EVALUATING POSTOPERATIVE OPIOID PRESCRIBING PATTERNS AND THEIR ASSOCIATION WITH PAIN OUTCOMES: EVIDENCE SYNTHESIS USING ELECTRONIC HEALTH RECORDS

Purpose:

Evidence-based guidelines for prescribing postoperative pain medication following surgery are limited yet severe postoperative pain is a common adverse outcome. The objective of our study was to characterize the association between discharge oral medication prescribing patterns and postoperative pain.

Methods:

This retrospective study used electronic health records (EHR) from a large academic institute. We identified patients undergoing three surgical procedures (mastectomy, thoracotomy and total knee replacement) using ICD-9-CM/ICD-10-CM codes. We extracted discharge oral pain medications and pain scores (scale 0-10, with 10 being extreme pain) from the EHR. We analyzed oral pain medications including: Opioids, Non-steroidal anti-inflammatory drugs (NSAID) (e.g. ibuprofen) and Acetaminophen (e.g. Tylenol). Maximum pain score at discharge and within 30-day follow-up encounters were dependent variables used in separate multivariate models to examine the association of different prescribing patterns with postoperative pain, which controlled for important patient demographics.

Results:

The study comprised of 3538 surgery patients all of which had a 30-day follow-up visit. Within the cohort, 14.1% patients were discharged with a high pain score (>7) and 55% with high pain scores at follow-up. A total of 62% of patients with high pain at discharge also reported high pain at follow-up. Most patients were discharged with either only Opioid (26%) or Opioid with Acetaminophen (49%). The most commonly prescribed medication was Acetaminophen (27%) followed by Hydrocodone (19%) and Oxycodone (19%). The combined prescription of Opioids and Acetaminophen was significantly associated with lower discharge pain scores (Odds Ratio [OR]: 0.67, 95% Confidence Interval [CI]: 0.53, 0.85) and lower follow-up pain scores (OR: 0.74, 95% CI: 0.63, 0.88) compared to those prescribed Opioids only.  Patients prescribed Opioid, NSAID & Acetaminophen also had significantly lower discharge (OR: 0.67, CI: 0.47, 0.95) and follow-up pain scores (OR: 0.67; CI: 0.52, 0.86) compared to Opioids only.

Conclusions:

In our cohort, postoperative pain medication prescribing patterns at discharge varied remarkably. A significant number of surgical patients are discharged from inpatient setting with high pain scores and a third are still in pain 30-days post-discharge. Our results suggest multimodal pain prescribing is associated with better postoperative pain management compared to only opioid use. Findings of this EHRs study support the need for more effective and streamlined efforts in dissemination of evidence and strategies to improve postoperative pain management.