Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study

Naheed K Jivraj^{1

2

3

4}, Karim Ladha^{5

6}, Akash Goel⁶, Andrea Hill⁷, Duminda N Wijeysundera^{5

6}, Brian T Bateman⁸, Hannah Wunsch^{5

9

10}

Affiliations

¹ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada. naheed.jivraj@mail.utoronto.ca.
² Institute of Health Policy Management and Evaluation, Toronto, ON, Canada. naheed.jivraj@mail.utoronto.ca.
³ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. naheed.jivraj@mail.utoronto.ca.
⁴ Department of Anesthesiology and Pain Medicine, University of Toronto, 12th Floor, 123 Edward Street, Toronto, ON, M5G 1E2, Canada. naheed.jivraj@mail.utoronto.ca.
⁵ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
⁶ Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
⁷ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁸ Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
⁹ Institute of Health Policy Management and Evaluation, Toronto, ON, Canada.
¹⁰ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

PMID: 35534769
DOI: 10.1007/s12630-022-02266-5

Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study

Naheed K Jivraj et al. Can J Anaesth. 2022 Aug.

. 2022 Aug;69(8):974-985.

doi: 10.1007/s12630-022-02266-5. Epub 2022 May 10.

Authors

Naheed K Jivraj^{1

2

3

4}, Karim Ladha^{5

6}, Akash Goel⁶, Andrea Hill⁷, Duminda N Wijeysundera^{5

6}, Brian T Bateman⁸, Hannah Wunsch^{5

9

10}

Affiliations

¹ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada. naheed.jivraj@mail.utoronto.ca.
² Institute of Health Policy Management and Evaluation, Toronto, ON, Canada. naheed.jivraj@mail.utoronto.ca.
³ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. naheed.jivraj@mail.utoronto.ca.
⁴ Department of Anesthesiology and Pain Medicine, University of Toronto, 12th Floor, 123 Edward Street, Toronto, ON, M5G 1E2, Canada. naheed.jivraj@mail.utoronto.ca.
⁵ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
⁶ Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
⁷ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁸ Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
⁹ Institute of Health Policy Management and Evaluation, Toronto, ON, Canada.
¹⁰ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

PMID: 35534769
DOI: 10.1007/s12630-022-02266-5

Abstract
in English, French

Purpose: Many hospital and provincial-level recommendations now advise a tailored approach to postoperative opioid prescribing; recent trends in postoperative prescribing at the population level have not been well described.

Methods: This population-based cohort study included opioid-naïve patients ≥ 18 yr of age who underwent one of 16 surgical procedures with varying anticipated postoperative pain between July 2013 and March 2020. We evaluated the rate of filled opioid prescriptions within seven days postoperatively, the total morphine milligram equivalent (MME) dose, duration, and type of the first opioid prescription. We then compared the MMEs in initial opioid prescriptions with available procedure-specific recommendations.

Results: The sample included 900,989 opioid-naïve patients (mean [standard deviation (SD)] age of 50 [17] 31 yr; 66% women). The percentage of patients filling an opioid prescription within 7 days postoperatively increased from 65% in 2013 to 69% in 2016, and returned to the baseline (65%) in 2019. The mean (SD) MMEs dispensed increased until 2015/2016 and then declined (226 [176] MMEs in 2013, 240 [202] MMEs in 2016, and 175 [175] MMEs in 2019). The most frequently prescribed opioid in 2013 was oxycodone compared with hydromorphone in 2019. Among patients who filled an opioid prescription in 2013, 67% were prescribed an opioid dose higher than those in one set of available prescribing recommendations, while in 2019, 41% were prescribed doses above those stated in recommendations.

Conclusion: While the proportion of patients filling an opioid prescription postoperatively remained s during the study period, MMEs decreased after 2016. Opioid prescribing remained significantly higher than available prescribing recommendations, particularly among low pain procedures. These findings highlight the need to identify strategies that improve adherence to surgery-specific prescribing guidelines in North America.

RéSUMé: OBJECTIF: De nombreuses recommandations à l’échelle hospitalière et provinciale préconisent aujourd’hui une approche personnalisée de la prescription d’opioïdes postopératoires; les tendances récentes de la prescription postopératoire au niveau de la population n’ont pas été bien décrites. MéTHODE: Cette étude de cohorte basée sur la population englobait des patients naïfs aux opioïdes et âgés de ≥ 18 ans ayant bénéficié de l’une de 16 interventions chirurgicales entraînant une douleur postopératoire anticipée variable entre juillet 2013 et mars 2020. Nous avons évalué le taux d’ordonnances d’opioïdes remplies dans les sept jours suivant l’opération, la dose totale d’équivalent en milligrammes de morphine (EMM), ainsi que la durée et le type de la première ordonnance d’opioïdes. Nous avons ensuite comparé les EMM des ordonnances initiales d’opioïdes avec les recommandations spécifiques à l’intervention disponibles. RéSULTATS: L’échantillon comprenait 900 989 patients naïfs aux opioïdes (âge moyen [écart type (ET)] de 50 [17] ans; 66 % de femmes). La proportion de patients remplissant une ordonnance d’opioïdes dans les 7 jours suivant l’opération est passée de 65 % en 2013 à 69 % en 2016, et est revenue à la valeur de référence (65 %) en 2019. Les EMM moyens (ET) administrés ont augmenté jusqu’en 2015-2016, puis ont diminué (226 [176] EMM en 2013, 240 [202] EMM en 2016 et 175 [175] EMM en 2019). L’opioïde le plus fréquemment prescrit en 2013 était l’oxycodone par rapport à l’hydromorphone en 2019. Parmi les patients qui ont rempli une ordonnance d’opioïdes en 2013, 67 % se sont vu prescrire une dose d’opioïdes supérieure à celle d’un ensemble de recommandations de prescription disponibles, tandis qu’en 2019, 41 % se sont vu prescrire des doses supérieures à celles indiquées dans les recommandations. CONCLUSION: Alors que la proportion de patients remplissant une ordonnance d’opioïdes en période postopératoire est restée stable au cours de la période d’étude, les EMM ont diminué après 2016. La prescription d’opioïdes est demeurée beaucoup plus élevée que les recommandations de prescription disponibles, en particulier dans le cas d’interventions à faible douleur. Ces résultats soulignent la nécessité d’identifier des stratégies pour améliorer l’adhérence aux recommandations de prescription spécifiques au type de chirurgie en Amérique du Nord.

Keywords: opioid prescribing; physicians; postoperative pain; prescription drugs; surgery.

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References

1. Government of Canada; Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioids and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; 2021. Available from URL: https://health-infobase.canada.ca/substance-related-harms/opioids-stimul... (accessed January 2022).
1. Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and geographic patterns in drug and synthetic opioid overdose deaths - United States, 2013-2019. MMWR Morb Mortal Wkly Rep 2021; 70: 202-7. - DOI
1. Gomes T, Pasricha SV, Martins T, et al. Behind the Prescriptions: A snapshot of opioid use across all Ontarians. Toronto, Canada: Ontario Drug Policy Research Network; 2017. Available from URL: https://odprn.ca/wp-content/uploads/2017/08/ODPRN-Report_Behind-the-Pres... (accessed January 2022).
1. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet 2019; 393: 1547-57. - DOI
1. Waljee JF, Li L, Brummett CM, Englesbe MJ. Iatrogenic opioid dependence in the United States: are surgeons the gatekeepers? Ann Surg 2017; 265: 728-30. - DOI

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Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study

Affiliations

Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study

Authors

Affiliations

Abstract
in English, French

References

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Abstract in English, French

References

MeSH terms

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Grants and funding

LinkOut - more resources

Full Text Sources

Miscellaneous

Abstract
in English, French