Statewide Implementation of Postoperative Opioid Prescribing Guidelines

To the Editor:

Opioids are widely overprescribed after surgery.¹ Leftover medication is often diverted into the community, contributing to the opioid epidemic.² The lack of evidence on which to base prescribing practices after surgery may hinder efforts to reduce overprescribing.³ In this study, we developed and disseminated postoperative prescribing guidelines and measured the effect on prescribing in a statewide hospital collaborative.

The Michigan Surgical Quality Collaborative (MSQC) is a statewide quality-improvement collaborative that maintains a clinical registry of general, vascular, and gynecologic surgical procedures, capturing a random sample of 50,000 patients per year. From January through September 2017, the MSQC collected data on patient-reported opioid consumption after surgery. In partnership with the Michigan Opioid Prescribing Engagement Network (Michigan OPEN), these data were used to develop prescribing guidelines for nine surgical procedures (see the Supplementary Appendix, available with the full text of this letter at NEJM.org).⁴ In October 2017, these guidelines were communicated to MSQC clinicians through in-person presentations and electronic distribution.

We conducted an interrupted time-series analysis to compare postoperative opioid prescribing before and after the release of the guidelines. The primary outcome was opioid prescription size, assessed as the number of 5-mg oxycodone pills. We collected data on patient-reported outcomes as secondary outcomes, including opioid consumption, a rating of satisfaction with the experience after surgery on a scale of 0 (“extremely dissatisfied”) to 10 (“extremely satisfied”), and a rating of pain in the first week after surgery (with 1 denoting “no pain,” 2 “minimal pain,” 3 “moderate pain,” and 4 “severe pain”) (see the Supplementary Appendix).

Figure 1. Figure 1. Opioid Prescription Size and Consumption before and after Release of the Prescribing Guidelines.

Panel A shows the interrupted time-series analysis of postoperative opioid prescription size. After the prescribing guidelines were released in October 2017, prescription size declined significantly. The change in the slope (i.e., the change in the rate of the decrease in prescription size, measured as 5-mg pills of oxycodone per month) from before the guideline release to after guideline release was also significant (P=0.02). Panel B shows patient-reported opioid consumption among the 6585 patients who completed surveys for the analysis of patient-reported outcomes. Opioid consumption decreased by 50% over the study period, while patient-reported satisfaction with care and pain in the week after surgery remained clinically stable. The satisfaction score ranged from 0 (“extremely dissatisfied”) to 10 (“extremely satisfied”), and the pain score ranged from 1 (“no pain”) to 4 (“severe pain”).

We analyzed prescription data from 11,716 patients across 43 hospitals, collected from February 2017 through May 2018. A total of 6718 (57%) of the patients were female, the mean (±SD) age was 52.1±16.3 years, and 6585 patients (56%) completed surveys for the analysis of patient-reported outcomes. Before guideline release, the change in prescription size over time was −0.5 pills per month (95% confidence interval [CI], −1.1 to 0.06). During the period after guideline release, the change in prescription size was −1.3 pills per month (95% CI, −1.6 to −1.0). This represented a significant difference in slope of −0.8 pills per month (95% CI, −1.5 to −0.12; P=0.02) between the pre- and post-guideline periods (Figure 1A). The mean prescription size decreased from 26±2 pills in the preguideline period to 18±3 pills after the guidelines were released (difference, 8 pills; 95% CI, 6 to 11). Opioid consumption also decreased from 12±1 to 9±2 pills (difference, 3 pills; 95% CI, 2 to 5), possibly as a result of patients anchoring and adjusting their expectations for opioid use to smaller prescriptions.⁵ Despite the reductions in prescription size and opioid use, no clinically important changes in satisfaction or pain scores were observed (Figure 1B).

This study is not the only effort to address the opioid crisis in Michigan. Most notably, Public Act 251 legislatively limited prescription size starting in July 2018. However, this law did not go into effect until after the study period. In our study, we found that evidence-based prescribing guidelines reduced postoperative opioid prescription size across a statewide population without negatively affecting patient satisfaction or pain.

Joceline V. Vu, M.D.
Ryan A. Howard, M.D.
University of Michigan, Ann Arbor, MI

Vidhya Gunaseelan, M.S.
Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI

Chad M. Brummett, M.D.
Jennifer F. Waljee, M.D.
Michael J. Englesbe, M.D.
University of Michigan, Ann Arbor, MI
[email protected]