Oral Abstract presentation at the Annual National Conference Society of General Internal Medicine 5/13/2106 Hollywood FL

1. Opioid Analgesia Use After Ambulatory
Surgery: Mismatch Between Quantities
Prescribed and Used
Christopher Shanahan MD MPH,
Inga Holmdahl BA, Olivia Gamble BA, Julia Keosaian MPH,
Marc LaRochelle MD, Ziming Xuan ScD, Jane Liebschutz MD MPH
Boston Medical Center
Boston University School of Medicine
May 13, 2016
Substance Abuse: Opioids
Supported by a grant
from the CAREFUSION
Foundation

2. Prescription Opioid Misuse
• Post surgical overprescribing of opioids may
contribute to diversion and addiction1,2
– Post-op patients may not take full prescription3,4
– Leftover medication may be risky because of potential for
diversion or abuse
• Day surgery patients self-manage their opioid
prescriptions1,2
• Lack of clinical guidelines for day surgery prescribing
2
(1) Bateman BT, Choudhry NK. Limiting the Duration of Opioid Prescriptions: Balancing Excessive Prescribing and the Effective Treatment of Pain. JAMA Intern
Med. Apr 2016 [Epub before print]. (2) Alam A, et al. Long-term Analgesic Use After Low-Risk Surgery: A Retrospective Cohort Study. Arch Intern Med. Mar
2012;172(5)425-430. (3) Bates C, et.al. Overprescription of Postoperative Narcotics: A Look at Postoperative Pain Medication Delivery, Consumption and Disposal in
Urological Practice. J Urol. Feb 2011;185(2):551-555. (4) Rodgers J, et.al. Opioid Consumption Following Outpatient Upper Extremity Surgery. J Hand Surg.
2012;37(4):645-50.

3. Study Aims
Among a cohort of patients who underwent elective,
ambulatory surgery, we sought to study:
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1. Surgeons’ post-operative
opioid prescribing patterns
2. Patients’ use of prescribed
opioids in post-operative period
3. Patients’ plans for leftover
medications

4. Setting and Design
Setting:
– Ambulatory surgery
– Academic safety-net hospital
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Design:
– Prospective observational study

5. Participant Selection
Inclusion Criteria
– Aged ≥18 years
– Undergoing elective, ambulatory surgery
– Working phone
– English speaking
Exclusion Criteria
– Procedures not expected to require post-operative
pain management (eye surgery, endoscopy, etc.)
– Cancer-related procedures
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6. Data Collection
Recruitment:
– List of upcoming surgeries selected
from EHR
– Surgeons signed opt-out letter to
patients
– Patient letter included a phone
number for patients to call to “opt out”
– Research Assistants called potential
participants (January-August 2015)
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7. Data Collection
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• 7-10 days post-surgery
• Medication-taking
(Time Line Follow-Back)
• Plans for leftover
medication
Follow-Up SurveyBaseline Survey
• ≤1 week prior to surgery
• Demographics
• Pain (GCPS)
• Depression (PHQ-8)
• Substance use (CAGE-
AID, AUDIT, & DUDIT)
GCPS: Graded Chronic Pain Scale
PHQ-8: Patient Health Questionnaire depression scale
AUDIT: Alcohol Use Disorders Identification Test
DUDIT: Drug Use Disorders Identification Test

8. Aim 1 Methods: Describe Surgeon’s
Post-operative Prescribing Patterns
• Patient interview within 1 week before day of surgery
• Chart review to confirm opioid prescription
– # of tablets
– Dosage
– Instructions (Sig.)
• Calculate Days Supplied Opioid
• Calculate Morphine Equivalent Dose (MED)
• Sort patients by Total MED prescribed (Quintiles)
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9. Aim 1 Methods:
Prescription Conversion Calculations
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Days Prescribed Opioid =
Total Pills Dispensed / Max Daily Pills
Total MED Dispensed =
Total Mg of Opioid Dispensed / Max Daily Pills
Conversion Factor:
1 mg Oxycodone =
1.5 mg Morphine
Example
Total Oxycodone mg dispensed:
5 mg x 30 pills = 150mg
Convert to Total MED = 1.5 x 150 = 225 MED
Example
Dispensed pills = 30
Max daily pills: 2 q 4 hours = 12 pills/day
30 pills/12 pills per day = 2.5 days Prescribed Opioid

10. Aim 2 Methods: Describe Patient’s Post-
Operative Use of Prescribed Opioids
Self-reported use
– Patient telephone Interview
within 10 days of day of surgery
– 10-Day Time-Line Follow Back
– # of tablets taken per day
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11. Aim 3 Methods: Describe Patient’s
Plans for Leftover Medications
• Patient telephone interview within 10 days
of day of surgery
• Plan for leftover medication
• Self-reported, open written responses (TLFB)
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12. Screened
(n=338)
Consented
(n=181)
Baseline Complete
(n=177)
Follow-Up Complete
(n=149)
Patient Selection
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Identified Patients
(n=619)
Eligible
(n=266)
Could not be reached/ opted out
(n=281)
Ineligible
(n=72)
Refused
(n=85)
Did not Complete Baseline
(n=4)
Lost to Follow-Up
(n=28)

13. Baseline Characteristics
N = 149
Mean age (range)
49
(20-81)
Female (%) 53
Hispanic (%) 17
Limiting & Disabling Pain or worse (GCPS) (%) 42
Depression (PHQ-8) (% score ≥ 10/40) 15
Alcohol Risk (AUDIT) (% score ≥ 8/40) 9
Drug Risk (DUDIT) (% score ≥ 2/44) 18
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14. Follow Up Characteristics
N=149 (%)
Complete or High Pain Relief (7 to 10/10) 68
Moderate Pain Relief (4 to 6/10) 24
Low or No Pain Relief (0 to 3/10) 8
Would have liked more pain treatment (Yes) 22
Took opioids more often than prescribed (Yes) 15
Needed early refill of prescription (Yes) 10
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15. Total MED Prescribed
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5% 7%
17%
51%
19%
0%
10%
20%
30%
40%
50%
60%
0 1-100 101-200 201-300 >300
Total MED Prescribed (mg)
N = 149

16. MED: Mean Taken vs. Mean Leftover
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48.6 (61%) 68.6 (46%)
125.4 (50%)
213.6 (47%)
30.6 (39%)
81.1 (54%)
123.2 (50%)
243.0 (53%)
0
100
200
300
400
500
1-100 101-200 201-300 >300
Meds Taken Meds Leftover
MeanMED
Total MED Prescribed
N = 116

17. Number of Days
Prescribed Opioid 17
9-11 days (4%)
12-14 days (1%)
15-17 days (1%)
N = 149
3-5 days (63%)
0-2 days (14%)
6-8 days (17%)

18. Plans for Leftover Medication
N = 107
Among Participants who endorsed
having leftover medication
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Safe Disposal
(34%)
Keep/Store
Pills (43%)
Keep Taking
Prescription (10%)
Throw Away (7%)
Don’t Know (6%)

19. Limitations
• Study performed at one site only
• Convenience sample
• Limited number of surgeons per specialty
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20. Leftover Medication
• The equivalent of 4,049, 5 mg Oxycodone pills were
prescribed to this group (30,368 MED)
• 29% of participants took all prescribed medication
• Patients used Less than half the medication
prescribed to them
– 14,820 MED (49%), the equivalent of 1,976 pills, were
consumed
– 15,548 MED (51%), the equivalent of 2,073 pills, were
leftover
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21. Conclusions: Mismatch between Surgeon
Prescribing Practice and
Patient Use of Pain Medication
• Substantially less post-operative opioid pain
medication was used than prescribed
• Post-operative opioid pain medication was used for a
substantially shorter time period than prescribed
• The percentage of prescribed pain medication not
taken by patients was just over 50% for patients
prescribed higher Total MED
• Over 50% of patients reported plans to retain
unused medications after pain resolution
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22. Implications: Minimize Mismatch
Steps should be considered to:
• Reduce unnecessary ambulatory post-operative opioid
prescribing may be possible by improving:
 Physician prescribing practices
 Patient disposal options
• Set realistic expectations for pain management with
patients
• Create enhanced systems that facilitate more flexible
prescribing for pain management
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23. Future Directions
Include:
• Complete multivariate analysis of patient & surgeon
characteristics that may impact prescribing taking
practices & medication taking behaviors
• Review physician prescribing practices in detail
• Develop approaches to provide:
• Individualized prescribing feedback to surgeons
• Pre-operative pain management counseling to patients
• Education for safe opioid use & disposal to patients
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24. Acknowledgements
Collaborators:
Inga Holmdahl BA
Olivia Gamble BA
Julia Keosaian MPH
Marc LaRochelle MD
Ziming Xuan ScD
Jane Liebschutz MD MPH
David McAneny MD (Vice Chair Surgery)
Gerry Doherty MD (Chief of Surgery Surgery)
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