SEPTEMBER 4, 2023
FORT LAUDERDALE, Fla.—Ensuring clinicians switch from prescribing combination-agent opioids to single-agent opioids for postoperative pain is possible following the implementation of a comprehensive education program, according to a study reported at the 2023 annual meeting of the American Academy of Pain Medicine.
Implementing such a change enables providers to use nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen more freely for postoperative pain without concern about
FORT LAUDERDALE, Fla.—Ensuring clinicians switch from prescribing combination-agent opioids to single-agent opioids for postoperative pain is possible following the implementation of a comprehensive education program, according to a study reported at the 2023 annual meeting of the American Academy of Pain Medicine.
Implementing such a change enables providers to use nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen more freely for postoperative pain without concern about drug–drug interactions—a particularly important consideration in pediatric patients.
“Following surgery, our pediatric patients were commonly given combination opioids, a practice that often led to confusion among parents, who were left wondering whether they could or could not also give their children acetaminophen and NSAIDs, which were often included in the combination opioids,” said study investigator Alicia Segovia, MS, a medical student at the Texas College of Osteopathic Medicine, in Dallas. “Given this confusion, a multidisciplinary opioid stewardship committee was established to oversee prescribing guidelines at Cook Children’s Medical Center.”
According to Segovia, the committee wanted to create guidelines for surgeons at the institution and provide information on the benefits of prescribing single-agent opioids instead of combination agents.
The education initiative took a broad-based approach and included such efforts as creation and circulation of informative brochures; group and individual meetings with surgeons; and email blasts that summarized relevant literature.
“The idea was to help surgeons feel more comfortable prescribing the single-agent opioids,” Segovia said.
To help ascertain the effectiveness of the quality improvement initiative, the researchers examined the records of all outpatients who were prescribed opioids after surgery at the institution between March 1, 2018 and Feb. 28, 2022, with several exclusions. Children prescribed methadone were not included because the drug was not primarily prescribed for pain management. In addition, those prescribed fentanyl, hydromorphone, morphine or tapentadol were excluded because those agents were prescribed mainly in inpatient settings.
Three primary outcome measures were examined for each procedure: hospital revisits for pain within seven days of discharge, emergency department revisits for pain within seven days of discharge and hospital length of stay. Each opioid prescribed for a given procedure was categorized as either single-agent or combination. If at least one combination opioid was prescribed, the procedure’s opioid was categorized as combination. A prescription was categorized as single-agent if only single-agent opioids were used.
The investigators then used these data to determine the change in single-agent prescriptions over time. Logistic regression analyzed whether the likelihood of single-agent opioid prescriptions differed by intervention and department. Finally, the team assessed guideline compliance among physicians in various specialties.
An Openness to Change
Segovia reported that the analysis comprised 5,227 pre-intervention procedures and 8,419 post-intervention procedures. It was found that 88.1% of post-intervention procedures resulted in single-agent opioid prescriptions, significantly more than the 8.84% of pre-intervention procedures that used single-agent opioids (odds ratio, 79.6; P<0.0001).
“Based on the data, it seems that surgeons were open to making the changes recommended by the committee,” Segovia said.
Furthermore, the likelihood of single-agent opioid prescriptions differed significantly by department (P<0.0001) and the proportion of these prescriptions increased in all seven departments examined. Among the three departments with the most procedures—orthopedics, urology and otolaryngology—single-agent opioid prescriptions increased by an average of 70%.
Finally, the study revealed that the likelihood of hospital revisits, revisits to the emergency department and having any length of stay all significantly decreased after the intervention for patients who were prescribed single-agent opioids.
“We also measured the likelihood of patients being prescribed single-agent opioids a year after the intervention, and those rates still remained high,” Segovia told Pain Medicine News. “That’s good news because it shows that the intervention was impactful enough to affect long-term change.”
In light of these findings, the investigators were confident that the implementation of an educational program and opioid prescribing guidelines may help promote safer, efficacious opioid prescribing practices, particularly for children.
“What is unique about this intervention is that it’s one of the first ones to be done at a pediatric institution,” Segovia noted. “This is important because children are very vulnerable to adverse drug interactions, especially after surgery.”
Impressive Educational Efforts
Marie N. Hanna, MD, MEHP, found the team’s efforts very interesting, particularly in the context of today’s multimodal analgesic protocols.
“We use multimodal techniques all the time to help decrease the amount of narcotics required by patients,” said Hanna, an associate professor of anesthesiology and critical care medicine and the chief of the Division of Regional Anesthesia and Acute Pain Management, and the medical director of the perioperative pain program at Johns Hopkins University, in Baltimore. “While giving combination drugs like Percocet (acetaminophen plus oxycodone hydrochloride, Vintage Pharms LLC) and Vicodin (acetaminophen plus hydrocodone bitartrate, AbbVie) can be beneficial for patients, they can result in excess consumption of acetaminophen if the patient is prescribed acetaminophen separately.
“This is especially important because when we write an acetaminophen prescription as an adjunct, we first look at liver function tests to make sure they are normal,” Hanna added. “Prescribers who write prescriptions for Percocet and Vicodin who don’t look at the liver function tests might end up hurting patients more than helping them.”
Given the possibility of such interactions, Hanna’s institution removed combination opioid products from its formulary years ago. “We don’t want our providers to write Percocet while we know that acetaminophen will be given separately, assuming it’s appropriate and safe to do so.”
That said, Hanna was impressed with the investigators’ educational efforts and the benefits they realized. “It definitely seems like it was helpful,” she said. “Their clinicians use combination opioids much less frequently than previously, which will certainly make a difference.”
—Michael Vlessides
Hanna and Segovia reported no relevant financial disclosures.
