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Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery
  1. Sarah S Joo1,
  2. Oluwatobi O Hunter2,
  3. Mallika Tamboli1,2,
  4. Jody C Leng1,2,
  5. T Kyle Harrison1,2,
  6. Kate Kassab3,
  7. Jody D Keeton3,
  8. Stephen Skirboll3,4,
  9. Suzanne Tharin3,4,
  10. Emam Saleh3,4,
  11. Seshadri C Mudumbai1,2,
  12. Rachel R Wang1,2,
  13. Alex Kou1,2 and
  14. Edward R Mariano1,2
  1. 1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  2. 2Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  3. 3Neurosurgery, VA Palo Alto Health Care System, Palo Alto, California, USA
  4. 4Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
  1. Correspondence to Dr Edward R Mariano, Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA; emariano{at}stanford.edu

Abstract

Background and objectives At our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.

Methods In this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1 year before and after introduction of the protocol. This protocol used the patient’s prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.

Results Eighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420–1440) preintervention compared with 300 (112–806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.

Conclusions This patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.

  • opioids, adverse effects
  • acute pain
  • postoperative pain

https://doi.org/10.1136/rapm-2020-101324

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    Footnotes

    • Twitter @EMARIANOMD

    • Presented at Accepted for presentation at the 2020 spring annual meeting of the American Society of Regional Anesthesia and Pain Medicine.

    • Contributors SSJ helped design the study, collected data, drafted and revised the initial manuscript, reviewed and approved the submitted manuscript. OOH helped design the study, implemented the tapering protocol, collected data, reviewed and approved the submitted manuscript. MT helped design the study, collected data, reviewed and approved the submitted manuscript. JCL helped design the study, implemented the tapering protocol, reviewed and approved the submitted manuscript. TKH, SCM, and RRW helped design the study, reviewed and approved the submitted manuscript. KK implemented the tapering protocol, collected data, reviewed and approved the submitted manuscript. JDK, SS, ST, and ES implemented the tapering protocol, collected data, reviewed and approved the submitted manuscript. AK helped design the study, collected and analyzed data, reviewed and approved the submitted manuscript. ERM helped design the study, collected and analyzed data, drafted and revised the initial manuscript, reviewed and approved the submitted manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval This retrospective cohort study was reviewed and approved with waiver of informed consent by the local institutional review board (Stanford, California) and the Veterans Affairs Research Committee (Palo Alto, California).

    • Provenance and peer review Not commissioned; externally peer reviewed.