Abstract
This study compares patient-reported outcomes after surgery between opioid-sparing recovery and standard of care.
Despite significant progress, excessive opioid prescribing after surgery is still common.1 This practice increases patient morbidity and introduces pills into the community.2,3 Although opioid-sparing postoperative pathways offer a novel approach to mitigate these risks, concerns about inferior pain control and patient satisfaction have hindered their adoption.4 Therefore, the following study compares patient-reported outcomes (PROs) after common operations between an opioid-sparing recovery pathway and standard of care.
Methods
This quality improvement study of deidentified data was exempted from regulation by the institutional review board of the University of Michigan. The study follows the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline.
We retrospectively compared outcomes of opioid-naive patients participating in an opioid-sparing pathway after surgery at our institution with a propensity score–matched cohort of opioid-naive patients who received standard of care for the same procedures. Patients were included if they underwent laparoscopic cholecystectomy, hernia repair, or thyroidectomy between August 1, 2018, and December 31, 2019. Patients in the opioid-sparing pathway received preoperative counseling to use scheduled acetaminophen and ibuprofen for 1 week after surgery. Postoperatively, they received prescriptions for these medications and a small prescription of 4 to 10 oxycodone 5-mg tablets, depending on procedure. The comparison group received standard of care at the discretion of the prescribing surgeon and was sampled from the Michigan Surgical Quality Collaborative, a statewide registry that routinely collects clinical outcomes and PROs at 70 hospitals. Both groups were contacted between postoperative days 30 to 90 to complete PRO surveys.
Primary outcomes were the number of opioid pills prescribed, number of pills taken, pain score in the 7 days after surgery (0, no pain; 1, minimal pain; 2, moderate pain; 3, severe pain), satisfaction (scale 0, extremely dissatisfied; 10, extremely satisfied), regret (scale 1, absolutely regret surgery; 5, absolutely no regret), and quality of life (scale 1, absolute worst possible quality of life; 5, absolute best possible quality of life).
Propensity-score matching was performed based on patient age, sex, and procedure. Outcomes were compared using t test, Wilcoxon test, or χ2 tests as appropriate. Analysis was performed in Stata, version 16.0 (StataCorp). Two-sided P values were significant at .05.
Results
A total of 310 opioid-sparing patients were matched to 310 patients who received standard of care following surgery. Patients in the opioid-sparing pathway received smaller prescriptions, used fewer pills, and reported less pain following surgery compared with patients who received standard of care (Table 1). In the opioid-sparing pathway, 36.8% of patients (n = 114) did not receive an opioid prescription compared with 0% of patients receiving standard of care. There was no difference in patient satisfaction, regret to undergo surgery, or quality of life between the groups. These findings were consistent across each procedure (Table 2).
Table 1. Age, Sex, Procedure Type, and Outcomes After Propensity-Score Matching.
| Variable | Opioid sparing (n = 310) | Standard of care (n = 310) | P value |
|---|---|---|---|
| Age, mean (SD), y | 52.2 (15.0) | 52.2 (15.0) | >.99 |
| Female, No. (%) | 185 (59.7) | 185 (59.7) | >.99 |
| Procedure, No. (%) | |||
| Laparoscopic cholecystectomy | 91 (29.4) | 91 (29.4) | >.99 |
| Hernia repair | 81 (26.1) | 81 (26.1) | |
| Thyroidectomy | 138 (44.5) | 138 (44.5) | |
| Opioid prescription quantity, pills, median (IQR) | 4 (0-8) | 20 (15-30) | <.001 |
| Patients receiving no opioid prescription, No. (%) | 114 (36.8) | 0 | <.001 |
| Opioid prescription use, pills, median (IQR) | 0 (0-3) | 5 (0-13) | <.001 |
| Pain score, median (IQR) | 1 (1-2) | 2 (2-3) | <.001 |
| Satisfaction score, median (IQR) | 10 (8-10) | 10 (9-10) | .29 |
| Regret score, median (IQR) | 5 (5-5) | 5 (5-5) | .48 |
| Quality of life score, median (IQR) | 5 (4-5) | 5 (4-5) | .74 |
Abbreviation: IQR, interquartile range.
Table 2. Propensity Score–Matched Results for Each Surgical Procedure.
| Variable | Median (IQR) | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Laparoscopic cholecystectomy | Hernia repair | Thyroidectomy | |||||||
| Opioid sparing (n = 91) | Standard of care (n = 91) | P value | Opioid sparing (n = 81) | Standard of care (n = 81) | P value | Opioid sparing (n = 138) | Standard of care (n = 138) | P value | |
| Age, mean (SD), y | 46.6 (15.0) | 46.6 (15.0) | >.99 | 52.9 (16.0) | 52.9 (16.0) | >.99 | 55.5 (13.2) | 55.5 (13.2) | >.99 |
| Female, No. (%) | 67 (73.6) | 67 (73.6) | >.99 | 8 (9.9) | 8 (9.9) | >.99 | 110 (79.7) | 110 (79.7) | >.99 |
| Opioid prescription quantity, No. of pills | 4 (4-5) | 20 (15-30) | <.001 | 10 (0-10) | 24 (15-30) | <.001 | 0 (0-5) | 15 (10-20) | <.001 |
| Patients receiving no opioid prescription, No. (%) | 16 (17.6) | 0 | <.001 | 25 (30.9) | 0 | <.001 | 73 (52.9) | 0 | <.001 |
| Opioid prescription use, No. of pills | 1 (0-4) | 8 (1.5-15) | <.001 | 1 (0-4) | 10 (2-16) | <.001 | 0 (0-1) | 3 (0-7) | <.001 |
| Pain score | 2 (1-2) | 3 (2-3) | <.001 | 2 (1-2) | 3 (2-3) | <.001 | 1 (1-1) | 2 (2-3) | <.001 |
| Satisfaction score | 9 (8-10) | 10 (8-10) | .23 | 10 (9-10) | 10 (9-10) | .18 | 10 (9-10) | 10 (9-10) | .67 |
| Regret score | 5 (5-5) | 5 (5-5) | .63 | 5 (5-5) | 5 (5-5) | .39 | 5 (5-5) | 5 (5-5) | .36 |
| Quality of life score | 5 (4-5) | 5 (4-5) | .52 | 5 (4-5) | 5 (4-5) | .41 | 5 (4-5) | 5 (4-5) | .55 |
Abbreviation: IQR, interquartile range.
Discussion
Patients participating in an opioid-sparing postoperative pathway received and used fewer opioids but reported less pain and similar satisfaction compared with patients receiving standard of care. Similar satisfaction despite differing pain scores may be explained by the influence of other unmeasured factors on overall satisfaction.5 Importantly, more patients in the opioid-sparing group received no opioid prescription, which avoids the risk of diversion into communities. A 2020 analysis of surgical practice outside of the United States corroborates our finding that pain control is not compromised in patients who receive no opioids after surgery.6
This study is limited by its retrospective nature, lack of intraoperative analgesic data, and its exclusion of patients using prescription opioids prior to surgery. Future work is needed to investigate whether patients can recover without opioids after other operations, and whether this strategy can be adapted for patients with preoperative opioid use. Expanding this approach may be an effective way to combat opioid-related morbidity without negatively affecting the patient experience.
References
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