QS301 - Discharge Opioid Prescribing In Colorectal Surgery

Purpose/Background: Balancing pain control and opioid exposure for colorectal surgery patients can be challenging. Although the promotion of multimodal pain therapy has decreased the reliance on opioids, they remain the cornerstone of pain control in the postoperative setting. Discharge opioid prescriptions informed by the procedure performed are popular and have reduced opioid over-prescription, but these practices don’t reflect the unique needs of the individual patient. In fact, this practice may inadvertently lead to the under-treatment of some patients, leading to increased request for opioid refills. We hypothesized that discharge prescriptions informed by a patients in-hospital opioid use during the 24-hour prior to discharge could reduce the rate of refills.

Methods/Interventions: This was a retrospective, single-institution, multi-hospital study at a tertiary care center between January 2017 - December 2023 of patients who underwent non-ambulatory colorectal surgery. The final inpatient opioid consumption was calculated in oral morphine equivalents (OME) based on the amount of opioids required in the 24-hour prior to discharge. Patients were categorized into opioid prescription matched (matched-Rx) if the discharge prescription (recommended pills per 24 hours) was within 7.5 OME per day of the inpatient requirement. Opioid over-prescription (over-Rx) and under-prescription (under-Rx) was defined as being prescribed greater than 7.5 OME or less than 7.5 OME, respectively, of the inpatient requirement. Multiple logistic regression analysis was used to study opioid refill rates, adjusting for patient demographic factors, operative factors, preoperative opioid, benzodiazepine, or substance use, in-hospital OME, and pain levels.

Results/Outcomes: A total of 2,176 patients were included in the study, 1,189 (54.6%) in the matched-Rx group, 716 (32.9%) in the over-Rx group, and 271 (12.5%) in the under-Rx group. Compared to the matched-Rx group, the over-Rx group had decreased lengths of stay (aOR 0.95, 95% CI 0.92 – 0.97) and was less likely to be discharged to home (aOR 0.77, 95% CI 0.60 – 0.98). In contrast, the under-Rx group was more likely to have preoperative opioid use (aOR 1.86, 95% CI 1.30 – 2.64) and higher pain levels before discharge (aOR 1.01, 95% CI 1.01 – 1.01). In multiple logistic regression analysis, compared with matched-Rx, over-Rx was associated with increased opioid refills between 1 – 30 days (p = 0.04) and 31 – 90 days (p = 0.04) post-discharge. When compared with matched-Rx, under-Rx was also associated with increased opioid refills between 1 – 30 days (p = 0.009) but not at 31 – 90 days (p = 0.18). When looking at trends over time, the rates of over-Rx decreased, while rates of matched-Rx increased. However, the rates of under-Rx remain unchanged (Figure 1a). Over time there is also a trend towards decreased opiate refills, with 31 – 90 day refills significantly lower (p = 0.002) (Figure 1b).

Conclusion/Discussion: In comparison to matched-Rx, over-Rx and under-Rx appear to be associated with an increased need for opioid refills after surgery. A patient-centered approach to post-colorectal surgery opioid prescribing, utilizing information technology tools within the electronic health record to provide decision support to providers, is a promising approach to further optimize pain management after discharge from the hospital. By individualizing the opioid needs of the patient, opioid refills and prolonged exposure, both risk factors for opioid use disorder, can be reduced.

Annual changes of mismatched opioid prescriptions and opioid refills from 2017 to 2023
a. While the annual rate of over-prescription decreased and that of matched prescription increased from 2017 to 2023, the rate of under-prescription remained unchanged.
b. The annual rate of opioid refill 1-30 days remained unchanged, while the annual rate of opioid refill 31-90 days after discharge decreased from 2017 to 2023.