Post-op opioid scripts for seniors: Numbers unchanged but doses lower

The number of opioid prescriptions after surgery among older people has remained constant over a period of 7 years, although the doses have dropped, owing to a shift from fixed-dose combination towards separate opioid and nonopioid prescriptions, according to a study presented at the Anesthesiology 2022 Annual Meeting.

Between 2013 and 2019, the number of patients who filled separate nonopioid prescriptions, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) within 7 days after surgery jumped from 9 percent to 28 percent (p<0.001). Many of these patients also received a separate opioid prescription, and the percentage of patients who received opioid-containing prescriptions either in a fixed-dose combination or a separate agent stayed the same over time (76 percent in 2013 to 75 percent in 2019). [ANESTHESIOLOGY 2022, abstract A1018]

Nevertheless, the overall dose of the opioid prescriptions dropped from an average of 317 morphine milligram equivalent (MME) in 2013 to 260 MME in 2019. A notable trend emerged in 2019, where patients who filled separate prescriptions for an opioid and nonopioid analgesic were prescribed a lower opioid dose as compared to those prescribed an opioid alone or a fixed-dose opioid/nonopioid combination (adjusted mean MME, 93 vs 133 and 116, respectively).

“While it’s good news that the doses in opioid prescriptions are being reduced, the fact that the actual number of opioid prescriptions filled has remained the same shows there is still an opportunity for improvement,” said Dr Naheed Jivraj, principal investigator of the study and a critical care medicine fellow at the University of Toronto, Ontario in Canada.

“That’s particularly true for procedures associated with low postoperative pain that can be effectively controlled with nonopioid medications such as acetaminophen and NSAIDs,” he added.

Turning to nonopioid painkillers

Opioids can be an important part of pain management after surgery. However, opioids have been shown to cause side effects and lead to addiction, as well as a potentially deadly overdose.

“To limit excess opioid prescribing in the perioperative period among older patients, physicians are turning to other analgesic strategies,” such as lowering the opioid dose and prescribing nonopioid analgesics, according to Jivraj.

In the study, Jivraj and colleagues evaluated the annual trends of nonopioid analgesic prescribing for 278,366 patients aged ≥66 years (median age 72 years, 55.1 percent women) who had undergone surgical procedures. Overall, 60,181 (22 percent) patients filled no analgesic prescriptions within 7 days of discharge, 5,534 (2 percent) filled a nonopioid prescription only, 59,608 (21 percent) filled an opioid prescription only, and 153,043 (55 percent) filled some combination of opioid and nonopioid.

“Almost a third of patients now receive a separate nonopioid prescription after surgery. Rather than prescribing nonopioids alone, this represents a shift away from combination opioid/nonopioid prescribing towards separate opioid and nonopioid prescriptions,” Jivraj pointed out.

“Our study highlights how pain management practices are changing after surgery,” he said. “The increase in seniors filling nonopioid prescriptions and the lower opioid dose may reflect the development of surgery-specific prescribing guidelines and the increasing use of anaesthesiologist-championed Enhanced Recovery After Surgery protocols and other programs that focus on improving patient outcomes.”

Jivraj called for additional studies to identify the barriers to use of nonopioid analgesia at the patient and provider level.