Friday, February 28, 2020
Reducing Opioid Prescription Volume for Outpatient Spine Surgery
Physicians are well aware of the need to reduce the amount of opioids prescribed in order to decrease the risk of dependence and diversion. Outpatient spine surgery is a challenging arena in which to do this work as patients are being treated for painful conditions with fairly painful procedures, and it is difficult to predict how much opioid medication they will need post-operatively. Surgeons have traditionally erred on the side of over prescription in order to avoid the need for refills requiring phone calls and paperwork. This motivation to avoid writing additional refill prescriptions has grown stronger as new regulations have increased the burden to providers writing opioid prescriptions (i.e. checking online drug monitoring programs, the requirement for electronic prescriptions, and the need for two-factor identification while writing these prescriptions). Most outpatient spine surgery patients end up with left-over opioid pain medication, increasing the risk of dependence and diversion. In an effort to reduce excess opioid prescribing for outpatient spine surgery, Nicholas Eley and colleagues from Virginia Mason Medical Center in Seattle developed a post-operative opioid prescription protocol with the goal of prescribing no more than 24 tablets (5 mg) of hydrocodone or oxycodone. In their before-after study, they included 246 opiate naïve patients (defined as not having received an opioid prescription within 30 days of surgery) undergoing outpatient spine and neurosurgery procedures (one or two level lumbar laminectomy or diskectomy, one or two level cervical laminectomy or foraminotomy, one level ACDF or removal/replacement of a deep brain stimulator). Prior to protocol adoption, the mean opioid prescription was 52 tablets, which decreased to 28 tablets for the year following adoption and down to 22 tablets for the 3rd and 4th quarter of that year. Posterior cervical procedures required the highest amount of opioids (mean 36 tabs after protocol adoption). Fewer than 20% of patients required an opioid refill, and this did not increase after protocol adoption. Following the intervention, there were slight increases in number of phone calls per patient (4.3 vs. 4), return visits to the ED (4% vs. 2%), and readmissions (3% vs. 1%), though none of these differences were statistically significant. Prior to protocol adoption, five percent of patients received a prescription for narcotics over 90 days out from surgery compared to 2% after adoption. Based on the results, the authors concluded that adoption of an opioid reduction protocol could decrease the amount or opioids prescribed without increasing the burden of caring for patients with insufficient pain control.
The authors have done a nice job reporting on their adoption of a protocol to reduce opioid prescription volumes for outpatient spine surgery. Studies of process improvement measures can be difficult as they reflect actual practice in the real world and do not always lend themselves to being described neatly. In this study, the most significant limitation is related to the fact that almost 60% of patients were excluded for having received an opioid prescription in the 30 days leading up to surgery. As such, the patients were highly selected and the results may not be generalizable to the overall outpatient spine surgery population. Additionally, the authors excluded patients who were admitted for over 23 hours, and it is difficult to determine what proportion of patients undergoing the included procedures were treated as outpatients. Despite these limitations, the authors have demonstrated that the volume of opioids prescribed following outpatient spine surgery can be reduced significantly—approximately 50% in this series—without an increased burden related to insufficient pain control. Many institutions have already adopted similar protocols, and further publication of their experiences may help guide groups who are still working on creating opioid prescribing protocols.
Please read Mr. Eley's article in the March 15 issue. Does this change how you view opioid prescribing for outpatient spine surgery?
Adam Pearson, MD, MS
Associate Web Editor