Patterns of opioid use after surgical discharge: a multicentre, prospective cohort study in 25 countries
Authors:   TASMAN Collaborative, Varghese Chris 
Published: October 2023

Background

Excessive post-surgical opioid prescribing is contributing to the growing opioid crisis. Prescribing practices are modifiable, yet data to guide appropriate prescription of opioids at surgical discharge remain sparse. We therefore aimed to evaluate the factors associated with opioid consumption following discharge from surgery.

Methods

We performed an international, prospective, multicentre, cohort study between 4 April 2022 and 4 September 2022 among adult patients undergoing common general, orthopaedic, gynaecological and urological operations, with follow-up 7 days after hospital discharge. The primary outcome measure was the quantity of prescribed and consumed opioids in oral morphine equivalents (OMEs). Descriptive and multivariable analyses were performed to investigate factors associated with OME quantities prescribed and consumed.

Findings

This analysis includes 4273 patients across 144 hospitals in 25 countries. Overall, 30.7% (n=1311) of patients were prescribed opioids at discharge. For those prescribed opioids, a median of 100 OMEs (IQR 60 - 200) were prescribed but only a median of 40 OMEs (IQR 7.5 - 100; p<0.001) were consumed at follow-up 7 days after discharge. After risk-adjustment, an increased amount of opioids prescribed was independently associated with increased opioid consumption in the follow up period (β = 0.33, 95% CI 0.31 - 0.34, p<0.001), and side-effects. The risk of prescribing more opioids than patients’ consumed increased as quantities of opioids prescribed exceeded 100 OMEs, independent of patient comorbidity, procedure, and pain.

Interpretation

Patients were prescribed more than twice the quantity of opioids they consumed in the 7 days following discharge from surgery. Prescription quantity was associated with increased consumption of opioids even after adjusting for pain levels, suggesting that prescribing practice is a modifiable risk factor to curtailing excessive opioid consumption. Current quantities of opioids provided are in excess of patient needs and may contribute to increasing community opioid use and circulation.

Funding

Maurice and Phyllis Paykel Trust, Surgical Research Funds University of Newcastle.

Research in context

Evidence before this study

Opioids are frequently prescribed at discharge after surgery, yet little is understood about the drivers of opioid use in this setting. We conducted a literature search between November 2020 and February 2021 for studies reporting on opioid prescription and consumption after discharge from surgery. We used the search terms “opioid”, “surgery”, “discharge”, and applied no language or date restrictions. Several global studies examined variations in opioid prescribing, however, little data exists specific to surgical practice. Several single centre and retrospective surgical series examined the independent role of prescribing practice on opioid consumption; however, these data are not globally generalisable. A recent systematic review and meta-analysis suggests the analgesic efficacy of opioids in the post-surgical-discharge setting may be overstated, exposing populations to their adverse events with minimal improvements in pain management. Given the lack of global, generalisable, high-quality data in the setting of post-surgical discharge, practice is predominantly guided by clinician preferences, dogma, and health system cultures.

Added value of this study

This prospective, international, cohort study provides high-quality, cross-specialty, patient-reported data after surgical discharge following a variety of common surgical procedures, including both emergency and elective, minor and major, surgeries. This study includes 4273 patients from 144 centres across 25 countries. Among those prescribed opioids, the median prescription of opioids was 100 oral morphine equivalents (OMEs; IQR 60 - 200) and median consumption at 7-days follow-up was 40 OME (IQR 7.5 - 100; p<0.001). Prescription and consumption of opioids varied by specialty, but predominantly prescribed quantities were in excess of what was consumed by patients within the first 7 days after hospital discharge. This was particularly evident for patients prescribed over 100 OMEs. The quantity of opioids prescribed was associated with higher patient-reported opioid consumption at surgical discharge, and increasing quantities of opioids prescribed and consumed were associated with increased risk of opioid-related harm.

Implications of all the available evidence

Overprescribing opioids increases absolute consumption of opioids, even after adjusting for patients’ pain levels, with an associated increase in opioid-related side effects. The value of opioids after surgical discharge has been questioned, and when prescribed, are frequently in excessive quantities. Prescribing practices need to be altered with a more cautious approach to prescribing opioids after surgical procedures. When required, quantities should be rationalised to minimise opioid-related harm, community circulation of opioids, dependence, misuse, and overdose. Our study bridges a crucial knowledge gap and offers guidance on opioid prescribing across a range of common surgical procedures.