Impact of a perioperative oral opioid substitution protocol during the nationwide intravenous opioid shortage: A single center, interrupted time series with segmented regression analysis

Abstract

Introduction: To mitigate the recent nationwide shortage of intravenous opioids, we developed a standardized perioperative oral opioid guideline anchored with appropriate use of nonopioid analgesia, neuraxial and loco-regional techniques. We hypothesize that adoption of this new guideline was associated with: 1) equivalent patient reported pain scores in the post-anesthesia care unit (PACU); and 2) equivalent total opioid use (oral and parenteral) during the perioperative period.

Methods: Cases performed from July 1, 2017 to May 31, 2019 were screened. All opioids administered were converted to intravenous morphine milligram equivalents. Segmented regression analyses of interrupted time series were performed examining the change in opioid use, PACU pain scores and number of non-opioid analgesic medications used before and after the protocol implementation in April 2018.

Results: After exclusions, 29, 621 cases were included in the analysis. No significant differences in demographic, ASA status, case length and surgical procedure type were present in the pre and post-intervention period. A significant decrease in total (Estimate: -39.9 mg, SE: 6.9 mg, p < 0.001) and parenteral (Estimate: -51.6 mg, SE: 7.1 mg, p < 0.001) opioid use with a significant increase in oral opioid use (Estimate: 9.4 mg, SE: 1.1 mg, p < 0.001) was noted after the intervention. Pain scores were not significantly different between the pre- and post-intervention period (Estimate: 0.05, SE: 0.13, p = 0.69).

Conclusion: We report our experience with a primary perioperative oral based opioid regimen that is associated with decreased total opioid consumption and equivalent patient reported pain scores.

Fig 1. Flow diagram of study participant selection.

Fig 2. Proportion of surgical procedures over time.

Fig 3. Interrupted time series with segmented regression analyses demonstrating mean (standard error) total, parenteral and oral morphine equivalents per case by month before and after the intervention.

Fig 4. Interrupted time series with segmented regression analyses demonstrating mean (standard error) post anesthesia care unit patient reported pain scores per case by month before and after the intervention.

Fig 5. Interrupted time series with segmented regression analyses demonstrating mean (standard error) number of nonopioid analgesics utilized per case by month before and after the intervention.