Abstract
The paper from Samargandi et al 1 raises many important points when considering the use of opioids for pain management and the risk of opioid dependency, addiction, diversion and accidental overdose and even death.
The first background sentence could also read: “For many patients, the postoperative period represents a common reason for receiving an opioid prescription, with the prescriber, potentially initiating dependency or addiction.”
Opioids are used to treat acute pain. For surgical patients, this is in the early post operative period. As the authors describe there are other options to manage pain and reduce the need for opioids: ERAS protocols and multimodal pain management being two.2,3
Despite some design issues which, while perhaps preventing a Hawthorne effect may result in recall bias, the paper follows pain management of 46 patients after breast surgery. Like other evidence in the literature, this paper indicates that not all patients need opioids for pain. Most did very well with acetaminophen and/or NSAID's. Only 20/46 filled their Rx. No one used a refill. No one wants to prescribe too few tablets as there is the cost of time, money and discomfort to get a refill, yet only a third of the prescribed tablets were taken. This would be about ten doses (4 the first day, 3 the second, 2 the third and one the fourth).
One patient returned the excess to pharmacy, three flushed or binned their extra tablets and 8 have them somewhere in their house (likely the medicine cabinet). No evidence of misuse or diversion or accident is documented but the potential is there and is identified.
Table 3 implies a possible prescribing pattern by surgeon. Our research group looked at 16 million opioid prescriptions in BC between 2013 and 2017. 4 We found that different specialties and even individuals have unique prescribing patterns and some are far from the “norm”.
Below is the Summary Plot of all opioid prescriptions (Rx) in BC, by plastic surgeons, in the five years 2013 to 2017 (Figure 1). Each dot represents an individual surgeon's median milligram morphine equivalent (MME) Rx and number of Rx per month. Most are crowded in the bottom left of the plot. Each colour represents a different drug (eg one surgeon wrote an average of 32 Rx per month for codeine at 48 MME, another surgeon wrote 1 Rx per month for hydromorphone for 340 MME).
Summary plot of all opioid prescriptions (Rx) in BC, by plastic surgeons, in the period 2013 to 2017[9].
Any prescribing plastic surgeon in BC can look at this plot and see, for a particular drug whether they are in the range of prescribing of their colleagues or an outlier.
In 2020 the Nova Scotia Prescription Monitoring Program stated that unfortunately they are unable to share the contents of their peer comparison reports as the information is “proprietary, in that it is linked to [their] monitoring activities and is intended to be shared with a focused audience in the short term.” 5 Still these reports used in Nova Scotia, by physicians, will enhance opioid stewardship.
Papers like this and peer comparison data, such as that available in Nova Scotia and a similar program in Alberta will help surgeons reduce their opioid prescribing to what is really required by patients, improving patient and public health and safety. 6
