Abstract
Adverse events related to opioid analgesics are common.1,2 Although opioids represent a component of pain treatment regimens following low-risk surgery,3,4 few data exist regarding patterns of postoperative opioid prescribing over time. We assessed trends in the amount of hydrocodone/acetaminophen and oxycodone/acetaminophen prescribed, 2 opioids commonly used for postoperative pain management.
Methods
The University of Pennsylvania determined this research was exempt from review. We identified patients from the Clinformatics Data Mart Database (OptumInsight),5 including health care encounters of approximately 14 million primarily commercially insured patients. Adults in the database tend to be younger and from the South compared with the US population. The database includes pharmacy and medical claims with data on services and procedures.
The sample included opioid-naive adults (age, 18–64y) who underwent 1 or more of 4 low-risk surgical procedures in 2004, 2008, or 2012: carpal tunnel release, laparoscopic cholecystectomy, inguinal hernia repair, or knee arthroscopy. Patients who filled any opioid prescription in the 6 months before surgery were excluded. We assessed the proportion of patients who filled any opioid prescription (and specifically hydrocodone/ acetaminophen or oxycodone/acetaminophen) in the 7 days after hospital discharge (inpatients) or after the procedure date (outpatients).
For patients who filled a prescription for hydrocodone/ acetaminophen or oxycodone/acetaminophen, we calculated morphine equivalents dispensed using a standard conversion table.6 We calculated the mean duration of prescriptions, daily morphine equivalent dose, and total morphine equivalents across the procedures and over time. We assessed trends using linear regression, adjusting for age, sex, inpatient/outpatient procedure, and region. Two-sided P values less than .05 were considered statistically significant; SAS (SAS Institute), version 9.3, was used.
Results
Characteristics of opioid-naive patients who underwent a low-risk surgical procedure (N = 155 297) changed over time, becoming more likely to be older and male and less likely to have inpatient surgery. Within 7 days, 80.0% filled a prescription for any opioid, and 86.4%of these prescriptions were for hydrocodone/acetaminophen or oxycodone/acetaminophen (Table 1). The proportion filling a prescription for hydrocodone/ acetaminophen or oxycodone/acetaminophen varied across surgical procedures from 59.7% (carpal tunnel release) to 75.5% (inguinal hernia repair). The proportions of patients filling prescriptions for any opioid and for hydrocodone/ acetaminophen and oxycodone/acetaminophen increased over time for all surgical procedures (Table 1).
Table 1.
Characteristics of Opioid-Naive Patients Who Underwent Carpal Tunnel Release, Laparoscopic Cholecystectomy, Inguinal Hernia Repair, or Knee Arthroscopy Surgical Procedures, 2004–2012
| Patient Characteristics | Total Cohort | Carpal Tunnel Release
|
Laparoscopic Cholecystectomy |
Inguinal Hernia Repair
|
Knee Arthroscopy
|
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2004 | 2008 | 2012 | 2004 | 2008 | 2012 | 2004 | 2008 | 2012 | 2004 | 2008 | 2012 | ||
| Total patients, No. | 155 297 | 7459 | 7123 | 6567 | 14 615 | 17 165 | 15 409 | 8719 | 8311 | 6266 | 20 867 | 22 945 | 19 851 |
|
| |||||||||||||
| Filling a prescription within 7 d, No. (%) | |||||||||||||
|
| |||||||||||||
| Any opioid | 124 207 (80.0) | 5402 (72.4) | 5369 (75.4) | 5000 (76.1) | 10 995 (75.2) | 13 621 (79.4) | 12 464 (80.9) | 7223 (82.8) | 7098 (85.4) | 5375 (85.8) | 16 504 (79.1) | 18 882 (82.3) | 16 274 (82.0) |
|
| |||||||||||||
| Hydrocodone/ acetaminophen or oxycodone/acetaminophen | 107 348 (69.1) | 4030 (54.0) | 4249 (59.7) | 4340 (66.1) | 8586 (58.8) | 11 538 (67.2) | 11 469 (74.4) | 6197 (71.1) | 6378 (76.7) | 5019 (80.1) | 14 172 (67.9) | 16 620 (72.4) | 14 750 (74.3) |
|
| |||||||||||||
| Age, mean (SD), y | 45.3 (11.9) | 48.4 (9.7) | 49.7 (9.3) | 50.2 (9.7) | 42.6 (11.5) | 43.0 (11.8) | 43.2 (11.9) | 45.1 (12.0) | 46.4 (11.9) | 47.5 (12.0) | 44.3 (11.9) | 45.7 (12.1) | 46.4 (12.3) |
|
| |||||||||||||
| Men, No. (%) | 76 912 (49.5) | 2210 (29.6) | 2254 (31.6) | 2333 (35.5) | 3342 (22.9) | 4201 (24.5) | 4075 (26.5) | 7919 (90.8) | 7593 (91.4) | 5755 (91.8) | 12 309 (59.0) | 13 437 (58.6) | 11 484 (57.9) |
|
| |||||||||||||
| Inpatient procedure, No. (%) | 6367 (4.1) | 53 (0.7) | 56 (0.8) | 35 (0.5) | 2014 (13.8) | 1910 (11.1) | 1439 (9.3) | 203 (2.3) | 164 (2.0) | 116 (1.9) | 168 (0.8) | 130 (0.6) | 79 (0.4) |
|
| |||||||||||||
| Region, No, (%) | |||||||||||||
|
| |||||||||||||
| Northeast | 14 454 (9.3) | 669 (9.0) | 640 (9.0) | 542 (8.3) | 1120 (7.7) | 1228 (7.2) | 1100 (7.1) | 999 (11.5) | 864 (10.4) | 666 (10.6) | 2130 (10.2) | 2336 (10.2) | 2160 (10.9) |
|
| |||||||||||||
| South | 68 060 (43.8) | 2888 (38.7) | 3152 (44.3) | 2848 (43.4) | 6827 (46.7) | 9030 (52.6) | 7943 (51.6) | 3504 (40.2) | 3777 (45.5) | 2728 (43.5) | 7728 (37.0) | 9817 (42.8) | 7818 (39.4) |
|
| |||||||||||||
| Midwest | 51 859 (33.4) | 3252 (43.6) | 2529 (35.5) | 2352 (35.8) | 5047 (34.5) | 4737 (27.6) | 4311 (28.0) | 3131 (35.9) | 2551 (30.7) | 1886 (30.1) | 7981 (38.3) | 7323 (31.9) | 6759 (34.1) |
|
| |||||||||||||
| West | 20 853 (13.4) | 647 (8.7) | 799 (11.2) | 823 (12.5) | 1611 (11.0) | 2168 (12.6) | 2047 (13.3) | 1078 (12.4) | 1114 (13.4) | 982 (15.7) | 3011 (14.4) | 3467 (15.1) | 3106 (15.7) |
|
| |||||||||||||
| Unknown | 71 (0.1) | <10 | <10 | <10 | 10 (0.1) | <10 | <10 | <10 | <10 | <10 | 17 (0.1) | <10 | <10 |
Among patients filling a prescription for hydrocodone/ acetaminophen or oxycodone/acetaminophen, the mean morphine equivalents dispensed ranged from 203.0(95%CI, 202.1–204.0) for laparoscopic cholecystectomy to 268.8 (95% CI, 267.6–270.0) for knee arthroscopy (Table 2). The mean morphine equivalents dispensed increased over time for all procedures: adjusted increase from 2004 through 2012,29.71 (95% CI, 28.08–31.35; P < .001). The adjusted increase was highest for knee arthroscopy: 45.16 morphine equivalents (95% CI, 42.26–48.07; P < .001). This increase was driven by an increase in the mean daily dose prescribed, with little change in the duration of prescriptions (Table 2).
Table 2.
Total Opioids Prescribed, Mean Daily Dose, and Duration of Prescription for Opioid-Naive Patients Who Filled an Opioid Prescription for Hydrocodone/Acetaminophen or Oxycodone/Acetaminophen Within 7 Days After Surgery (Outpatients) or Hospital Discharge (Inpatients), 2004–2012
| Surgery Type | Total Morphine Equivalents Prescribed
|
Mean Daily Dose Prescribed, mg
|
Duration of Prescription, d
|
||||||
|---|---|---|---|---|---|---|---|---|---|
| Mean (95% CI) | Absolute Change (95% CI) | P Valuea | Mean (95% CI) | Absolute Change (95% CI) | P Valuea | Mean (95% CI) | Absolute Change (95% CI) | P Valuea | |
| All 4 surgical proceduresb | |||||||||
|
| |||||||||
| All years | 235.1 (234.4 to 235.8) | 51.6 (51.4 to 51.7) | 5.0 (5.0 to 5.1) | ||||||
|
| |||||||||
| 2004 | 219.2 (218.1 to 220.2) | Reference | 48.7 (48.5 to 49.0) | Reference | 5.1 (5.0 to 5.1) | Reference | |||
|
| |||||||||
| 2008 | 237.4 (236.3 to 238.5) | 17.83 (16.23 to 19.44) | <.001 | 51.0 (50.7 to 51.2) | 2.19 (1.84 to 2.54) | <.001 | 5.1 (5.1 to 5.1) | 0.03 (−0.01 to 0.07) | .10 |
|
| |||||||||
| 2012 | 247.4 (246.1 to 248.8) | 29.71 (28.08 to 31.35) | <.001 | 54.8 (54.6 to 55.1) | 6.29 (5.93 to 6.65) | <.001 | 4.9 (4.9 to 5.0) | −0.12 (−0.17 to 0.08) | <.001 |
|
| |||||||||
| Carpal tunnel releasec | |||||||||
|
| |||||||||
| All years | 213.1 (211.1 to 215.1) | 47.0 (46.7 to 47.4) | 5.0 (4.9 to 5.0) | ||||||
|
| |||||||||
| 2004 | 201.6 (198.7 to 204.5) | Reference | 44.4 (43.8 to 45.1) | Reference | 5.1 (5.0 to 5.2) | Reference | |||
|
| |||||||||
| 2008 | 216.4 (213.1 to 219.8) | 13.21 (8.34 to 18.08) | <.001 | 46.6 (45.9 to 47.2) | 2.03 (1.06 to 2.99) | <.001 | 5.1 (5.0 to 5.1) | −0.05 (−0.17 to 0.07) | .39 |
|
| |||||||||
| 2012 | 220.5 (216.6 to 224.4) | 17.58 (12.74 to 22.43) | <.001 | 50.0 (49.3 to 50.7) | 5.38 (4.42 to 6.34) | <.001 | 4.8 (4.7 to 4.9) | −0.30 (−0.41 to −0.18) | <.001 |
|
| |||||||||
| Laparoscopic cholecystectomyc | |||||||||
|
| |||||||||
| All years | 203.0 (202.1 to 204.0) | 49.2 (49.0 to 49.5) | 4.6 (4.5 to 4.6) | ||||||
|
| |||||||||
| 2004 | 190.1 (188.4 to 191.8) | Reference | 47.0 (46.6 to 47.5) | Reference | 4.6 (4.5 to 4.6) | Reference | |||
|
| |||||||||
| 2008 | 203.8 (202.2 to 205.4) | 12.47 (10.07 to 14.86) | <.001 | 48.9 (48.5 to 49.3) | 1.75 (1.12 to 2.37) | <.001 | 4.6 (4.5 to 4.6) | −0.02 (−0.08 to 0.05) | .58 |
|
| |||||||||
| 2012 | 211.9 (210.2 to 213.5) | 20.39 (17.99 to 22.79) | <.001 | 51.3 (50.9 to 51.7) | 4.15 (3.52 to 4.78) | <.001 | 4.6 (4.5 to 4.6) | −0.05 (−0.12 to 0.01) | .13 |
|
| |||||||||
| Inguinal hernia repairb | |||||||||
|
| |||||||||
| All years | 221.5 (220.1 to 222.9) | 51.9 (51.6 to 52.3) | 4.7 (4.7 to 4.7) | ||||||
|
| |||||||||
| 2004 | 212.1 (209.9 to 214.3) | Reference | 50.4 (49.8 to 50.9) | Reference | 4.7 (4.7 to 4.8) | Reference | |||
|
| |||||||||
| 2008 | 224.6 (222.2 to 226.9) | 11.84 (8.57 to 15.10) | <.001 | 51.7 (51.1 to 52.2) | 1.29 (0.47 to 2.11) | .002 | 4.8 (4.7 to 4.8) | 0.03 (−0.05 to 0.11) | .51 |
|
| |||||||||
| 2012 | 229.3 (226.7 to 232.0) | 16.57 (13.09 to 20.05) | <.001 | 54.2 (53.6 to 54.9) | 3.82 (2.95 to 4.69) | <.001 | 4.6 (4.6 to 4.7) | −0.10 (−0.18 to −0.01) | .03 |
|
| |||||||||
| Knee arthroscopyb | |||||||||
|
| |||||||||
| All years | 268.8 (267.6 to 270.0) | 54.3 (54.0 to 54.5) | 5.5 (5.5 to 5.5) | ||||||
|
| |||||||||
| 2004 | 244.8 (243.1 to 246.6) | Reference | 50.3 (49.9 to 50.7) | Reference | 5.5 (5.5 to 5.6) | Reference | |||
|
| |||||||||
| 2008 | 271.1 (269.1 to 273.0) | 25.30 (22.47 to 28.12) | <.001 | 53.3 (52.9 to 53.6) | 2.90 (2.33 to 3.47) | <.001 | 5.6 (5.6 to 5.7) | 0.10 (0.03 to 0.16) | .005 |
|
| |||||||||
| 2012 | 289.2 (286.8 to 291.6) | 45.16 (42.26 to 48.07) | <.001 | 59.2 (58.7 to 59.6) | 9.11 (8.53 to 9.70) | <.001 | 5.4 (5.3 to 5.4) | −0.14 (−0.21 to −0.08) | <.001 |
Linear regression adjusting for patient characteristics assessing trends over time.
Adjusted for age, sex, inpatient/outpatient procedure, region, and surgical procedure.
Adjusted for age, sex, inpatient/outpatient procedure, and region.
Discussion
In this cohort, 70%of opioid-naive patients who underwent low-risk surgical procedures filled a prescription for hydrocodone/acetaminophen or oxycodone/acetaminophen within 7 days after discharge or the procedure date. The mean morphine equivalent dose increased over time for all procedures examined, with an increase of 18%(potency equivalent to an additional 45mg of morphine) for patients undergoing knee arthroscopy, driven by a change in the mean daily dose. Because the cohort was restricted to opioid-naive individuals, these changes are unlikely to represent an appropriate response by prescribing physicians to increasing rates of opioid tolerance over time within the population. Possible explanations include an increased focus on pain treatment or an increasing reliance on opioids for postoperative pain relief vs alternative therapies.
Limitations include restriction to 4 surgical procedures; lack of data after 2012, as further changes in prescribing practices could have occurred; use of data that may not be generalizable; and an inability to determine which patients received a prescription that they did not fill. Details regarding source data for the database were provided to us by the vendor in working documents; there may be uncertainty regarding the validity, completeness, and accuracy of the data. Further research should assess the contribution of postoperative opioid prescribing practices to the epidemic of prescription opioid-related abuse.
Acknowledgments
Funding/Support: This work is supported in part by a New Investigator Award from the Canadian Institutes of Health Research (Dr Wijeysundera) and a Merit Award from the Department of Anesthesia at the University of Toronto (Dr Wijeysundera).
Footnotes
Author Contributions: Dr Neuman and Ms Passarella had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Wunsch, Wijeysundera, Neuman.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Wunsch, Neuman.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. OptumInsight approved the manuscript specifically for accuracy of information related to Clinformatics Data Mart Database.
References
- 1.Yokell MA, Delgado MK, Zaller ND, Wang NE, McGowan SK, Green TC. Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA Intern Med. 2014;174(12):2034–2037. doi: 10.1001/jamainternmed.2014.5413. [DOI] [PubMed] [Google Scholar]
- 2.Han B, Compton WM, Jones CM, Cai R. Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003–2013. JAMA. 2015;314(14):1468–1478. doi: 10.1001/jama.2015.11859. [DOI] [PubMed] [Google Scholar]
- 3.Strassels SA, McNicol E, Suleman R. Postoperative pain management: a practical review, part 2. Am J Health Syst Pharm. 2005;62(19):2019–2025. doi: 10.2146/ajhp040490.p2. [DOI] [PubMed] [Google Scholar]
- 4.Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425–430. doi: 10.1001/archinternmed.2011.1827. [DOI] [PubMed] [Google Scholar]
- 5.Optum. [Accessed February 16, 2016];Clinformatics Data Mart. https://www.optum.com/content/dam/optum/resources/productSheets/Clinformatics_for_Data_Mart.pdf.
- 6.University of North Carolina at Chapel Hill School of Medicine. [Accessed February 16, 2016];Opiate equianalgesic dosing chart. https://www.med.unc.edu/aging/fellowship/current/curriculum/palliative-care/UNC%20Equianalgesic%20Card%20-Dec2009.pdf.