How long should people take opioids for pain after surgery?

By Marilynn Larkin

NEW YORK (Reuters Health) – Optimal opioid prescriptions are four to nine days after general surgery, four to 13 days for women’s health procedures and six to 15 days for musculoskeletal procedures, researchers suggest.

“The overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic,” note Dr. Louis Nguyen of Brigham and Women’s Hospital, in Boston, and colleagues in the JAMA Surgery report, online September 27. “However, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery.”

To investigate, Dr. Nguyen and colleagues used data from the Military Health System Data Repository and identified 215,140 adults (mean age, 40; half women; 60% white) who had undergone one of eight common surgical procedures between 2005 and 2014: cholecystectomy, appendectomy, inguinal hernia repair, anterior cruciate ligament (ACL) reconstruction, rotator cuff repair, discectomy, mastectomy or hysterectomy. All had filled at least one opioid pain medication prescription in the two weeks after the procedure.

More than 122,000 people had undergone general surgery procedures, about 48,000 had undergone musculoskeletal procedures and more than 44,000 had undergone a women’s health (mastectomy or hysterectomy) procedure.

Using a mathematical model, the team determined that the median length of a prescription was four days for hysterectomy, appendectomy and cholecystectomy; five days for inguinal hernia repair, mastectomy, ACL repair and rotator cuff repair; and seven days for discectomy.

Overall, 19% of the study population received at least one refill prescription. The initial prescription duration associated with the lowest modeled refill risk was nine days for general surgery procedures (10.7% probability of refill), 13 days for women’s health procedures (16.8% probability) and 15 days for musculoskeletal procedures (32.5% probability).

“This information is meant as a general guideline to optimize patient comfort after surgery while minimizing opiate prescriptions,” Dr. Nguyen told Reuters Health by email. “However, specific patients may need more or less opiate medications, depending on their prior home medications, chronic pain issues, and the complexity of the surgery or recovery.”

“Thus, we also support methods of assessing opiate need and ways to reduce opiate usage that is tailored to the individual,” he said. “We plan additional studies to further elucidate the patients and clinical conditions that can tolerate lower opiate prescriptions.”

“Likewise, we would like to identify patients at (greatest) risk for high opiate need after surgery, so that adjunct steps can be taken to reduce that need,” he concluded.

Dr. Houman Danesh, director of Integrative Pain Management at Mount Sinai in New York City, said in an email to Reuters Health, “These findings are consistent with what should be expected for opiate use after surgery. However, these suggestions have not been fully adopted.”

“It is important to realize that these recommendations are for most people,” said Dr. Danesh, who was not involved in the study. “While there may be some outliers, they should not be too far off the recommended use. For example if 100 people have surgery, 80 will be OK with the 7-day supply, 10-15 may need another 7 days, and 5-10 may need longer.”

“Most importantly,” he concluded, “this study adds to the evidence that patients should not be on these medications for months and months.”

Dr. Selwyn Rogers, of the University of Chicago Medicine, said in a related editorial that surgeons can help reduce prescriptions by setting realistic expectations for patients. “If a surgeon allows a patient to expect a pain-free recovery, he or she will see refill requests increase.”

SOURCES: https://bit.ly/2xKZazk and https://bit.ly/2yLjmQa

JAMA Surg 2017.