Low-cost intervention could easily be used to right-size opioid prescribing after surgery

New studies show that minor adjustments to the hospital’s prescribing system can help surgical patients relieve postoperative pain while reducing the risk of remaining opioid analgesics.

In teens and young adults who removed tonsil at a major pediatric hospital, patients returned home with a 29% reduction in opioid analgesic doses, but researchers found the default opioid prescription size that doctors saw in the ordering system. After reducing, reported similar pain management. The remaining doses increase the risk of long-term opioid use and the potential for misuse.

On the other hand, prescription size remained high in a comparative group of young adults who simultaneously developed tonsils at a nearby surgical center that did not change the default prescription size. This study by the University of Michigan Medical Team, the University of Michigan Academic Medical Center, JAMA network open..

UM Health CS Mott Children’s Hospital’s new default prescription size – 12 doses – is based on a study of the number of opioid doses that young patients actually take for tonsillectomy pain. This replaced the previous default size of 30 doses, but doctors were always more or less free to prescribe.

After the default was changed in October 2020, the proportion of patients discharged after 12 doses increased from 1% to 44%, with an average prescription size of 22 to 16 doses, significant for pain management satisfaction scores. There was no change. The number of prescription replenishments within 2 weeks of surgery.

On the other hand, young adults who had tonsils at the same time at UM’s university hospitals or other UM Health surgical centers showed little change in their prescriptions. They received an average of about 30 opioids.

Our findings show that hospitals can reduce excess opioid prescriptions without compromising pain management by simply implementing default settings based on evidence of opioid prescriptions written on electronic medical records. Since almost all hospitals use electronic health record systems, this low-cost intervention can be easily used for properly sized opioid prescriptions after surgery across the country. “

Kao-Ping Chua, MD, Ph.D., Lead Author, UM Pediatrician, Susan B. Meister Child Health Assessment and Research (CHEAR) Center and Member of UM Healthcare Policy Innovation Institute

Possibility of use in other operations

Chua states that tonsillectomy is one of the most common reasons for opioid prescribing in adolescents and young adults.

He and his colleagues did not knowingly announce that the default settings were changed. He states that the fact that prescriptions have changed dramatically, despite the lack of awareness of change, is noteworthy.

“Our findings suggest that default settings have a powerful ability to influence how doctors prescribe opioids,” he said. “This can be used to improve quality, but it can also have unintended consequences if the defaults are not based on evidence of the patient’s opioid needs.”

He states that evidence-based acute pain prescribing guidelines published by UM-based opioid prescribing and involvement networks can be adopted as the default opioid prescribing sequence set. New studies may help inform new guidelines on the number of opioids prescribed after tonsillectomy in teens and young adults.

While it is important to give the prescriber the flexibility to customize the opioid prescription, the default prescription size for the sequence set will be appropriate for most patients.

This is especially important when teaching hospitals. This is because training doctors are often doctors entering discharge prescriptions and may not yet have extensive experience with postoperative pain management needs.

He states that the default is the lowest number of clicks, so it’s easy to choose the right prescription size. It is important in a busy surgical setting, as doctors are often busy with time.

Details about the study

The study enrolled 247 adolescents and young adults in the Pediatric and General Otorhinolaryngology Services of Michigan Medicine between October 2019 and July 2021. Of these patients, 131 were primarily pediatric otolaryngologists aged 12-21 years. The rest were mostly general otolaryngologists aged 18-25 years.

The 12-dose default reflected the number of opioid doses reported to be taken by about three-quarters of patients before the default was implemented. The American Academy of Otorhinolaryngology includes most doctors who perform tonsillectomy to treat sleep and breathing problems in children and young adults, and recommends non-opioid analgesics such as acetaminophen and ibuprofen over opioids. I am.

“Non-opioid analgesics should be the first choice for tonsillectomy pain, but it is difficult to know in advance which patients will receive adequate relief from these drugs and which will not. , Surgeons tend to prescribe opioids “just in case”. “Chua said. “If they choose to prescribe opioids, they can also prescribe an amount that reflects the amount the patient actually needs. Evidence-based default settings in the sequence set make this easy. I can do it.”

In addition to assessing pain management, the authors found that the new defaults do not affect a variety of other outcomes, such as emergency department visits for postoperative pain and exacerbation of anxiety. Chua states that hospitals wishing to implement the new default settings would ideally collect data on these results to assess unintended effects.

Chua states that a large study may have shown an increase in replenishment, but replenishment requests did not increase significantly. Still, he says many surgeons are willing to tolerate a somewhat higher replenishment rate if it means reducing the chances of remaining opioids.

In tonsillectomy, opioid prescriptions are often written for liquids that are easier to swallow than tablets and are difficult to obtain outside of major hospital pharmacies, Chua said. However, the remaining opioid fluid is also difficult to safely dispose of because it cannot be accepted at many drop-off locations.

Do not flush the remaining opioids into the sewers or toilets. It is preferable to mix them with coffee grounds or cat litter and throw them into a tied trash bag.

Other co-authors include Pain Medicine expert and opioid researcher Dr. Chad Blumet, pediatric otolaryngology director Mark Thorne, and statisticians Dr. Sophia Ng and Mary Donahue. .. Chua recognizes the work of the Michigan Medical Health Information Technology Services Electronic Health Records team for helping to change the default settings for the Tonsil Resection Prescription Order Set.