The Optimal Length for an Opioid Prescription - The Crowd Speaks

Finally, a bit of science, even if it is observational in the continuing drumbeat around opioid use and misuse. JAMA Surgery has an article this week entitled, Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures, by Rebecca Scully, et. al.

They looked at the prescriptions of opioid-naïve (no opioid use within a year) military personnel for eight common operations during the period 2005 to 2014. Prime time for the seeds of the “opioid crisis” and before the “experts” told us how to prescribe opioids given our “irresponsible behavior.”

The median age was 40, 50% male, and they underwent on of eight common surgical procedures. 

• A general surgery procedure (cholecystectomy - removal of the gallbladder, appendectomy or removal of the appendix, or repair of a hernia). 
• An orthopedic procedure (repair of cruciate ligament repair – repair of knee ligament, rotator cuff tear repair – repair of shoulder ligament, or discectomy – removal of a disc in the spine).  
• A gynecologic procedure (mastectomy – breast removal or hysterectomy – removal of the uterus). 

Patients were excluded who had been treated with narcotics within the last six months and for prescriptions lasting more than 30 days. As one would expect from a group of military personnel, there were few other co-morbidities (e.g., hypertension, coronary artery disease, etc.) They looked at 215,140 patients or 50% of the entire cohort after exclusions. And here is what they found

• The mean duration of a prescription varied with the type of surgery ranging from 4 to 7 days. 4-day prescriptions were given for appendectomy, cholecystectomy, anterior cruciate and rotator cuff repair and hysterectomy. Hernia repair and mastectomy had a mean prescription duration of 5 days and discectomy seven days.
• Refills were stratified based upon the number of days in the original prescription. That is, a one-day prescription was refilled 43% of the time while a 14-day prescription was refilled far less frequently. Refill rates also varied with the procedure from 10.7% for general surgery procedures with initial prescriptions of 9 days, 32.5% for orthopedic procedures with initial prescriptions of 15 days and 16.8% for gynecologic procedures with initial prescriptions of 13 days.

And from their discussion:

• The optimal length of opioid prescription after common surgical procedures likely lies between the observed median prescription length and the early nadir in the modeled probability of refill: 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures.
• Although a 7-day limit on initial opioid prescriptions appears to be adequate for many common general and gynecologic procedures, for patients undergoing orthopedic and neurosurgical interventions, a 7-day limit may be inappropriately restrictive and place an undue burden on patients and clinicians.

Here is my bottom line. A 7-day prescription fits all may be too much for some general surgery procedures and not enough for some orthopedics ones. Prescribing pain medications involves knowing the patient and the procedure. A one size fits all approach will continue to guarantee that some people remain in pain and others will have excess medications. The wisdom of the crowd depends on four characteristics, that the choices are independent of one another, that there is a diversity of individuals making the choices, that those decisions are made based upon private or local knowledge and that the choices can be aggregated. This study meets those criteria and I believe reflects the wisdom of a crowd. In a world that demands evidenced-based care and precision medicine perhaps these observational findings should be used to inform decisions by policymakers rather than the opinion of the experts - the experts who told us to prescribe more opioids when pain as the fifth vital sign was so fashionable.