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Journal of General Internal Medicine

, Volume 33, Issue 10, pp 1685–1691 | Cite as

Transitions of Care for Postoperative Opioid Prescribing in Previously Opioid-Naïve Patients in the USA: a Retrospective Review

  • Michael P. Klueh
  • Hsou M. Hu
  • Ryan A. Howard
  • Joceline V. Vu
  • Calista M. Harbaugh
  • Pooja A. Lagisetty
  • Chad M. Brummett
  • Michael J. Englesbe
  • Jennifer F. Waljee
  • Jay S. Lee
Original Research

Abstract

Background

New persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3–6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients.

Objective

To identify specialties prescribing opioids to surgical patients who develop new persistent opioid use.

Design, Setting, and Participants

Using a national dataset of insurance claims, we identified opioid-naïve patients aged 18–64 years undergoing surgical procedures (2008–2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes.

Main Measures

Percentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery.

Key Results

We identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%.

Conclusions

Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence.

KEY WORDS

care transitions postoperative care patient-centered outcomes research surgery health services research surgery 

Notes

Prior Presentations

This work has not been previously published or presented.

Research Support

Dr. Lee is a National Research Service Award postdoctoral fellow supported by the National Cancer Institute (5T32 CA009672-23). Drs. Brummett, Englesbe, and Waljee receive funding from the Michigan Department of Health and Human Services. Mr. Klueh is supported by the National Institutes of Health’s T35 Short-Term Training Grant for Medical Students (5T35 HL007690-34). The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Michigan Department of Health and Human Services.

Contributors

Significant contributions to the work were completed by the authors. All authors had full access to the study data, take responsibility for the accuracy of the analysis, and approve the submission of this manuscript.

Funding

Dr. Brummett is a consultant for Recro Pharma (Malvern, PA) and Heron Pharm; not related to the present work. Dr. Brummett receives research funding from Neuros Medical Inc. (Willoughby Hills, Ohio). Dr. Englesbe receives research funding from the Substance Abuse and Mental Health Services Administration. Dr. Waljee receives research funding from the Agency for Healthcare Research and Quality (K08 1K08HS023313-01), the American College of Surgeons, and the American Foundation for Surgery of the Hand. Dr. Waljee is an unpaid consultant for 3M Health Information systems.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

11606_2018_4463_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 21 kb)

References

  1. 1.
    Thiels CA, Anderson SS, Ubl DS, et al. Wide variation and overprescription of opioids after elective surgery. Ann Surg. 2017.Google Scholar
  2. 2.
    Hill MV, McMahon ML, Stucke RS, Barth RJ, Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265(4):709–714.CrossRefPubMedGoogle Scholar
  3. 3.
    Bates C, Laciak R, Southwick A, Bishoff J. Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice. J Urol. 2011;185(2):551–555.CrossRefPubMedGoogle Scholar
  4. 4.
    Shah A, Hayes CJ, Martin BC. Factors influencing long-term opioid use among opioid naive patients: an examination of initial prescription characteristics and pain etiologies. J Pain. 2017.Google Scholar
  5. 5.
    Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.CrossRefPubMedGoogle Scholar
  6. 6.
    Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Soneji N, Clarke HA, Ko DT, Wijeysundera DN. Risks of developing persistent Opioid use after major surgery. JAMA Surg. 2016;151(11):1083–1084.CrossRefPubMedGoogle Scholar
  8. 8.
    Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425–430.CrossRefPubMedGoogle Scholar
  9. 9.
    Kehlet H, Rathmell JP. Persistent postsurgical pain: the path forward through better design of clinical studies. Anesthesiology. 2010;112(3):514–515.CrossRefPubMedGoogle Scholar
  10. 10.
    Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445–1452.CrossRefPubMedGoogle Scholar
  11. 11.
    Baker-White A. A look at state legislation limiting opioid prescriptions. 2017; http://www.astho.org/StatePublicHealth/A-Look-at-State-Legislation-Limiting-Opioid-Prescriptions/2-23-17/. Accessed March 22, 2018.
  12. 12.
    Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med. 2015;49(3):409–413.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6):1259–1265.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Lee JS, Hu HM, Edelman AL, et al. New persistent opioid use among patients with Cancer after curative-intent surgery. J Clin Oncol. 2017;35(36):4042–4049.CrossRefPubMedGoogle Scholar
  15. 15.
    Porucznik CA, Johnson EM, Rolfs RT, Sauer BC. Specialty of prescribers associated with prescription opioid fatalities in Utah, 2002-2010. Pain Med. 2014;15(1):73–78.CrossRefPubMedGoogle Scholar
  16. 16.
    Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315–1321.CrossRefPubMedGoogle Scholar
  18. 18.
    Leider HL, Dhaliwal J, Davis EJ, Kulakodlu M, Buikema AR. Healthcare costs and nonadherence among chronic opioid users. Am J Manag Care. 2011;17(1):32–40.PubMedGoogle Scholar
  19. 19.
    Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415–2423.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Ho D, Imai K, King G, Stuart EA. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw. 2011;42(8):28.CrossRefGoogle Scholar
  21. 21.
    Eaton LH, Gordon DB, Wyant S, et al. Development and implementation of a telehealth-enhanced intervention for pain and symptom management. Contemp Clin Trials. 2014;38(2):213–220.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Penney LS, Ritenbaugh C, DeBar LL, Elder C, Deyo RA. Provider and patient perspectives on opioids and alternative treatments for managing chronic pain: a qualitative study. BMC Fam Pract. 2017;17(1):164.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Frank JW, Levy C, Matlock DD, et al. Patients’ perspectives on tapering of chronic opioid therapy: a qualitative study. Pain Med. 2016;17(10):1838–1847.CrossRefPubMedGoogle Scholar
  24. 24.
    Hao J, Lucido D, Cruciani RA. Potential impact of abrupt opioid therapy discontinuation in the management of chronic pain: a pilot study on patient perspective. J Opioid Manag. 2014;10(1):9–20.CrossRefPubMedGoogle Scholar
  25. 25.
    Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825–834.CrossRefPubMedGoogle Scholar
  26. 26.
    Hill MV, Stucke RS, McMahon ML, Beeman JL, Barth RJ, Jr. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg. 2017.Google Scholar
  27. 27.
    Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic. Anesth Analg. 2017;125(5):1733–1740.CrossRefPubMedGoogle Scholar
  28. 28.
    Kumar K, Kirksey MA, Duong S, Wu CL. A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg. 2017;125(5):1749–1760.CrossRefPubMedGoogle Scholar
  29. 29.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.CrossRefPubMedGoogle Scholar
  30. 30.
    Cifuentes M, Powell R, Webster B. Shorter time between opioid prescriptions associated with reduced work disability among acute low back pain opioid users. J Occup Environ Med. 2012;54(4):491–496.CrossRefPubMedGoogle Scholar
  31. 31.
    Thomas DA, Chang D, Zhu R, Rayaz H, Vadivelu N. Concept of the ambulatory pain physician. Curr Pain Headache Rep. 2017;21(1):7.CrossRefPubMedGoogle Scholar
  32. 32.
    Peppin JF, Cheatle MD, Kirsh KL, McCarberg BH. The complexity model: a novel approach to improve chronic pain care. Pain Med. 2015;16(4):653–666.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Michael P. Klueh
    • 1
  • Hsou M. Hu
    • 1
  • Ryan A. Howard
    • 1
  • Joceline V. Vu
    • 1
  • Calista M. Harbaugh
    • 1
  • Pooja A. Lagisetty
    • 2
    • 3
  • Chad M. Brummett
    • 4
  • Michael J. Englesbe
    • 1
    • 5
  • Jennifer F. Waljee
    • 1
  • Jay S. Lee
    • 1
  1. 1.Department of SurgeryUniversity of MichiganAnn ArborUSA
  2. 2.Department of Internal MedicineUniversity of MichiganAnn ArborUSA
  3. 3.VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborUSA
  4. 4.Department of AnesthesiologyUniversity of MichiganAnn ArborUSA
  5. 5.Section of Transplant Surgery University of Michigan Health SystemAnn ArborUSA

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