Predicting Whether Surgery Patients Will Continue to Refill Opioid 'Scripts
Although opioids play a key role in reducing pain when recovering from surgery, some patients transition to chronic users and become dependent on them. In order to find out what situations result in patients continuing to refill their opioid prescriptions after a surgery, Johns Hopkins researchers scoured a database of more than 900,000 people who had a surgery scheduled and were prescribed opioids for the first time.
Although some procedures and specialties are more inherently painful or leave a person with chronic pain, in their study, published online April 15 in The American Journal of Surgery, the researchers say physicians could be doing more to prevent patients from continuing to take opioids.
"Based on our data, there are some easy changes that we can suggest to reduce the chance that patients will continue on opioids beyond the time needed for surgical healing, such as asking surgeons to prescribe opioids on the day of surgery rather than in advance," says Mark Bicket, M.D., assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. "We also recommend prescribing the smallest amount of opioids to treat a patient's pain at a time, as this seems to curb long-term use."
The researchers found that colorectal surgery patients were 35% more likely to continue to fill opioid prescriptions, cardiovascular surgery patients were 30% more likely and thoracic surgery patients were 26% more likely compared to urology patients, who had a lower likelihood of continuation.
Bicket's team also found that patients who underwent surgeries outside of an operating room were 60% more likely to continue on opioids compared to those who had procedures in operating rooms. These trends continued at six months and at a year after surgery. Bicket says that physicians in an outpatient care setting should consider using anesthesia or working with a physician anesthesiologist to help minimize pain during surgeries, which could result in less opioids needed for long-term recovery.
The team also found that increased access to and greater numbers of pills made people more likely to continue on them. For example, each extra day of medication that the patient was prescribed increased the likelihood that they'd continue taking opioids by 5%. Also, having the prescription up to 30 days before the surgery increased in the likelihood that they would continue on opioids by 2%. And, compared to filling one prescription, filling two or more prescriptions increased the odds of continuing by 40%. For any prescription for more than 375 morphine equivalents, or about 50 oxycodone pills, patients were 5% more likely to refill another opioid prescription than those on the lowest doses.
Generalist Nurse Practitioners and Physician Assistants May Prescribe Disproportionate Share of Opioids
In an effort to identify which health care providers may be overprescribing opioids and potentially fueling the opioid epidemic, Johns Hopkins researchers looked at the different type of providers at the front lines of caring for patients -- general practitioners.
The researchers found that among general practitioners in a primary care, urgent care or hospital setting, physician assistants (PAs) prescribed the most opioids, followed by nurse practitioners (NPs) and then physicians.
The researchers say their findings, published online on March 1 in Pain Medicine, suggest that physician assistants and nurse practitioners may need more education and better oversight to prevent overprescribing.
Using data from Medicare's publicly available Part D prescription database of older Americans from 2013-2016, the researchers identified 36,999 general practitioners including physicians, nurse practitioners and physician assistants who prescribed more than 10 prescriptions over a year-long period in a primary care, urgent care or hospital setting.
Of the generalist prescribers among the highest 5% of opioid prescription rates, 43% are PAs even though PAs only make 12% of all general practitioners. PAs practicing in an urgent care setting prescribed opioids at the highest rate of all groups in all settings ¾ nearly 12% of their prescriptions were for opioids compared to 6.7% for physicians and 4.8% for NPs. In hospitals, physician assistants wrote 11% of their prescriptions for opioids, compared to 8.1% for nurse practitioners and 6.7% for physicians.
"It's possible that the numbers come out this way due to different roles that PAs and NPs have in each setting, or it could be a result of drug reps marketing directly to this kind of health care provider, which could lead to higher prescribing rates," says Michael Ellenbogen, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine. "In fact, evidence from recent lawsuits against Purdue Pharmaceuticals suggests this may be the case."