Opioids Overprescribed After Surgery

Patients need only half of the opioids they're prescribed after surgery and take only a fraction of the opioids they receive, according to new research published in the Annals of Surgery, which suggests overprescribing the painkillers increases the risk of abuse.

Researchers at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., assessed the post-op opioid prescription fill and refill rates of 642 patients who underwent outpatient partial mastectomy, partial mastectomy with sentinel lymph node biopsy, laparoscopic cholecystectomy, laparoscopic inguinal hernia repair or open inguinal hernia repair.

The researchers also conducted phone interviews to determine how many pills the patients actually took. Overall, only 28% of the prescribed pills were consumed. The researchers say only 43% of the actual number of prescribed pills was needed to provide patients with the amount of pills they actually took. The findings also indicate a wide variation in the number of pills that were prescribed: For example, the number of opioids received by patients who underwent lap choles ranged from 10 to 100 pills.

Richard Barth Jr., MD, chief of general surgery at Dartmouth-Hitchcock and one of the study's authors, says the variation in the number of prescribed opioids is based on physicians' perceptions of how many opioids patients will need to control post-op pain, a lack of knowledge about how many pills patients actually take and differing guidelines regarding the number of pills that should be prescribed after particular types of cases.

"Providers also want to make sure the pain that patients experience is minimized, so they prescribe enough to satisfy the patient who requires the most opioids," says Dr. Barth. "It's also likely that the desire to avoid the inconvenience — both to the patient and the provider — of a return trip to the clinic to obtain a prescription refill drives over-prescription."

The study says setting patients' expectations about the number of pills they'll need to mange post-op pain and using non-opioid analgesics such as ibuprofen and acetaminophen would decrease the amount of opioids prescribed and, therefore, potentially abused.

"Opioid overdose is now the leading cause of injury-related death in the United States, having surpassed motor vehicle accidents for the first time," says Dr. Barth. "We can do better than this to keep our patients comfortable after surgery and safe from the dangers of misuse."

Daniel Cook

Video Laryngoscopy Tops All Rescue Methods

When direct laryngoscopy fails and rescue intubation is needed, video laryngoscopy is likely to be your best bet, a large retrospective study finds.

Researchers who analyzed almost 350,000 anesthesia cases found that among the roughly 1,400 for whom direct laryngoscopy failed (about 1 in every 250), video scopes succeeded 92% of the time, outperforming supraglottic airway conduit and flexible bronchoscopic intubation (each of which saw a 78% success rate), lighted stylets (77%) and optical stylets (67%).

They also found that the frequency of video laryngoscopy use for rescue attempts increased from 30% in 2004 to more than 80% in 2012. The technology "will increasingly replace traditional direct laryngoscopy in routine airway management," they write.

Jim Burger

Are ACL Injury Rates and Testosterone Linked?

Women are up to 10 times more likely than men to suffer anterior cruciate ligament injuries, but orthopedists have not yet been able to conclusively explain why. In a recent study, however, researchers at Johns Hopkins Medicine in Baltimore, Md., speculate that sex hormones play a big part.

"The primary implication of the study is that testosterone may contribute to the ACL's ability to withstand tensile loads," says physical therapist and sports medicine researcher William Romani, PhD, MHA, "and may be one of multiple factors responsible for the disparate ACL injury rate between men and women."

Through a series of rat studies, Dr. Romani and his colleagues determined that male rats with normal, natural testosterone levels had stronger ACLs which ruptured under higher tensile forces than those whose testosterone was low due to clinical castration. Their study was published online by the journal The Knee earlier this month.

While study's authors acknowledge that they still don't know exactly how testosterone and estrogen affect ACL strength, or that of other ligaments, they suggest that benchmarking athletes' hormone levels may identify injury risks and optimal training strategies.

David Bernard

InstaPoll: Rate Your Out-of-Pocket Patient Collections

With more patients paying more out of pocket than ever before, collecting deductibles and co-pays on the day of surgery has never been more critical to maintain a healthy revenue stream for your surgical business. Tell us in this week's InstaPoll how often you collect the amounts due from patients in full on the day of surgery.

Nearly three-fourths (72%) of the 410 respondents to last week's InstaPoll say that their staff bring their cell phones into the OR "often" (22%) or "very often" (50%).

Does your staff sneak their cell phones into the OR?

  • never 4%
  • rarely 7%
  • sometimes 17%
  • often 22%
  • very often 50%

Dan O'Connor

News & Notes

  • ASA and BevMD resolve dispute The American Society of Anesthesiologists and BevMD have settled their dispute regarding advertising claims the manufacturer made about Clearfast, its pre-op carbohydrate-rich drink. The ASA objected to the company maintaining that the drink met the ASA's pre-op guideline for clear liquid consumption and that it has the organization's "seal of compliance." BevMD has since removed that language from its marketing materials, according to the ASA.
  • Are you transformational or are you avoidant? A nurse manager who leads her staff through transactional and transformational communication will find that her nurses are more engaged in their work and ultimately deliver better outcomes than a passive and avoidant leader, according to a behavioral study in the September issue of the Journal of Nursing Administration.
  • Pinpointing post-op delirium A 2- to 3-minute test can accurately predict the risk of post-op delirium among surgical candidates, say researchers. The test, which involves having patients try to remember 3 simple words and draw a clock face, can mark the probability that the patient will suffer the cognitive complication at 50%, 20%, 13% or 5% or less.