Calling surgery "a long-ignored gateway to persistent opioid use, dependence, and addiction," the Plan Against Pain (PAP) has issued a new report that focuses on the relationship between opioid prescriptions for surgical procedures and later opioid dependence and abuse. The bottom line: though there are glimmers of hope, the overall outlook remains bleak, with 12% of patients who had a soft tissue or orthopedic operation in the past year reporting that they had become addicted or dependent on opioids after surgery. APTA's #ChoosePT opioid awareness campaign is a Selected Partner of PAP.
The report, which tracks surgery-related prescribing rates overall and as linked to 7 common surgical procedures—including total knee arthroplasty (TKA), total hip arthroplasty (THA), and rotator cuff repair—also breaks down statistics by demographic and geographic variables. Researchers relied on data from the National Prescription Audit, the PharMetrics Plus Database, and surveys of 500 US adults who had soft tissue or orthopedic surgery in the past 12 months. In addition, 200 surgeons were surveyed to assess, among other issues, their motivations for prescribing opioids. The study results were released on October 10 in conjunction with the "Summit for Solutions" event In Washington, D.C., attended by APTA.
Among the findings:
Overall opioid prescription numbers are declining, but state rates vary dramatically.
Nationally, in 2017, there were enough opioids prescribed to supply every person in the US with 32 pills, only a slight decrease from the 36-pill rate reported in 2016. And while every state in the country reported a drop in opioid use in 2017, those reductions varied widely, and the improvements for some states, while significant, only made a dire situation slightly better. Example: Alabama, the nation's top opioid-prescribing state, recorded a 10% decrease in opioid prescriptions between 2016 and 2017, but that only brought its opioid pills-per-resident ratio down to 65 pills for every resident—more than twice the national average.
Progress has been slow in reducing opioid prescription rates related to surgery.
Researchers found that among the 7 surgeries studied—TKA, THA, rotator cuff surgery, hysterectomy, hernia surgery, colectomy, and sleeve gastrectomy—the average number of opioid pills prescribed dropped, but only slightly, from 85 pills per patient to 82. Authors of the report speculate that the slow progress could be due in part to the level of pressure surgeons feel to prescribe more opioids then they feel are necessary—a pressure reported by 66% of surgeons surveyed.
The number of pills prescribed doesn't tell the whole story. The use of fewer pills at a higher potency also poses a risk—especially for orthopedic patients.
The study found that more than half of patients undergoing TKA, THA, and rotator cuff surgery were prescribed opioids of 50 or more morphine milligram equivalents (MMEs), more than double the 20 MME dosage recommended by the US Centers for Disease Control and Prevention (CDC). Nearly 1 in 4 orthopedic patients received prescriptions in excess of 90 MMEs per day, an amount that the CDC says poses a serious overdose risk.
Average rate of later opioid dependence and addiction among surgical patients hovered at 12%, but was higher for TKA patients.
Patients who received colectomy reported the highest incidence of later dependence, at 17%, but TKA patients weren't far behind, with a 15.2% rate of later misuse. Rotator cuff surgery and THA patients reported lower rates of later dependence, at 9.5% and 9.3% respectively. The 12% overall average is an increase from the 2017 study, which estimated the later dependence rate at 9%.
Women—and Millennial women in particular—are the most at-risk for becoming "newly persistent" opioid users after surgery.
Women were found to be 40% more likely than men to become "newly persistent" users—individuals who received opioid prescriptions 90 to 180 days post-discharge. Millennial women were found to be particularly at-risk, with more than 10% reporting persistent use, compared with 6% or Millennial men. The persistent use rate for Millennial women in the 2018 PAP study represents a 17% jump from the previous survey.
Authors of the report believe that until better guidelines are developed it's unlikely gains can be made in more careful use of opioids related to postsurgical pain. Although there has been some progress in this area, they write, more needs to be done to "relieve the pressure surgeons often feel to prescribe more opioids than patients actually need and help set patient expectations on the amount of opioids they'll be prescribed."
"[The lack of clear guidelines] has left surgeons mainly on their own in determining the appropriate quantity and strength of opioids needed to address their patients' pain," authors write. "As this report reveals, the absence of clear guidelines has led to tremendous variation in prescribing patterns and a great deal of overprescribing that can lead to persistent opioid use, addiction and dependence among patients, as well as unused pills that can be misused or abused by others."
APTA has been heavily engaged in the fight against opioid misuse on several fronts. In addition to its flagship #ChoosePT opioid awareness campaign, the association also hosted a Facebook Live panel discussion and satellite media tour to highlight the effectiveness of nonopioid approaches to pain management. In addition, APTA produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship.