In the last 15 years, the number of Americans receiving an opioid prescription and the number of deaths involving overdoses have roughly quadrupled, according to the Centers for Disease Control and Prevention. More than 90 people per day died in 2015 from an overdose of a prescription opioid or heroin – an illegal opioid made from morphine.
As the opioid epidemic continues, health care providers are hoping to do their part. For decades, the emphasis nationwide for treating surgical patients was to prescribe enough opioid pain medication to ensure they didn’t have any pain. But health care providers are realizing it’s a balancing act between managing pain and ensuring patients aren’t overprescribed.
To that end, Mayo Clinic researchers are studying the clinic’s opioid prescribing practices after surgery, outlining areas for improvement based on evidence, and implementing change. The team includes scientists in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, along with surgeons, pain medicine specialists, nurses and pharmacists. Their goal is to identify the right amount for each patient.
“The key factor is that we want to make a reduction in opioid prescriptions in an informed way – based on current patient needs – so that we don’t under-treat patients’ pain,” says Tad Mabry, M.D., a Mayo Clinic orthopedic surgeon. “We want to achieve the best possible patient outcomes, and patient experience, with minimal exposure to opioids.”
The research team published a study July 13 in the Annals of Surgery which highlighted prescribing practices from January 2013 to December 2015 for 25 common surgeries at Mayo Clinic campuses in Arizona, Florida and Rochester. In particular, the researchers examined patients who weren’t taking opioids in the 90 days before surgery. Within that group of 5,756 patients, they found 4 of 5 patients received more than recommended by Minnesota state guidelines now in development.
The median opioid prescription for that subgroup was equal to 50 pills of five-milligram oxycodone. That’s almost twice the amount the draft guidelines from the state of Minnesota recommend for a maximum, which is roughly a seven-day supply or about 27 pills of five-milligram oxycodone.
And, within that group, the prescriptions varied within specific surgical procedures and among the three campuses after adjusting for other factors. The Rochester campus median equaled 40 pills of oxycodone; whereas, the Arizona and Florida campuses’ median equaled 50 and 60 pills, respectively.
Based on these data, the Mayo Clinic Department of Orthopedic Surgery already has transformed its prescribing practices for patients who weren’t taking opioids in the 90 days before surgery. The department is developing four recommended levels based on surgical procedure and patient need.
“Furthermore, we have encouraged all our providers to maximize non-opioid pain strategies, such as ice, compression and over-the-counter medications,” Dr. Mabry says.
Other departments – such as Neurosurgery, General Surgery and Obstetrics and Gynecology – are following suit with their own guidelines. And the Mayo Enterprise Opioid Stewardship Program Oversight Group is using this research to make institution-wide improvements.
While the researchers say this is just the first step, it’s advancing the practice in the right direction for the benefit of Mayo patients and the community.
“By publishing our experience we hope other institutions across the country begin a process similar to Mayo’s,” says co-author Robert Cima, M.D., a colorectal surgeon and medical director of surgical outcomes research.
It also provides a foundation for evidence-based guidelines for prescribing opioids post-surgery, something that was previously lacking.
“When I first looked at the medical literature I was surprised that, even for common surgeries, there wasn’t data to help guide surgeons on post-operative opioid prescribing practices,” says lead author Cornelius Thiels, D.O., a general surgery resident in the Mayo Clinic School of Graduate Medical Education, and alumnus of the Surgical Outcomes Research Fellowship.
The team also is hoping the study will help shape government policy and health care guidelines. The state of Minnesota is considering the study as it finalizes its guidelines, which in their current form aren’t appropriate for all cases, the researchers say.
“For some of the procedures, the guideline is probably appropriate and we have an opportunity to reduce the amount prescribed,” says senior author Elizabeth Habermann, Ph.D., scientific director of surgical outcomes research in the Kern Center for the Science of Health Care Delivery. “For some of the more painful procedures, in orthopedics, for example, the draft guideline is likely too low.”
Now, the team is surveying patients after surgery to see which types of patients are receiving excess opioids, and to determine how well they’re managing their pain.
“That’s important because pain is a very subjective experience and health care providers have to make sure they take the patients perspective into account when they alter how they treat their pain after surgery,” Dr. Thiels says.
The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery funded the research. The center analyzes data with the goal of making broad-based quality and efficiency improvements in patient care at Mayo and beyond.
The other authors ─ all from Mayo Clinic ─ are: