A Nationwide Population Study of Opiate Prescribing Practices Following Surgical Reduction Mammoplasty
Nicholas A. Calotta, MD1, David Merola, PharmD2, Zhen A. Lu, BA1, Devin O'Brien-Coon, MD, MSE1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Breast reduction mammoplasty (BRM) is a common cosmetic and reconstructive procedure performed in the United States. Opioids are an important element of post-operative analgesia but evidence-based guidelines regarding their prescription after BRM are lacking. We examined opioid use within a large patient population that underwent outpatient BRM to study prescribing patterns.
We studied the Truven Health Analytics MarketScan Commercial Claims and Encounters database, which is an administrative database derived from approximately 350 health plans in the United States. Patients who underwent outpatient BRM from January 1, 2010 to December 31, 2015 and who were continuously enrolled in a health plan for 6 months before and after surgery were included. We collected data regarding medical history, opioid drug prescribed, dosage, duration, and refills. Prescriptions were stratified into two time periods 1) a peri-operative period, defined as the time from two weeks before BRM to two weeks after BRM, to encompass index prescriptions; and 2) a post-operative period, which spanned two weeks after BRM to six months after BRM, to capture refills. All dosages were converted to milligram daily milligram morphine equivalents (DMME) to facilitate direct comparisons.
We identified 56,785 patients that met our study criteria. Of those studied, 99.5% were women, 77.6% were between the ages of 18 and 54, and 83.8% had a Charlson Comorbidity index ≤ 1. With regard to opioid prescribing, 90% of patients filled a prescription in the peri-operative period. Of these, 76% were opioid na´ve at time of surgery ("na´ve"), 19% had a history of one episode of acute opioid use in the previous 6 months before surgery ("acute"), and 5% were chronic users ("chronic"). For patients who filled post-operative scripts, 51% were previously na´ve, 31% acute users, and 18% chronic users. The average DMME of opioid drug for both the peri-operative and post-operative groups are shown in figure 1. Notably, the average dose in these time periods was significantly lower for the acute and na´ve users but not so for the chronic users.
On average, patients undergoing BRM are young, otherwise healthy women. For those who had limited or no previous opioid exposure, they received over double the opioids on average (62 DMME) than what is recommended for similar procedures, such as radical mastectomy (30 DMME). Interestingly, chronic users did not appear to require significantly different narcotic doses to control their acute surgical pain. This data may help prescribers limit opioid exposure to previously na´ve or acute users as well as reduce anxiety about the post-operative analgesic needs of chronic narcotic users.
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