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Prescribe higher dose opioids for shorter time after surgery

Treatment duration rather than dose more strongly associated with opioid misuse after surgery

Louise Prime

Friday, 19 January 2018

Opioid dependence, overdose or abuse is more likely when patients are prescribed opioids for a longer duration to treat pain after surgery, whereas the prescribed dose has a lesser impact on the risk of subsequent opioid misuse, US researchers have found. In their study*, published in the BMJ, they recommend prescribing higher doses for shorter periods after surgery, to reduce the rate of longer-term misuse.

The research team, led from Harvard Medical School in Boston, said it is believed that opioid over-prescription is contributing to the rapid global rise in opioid misuse. So, they investigated the factors associated with the likelihood of opioid misuse among 1,015,116 commercially insured US patients, with no history of opioid misuse and not currently using opioids, who had routine surgery between 2008 and 2016.

They used administrative data to track prescription refills for oral opioids after discharge and diagnostic coding data to identify opioid dependence, abuse or overdose. They found that more than half of these patients (568,612–56%) received a prescription for post-operative opioids, of whom 90% filled the prescription within three days of hospital discharge.

During an average of two and a half years’ follow up, opioid misuse was identified in just 0.6% of patients overall, but certain factors were associated with increasing likelihood of misuse. Total duration of opioid use was the strongest predictor of misuse: each additional week of opioid use was associated with an average increase in the rate of misuse of 34.2%; adjusting for covariates, each additional week of opioid use was associated with a 19.9% increase in hazard.

The research team also calculated that each additional prescription refill increased the rate of misuse by 70.7% before adjustment, and increased the hazard of misuse by 44.0% after adjusting for covariates.

They reported that compared with duration of use, the dosage prescribed was a weaker predictor of misuse, and dose became important only with extended use.

The study authors commented: “This study quantifies the strong relation between number and duration of refills of prescribed opioid drugs and subsequent opioid misuse in the surgical population. We… estimated an adjusted 44% increase in misuse for every refill fulfilled, or 20% increase for every week of prescription.”

They concluded: “Our findings are important as they offer a potential lever for intervention and behaviour change after surgery. Given that surgical and non-surgical patients receive similar numbers of opioid refills, these findings have the potential to extend beyond surgery.… Our analysis provides a broad evidentiary framework to inform clinician behaviour and promote protocol development."

*Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018; 360 :j5790.

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