Development of a Practice Guideline for Discharge Opioid Prescribing After Major Colorectal Surgery

BACKGROUND: Better alignment of opioid prescription quantities with patient need could help reduce excessive prescribing. OBJECTIVE: The study sought to develop an institutional prescribing guideline based on defined opioid consumption patterns after inpatient colorectal operations. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients who underwent elective major colorectal procedures between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES: The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS: Patients were categorized into 3 groups based on consumption in the 24-hour period before discharge: tier 1 consumed 0 equianalgesic oxycodone 5-mg pills (n = 53), tier 2 consumed 0.1 to 3.0 equianalgesic oxycodone 5-mg pills (n = 25), and tier 3 consumed >3.0 equianalgesic oxycodone 5-mg pills (n = 22). Average prescription quantity was 17.5 +/- 10.5 equianalgesic oxycodone 5-mg pills (range, 0-78). Patients consumed a mean of 6.7 +/- 10.9 equianalgesic oxycodone 5-mg pills after discharge and had 10.8 +/- 10.2 equianalgesic oxycodone 5-mg pill excess, whereas 51% of patients consumed no pills. Opioid consumption was significantly different between each tier (p < 0.001). A prescribing guideline was developed to satisfy the majority of patients: 0 equianalgesic oxycodone 5-mg pills if tier 1, 12 pills if tier 2, and 30 pills if tier 3. Tiered guideline adoption could reduce prescribed pills by 45% and excess pills per prescription by 73%. Patient history of IBD was independently associated with increased odds of exceeding the guideline (adjusted OR = 7.2 (95% CI, 1.6-32.6)). LIMITATIONS: The study was limited by its singlecenter, retrospective design and that outpatient opioid consumption was self-reported. CONCLUSIONS: Following hospital discharge after major colorectal surgery, more than half of patients consumed no opioid pills, and 62% of prescribed opioids were in excess. Outpatient opioid consumption was highly associated with inpatient opioid use in the 24 hours before discharge. Prospective validation of this prescribing guideline is needed, but adoption could reduce excessive prescribing.