Optimizing Opioid Prescription for Outpatient Surgery

INTRODUCTION: Opioid overprescribing by surgeons has contributed to the current opioid epidemic. This has occurred both from the transition of patients to chronic opioid use after initial use for acute pain only and from diversion of unused opioids from prescriptions intended for acute surgical pain. Factors leading to overprescribing by surgeons include historical misinformation about the addictive nature of opioids, societal and governmental expectations, and lack of standard prescribing guidelines. Multiple academic medical centers have developed opioid stewardship programs to study, optimize, and standardize opioid prescribing after surgery through consensus of all relevant stakeholders without changes to patient satisfaction or pain control. OBJECTIVE: No similar guidelines existed at the University of Texas Southwestern Medical Center's Clements University Hospital for acute surgical pain prescription oversight. Our project centered around developing an opioid stewardship program at our own institution using existing resources to align opioid prescribing after common day surgery procedures with established guidelines published by other major institutions. METHODS: We developed a multitiered approach for our opioid stewardship program. This included developing a database, providing educational opportunities to prescribers, and implementing process change in EPIC workflow. Our multidisciplinary team analyzed surgery billing information and EPIC pharmacy data for prescriber type, strength, and average number of pills/dosage of each opioid prescription. Procedures initially targeted included laparoscopic cholecystectomies, laparoscopic appendectomies, inguinal hernia repairs (both open and laparoscopic), and umbilical hernia repairs. To standardize measurements, prescriptions were converted to morphine milligram equivalent (MME), where one opioid tablet= Oxycodone 5mg= MME of 7.5 per tablet. Data was compared to current Outpatient Procedure Guidelines as set forth by the University of Michigan and Johns Hopkins University. A dashboard was created for physicians using collected data to enable review of prescribing habits. Small and large group education sessions on prescribing guidelines were implemented targeting attendings and residents. We identified areas of potential improvement in existing process and changed EPIC order-sets and quantity defaults for prescriptions after routine outpatient procedures. RESULTS: A prescription database was created and formatted for easy analysis in Tableau. Preliminary analysis suggests residents write more than 80% of prescriptions following routine outpatient surgical procedures. Tylenol #3 and Tramadol are the most commonly prescribed. Large variation exists regarding the type and quantity of the opioid medication prescribed. There appears to be a clear downward trend each year in the average MME prescribed, particularly following initial interventions in the summer of 2018, however no robust statistical analysis has yet been performed. There also appears to be less variation in MME and type of medication prescribed beginning in 2017. Educational opportunities in the form of small group and Grand Rounds were offered to faculty, residents and students. EPIC order-sets were implemented within our system for the prescribing of opioids following outpatient procedures and defaults within EPIC were changed. CONCLUSIONS: It is possible to set up a multidisciplinary multi-tiered opioid stewardship program using existing resources. Residents are the primary prescribers of opioids at our institution and targeting this group remains a high priority of the authors of this study. Smaller quantities of opioids are being prescribed after targeted surgical procedures over time post-intervention, and it appears that opioid quantities being prescribed are aligning more closely with published guidelines.