A study by investigators from Massachusetts General Hospital (MGH) and Newton-Wellesley Hospital (NWH) found that patients prescribed opioid medications after inguinal (groin) hernia surgery used significantly fewer tablets than prescribed, even though they had received fewer than typically administered for such surgery. Not only did 86 percent of patients use less than half the prescribed tablets, 60 percent of them used no opioids at all, relying totally on other types of pain medication.
"The implication of our study is that, even though surgeons have been careful to limit the number of opioid tablets that we prescribe following operations, we may still be prescribing more medication than is actually needed by our patients," says Peter Masiakos, MD, Department of Pediatric Surgery, MassGeneral Hospital for Children, senior author of the paper that has been published online in the journal Surgery. "While these results need to be replicated in other practices and institutions, we have initiated a change in our prescribing practices in light of these findings."
Noting the significant impact of the opioid epidemic throughout society—with a quadrupling of deaths caused by prescription opioid overdoses during the past decade—the authors cite recent data indicating that the risk of postoperative opioid prescriptions leading to dependence may be as high as 6 percent and even higher if patients are prescribed longer-term, higher-dose opioid treatment. While several studies have traced opioid overprescribing to primary care physicians, the authors note that surgeons may also overprescribe. One recent study reported that patients routinely were prescribed an average of 30 opioid tablets after inguinal hernia repair surgery and recommended a reduction to 15 tablets.
Since the conclusions of that study were not based on patients' reports of their actual need for opioid treatment, the research team—including Michael Reinhorn, MD, an NWH general surgeon who specializes in hernia repair - surveyed 186 patients treated in Reinhorn's practice from October 2015 through September 2016. Participants were adults who had elective inguinal hernia repair under local anesthesia with intravenous sedation. For postoperative pain relief, each patient was given a prescription for 10 tablets of the opioid medication Vicodin but also was encouraged to use nonopioid medications like acetaminophen or ibuprofen to manage their pain whenever possible.
At their follow-up appointments two to three weeks after surgery, participants were surveyed regarding the levels of postoperative pain they experienced, how it had affected their functioning and how many opioid tablets they had taken. While 13 patients reported needing nine or more opioid tablets, 159 (86 percent) took four or fewer tablets, and 110 (60 percent) took none. No patient reported taking any Vicodin during the week before the follow-up visit.
Asked how much their pain had interfered with their daily lives, 67 percent reported no interference, 23 percent indicated only slightly restricting their activities because of pain, and only five patients reported a significant effect of postoperative pain on their daily activities. The patients who reported taking no opioid tablets were least likely to report having experienced a high level of pain or curtailing their daily activities because of pain.
"We've been informally asking postoperative patients about their use of opioids for years, so we expected to see about 50 percent of our patients using opioids," says Reinhorn. "While we were quite pleased to have our suspicions confirmed, it was surprising that, of the 40 percent who did take opioids, most only took two to four pills, and most reported only needing Vicodin to help them sleep comfortably at night."
Masiakos says, "These results suggest that we should take a detailed look at our patient's experiences and our prescribing habits to really determine how much opioid medication we should provide our patients. Writing smaller prescriptions should help reduce the number of extra opioid tablets that could be diverted or abused. Patients who experience more pain than expected or need more pain tablets than they are prescribed would alert us to the possibility of a postoperative problem that might need attention."
More information: Konstantinos S. Mylonas et al, Patient-reported opioid analgesic requirements after elective inguinal hernia repair: A call for procedure-specific opioid-administration strategies, Surgery (2017). DOI: 10.1016/j.surg.2017.06.017
Provided by: Massachusetts General Hospital