Despite a substantial reduction in discharge opioid prescribing between 2017 and 2023, opioid refill rates within 90 days of discharge remained unchanged, with both overprescribing and underprescribing at discharge independently associated with higher refill risk, according to a recent study.
Mismatch between discharge opioid daily doses and patients’ inpatient opioid use was independently associated with opioid refills within 90 days following inpatient otolaryngology–head and neck surgery. In a retrospective cohort study of 4,132 adult patients, investigators found that both discharge opioid underprescription and overprescription were associated with a higher risk of refills within 30 days of discharge, while overprescription was also associated with an increased risk of refills at 31 to 60 days postdischarge. Additional factors independently associated with postdischarge refills included preoperative use of opioids, benzodiazepines, and cannabis; higher postoperative pain scores; and receipt of a prior refill.
The investigators examined electronic health record and prescription data from a large academic medical center involving adult patients who underwent inpatient otolaryngology–head and neck surgery with a postoperative hospital stay of at least 24 hours and were discharged between January 2017 and December 2023. Opioid doses were standardized to oral morphine equivalents. The primary outcomes were opioid refill prescriptions issued by surgical teams at 1 to 30, 31 to 60, and 61 to 90 days following discharge. Discharge opioid prescribing patterns were categorized as matched, overprescribed, or underprescribed based on whether the prescribed daily dose was within 7.5 oral morphine equivalents of the patient’s inpatient opioid consumption during the final 24 hours prior to discharge. Multivariable logistic regression models were used to identify independent factors associated with refills at each time interval.
Overall, 25.3% of patients received an opioid refill within 30 days of discharge, 13.7% of them received a refill at 31 to 60 days, and 13.0% of them received a refill at 61 to 90 days. From 2017 to 2023, the median total dose of discharge opioid prescriptions declined; however, refill rates remained unchanged across the study period. In adjusted analyses, intraoperative opioid use, inpatient opioid consumption, and total discharge opioid dose weren't independently associated with refill risk. In contrast, discharge daily dose mismatch was consistently associated with refills, with both underprescription and overprescription increasing the likelihood of refills within 30 days.
Preoperative opioids on the medication list were associated with an increased risk of opioid refills across all three postdischarge intervals. Preoperative benzodiazepine use was associated with a higher risk of refills at 31 to 60 days, and preoperative cannabis use was associated with a higher risk of refills at 31 to 60 and 61 to 90 days. Higher postoperative pain scores were only associated with refills within 30 days. Receipt of a prior refill was the strongest predictor of subsequent refills, particularly during the second and third postoperative months.
The investigators acknowledged several limitations. The analysis assessed refill occurrence rather than opioid quantity dispensed or consumed, which may not reflect the true exposure to opioids. Refills prescribed by clinicians outside the surgical teams weren't captured. The cohort was limited to patients hospitalized for at least 24 hours, limiting generalizability to outpatient procedures. Additionally, the observational design precluded causal inference, and prospective studies are needed to determine whether modifying discharge prescribing practices could reduce postoperative opioid refills.
“[A]ligning the daily [oral morphine equivalents] of discharge prescriptions with the patient’s own inpatient [oral morphine equivalents] during the last 24 hours before discharge may be the most effective opioid management approach to reduce refills,” noted lead study author Lingyi Zhang, MD, of the Department of Anesthesia and Perioperative Care at the University of California, San Francisco, and colleagues.
Disclosures: Co–study author Andrew Murr, MD, reported receiving fees from the American Board of Otolaryngology–Head and Neck Surgery and the Triological Society unrelated to the submitted work. The remaining researchers reported no relevant disclosures.