A patient-centered study of postoperative analgesic needs found that surgeons may be overprescribing opioids for pain management after hernia repair operations.
The growing opioid public health crisis – and potential contribution of pain control prescriptions to the crisis – has prompted empirical work on surgeons’ prescribing and actual patient use of opioids ( Ann Surg. 2017 Jul 10. doi: 10.1097/SLA.0000000000002365. [Epub ahead of print ]; J Arthroplasty. 2017;322395-2398 ). Excess pain medications are thought to raise the risk of patient dependence and to be potentially diverted to nonpatients’ use. A recent study ( Ann Surg. 2017;265:709-16 ) found that a median of 30 opioid tablets were routinely prescribed by surgeons for pain management after hernia repair.
Konstantinos Mylonas, MD, a research fellow at Massachusetts General Hospital, Boston, and his coinvestigators conducted a prospective, observational study of 185 patients who had an outpatient inguinal hernia repair between October 2015 and September 2016. Participants completed a survey on their pain levels and opioid use during the 2- to 3-week period between their procedure and follow-up appointment (Surgery. 2017 Aug 1. doi: 10.1016/j.surg.2017.06.017 ).
Most of the patients (177) were male, were over age 60 (96) and underwent an open Kugel procedure (151). Each patient had local anesthesia and IV sedation.
For postop pain control, the patients were given 10 Vicodin (hydrocodone 5 mg/acetaminophen 325 mg) tablets, although all were advised that they may not require the medication but could instead use acetaminophen or ibuprofen as needed.
Of the 185 patients who were surveyed, 159 (86%) reported taking 4 or less of the 10 opioid tablets prescribed to them, with 110 (60%) reporting taking no tablets at all
While 13 (7%) of the patients did report using nine or more of the prescribed Vicodin tablets, none of the patients surveyed were still taking the pain medication within 7 days of their follow-up appointment.
When asked about how pain affected their returning to daily activities, 123 patients (66.5%) reported not having any pain interference, 42 (22.7%) mentioned slight problems, and 5 (2.7%) were noticeably affected. No patients were unable to return to their daily activities, and those 111 (75%) of the 147 patients who were employed were able to return to work within 3 days of surgery, according to the investigators.
As might be expected, those patients who experienced higher pain levels and persistent pain took more Vicodin tablets, but only one patient required a refill of the original prescription.
Patients were also not blinded to the study, which may have caused them to either take less opioid medication or not report their intake accurately. But the findings suggest that opioid prescribing could be tailored much more narrowly to patients’ needs and to individual procedures than is currently common practice. “Although our study was limited to a single procedure, performed by a single surgeon in a high-volume center, implementing patient-centered, procedure-specific opioid administration strategies may be conceivable across a variety of surgical disciplines,” the investigators concluded.
For the 750,000 inguinal hernia repairs done in the United States each year, prescribing 4 instead of 30 opioid tablets would decrease the number of opioid analgesics dispensed annually for hernia operation from 22.5 million to 3 million,” the investigators wrote. “As a result, 20 million fewer tablets per year would be available for potential diversion and abuse or as a stimulus for the start of opioid dependency.”
The researchers reported no relevant financial disclosures.
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