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Opioid Discharge Prescriptions After Inpatient Surgery: Risks of Rebound Refills by Length of Stay

      Abstract

      Introduction

      As inpatient stays become shorter, one concern with standardizing discharge opioid prescriptions is the potential risk of “rebound refills.” We sought to compare opioid prescription refill rates and volumes for surgical patients discharged on postoperative day (POD) 2-3, 4-7, and 8+.

      Methods

      In a prospective quality improvement protocol, faculty volunteered to use either a 5x-multiplier (5x) or usual care (UC) for discharge prescriptions after inpatient (≥48 h stay) surgery from Sep-Dec 2019. The 5x-multiplier is 5-times the patient's last 24-h opioid use (by oral morphine equivalents, OME). Cohorts were compared by POD of discharge: POD 2-3 (“SHORT”), POD 4-7 (“INTERMEDIATE”), and POD 8+ (“LONG”). The primary endpoint was 30-d refill rates. Secondary endpoints included 30-d refill OME and inpatient opioid weaning/discharge metrics.

      Results

      From 22 faculty, 409 patients were included. When stratified by POD, 154 (37.7%) were discharged SHORT, 176 (43.0%) INTERMEDIATE, and 79 (19.3%) LONG. SHORT stay patients had a median last 24-h OME of 10 mg (versus 5 mg INTERMEDIATE, 5 mg LONG; P = 0.268), and a median discharge OME of 55 mg (versus 75 mg INTERMEDIATE, 100 mg LONG; P = 0.221). Patients with SHORT stays did not have higher refill rates (11.7% versus 18.2% INTERMEDIATE, 19.0% LONG; P = 0.193) or higher median refill OME (150 mg versus 300 mg INTERMEDAITE, 339 mg LONG; P = 0.154).

      Conclusions

      Despite concerns of increased refills, patients discharged by POD 2-3 were not associated with “rebound refills.” A patient-centered 5x-multiplier standardization of discharge opioid prescriptions is feasible in all inpatient surgery patients, even those discharged following a short inpatient stay.

      Keywords

      Introduction

      Over the past 2 decades, there have been nearly 500,000 deaths attributed to the opioid epidemic in the United States.
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      Prevention of opioid overdose.
      Surgical patients who develop persistent opioid use are often first exposed to opioids in the perioperative period, and efforts have been made at both regional and national levels to mitigate this adverse iatrogenic sequela.
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      Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic.
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      • Brummett C.M.
      • Waljee J.F.
      • Englesbe M.J.
      Statewide implementation of postoperative opioid prescribing guidelines.
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      Prescription opioid analgesics commonly unused after surgery: a systematic review.
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      • et al.
      Provider characteristics associated with outpatient opioid prescribing after surgery.
      • Hill M.V.
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      • Stucke R.S.
      • Barth Jr., R.J.
      Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.
      • Lancaster E.
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      • Hirose K.
      • et al.
      Variability in opioid-prescribing patterns in endocrine surgery and discordance with patient use.
      Higher opioid prescription volumes are harmful as they are closely linked to patient opioid consumption and may increase the likelihood of persistent, or long-term, opioid use.
      • Shah A.
      • Hayes C.J.
      • Martin B.C.
      Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015.
      Efforts to overcome this include preoperative counseling to set expectations, limiting the number of opioids administered intraoperatively, expeditiously weaning opioids while inpatient, and standardizing discharge prescriptions.
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      Patient-centered opioid prescribing: breaking away from one-size-fits-all prescribing guidelines.
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      • et al.
      Standardizing opioid prescriptions to patients after ambulatory oncologic surgery reduces overprescription.
      Beyond the risk for persistent use, excess discharge opioid prescriptions may result in community diversion, and therefore it is critical to understand who receives the largest opioid prescriptions at discharge and which patients are requiring refills.
      • Brummett C.M.
      • Waljee J.F.
      • Goesling J.
      • et al.
      New persistent opioid use after minor and major surgical procedures in US adults.
      • Porter E.D.
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      • Molloy I.B.
      • et al.
      Guidelines for patient-CenteredOpioid prescribing and optimal FDA-compliant disposal of excess pills after inpatient operation: prospective clinical trial.
      • Lee J.S.
      • Hu H.M.
      • Edelman A.L.
      • et al.
      New persistent opioid use among patients with cancer after curative-intent surgery.
      Opioid prescribing practices following oncologic surgery are highly variable, which has been established on both an institutional and national level.
      • Newhook T.E.
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      • Dewhurst W.L.
      • et al.
      Clinical factors associated with practice variation in discharge opioid prescriptions after pancreatectomy.
      ,
      • Newhook T.E.
      • Vreeland T.J.
      • Dewhurst W.L.
      • et al.
      Opioid-prescribing practices after oncologic surgery: opportunities for improvement and a call to action.
      Early efforts to address these concerns within our Department of Surgical Oncology first assessed provider practices by survey evaluation and implementation of an educational program on perioperative use, which yielded a substantial decrease in opioid usage.
      • Lillemoe H.A.
      • Newhook T.E.
      • Aloia T.A.
      • et al.
      Perceptions of opioid use and prescribing habits in oncologic surgery: a survey of the society of surgical oncology membership.
      ,
      • Lillemoe H.A.
      • Newhook T.E.
      • Vreeland T.J.
      • et al.
      Educating surgical oncology providers on perioperative opioid use: results of a departmental survey on perceptions of opioid needs and prescribing habits.
      Following these quality improvement measures, we introduced a novel 5x-multiplier calculation to standardize discharge prescriptions to limit provider bias by basing discharge volumes on a patient's last 24-h opioid usage (e.g., if the last 24-h use was two 5-mg oxycodone pills, the discharge prescription would be 2 × 5 = 10 oxycodone pills).
      • Chen E.Y.
      • Marcantonio A.
      • Tornetta 3rd, P.
      Correlation between 24-hour predischarge opioid use and amount of opioids prescribed at hospital discharge.
      A retrospective analysis of hepatopancreatobiliary (HPB) surgery patients at our institution demonstrated that following implementation of the 5x-multiplier, discharge opioid volumes were a third of the size when compared to a historical cohort.
      • Day R.W.
      • Newhook T.E.
      • Dewhurst W.L.
      • et al.
      Assessing the 5x-multiplier calculation to reduce discharge opioid prescription volumes after inpatient surgery.
      To further validate the generalizability of the 5x-multiplier in additional surgical sites, we initiated a prospective quality improvement protocol to compare the 5x-multiplier (5x) using a patient's last 24-h oral morphine equivalents (OME) usage to standardize discharge opioid prescriptions versus usual care (UC).
      A natural concern of standardizing discharge opioid prescriptions is the potential risk of “rebound refills” for patients after a short inpatient stay. Especially for patients who benefit from accelerated discharge via enhanced recovery protocols, many providers are worried about providing adequate pain medication for their projected continued opioid wean as an outpatient, which may lead to either overprescribing, or alternatively, to rebound refills. We hypothesized that the 5x-multiplier adequately takes into account remaining post-discharge outpatient opioid needs regardless of actual LOS and would not result in differences in refill rates. Therefore, we compared refill rates and volumes for patients discharged by POD 2-3, 4-7, and 8+ within a specified quality improvement study period.

      Materials and Methods

      Study approval

      A non-randomized, prospective quality improvement study was designed to compare opioid discharge strategies in March 2019 and approved by the institutional Quality Improvement Assessment Board in August 2019. Patients undergoing inpatient surgery (stay ≥48 h) during a specified study period from September 9th, 2019 to December 31st, 2019 were included. Consent was waived as both discharge methods were within our standard of care. The data analysis required for this retrospective cohort study was approved by the Institutional Review Board (PA17-0726).

      Patients and study design

      Faculty in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center voluntarily chose to participate in the 5x-multiplier (5x) or usual care (UC) arms. We selected a modern comparison arm (UC) rather than a historical cohort considering the secular changes in opioid prescribing across our Department of Surgery.
      • Kim B.J.
      • Newhook T.E.
      • Blumenthaler A.
      • et al.
      Sustained reduction in discharge opioid volumes through provider education: results of 1168 cancer surgery patients over 2 years.
      Those whose clinical teams were enrolled in the 5x arm were directed to standardize opioid prescriptions at discharge by multiplying the patient's last 24-h oral morphine equivalents (OME) by 5 (e.g., if last 24-h use was two 50-mg tramadol pills, the discharge prescription would be 10 tramadol pills) to established feasibility of the 5x-multiplier in a broad spectrum of patients. Faculty enrolled in the UC arm were directed to discharge opioid prescriptions at the discharging fellow/advance practice provider's discretion. This is a post hoc analysis of a specific concern by some providers regarding patients who underwent fast-track, or short, inpatient stays. Patients were excluded if hospitalization was <48 h (e.g., same-day or overnight recovery for laparoscopies or aborted operations), discharge was completed by a non-primary team, or for duplicate encounters in the medical record if multiple operations were performed during a single admission. There were no standardized or mandated inpatient opioid order sets or non-opioid bundles during this study period for the disease sites in this study. However, the concept of using routine non-opioid bundles (acetaminophen, celecoxib, and methocarbamol) had been introduced to our department in summer 2018 through a formal education process.
      • Lillemoe H.A.
      • Newhook T.E.
      • Vreeland T.J.
      • et al.
      Educating surgical oncology providers on perioperative opioid use: results of a departmental survey on perceptions of opioid needs and prescribing habits.
      ,
      • Kim B.J.
      • Newhook T.E.
      • Blumenthaler A.
      • et al.
      Sustained reduction in discharge opioid volumes through provider education: results of 1168 cancer surgery patients over 2 years.
      ,
      • Kim B.J.
      • Lillemoe H.A.
      • Newhook T.E.
      • et al.
      Educating surgical oncology providers on perioperative opioid use: a departmental survey 1 year after the intervention.

      Data collection and endpoints

      Clinical, demographic, inpatient/discharge prescriptions, and 30-d refill data were abstracted from the electronic medical record. Opioid prescriptions (last 24-h, discharge, and 30-d refill volumes) were converted to OME using institutionally-approved tables. Patients in the 5x and UC arms were stratified into cohorts based on POD of discharge. Discharges were classified as SHORT (POD 2-3), INTERMEDIATE (POD 4-7), and LONG (POD ≥8) based on our particular focus on the POD 2-3 cohort. Additionally, we performed a subset analysis of patients with opioid prescriptions listed in the medical record at the preoperative clinic visit encounter, with the limitation that there was no ability to validate whether these preoperative prescriptions were actively used or not. The primary endpoint of the study was 30-d refill rates and the secondary endpoints included 30-d refill volumes, last 24-h OME, and discharge OME.

      Statistics and data reporting

      Normality for continuous data were evaluated by Shapiro–Wilk test. Statistical comparisons were performed using the Kruskal–Wallis test for nonparametric continuous variables and chi-squared test for categorical variables using SPSS version 22 (IBM, Armonk, NY). Tests were two-sided and P-value of <0.05 was considered statistically significant. Figures were generated using Prism version 8 (GraphPad Software, La Jolla, CA). Study design and data reporting were based on the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellent) consensus process.
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      • Stevens D.
      SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

      Results

      Demographics and clinical characteristics

      A total of 22 faculty from five surgical sections (sarcoma, colorectal, gastric/peritoneal, endocrine, and general) voluntarily enrolled. There were 753 cases completed during the predetermined timeframe with 409 patients ultimately eligible for assessment, including 209 (51.1%) which were assigned to the 5x arm and 200 (48.9%) assigned to the UC arm. When stratified by LOS, 154 (37.7%) were SHORT discharges, 176 (43.0%) were INTERMEDIATE discharges, and 79 (19.3%) were LONG discharges (Fig. 1). Median LOS for SHORT discharges was 3 d (interquartile range [IQR] 2-3 d), INTERMEDIATE discharges was 5 d (IQR 4-6 d), and LONG discharges was 12 d (IQR 8-16 d).
      Figure thumbnail gr1
      Fig. 1Flowchart of study design and stratification by length of stay. POD = postoperative day.
      We first compared demographic and clinical characteristics when stratified by timing of discharge. There was a similar distribution by sex, age, smoking status, and body mass index (BMI) amongst cohorts (Table 1). Patients had similar rates of preoperative opioid (34.4% SHORT, 37.5% INTERMEDIATE, 30.4% LATE; P = 0.536) and non-opioid analgesic prescriptions documented in the electronic medical record at the time of surgical consent. More SHORT stay patients underwent minimally invasive surgery (MIS) (53.2% versus 21.6% INTERMEDIATE, 19.0% LONG; P < 0.001). LONG stay patients had higher use of epidurals (34.2% versus 3.2% SHORT, 19.3% INTERMEDIATE; P < 0.001) and required reoperations (7.6% versus 0% SHORT, 2.3% INTERMEDIATE; P = 0.011). More LONG stay patients had major complications (21.5% versus 2.6% SHORT, 4.5% INTERMEDIATE; P < 0.001) and were readmitted (19.0% versus 7.8% SHORT, 8.0% INTERMEDIATE; P = 0.013).
      Table 1Baseline patient clinical and demographic characteristics.
      CharacteristicTotalShortIntermediateLongP-value
      N = 409N = 154N = 176N = 79
      Age
       Year, IQR58.050.0-69.058.551.0-70.058.058.0-69.060.060.0-70.00.523
      Length of stay
       Days, IQR43-732-354-6128-16<0.001
      Body Mass index
       kg/m2, IQR27.323.6-31.627.624.3-32.827.123.5-31.227.124.0-31.60.563
      Sex (male)
      N, %21552.6%7951.3%9453.4%4253.2%0.923
      Study arm0.004
       Usual care (N, %)20048.9%6441.6%8548.3%5164.6%
       5x-Multiplier (N, %)20951.1%9058.4%9151.7%2835.4%
      Smoker
      N, %194.6%95.8%84.5%22.5%0.522
      Preoperative analgesics
       Opioids (N, %)14335.0%5334.4%6637.5%2430.4%0.536
       Acetaminophen (N, %)13132.0%5435.1%5229.5%2531.6%0.561
       NSAID (N, %)10726.2%3925.3%5430.7%1417.7%0.089
       Muscle relaxer (N, %)276.6%159.7%105.7%22.5%0.090
       Gabapentin (N, %)4110.0%138.4%2413.6%45.1%0.077
      Smoker
      N, %194.6%95.8%84.5%22.5%0.522
      Minimally invasive surgery
      N, %13533.0%8253.2%3821.6%1519.0%<0.001
      Epidural
      N, %6616.1%53.2%3419.3%2734.2%<0.001
      Return to OR
      N, %102.4%00.0%42.3%67.6%0.011
      Major complication
      N, %297.1%42.6%84.5%1721.5%<0.001
      Readmission
      N, %4110.0%127.8%148.0%1519.0%0.013
      IQR = interquartile range; kg = kilogram; m = meters; NSAID = non-steroidal anti-inflammatory drug; OME = oral morphine equivalents; OR = operating room. Short = postoperative day 2-3 discharge; Intermediate day 4-7; Long day 8+.

      Inpatient opioid weaning and discharge metrics

      Inpatient and discharge opioid metrics were then compared among patients when stratified by LOS (Table 2). Patients with SHORT stays had a median last 24-h OME of 10 mg (versus 5 mg INTERMEDIATE, 5 mg LONG; P = 0.268), and median discharge OME of 55 mg (versus 75 mg INTERMEDIATE, 100 mg LONG; P = 0.221, Fig. 2). There were similar rates of discharge with two or greater multimodal non-opioid analgesics among groups (61.0% SHORT, 64.2% INTERMEDIATE, 64.6% LONG; P = 0.801). Patients had similar rates of opioid-free discharges (22.7% SHORT, 24.4% INTERMEDIATE, 35.4% LONG; P = 0.093). Overall, the median discharge OME (by intent to treat) for patients in the 5x arm was 50 mg versus 75 mg in the UC arm (P < 0.001).
      Table 2Inpatient and discharge opioid metrics by length of stay cohort.
      CharacteristicTotalShortIntermediateLongP-value
      N = 409N = 154N = 176N = 79
      Last 24-h OME
       mg, IQR7.50-20.010.00-20.05.00-21.35.00-20.00.268
      Discharge OME
       mg, IQR75.00-125.055.025.0-100.075.017.5-150.0100.00-200.00.221
      Zero discharge OME
      N, %10625.9%3522.7%4324.4%2835.4%0.093
      2+ multimodal at DC
      N, %25863.1%9461.0%11364.2%5164.6%0.801
      Refill rate
      N, %6515.9%1811.7%3218.2%1519.0%0.193
      Refill OME
       mg, IQR300.0112.5-900.0150.0100.0-900.0307.5134.4-843.8378.0225.0-1800.00.154
      DC = discharge; IQR = interquartile range; Mg = milligram; OME = oral morphine equivalents. Short = postoperative day 2-3 discharge; Intermediate day 4-7; Long day 8+.
      Figure thumbnail gr2
      Fig. 2Last 24-h (A) and discharge (B) opioid metrics in patients when stratified by postoperative day of discharge. The bolded horizontal bar indicates median (Q2) and the thin bars above and below indicate upper (Q3) and lower (Q1) quartiles, respectively. Mg = milligram; OME = oral morphine equivalents; Q = quartile.

      Thirty-day refill rates and volumes

      We next examined 30-d refill rates and refill volumes. Refill rates among SHORT cohort patients were 11.7%, compared to INTERMEDIATE (18.2%) and LONG (19.0%) (P = 0.193). Similarly, refill volumes (median OME) were not higher in SHORT patients (150 mg) compared to INTERMEDIATE (308 mg) and LONG (378 mg) discharges (P = 0.154; Fig. 3).
      Figure thumbnail gr3
      Fig. 3Refill rates (A) and refill volumes (B) in patients when stratified by postoperative day of discharge. The bolded horizontal bar indicates median (Q2) and the thin bars above and below indicate upper (Q3) and lower (Q1) quartiles, respectively. Mg = milligram; OME = oral morphine equivalents; Q = quartile.
      In the subset analysis that split opioid-naïve and opioid-exposed patients, SHORT cohort patients did not have higher refill rates. They were similar to rates from INTERMEDIATE and LONG patients in opioid-naïve patients (11.9% SHORT versus 9.1% INTERMEDIATE versus 18.2% LONG, P = 0.238) and less than INTERMEDIATE and LONG patients in the opioid-exposed subset (11.3% SHORT versus 33.3% INTERMEDIATE versus 20.8% LONGP = 0.017), respectively (Supplemental Table 1).

      Discussion

      Provider bias plays a critical role in the variability of opioid prescriptions at discharge, and just as patients with complex operations or complicated hospitalizations may get over-prescriptions by discharging providers, patients with early discharges paradoxically may be subjected to excess opioid volumes due to fear of “rebound refill” requests because providers feel they have not had time to assess the opioid weaning curve.
      • Newhook T.E.
      • Vreeland T.J.
      • Dewhurst W.L.
      • et al.
      Clinical factors associated with practice variation in discharge opioid prescriptions after pancreatectomy.
      ,
      • Lillemoe H.A.
      • Newhook T.E.
      • Aloia T.A.
      • et al.
      Perceptions of opioid use and prescribing habits in oncologic surgery: a survey of the society of surgical oncology membership.
      In this study, we retrospectively assessed opioid prescribing metrics and refill rate/volumes among patients who were included in a prospective feasibility study of the 5x-multiplier to standardize discharge prescriptions. Despite concerns for increased refill requests for patients discharged EARLY (POD 2-3), we found that these discharges were not associated with increased refills rates or volumes, although these patients had the highest last 24-h OME. Paradoxically, while inpatient weaning time was longer with lower last 24-h OME in INTERMEDIATE (POD 4-7) and LONG (POD 8+) stay patients, they still received larger opioid prescriptions at discharge. These findings provide evidence to support that standardizing patient-centered discharge opioid prescriptions is a viable strategy in patients with EARLY discharges, despite having a short window for studying inpatient opioid weaning.
      Excess opioid dissemination post-operatively is associated with an increased risk of persistent opioid usage and furthermore, community diversion.
      • Shah A.
      • Hayes C.J.
      • Martin B.C.
      Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015.
      ,
      • Porter E.D.
      • Bessen S.Y.
      • Molloy I.B.
      • et al.
      Guidelines for patient-CenteredOpioid prescribing and optimal FDA-compliant disposal of excess pills after inpatient operation: prospective clinical trial.
      ,
      • Howard R.
      • Fry B.
      • Gunaseelan V.
      • et al.
      Association of opioid prescribing with opioid consumption after surgery in Michigan.
      Standardization of opioid prescriptions at discharge can mitigate this by limiting the volumes of opioids prescribed rather than leaving this to a provider's discretion, which are often subjective and may lead to overprescribing.
      • Porter E.D.
      • Bessen S.Y.
      • Molloy I.B.
      • et al.
      Guidelines for patient-CenteredOpioid prescribing and optimal FDA-compliant disposal of excess pills after inpatient operation: prospective clinical trial.
      Several approaches to standardizing discharge opioid prescriptions have been evaluated in surgical patients, including both “tiered” protocols and those which incorporate a patient's inpatient opioid usage (last 24-h OME) to determine discharge volumes.
      • Chen E.Y.
      • Marcantonio A.
      • Tornetta 3rd, P.
      Correlation between 24-hour predischarge opioid use and amount of opioids prescribed at hospital discharge.
      ,
      • Meyer D.C.
      • Hill S.S.
      • Pavao R.
      • et al.
      Prospective evaluation of a tiered opioid prescribing guideline for inpatient colorectal operations [e-pub ahead of print].
      We developed the 5x-multiplier to address these concerns, which demonstrated a robust decrease in discharge OME in comparison to a historical cohort of HPB patients.
      • Day R.W.
      • Newhook T.E.
      • Dewhurst W.L.
      • et al.
      Assessing the 5x-multiplier calculation to reduce discharge opioid prescription volumes after inpatient surgery.
      To expand our study of the 5x-multiplier, we designed a prospective feasibility study to test this method of standardizing discharge opioid prescriptions in other surgical sites, which was met with concern regarding the generalizability in patients discharged after a short inpatient stay. Our findings here suggest that standardizing opioid prescriptions at discharge is in fact feasible even in patients discharged on POD 2-3 without risk of “rebound refills”.
      Enhanced recovery after surgery (ERAS) protocols have been integrated into many surgical practices with the goal of facilitating recovery through standardized, evidence-based approaches.
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      • et al.
      Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery [e-pub ahead of print].
      ,
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      • et al.
      Early implementation of Enhanced Recovery after Surgery (ERAS(R)) protocol - compliance improves outcomes: a prospective cohort study.
      One historical concern (now well disproven) with implementation of ERAS protocols included the putative risk of readmission following accelerated discharges in the early post-operative period.
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      • Neal K.R.
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      • Ljungqvist O.
      • Lobo D.N.
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      In discussing our thoughts on expanding the use of the 5x-multiplier, we received feedback that was analogous to historical concerns of rebound readmissions regarding the risk of “rebound refills” in patients who discharged “too early” after a complication-free “fast-track” (more often MIS procedures) short inpatient stay with near-zero or zero opioids at discharge. These apprehensions may lead to over-prescribing practices in which providers give patients extra pills to have enough opioids to avoid increased refill requests, especially in patients who are across state lines or discharged near weekends or holidays. Interestingly, several states have passed opioid-limiting laws for post-surgical patients, including those which limit prescriptions volumes to a 1-wk supply. Reid et al. conducted a retrospective analysis of patients undergoing spinal surgery which demonstrated that despite these limitations, implementation of mandatory prescribing limits did not lead to a rebound in opioid prescription refills.
      • Reid D.B.C.
      • Patel S.A.
      • Shah K.N.
      • et al.
      Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion.
      Similarly, a study of urogynecologic surgery demonstrated that an opioid-limiting pain regimen resulted in decreased postoperative opioid prescribing with similar refill rates.
      • Solouki S.
      • Vega M.
      • Agalliu I.
      • Abraham N.E.
      Patient satisfaction and refill rates after decreasing opioids prescribed for urogynecologic surgery.
      Taken together, these findings support that opioid-limiting practices can be implemented without increased refill requests.
      There are several limitations to the present retrospective cohort study. First, this subset analysis was carried out in the context of a prospective, non-randomized quality improvement study using both the 5x-multiplier and usual care. While distribution by study arm was balanced among patients with EARLY and INTERMEDIATE discharges, there were more LONG discharge patients who were in the UC arm, which could impart bias regarding discharge prescribing which may secondarily affect refill rates and volumes. Another source of imbalance between patients when stratified by discharge is that more SHORT discharges underwent minimally-invasive operations, and more LONG patients had major complications or required reoperations. While it is to be expected that patients with complications/reoperations would be discharged later in their hospital course, there are external factors which could influence opioid prescribing metrics in this population. Additionally, while most patients have their initial postoperative follow-up and refills through our institution (particularly within the first 30 d), we were unable to account for potential patients who received refills from other providers outside our hospital. We were unable to track and survey the actual opioid use (and leftover pills) of patients after discharge, but this is a priority for future planned clinical trials. Lastly, these findings should be taken into context of an ongoing opioid reduction quality improvement initiative within our Department of Surgery, with aggressive inpatient opioid weaning using regional anesthetic blocks and scheduled non-opioid medication bundles, and thus may influence the need for refills, although this effect should be seen in all patients.
      • Lillemoe H.A.
      • Newhook T.E.
      • Vreeland T.J.
      • et al.
      Educating surgical oncology providers on perioperative opioid use: results of a departmental survey on perceptions of opioid needs and prescribing habits.
      ,
      • Kim B.J.
      • Newhook T.E.
      • Blumenthaler A.
      • et al.
      Sustained reduction in discharge opioid volumes through provider education: results of 1168 cancer surgery patients over 2 years.
      Despite the limitations, this study of a broad spectrum of cancer surgery patients is the first to address the specific concern of providers skeptical of the 5x-multiplier being feasible in short-stay, fast-track, enhanced recovery (or any other semantic for a limited uncomplicated stay) patients.

      Conclusions

      Despite the concern for increased refills, discharges by POD 2-3 were not associated with “rebound refill” requests or volumes. Standardizing discharge opioid prescriptions is feasible in all inpatient surgery patients, regardless of length of stay, without risk of increased “rebound refills” in patients discharged following a short, uncomplicated inpatient stay.

      Supplementary Materials

      Supplementary data related to this article can be found at https://doi.org/10.1016/j.jss.2022.04.057.

      Author Contributions

      T.P.D. writing of the original manuscript, data curation, data analysis; T.E.N. reviewing and editing the manuscript, study implementation, conceptualization, data curation, data analysis; H.S.T.C. study implementation, reviewing and editing the manuscript; N.I. study implementation, reviewing and editing the manuscript; W.L.D. study implementation, reviewing and editing the manuscript; E.M.A. study implementation, reviewing and editing the manuscript; M.L.B. study implementation, reviewing and editing the manuscript; M.H.G.K study implementation, reviewing and editing the manuscript; J.N.V. study implementation, reviewing and editing the manuscript; J.E.L. study implementation, reviewing and editing the manuscript; C.W.D.T. writing of the original manuscript, study implementation, conceptualization, data curation, data analysis.

      Acknowledgments

      We would like to thank our Complex General Surgical Oncology, Surgical Endocrinology, Colorectal, and Hepatopancreatobiliary fellows for their outstanding patient care and participation in our opioid reduction efforts. We would like to thank the multidisciplinary partners within our “Perioperative Reduction in Opioids through Multidisciplinary Options, Trials, and Education” (PROMOTE) Consortium.

      Supplementary Materials

      Disclosure

      None declared.

      Funding

      Dr DiPeri is supported by the National Institutes of Health T32 CA 009599 and the MD Anderson Cancer Center support grant (P30 CA016672). Dr Tzeng is supported by the University Cancer Foundation and the Duncan Family Institute for Cancer Prevention and Risk Assessment via a Cancer Survivorship Research Seed Money Grant at the University of Texas MD Anderson Cancer Center and an Andrew Sabin Family Foundation Fellowship.

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