(3) Inpatient Acute Pain Management in the Opioid Epidemic Among Oral and Maxillofacial Surgical Patients

Abstract:Statements of the Problem
The opioid epidemic is a national crisis that has affected millions across the United States. Improving prescribing practices amongst healthcare physicians through education and legislation has been a major focus in reducing prescribed opioids. Prescribing guidelines and mandatory restrictions on opioids for acute pain have reduced the number of opioid prescriptions by 162 million doses or 20.4%, from 2012 to 2016¹ . With this decrease, we also have seen a 14% reduction in prescription-related opioid deaths and an overall reduction in drug-related deaths.² In 2017, the state of Ohio released new guidelines, which restricted prescribing opioid analgesics to a day supply at no more than 30 morphine-equivalent doses per day for acute pain. The purpose of this study was to evaluate and compare inpatient opioid prescribing in patients undergoing hospital-based oral and maxillofacial surgical procedures before and after implementation of the state prescribing guidelines.
Materials and

Methods:
This study is a single-center, retrospective and observational cohort analysis of surgical patients at a large academic medical center. Patients were identified electronically via the OSUWMC Information Warehouse and included all patients admitted to the oral and maxillofacial surgery service. The time points were July 1, 2013, to June 30, 2014, and July 1, 2017, to June 30, 2018 for the 2013 and 2017 cohorts, respectively. Pertinent demographic, laboratory, and clinical data were gathered and recorded on a data collection form including: age, gender, weight, allergies, history of cirrhosis, documentation of elevated liver enzymes, history of coronary artery disease or GI bleed, documentation of acute kidney injury, surgery performed, American Society of Anesthesiologist’s classification of physical health, multimodal therapy prescribed during admission and at discharge, and morphine milligram equivalent (MME) prescribed during admission and at discharge.
Method of data analysis:
There were 137 and 153 surgeries included in the 2013 and 2017 cohort, respectively. Scope of surgeries included were orthognathic, TMJ (arthrocentesis, arthroscopy, arthroplasty, and total joint replacement), benign pathology, reconstruction with bone grafting procedures, dentoalvolear, and odontogenic infections.
Statistical

Methods: The MME administered 24 hours prior to release and prescribed at discharge were analyzed by a 3-way repeated-measures ANOVA, where the between-subjects factors were the cohort year and the type of surgery, and the within-subject factor was the action taken (administered 24 hours prior to discharge or prescribed at discharge). All interactions were included in the model. The estimation method of the ANOVA was restricted maximum likelihood and the degrees of freedom method was that of Satterthwaite. Significant effects were resolved using Student’s t tests as corrected with the Bonferroni method.

Results:
The average MME prescribed at discharge in the 2013 group was 238 mg (95% confidence interval 217 to 258) compared to 101 mg (95% confidence interval 88 to 115) in the 2017 group (p <.0001) over all types of surgery studied. A difference in MME either given during hospitalization within 24 hours of discharge or prescribed at discharge was not found between the 2013 and 2017 cohorts. However, the MME given during hospitalization within 24 hours of discharge or prescribed at discharge was different between the types of surgery in both cohorts.
Conclusions
Based on the study results, there is a decrease in the MME prescribed at discharge for OMS hospital-based procedures after the implementation of the Ohio acute pain prescribing guidelines.

References:
1. The State of Ohio Board of Pharmacy for prescribers- new limits on prescription for acute pain. 2017
2. Wilson N. Drug and opioid-involved overdose deaths - Snited States, 2017-2018. MMWR. Morbidity and mortality weekly report. 2020;69(11):290-297. https://www-ncbi-nlm-nih-gov.proxy.lib.ohio-state.edu/pubmed/32191688. doi: 10.15585/mmwr.mm6911a4.