No Clear Guidance for Opioid Prescribing After Abdominal, Pelvic Surgery

By Marilynn Larkin

March 30, 2020

NEW YORK (Reuters Health) - Recommendations for opioid prescribing after abdominal and pelvic surgery vary, and few are supported by evidence, a systematic review reveals.

"There is a growing need for more evidence-based opioid prescribing practices to minimize the excessive prescription of these medications in our health care system," Dr. Nancy Baxter and Dr. David Zhang of the University of Toronto told Reuters Health in a joint email. "We know currently many patients receive an opioid prescription after surgery that far exceeds what they need."

"In current practice, abdominal surgeons prescribe opioids to their patients at the time of discharge based on a number of things: experience, institutional practices, intuition or simply habit," they said. "Our study showed that these surgeons have few high-quality guidelines and little scientific inform them."

As reported in JAMA Surgery, of 5,530 citations screened, 41 full-text documents were included in the systematic review. Fifteen clinical practice guidelines also were identified, and their quality was assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II).

AGREE II domain scores varied substantially.

Further, the 41 documents included 98 recommended interventions for the prescription of opioids at discharge; eight for the disposal of opioids; and eight for the prevention of chronic postsurgical opioid use.

Only 13 of 114 interventions (11.4%) were supported by an assessment of strength or level of evidence, and the amount of opioid recommended after specific abdominopelvic surgical procedures varied widely among guidance documents, even for the same procedure.

Only two interventions - patient education and comprehensive patient assessment - were supported by a recommendation strength and level of evidence.

Ten documents recommended that clinicians ensure that opioids are appropriately indicated. Only six provided a frequency of administration in their recommended opioid prescriptions.

Drs. Baxter and Zhang said, "In addition to prescribing opioids in a responsible manner, abdominal surgeons must actively engage in providing patient education, especially instructions on the appropriate disposal of excess opioids. However, despite the risk of misuse, diversion, or accidental overdose of surplus opioids kept by patients, there is little guidance about how to ensure that patients safely (do this)."

Dr. Yury Khelemsky, Associate Professor of Anesthesiology, Perioperative and Pain Medicine at Icahn School of Medicine at Mount Sinai, commented in an email to Reuters Health that the need for guidelines for opioid prescribing after abdominal or pelvic surgery is "self-evident." However, he said, "it is important to note that there are many types of surgeries and some are much more painful than others."

"In order to minimize opioid-related issues, leveraging the many available non-opioid medications, which can be just as effective for acute pain as opioids, should be a core objective," he said.

"Furthermore," he added, "close followup and reassessment of the patient within a few days of the surgery is crucial to guide further treatment."

SOURCE: JAMA Surgery, online March 11, 2020.