By Pat Anson, PNN Editor

The 2016 CDC opioid guideline was never intended to reduce the use of opioids for post-surgical pain. In fact, studies show that long-term use of prescription opioids after surgery is rare. Nevertheless, a number of states and hospitals have policies designed to reduce the use of opioids after surgery -- many of them modeled after the CDC guideline.  

Vermont was one of the first, adopting a rule in July 2017 that encourages doctors to use non-opioid pain relievers as first-line treatments for post-operative plan. If they do prescribe opioids, patients are initially limited to no more than 10 pills. The regulations also require doctors to discuss with patients the risk of opioid addiction and overdose.

This state-mandated policy has led to significant reductions in opioid prescribing to surgery patients at the University of Vermont Medical Center (UVMMC) without impacting patient satisfaction in pain management, according to a new study presented at the American College of Surgeons Clinical Congress.

The study evaluated opioid prescribing at UVMMC for 15 common operations for 12 months before the regulations went into effect and for 17 months afterward.

During that period, the daily morphine milligram equivalent (MME) dose declined by 33 percent, from 96 MME to 64 MME afterwards. The proportion of patients who did not receive any opioids after surgery more than doubled, from 12.7 to 26 percent. That’s one of every four patients.

Prescription refill rates for opioids increased from 5.5 percent to 6.3 percent, and the percentage of patients reporting an inadequate amount of pain medication also rose, from 11 percent to 12.3 percent. But those increases were not considered statistically significant by the researchers.

“The clear trend is that physicians are prescribing less, patients are using less, and there is no appreciable change in patient-reported pain control or satisfaction after implementation of these regulations,” said study presenter Mayo Fujii, MD, a clinical instructor in surgery at the University of  Vermont Larner College of Medicine.  

“That patients are using less may reflect the impact of patient education efforts to establish expectations of postoperative pain and use non-opioid pain management strategies, as well as public awareness of the opioid epidemic.”

Patient education about non-opioid analgesia increased from 82 percent to 98 percent during the study period, as did education on safe opioid disposal (19 percent to 52 percent).

“Patient education, particularly encouraging non-opioid pain management strategies was something that clearly increased after these regulations went into effect,” Fujii said. “It’s an intervention that’s easily implemented and may contribute to patients using less opioid medication than they otherwise would have.”

Vermont Overdoses Still Rising

The Vermont regulations appear to have been successful in reducing the frequency and amount of opioids prescribed to both acute and chronic pain patients. But what about their impact on addiction and overdose rates?  The evidence there is mixed at best.

According to state health officials, fatal overdoses in Vermont rose from 96 deaths in 2016 to 110 deaths last year. Most of those overdoses involve illicit fentanyl or heroin, not prescription opioids. Only 28% of the deaths in 2018 were linked to opioid painkillers, but it’s not known if the pills were prescribed or obtained illicitly.

A recent study in neighboring Massachusetts found that only 1.3% of overdose victims who died from opioid medication had an active opioid prescription – suggesting that the vast majority of pills were stolen, diverted or bought on the street.

As in other states, many doctors in Vermont have grown cautious about their opioid prescribing and some are aggressively tapering patients off opioids. A recent study of tapering in Vermont found only 5 percent of patients had a tapering period longer than 90 days. The vast majority (86%) were rapidly tapered in three weeks or less, including about half who were cut off without any tapering. Many of those patients were hospitalized for severe withdrawal symptoms, including respiratory failure.

A new federal tapering guideline suggests tapers of 5% to 20% every four weeks, although slower tapers of 10% a month may be appropriate for patients taking opioids for more than a year.