Background & Aims
The improper prescription of opioids after surgery is a well-known iatrogenic factor contributing to the current opioid crisis. However, the extent of mismatched opioid prescription after surgery has never been well-studied. In this study, we define mismatched opioid prescription as the difference between a patient’s daily dose of discharge opioid prescription and the same patient’s inpatient opioid consumption within 24 hours of discharge being ? 7.5 oral morphine milligram equivalent (MME) (one pill of 5 mg Oxycodone). There are two scenarios of mismatched opioid prescriptions: one in which the daily dose of discharge opioid prescription is at least 7.5 MME higher than the inpatient daily opioid consumption, and another in which the daily dose of discharge opioid prescription is at least 7.5 MME lower than the inpatient daily opioid consumption. For simplicity, we use the term “opioid over-prescription” to describe the former scenario and “opioid under-prescription” for the latter.
Methods
This is a retrospective cohort study of 34,385 opioid-naïve adult patients who underwent surgery across all surgical subspecialties, with postoperative hospital stay of ? 24 hours at UCSF Medical Center between June 2012 and December 2019. Opioid-naive patients were defined as those with no opioids listed in their admission medication records and no record of opioid use within six months before surgery. Patients who received regional nerve block or epidural analgesia within 24 hours of discharge were excluded because, with local anesthetics, the inpatient opioid usage in the last 24 hours before discharge did not represent patients’ true daily opioid requirement to control their postsurgical pain. The primary outcome was the extent of mismatched opioid prescription upon hospital discharge, and the secondary outcomes were opioid refill prescribed by surgical teams 1-30 and 31-90 days after discharge. The data were analyzed using chi-square test and multivariable logistic regression.
Results
We have observed a remarkable mismatch between the prescribed and inpatient daily MME. 66.6% of the patients were opioid over-prescribed, with median [interquartile range (IQR)] over-prescribed dose of 45.0 [25.0 to 75.0] MME, whereas 17.6% were opioid under-prescribed, with median [IQR] under-prescribed dose of -27.0 [-52.0 to -14.0] MME. Both opioid over- and under-prescription occurred across all surgical subspecialties. Our multivariable logistic regression showed that when other variables were controlled, opioid under-prescription, but not opioid over-prescription, emerged as an independent factor associated with increased risks of opioid refill 1-30 (adjusted odds ratio (aOR) [95% CI] 1.22 [1.08 to 1.38]) and 31-90 days (aOR [95% CI] 1.23 [1.06 to 1.43]) after discharge. While the rate of opioid over-prescription decreased from 69.8% in 2017 to 55.0% in 2019 (p<0.0001), the rate of opioid under-prescription increased from 15.0% in 2017 to 20.6% in 2019 (p<0.0001).
Conclusions
There is a substantial difference between the daily dose of discharge opioid prescription and patient’s own inpatient opioid consumption within 24 hours of discharge after surgery, and this mismatch presents as both opioid over-prescription and opioid under-prescription. In sharp contrast to the decreased rate of opioid over-prescription in recent years, the rate of opioid under-prescription has increased during the same period. Importantly, opioid under-prescription, not over-prescription, is an independent factor associated with increased risks of opioid refill 1-30 and 31-90 days after discharge.
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