Mayo Clinic Opioid Prescriptions Exceed Proposed Guidelines

The median opioid prescription was equivalent to 50 pills of five-milligram oxycodone, which is almost twice the amount proposed Minnesota state guidelines recommend for a maximum, researchers have found.

Clinicians at Mayo Clinic were routinely writing opioid prescriptions for surgery patients that exceed regulatory guidelines now being drafted by the state of Minnesota, an in-house review has found.

The research, published this week in Annals of Surgery, also found significant differences in opioid prescribing among Mayo Clinic’s Arizona, Florida and Rochester campuses, and within surgical procedures.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Since 2000, the number of Americans receiving an opioid prescription and the number of deaths involving prescription opioid overdoses have roughly quadrupled, according to the Centers for Disease Control and Prevention. More than 90 people each day died from a prescription opioid or heroin overdose in 2015.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said co-author Robert Cima, MD, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

Cima said there aren’t evidence-based guidelines for prescribing opioids after surgery.

“That’s the fundamental issue,” he said. “And because pain is very subjective, it makes it challenging.”

The study looked at 7,181 opioid prescriptions following 25 common surgeries from January 2013 to December 2015 at Mayo Clinic campuses in Arizona, Florida and Rochester. In particular, the researchers examined patients who weren’t taking opioids in the 90 days before surgery.

Within that group of 5,756 patients, they found the median opioid prescription was equivalent to 50 pills of five-milligram oxycodone. That’s almost twice the amount draft Minnesota state guidelines recommend for a maximum, which is roughly a seven-day supply or about 27 pills of five-milligram oxycodone.

Also, the prescriptions varied among the three campuses after adjusting for other factors. The Rochester campus median equaled 40 pills of oxycodone; whereas, the Arizona and Florida campus’ median equaled 50 and 60 pills, respectively.

Because different surgeries require different degrees of pain management, the researchers also compared the opioid prescribing ranges within each of the 25 surgeries. They found a wide variation ─ even after adjusting for individual patients.

The researchers say the results show there is room for improvement at Mayo, but that the draft Minnesota guidelines aren’t appropriate for all cases.

“For some of the procedures, the guideline is probably appropriate and we have an opportunity to reduce the amount prescribed,” Habermann said. “For some of the more painful procedures, in orthopedics, for example, the draft guideline is likely too low.”

Mayo’s Department of Orthopedic Surgery is using the data to improve its opioid prescribing practices, and is developing a tiered approach based on surgical procedure. Other departments plan to follow suit.

Cima said patients must adjust expectations on appropriate levels of pain after surgery.

“We actively support patients, but they also need to be educated that some discomfort is part of the process,” Cima said. “We want patients to be comfortable enough to function, but taking away all the pain isn’t an appropriate part of recovery.”

The Mayo findings are consistent with a study released this spring that found a “prevalence of chronic opioid usage in surgical patients is high with widespread disparity among different sex, age, ethnicity, BMI, and subspecialty groups” at large academic medical centers.