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VIDEO: Interventions target opioid overprescribing after gynecologic surgery

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Inpatient opioid needs can guide discharge prescribing

The important and thought provoking reports by Dr. Mark and by Dr. Weston and their associates present innovative ways for clinicians to address the opioid crisis by prescribing fewer narcotics to postsurgical patients when they leave the hospital. Their work suggests that doing this can have little or no negative impact on patient satisfaction with their care. Their findings give us important documentation for prescribing fewer opioid tablets, while still giving patients adequate pain relief.

Dr. Brent Smith

Dr. Brent Smith

Clinicians are often concerned about providing patients with inadequate pain medication following surgery and the possibility that patients will have to request a refill of their opioid prescription. The results from both of these studies indicate that the narcotic needs of patients while they are hospitalized provide an effective way to predict of the amount of pain medication they will need once they are discharged.

Their findings also provide clear documentation that, in current practice, without guidance like this opioids are often overprescribed, not out of negligence but because clinicians are simply not sure what a patient will need once they go home following gynecologic surgery. By reviewing the pain medication a patient needed in hospital we can better estimate what patients will need when they go home, and we can better avoid giving patients more opioid tablets than they will really need.

Brent Smith, MD , is a gynecologic oncologist at Ohio State University, Columbus. He had no disclosures. Dr. Smith made these comments in a video interview.



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– U.S. clinicians prescribe opioid tablets to postsurgical patients too often and at too high a pill count, according to results from two independent studies that examined prescribing patterns and opioid use in patients following gynecologic surgery.

Dr. Jaron E. Mark Mitchel L. Zoler/MDedge News

Dr. Jaron E. Mark

One of the studies also implemented an “ultrarestrictive” postsurgical opioid prescribing protocol for 337 patients at one U.S. center that did not allow the routine prescription at hospital dismissal of opioids to minimally invasive or outpatient surgery patients with no history of chronic pain. This approach cut opioid prescribing by 97%, compared with the historic rate from the preceding year while resulting in 96% of the patients reporting satisfaction with their treatment, Jaron E. Mark, MD, said at the annual meeting of the Society of Gynecologic Oncology.

In addition, “setting preoperative expectations about pain management led to increased compliance at discharge,” said Dr. Mark, a gynecologic oncologist at Roswell Park Comprehensive Cancer Center in Buffalo, N.Y.

Findings from the second study, of 122 women who underwent gynecologic surgery at Women and Infants Hospital in Providence, R.I., showed that 32% did not use any opioids for pain following hospital discharge, and that opioid use during hospitalization was a significant predictor of postdischarge opioid needs. This finding provided a way to devise a new prescribing guide for postsurgical patients based on their opioid use while hospitalized, said Erica Weston, MD, a gynecologic oncologist at Johns Hopkins University, Baltimore.

Dr. Erica Weston Mitchel L. Zoler/MDedge News

Dr. Erica Weston

The findings from both studies show that “if we educate patients, fewer opioids are needed for pain control” after gynecologic surgery, commented Sean C. Dowdy, MD, a professor of ob.gyn. and chair of gynecologic surgery at the Mayo Clinic in Rochester, Minn. “A large proportion of both minimally invasive surgery and laparotomy patients require no opioids after their hospital dismissal,” he noted as designated discussant for the two reports.

“No question, we are overprescribing,” Dr. Dowdy said, and described a program he and his colleagues at Mayo recently put in place that capped routine opioid pill prescriptions following various surgeries based on historic patient needs. For example, most laparotomy patients receive a prescription for 10 opioid doses on discharge. Based on the first 6 months of this program, it’s on track to cut the annual number of opioid tablets prescribed to postsurgical patients at Mayo by 35,000 for all gynecologic surgeries and by 1.5 million tablets for all Mayo surgical subspecialties, he said.

Dr. Sean C. Dowdy Mitchel L. Zoler/MDedge News

Dr. Sean C. Dowdy

But while he highlighted the need for widespread action to reduce the clear overprescribing that occurs, he also cautioned against underprescribing. “The goal is not less opioid prescribing, but more appropriate prescribing,” Dr. Dowdy declared.

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