the limit went into effect. On average, patients having these operations received about three fewer opioid-containing pills.

The study, which merges two statewide databases on patients covered by Blue Cross Blue Shield of Michigan, is the first large study to evaluate whether opioid prescribing limits change patient experience after surgery.

Measuring the impact of limits from patients’ perspectives

The BCBSM limit of five days’ supply, which went into effect in early 2018, is even stricter than the seven-days’ supply limit put in place a few months later by the state of Michigan.

Other major insurers and states have also implemented limits, most of which allow are seven-day limits.

Limits are designed to reduce the risk of long-term opioid use and opioid use disorder, as well as to reduce the risk of accidental overdose and the risk of unauthorized use of leftover pills.

“Opioid prescribing limits are now everywhere, so understanding their effects is crucial,” said lead author Kao-Ping Chua, MD, PhD.

“We know these limits can reduce opioid prescribing, but it hasn’t been clear until now whether they can do so without worsening patient experience.”

He noted that even the 15% of patients who had been taking opioids for other reasons before having their operations showed neither an increase in pain nor a decrease in satisfaction after the limit was put in place, even though opioid prescribing for these patients decreased.

That decrease was actually contrary to the intent of the limit, which was only designed to reduce prescribing to patients who hadn’t taken opioids recently.

How the study was done

For the new study, Chua and colleagues used data from the Michigan Surgical Quality Collaborative, which collects data on patients having common operations at 70 Michigan hospitals. The MSQC surveys patients about their pain, level of satisfaction and level of regret after their operations.

The team paired anonymized MSQC data with data on controlled substance prescription fills from Michigan state’s prescription drug monitoring programme, called MAPS.

In all, they were able to look at opioid prescribing and patient experience data from 1,323 BCBSM patients who had common operations in the 13 months before the five-day limit went into effect, and 4,722 patients who had operations in the 20 months after the limit went into effect.

About 86% of both groups were non-Hispanic white, patients’ average age was just under 49,  and just under a quarter of both groups had their operations on an emergency or urgent basis. Just under half were admitted to the hospital for at least one night.

About 27% of both groups had their gallbladders taken out laparoscopically, and a similar percentage had minor hernia repairs.

About 10% had an appendectomy done laparoscopically, and a similar percentage had laparoscopic hysterectomies.

The rest had more invasive procedures, like open hysterectomies major hernia repairs, or colon removal. 

The percentage of prescribers who prescribed opioids to their patients having these operations did not change, but the percentage of patients who filled a prescription for an opioid did, possibly because pharmacists rejected prescriptions that weren’t compliant with the BCBSM limit, Chua speculates.

Jennifer Waljee, MD, MPH, MS, senior author of the study, notes that the MSQC database doesn’t include all types of procedures, such as knee replacements and spine surgery, which typically require larger postoperative opioid prescriptions because of their associated pain.

She indicated that it’s important to understand the impact of opioid prescribing limits on the experiences of such patients, because limits have the most potential to worsen pain for these individuals. 

“Opioid prescribing limits may not worsen patient experience for common, less-invasive procedures like those we studied, because opioid prescriptions for most of these procedures were already under the maximum allowed by limits.

“But this may not be the case for painful operations where opioid prescribing was suddenly cut from an 8- to 10-day supply to a 5-day supply,” said Waljee.

She added, “The message of this study is not that we can simply go to five days’ supply across the board for operations.

“We need to understand the effects of these limits across a broad range of procedures and patients given how much pain needs vary in order to right size prescribing to patient need without resulting in additional harms.”

Source: University of Michigan

Categories : Hospitals Injury & TraumaTags :

Amino Acid Supplementation after Fracture Surgery Reduces Complications

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Lower leg bones
Photo by Nino Liverani on Unsplash

By adding conditionally essential amino acids (CEAA) to the diets of patients recovering from fracture fixation surgery, complications are reduced and skeletal muscle wasting is prevented, concludes a study published in The Journal of Bone & Joint Surgery.

The study supports the use of widely available CEAA supplements to promote recovery and preserve function in patients undergoing surgery for repair of major fractures. “Our results suggest that this inexpensive, low-risk intervention has considerable potential to improve outcomes after fracture fixation,” according to the report by Michael Willey, MD, and colleagues of University of Iowa Hospital and Clinics, Iowa City.

The study included 400 patients undergoing operative fixation of fractures in the limbs and/or pelvis at the researchers’ trauma centre. In equal numbers and stratified by fracture severity, patients were randomises to either standard postoperative nutrition or standard nutrition plus CEAA supplementation.

CEAAs are termed “conditionally essential” because the body doesn’t usually require them. However, during times of illness or stress, the need for these conditional amino acids increases dramatically. Previous studies have reported that CEAA supplementation can improve wound-healing and other outcomes in patients with a variety of conditions, including postoperative recovery. In the new trial, patients assigned to the CEAA group received a standard supplement that included arginine, leucine, and glutamine.

At follow-up, the overall complication rate was significantly lower for patients who received CEAA supplementation (30.5%) compared with those who did not receive CEAA (43.8%). The CEAA group also had a lower rate of nonunion (5.1 vs 13.2%, respectively). Some other types of complications, including surgical-site infections, were similar between groups.

Patients who undergo operative fracture fixation are at risk of skeletal muscle wasting, which often results in weight loss as a result of reduced muscle mass. In the new study, patients receiving CEAA supplements had little or no change in fat-free body mass. In contrast, patients receiving standard nutrition had a 1kg reduction in fat-free mass at 6 weeks postoperatively, which took until 12 weeks to return to normal.

An unexpected finding was a sharply reduced mortality rate in the CEAA group (0.5% compared to 4.1 % for the control). Although the authors could not explain the lower risk of death in patients receiving CEAA, they suggest it might result from “unidentified confounding factors.”

Despite advances in surgical techniques, trauma patients undergoing operative fixation of extremity and pelvic fractures remain at risk of complications and prolonged loss of function. “Malnutrition is a potentially modifiable risk factor for mortality, fracture nonunion, wound complications, and increased length of stay,” the authors wrote.

CEAA supplementation therefore appears to be a simple, risk-free, and inexpensive means of promoting good nutrition after fracture fixation surgery. Controlling for other factors, the relative risk of complications is about 40% lower in patients receiving CEAA, with no reduction in fat-free mass during the early weeks of recovery. The researchers concluded: “This study will serve as the foundation for multicentre [randomised controlled trials] that are designed to assess the impact of CEAA nutrition supplementation in reducing complications and loss of functional muscle mass in high-risk populations.”

Source: EurekAlert!