Canadian researchers take scalpel to opioid prescribing for surgical patients

With the recognition that physician prescribing plays a significant role in Canada's opioid crisis, a team of researchers has developed a program called STOP Narcotics to dramatically reduce the amount of painkillers patients are given following some common operations.

In a study presented Wednesday at the American College of Surgeons Clinical Congress in Boston, researchers from Western University showed that the STOP Narcotics protocol halved the amount of opioids prescribed after two types of outpatient surgery, while still adequately treating most patients' post-operative pain.

"By significantly reducing the amount of opioids prescribed, this decreases the exposure risk and potential for misuse of narcotic medication," said lead author Dr. Luke Hartford, a general surgery resident at the London, Ont., university.

"This also decreases excess medication available to be diverted to individuals for whom it was not intended," he said, noting that the STOP Narcotics program includes a combination of patient and health provider education, with an emphasis on non-opioid pain control.

The study, published Wednesday in the Journal of the American College of Surgeons, involved 416 patients at London Health Sciences Centre and St. Joseph's Health Care, who underwent either laparoscopic gallbladder removal or open hernia repair.

Roughly half the patients were randomly assigned either to a control group, which received a standard prescription for opioids, or to the STOP Narcotics protocol group, which were prescribed acetaminophen and an anti-inflammatory drug to manage post-surgical pain for the first 72 hours after their operations.

Under the protocol, surgeons were instructed to write a 10-pill opioid prescription, which expired seven days after surgery. Patients were asked to fill this prescription only if they couldn't achieve adequate pain control with the other drugs.

Opioids prescribed reduced by half

"Ninety per cent of the patients said that controlled their pain, they didn't need the narcotics script filled," said principal investigator Dr. Ken Leslie, chief of general surgery at London Health Sciences Centre.

Researchers found there was a 50 per cent reduction in the number of opioids prescribed by surgeons under the STOP Narcotics group, compared to the control group.

As well, just 45 per cent of patients in the protocol group filled their opioid prescription, compared to 95 per cent in the control group.

"So we not only decreased the amount we were prescribing in half, but we saw that [less than]half of patients were actually filling those prescriptions," Hartford said, adding that only "a very small number" needed the opioids for additional pain control.

"We found that in our control group, as well, that even though patients were getting prescribed 20 to 30 tablets of opioid medication, they were only taking around seven of them," he said.

People tend to hang on to extra opioids

That's why the STOP Narcotics initiative has another goal: to sharply limit the amount of unused opioids that can be diverted for recreational use, especially by young people who may come across them in the family medicine cabinet.

As part of the post-surgical program, patients were asked to return left-over opioids to their pharmacy or to the hospital for disposal. The researchers found the return rate was seven per cent among those in the control group versus 23 per cent among STOP Narcotics patients.

"It's really hard to get people to give up something that they have at home," said Leslie. "They hang onto to it just in case they have pain down the road."

Surgeons often say they prescribe "plenty of pills" to ensure patients have enough on hand to control their pain but also to avoid calls to their offices for renewals, Leslie said.

But the study found that renewal rates were low: 3.5 per cent for those initially prescribed opioids and 2.5 per cent for protocol patients.

"We recognized that before STOP Narcotics, every surgeon had a different approach to pain control and that most surgeons were prescribing more narcotics than are actually needed," said Leslie. "When we looked at the data from this new protocol, we saw that the patient's pain-control was just as good with this pathway, without a huge prescription for narcotics."

Dr. David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto, said the Western study isn't the first to show that more prudent prescribing of post-surgical opioids can be beneficial for patients, but "it's an important topic nevertheless."

"There's this increasing narrative that the opioid crisis is really about people with addiction who are dying by the thousands and that treatment of pain is not the problem," said Juurlink, who was not involved in the study.

"And that's not true ... It is also to no small extent about how we manage acute and chronic pain."

Juurlink said that every time a patient is given more opioids than they need whether for chronic pain or for pain following surgery or dental work they may be on the drugs longer than needed or the remaining tablets could stay in their medicine cabinet and offer a temptation to an experimenting teenager or to someone who might be at risk for addiction.

"So I think the more surgeons change their practice to this sort of model not avoiding opioids but prescribing them more judiciously the better off patients will be and society too."

The Western researchers hope to expand the STOP Narcotics initiative beyond general surgery to other specialties, such as gynecology and orthopedics, and possibly for some in-patient operations as well.

The protocol has already been presented to a couple of southwestern Ontario hospitals, which have adopted it, and the researchers are scheduled to present the program elsewhere in the coming months.

Leslie said there are about 45,000 laparoscopic gallbladder-removal and open hernia-repair operations performed in Ontario each year, and applying STOP Narcotics to just these two surgeries alone would remove almost a million opioid tablets from circulation.

"Our message isn't that narcotics or opioids are inherently bad," added Hartford. "They're great medications when used appropriately. But they also have significant side effects constipation, nausea, confusion in older patients.

"They're only one part of many things you can do to help someone's pain after surgery."