“There has been very little practical guidance on how to consistently implement reductions in prescribed doses, how to safely taper opioids after surgery, and how to personalize opioid prescribing to ensure that patients continue to receive effective pain management,” states Edward R. Mariano, MD, MAS. In line with national efforts by the American Society of Anesthesiologists and National Academy of Medicine, Dr. Mariano and colleagues tackled the problem of opioid overprescribing at the local level by developing a tool that could be rapidly implemented.
Testing an Opioid Prescribing & Tapering Protocol
For a retrospective cohort study, published in Pain Medicine, the team tested the hypothesis that implementing a multidisciplinary, patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) would decrease the morphine milligram equivalent (MME) dose of opioids prescribed. “At our hospital, patients who undergo lower extremity joint replacement surgery receive their care in a collaborative perioperative surgical home (PSH) model of care,” explains Dr. Mariano. “The PSH model facilitates regular communication between members of the healthcare team and promotes continuous process improvement. We chose to design a protocol that could be variable and patient-specific.”
The study team created a tool that calculates each patient’s total number of oxycodone tablets to be prescribed at discharge based on opioid consumption in the prior 24 hours, along with explicit instructions on how to taper the dosage and when (Table). “We avoided analgesics that combine an opioid with acetaminophen so patients could continue to take the maximum allowable daily dose of acetaminophen as part of their multimodal analgesic regimen,” notes Dr. Mariano. “We avoided prodrugs since the analgesia and side effects vary between individuals based on metabolism. We also attempted to keep the tool as simple as possible by using the prior 24-hour opioid consumption as the highest allowable dose and setting the taper downward from there every 2 days. Patients were given instructions to monitor for signs of withdrawal as well as recommendations for safe opioid storage and disposal. Patients who have received no opioid in the prior 24 hours should be given the option of going home without opioids rather than prescribing them unnecessarily.” Dr. Mariano and colleagues analyzed the PSH database and prescription data for all patients who underwent primary total hip arthroplasty 3 months before and 3 months after implementation of the new protocol.
“A Huge Difference”
The total median MME for 6 weeks postoperatively was 900—ranging from 57 to 2,082—during the 3 months prior to the intervention, compared with 295—ranging from 69 to 741) during the 3 months after. While refill rates did not differ, median initial discharge prescriptions in MME were 675—ranging from 57 to 1,035—prior to the intervention and 180—ranging from 18 to 534—after. “No aspect of our inpatient perioperative pain management protocol changed,” notes Dr. Mariano. “All patients received multimodal analgesia, and there were no differences in patients’ inpatient opioid usage, postoperative adverse events, or recovery trajectory that could account for the difference in prescribed opioid amount seen in our results. This emphasizes that discharge opioid prescribing prior to implementing our patient-specific protocol was arbitrary and that applying our new tool made a huge difference.”
With these results showing it is feasible to develop a relatively simple tool to guide discharge opioid prescribing and tapering for THA patients, according to Dr. Mariano, the researchers have applied the tool for all major orthopedic and spine surgery patients. “Not all physician practices may be able to use our tool in its current form since we have a PSH model of care and unique patient population,” he notes. “However, every practice can implement multimodal analgesia protocols, assess their own patients’ opioid use, and develop a similar tool that accounts for their patients’ inpatient opioid consumption when determining how much opioid to prescribe at discharge along with tapering instructions.”