Given that opioid prescriptions and dependence are on the rise in the UK, there is a growing societal concern around opioid prescriptions after surgery. Although opioids are effective analgesics and are commonly prescribed for post-operative pain, little is known about how to best prescribe them to meet patients’ needs and reduce risks. Opioids carry dangerous side effects, including addiction, with up to 5% of patients becoming long-term opioid users after surgery. The purpose of this study was to identify areas of improvement in opioid prescribing practices and post-surgical care by interviewing patients.
Current Issues in Post-Operative Prescribing
Did you know that up to 70% of opioids prescribed after surgery in the UK go unused and only 20% of patients dispose of them properly? This overprescription of opioids is worrying, as it can contribute to opioid misuse, with more than half of people who misuse prescription opioids obtaining them from friends or family.
Although opioids are often overprescribed after surgery, paradoxically, pain is still inadequately managed after some procedures. In particular, ethnic minorities and women report having their pain ignored and inadequately managed following surgery. A study analysing the pain levels of 200 women after IUD insertion found that HCPs significantly underestimated their pain levels. Inadequate pain relief after surgery is associated with psychological distress, prolonged recovery, and an increased risk of complications.
Insufficient pain management for some patients and excessive opioid prescriptions for others underscore the need for a more comprehensive understanding of patients’ postoperative pain management needs, particularly with respect to opioids.
What did we do?
During March, 20 patients who had recently undergone elective (non-emergency) surgery at UCLH were recruited and interviewed. In order to capture the experience of the average patient, we interviewed people who used opioids for less than three months after surgery. The focus of the analysis was on their interactions with HCPs after surgery and their overall experience with opioid prescriptions; this yielded three main findings:
1. Meeting patient needs in opioid education
Information about opioid benefits and risks, as well as instructions on how to use them, were primarily provided to patients in a pamphlet, with very limited verbal communication with HCP. This was generally considered adequate, however, patients with a more complex or painful recovery felt frustrated by the lack of communication with their HCP. One participant who spent time in hospital recovering after surgery experienced a sense of disconnection from their medical team and a lack of understanding about how their opioid treatment plan could be improved:
“The doctors don’t ever come to see you. So, the patient doesn’t know what’s going on … I know all the doctors are busy, and so I didn’t pester them … he didn’t say, look, we can up the dose of the pill you take every four hours. It would certainly have helped to have this simply explained to me. I was right there, in the hospital bed, so I don’t know why they didn’t.”
Implications: Though doctors are busy, small changes in communication, such as a simple discussion of pain levels and analgesia efficacy or a dosage adjustment, could improve pain relief for the patient.
2. Unused opioids
Analysis revealed a surplus of opioids among participants, with five participants not using them at all. Their reasons for not taking the opioids are shown in the figure below. Participants reported keeping leftover pills at home, posing a risk of diversion and misuse. Many participants who did not take opioids thought they were helpful to have in case of an emergency, and appreciated having them as an option in case of a complication with recovery.
Implications: Rather than sending patients home with opioids, HCPs could let them pick them up from a pharmacy if needed, thus reducing leftover opioids while maintaining the patient’s peace of mind.
3. Patient-centred opioid prescription
One participant expressed that opioids were not suitable for treating the pain from her surgery. This was due to the side effects complicating recovery: the opioids caused nausea, which coupled with recovery from oral surgery, made eating very difficult. A further frustration expressed by her was not being prescribed opioids for a more painful procedure for which she would have found them to be more helpful in her recovery:
“I don’t know if [opioids] should be prescribed for this surgery … I was a bit annoyed at that. When I got the coil (IUD), that’s when I think I really needed them, but I wasn’t given them then … I would have really wanted a prescription [after IUD insertion], but I didn’t get anything … it just doesn’t make the most sense to me”
Implications: Communication between patients and HCPs can enable a more accurate assessment of pain, informed decisions about side effects, and appropriate opioid prescriptions. Furthermore, it may be necessary to reevaluate the standard practices for opioid prescription and determine for which procedures they may be overprescribed or underprescribed. It is not standard practice to prescribe opioids for pain relief after IUD insertion, despite evidence suggesting their utility in mitigating the significant discomfort associated with the procedure.
Summary and key findings
This study examined the perspectives of patients who were prescribed opioids following surgery and identified potential improvements in prescribing practices that could enhance the utility of opioids for pain management following surgery:
● Communicate with patients and involve them in pain management plans
● Personalise prescription quantity and strength depending on pain levels
● Educate patients on safe medication disposal for opioids that do remain unused
Enhanced patient-doctor communication may promote the appropriate use of opioids in situations where they are not typically prescribed but could be beneficial, potentially leading to a reduction in existing disparities in the treatment of medical pain.
Limitations: This study utilised a sample of phone-recruited patients who were interviewed during working hours. As a result, full-time workers and individuals with limited English proficiency or technological literacy may have been underrepresented. Although structured interviews reduced researcher bias during the interviews, bias may have still impacted the data analysis.
References
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