Opioid prescribing preferences and practices among surgical residents and faculty differ, according to a new study published in the journal Surgery.
The study, titled “Evaluation of opioid prescribing preferences among surgical residents and faculty,” was based on a survey of 56 residents and 57 faculty within the University of Colorado School of Medicine Department of Surgery. In the survey, participants were asked how many oxycodone tablets they would prescribe for 14 common surgical procedures.
Answers were compared between residents and faculty, as well as against the Opioid Prescribing Engagement Network (OPEN) guidelines and actual opioids prescribed (pulled from electronic medical records).
“The opioid epidemic is a huge problem,” says Sarah Tevis, MD an assistant professor of surgery in Breast Surgical Oncology and the study’s principal investigator. “We know that more than two thirds of the prescriptions that surgeons prescribe aren't used in the immediate post-operative period by patients and that one in 16 patients who are prescribed opioids for surgery end up having chronic opioid use.”
“It's been very well established that post-operative opioid prescribing varies across the board,” continues Victoria Huynh, MD, a third-year resident in the department and first author on the study. “We wanted to look at how we're doing as a department in terms of opioid prescribing.”
Comparing resident and faculty opioid prescribing habits
The results showed that faculty preferred to prescribe more opioid tablets than suggested by OPEN in five of the 14 surgical procedures, while residents did so in nine of the procedures.
“In some instances, faculty and residents prescribed more than suggested for certain surgical procedures. So that’s certainly an opportunity for improvement,” Huynh says. “But I think the most striking aspect of the study was just how much faculty and resident prescribing preferences differ from each other.”
Tevis said one of the reasons providers may prescribe more than suggested by the OPEN guidelines is CU’s large catchment area.
“We have patients coming from hours away and from other states for surgery. So, one factor may be that prescribers are worried that patients are going to drive eight hours home and then not have enough pain medicine,” Tevis says.
Another concern is patient satisfaction. Tevis says providers may be worried that a patient who runs out of pain medicine will be less satisfied with their care or need to call back or even go to the emergency room for more pain medication.
As for why residents seem to prefer prescribing more opioids than faculty, Huynh thinks it may be at least partially due to the limited interaction residents have with patients after surgery.
“We often see patients pre-op and immediately post-op, and we help take care of them in the immediate post-operative period while they're in the hospital,” Huynh says. “But as far as the post-operative follow-up care, we're not as involved as the attendings are.”
Tevis agrees. “When I call patients with their pathology results about a week after surgery, I also ask them about their pain control. But the residents miss out on a lot of that feedback.”
The study also assessed the frequency with which faculty communicate prescribing preferences to residents and the desire among all participants for feedback and transparency in prescription practices.
Both residents (80%) and faculty (75%) were open to seeing regular reports of personal opioid prescription practices, and most of those were also open to seeing how their numbers compared with their peers.
Education and assessment: initiatives to address post-operative opioid over-prescription
Since studies show that most prescription opioid abusers get medication from family and friends, the challenge is learning how to adequately treat post-operative pain while limiting opportunities for misuse and diversion.
“For us, that means limiting the excessive opioids that we prescribe,” Huynh says.
As a result of their research, Huynh and some of her co-residents are setting up ongoing initiatives within the Department of Surgery to address over-prescription of opioids. For instance, they have been developing a dashboard that will allow anyone who prescribes opioids to receive regular feedback about how much they're prescribing and how their prescribing practices compare with their peers. They recently sent it out to a handful of faculty to get feedback on the functionality and features.
“We're hoping that once we get that worked out, we can send it out to the entire department so that everybody can use it,” Huynh says.
Tevis, one of the faculty members who has started using the dashboard, says it is already proving effective. “Surgeons are competitive people,” she says. “So, when we get that email every month, my partners and I immediately start emailing back and forth about how we did compared to last month, how we’re all doing compared to each other. I think people are really liking that feedback, and it's influencing what they're doing.”
In addition to the dashboard, Huynh and her colleagues have built pathways (called Enhanced Recovery after Surgery protocols) that providers can follow through a patient’s electronic medical record. The pathways recommend which pain medications to order before and after surgery, including how many opioids to prescribe for certain procedure based on the national guidelines.
Tevis predicts the pathways will be especially helpful for residents who periodically rotate between different services.
“If you haven't been on the breast service for three years, how are you going to remember how many pills you should prescribe after a lumpectomy?” she asks. “If it's built into this pathway, it becomes very clear.”
The clinicians have also developed a protocol to utilize multimodal pain management to try to decrease the need for opioids after surgery, as well as instituted an educational program for interns around opioid prescribing.
“It's really impressive what Tori has accomplished in just two years in the research lab,” Tevis says. She's examined this problem from multiple angles, and her work has already led to big changes in the Surgery Department.”