After the release of the 2016 US Centers for Disease Control and Prevention (CDC) guideline on opioid prescribing for chronic pain, opioid dispensing after surgery decreased substantially — following a 2-year trend of increases, according to research results published in JAMA Network Open.
The CDC guideline included recommendations for clinicians to use the “lowest effective dosage” when prescribing opioids for acute pain treatment. Commentators have also reported on the guidelines’ applicability to acute pain episodes following surgery.
To evaluate changes in postoperative pain treatment associated with these 2016 CDC guidelines, researchers conducted a cross-sectional study to compare the trends in postoperative opioid dispensing in a national cohort of privately insured patients before and after the guideline release. The investigators also compared the amount of opioids dispensed in initial prescriptions with prescribing recommendations based on the anticipated extent of pain.
Deidentified data from Optum’s Clinformatics Data Mart Database — which includes more than 15 million annual enrollees — were used for this study. The sample included all patients 18 years and older with a claim for any 8 common general and orthopedic surgical procedures in the 2 years before and after the 2016 publication: March 2014 to March 2018.
Procedures included breast excision, carpal tunnel release, inguinal hernia repair, knee arthroscopy, laparoscopic appendectomy, laparoscopic cholecystectomy, total hip replacement, and total knee replacement.
Data were restricted to opioid naive patients — that is, those with no filled opioid prescriptions in the 90 days prior to surgery — to effectively capture new opioid prescriptions instead of refills for established chronic pain.
The primary outcome measure was the total amount of opioids dispensed in the first prescription filled within 7 days of surgery or hospital discharge, measured as morphine milligram equivalents (MMEs). The secondary outcomes included total opioids dispensed across all filled prescriptions in MME within 30 days of surgery or hospital discharge, as well as the percentage of patients who received an opioid refill within 30 days of surgery, mean MME per day, and the number of days’ supply per month dispensed via the first filled prescription.
The total cohort included 361,556 opioid-naive patients who had surgery between 2014 and 2018 (45.4% men; median age, 58 years; interquartile range, 45-69 years). In total, 45.7% of patients had surgery before the 2016 guideline release; 54.3% had surgery after. There was a “modest difference” in the percentage of patients with obesity treated in the pre- vs post-release periods (15.0% vs 19.6%).
During each period, the most commonly performed procedures were laparoscopic cholecystectomy, knee arthroscopy, and total knee replacement (21.1%, 19.6%, and 15.9%, respectively).
In the 24 months before the guideline release, the mean amount of dispensed opioids within 7 days of surgery increased from 301 MME to 325 MME The mean amount of dispensed opioids in the first 30 days after surgery also increased, from 416 MME to 428 MME, and the percentage of patients who refilled a prescription decreased from 23.0% to 19.6%.
In the 24 months after the guideline release, the mean amount of opioid received with the first filled prescription decreased from 316 MME to 266 MME; mean amount of dispensed opioids in the first 30 days also decreased (415 MME to 352 MME), while the percentage of patients refilling a prescription remained stable at 19.1% and 19.0%. Similar changes were seen across procedure categories.
Investigators conducted an interrupted time series analysis which included all patients in the analytic sample. An estimated cumulative trend change in the first opioid prescription of -3.61 MME was associated with the CDC guideline release, while a similar cumulative change in mean total 30-day amount prescribed after surgery was noted (-3.52 MME/month).
Days’ supply of opioids in the initial postoperative prescription also decreased, from 0.05 days/month. Mean daily dispensed MME in the initial prescription decreased by 0.18 MME. Refill rates were “comparatively stable” but the rate of change following the guidelines’ release was “smaller in magnitude” compared with prior to the guideline release; this resulted in a small cumulative increase in refill rate trends of 0.14% per month.
Results of a multiple-group interrupted time series analysis showed that the monthly change in opioids dispensed in the initial prescription associated with the CDC guidelines for those undergoing hip and/or knee replacement was -8.64 MME/month. Among patients undergoing any 1 of the other 6 procedures, it was -2.83 MME/month. Trend change in 30-day average total opioid prescribing after hip and knee replacement was -9.70 MME/month, and -2.76 for all other procedures.
Researchers evaluated the fraction of patients for whom the initial filled opioid prescription amount exceeded the amount anticipated to treat postoperative pain. This cohort included 253,882 patients who underwent any of 6 procedures; within this group, the fraction of patients receiving twice the maximum anticipated amount required varied across procedures and decreased both progressively overall and within each procedure after the CDC guidelines were released.
In general, 89.2% of patients who underwent 1 of 6 procedures after the guideline release received an initial opioid prescription greater than the upper recommended amount; 47.7% received more than twice this amount.
Study limitations include the use of a private insurance database limiting generalizability to other context, a lack of data on prescriptions that were issued but not filled, no access to measures of pain, and an inability to exclude associations between secular prescribing trends and findings.
“This study has important policy and practice implications,” the researchers wrote. “Although the primary focus of the 2016 CDC guideline was on opioid prescribing for chronic pain, our findings suggest that the guideline was associated with clinically relevant changes in patterns of opioid prescribing after surgery.”
“Concurrently, our observation of high opioid amounts dispensed relative to recommendations indicates ongoing opportunities to improve pain treatment after surgery and the potential need for additional policy and clinical interventions to transform care,” they concluded.
Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Sutherland TN, Wunsch H, Pinto R, et al. Association of the 2016 US Centers for Disease Control and Prevention Opioid Prescribing Guideline with changes in opioid dispensing after surgery. JAMA Netw Open. 2021;4(6):e2111826. doi:10.1001/jamanetworkopen.2021.11826