Overprescribing of opioids, particularly after surgery, is an important contributor to the opioid crisis in the United States, where more than half of all patients receive opioids after surgery.1  Junior surgical residents do the majority of post-surgical opioid prescribing at academic medical centers.2  Two studies from 2018 found that, in surgery residency programs, residents prescribed 76% to 100% of opioids after surgery, while only 20% of programs required opioid prescribing education; 90% of residents did not receive any form of opioid prescribing education.3,4  Instead, 95% of residents reported attending surgeon preferences and 60% reported concern over patient satisfaction as motivating factors for how much to prescribe.3,5 

In 2019, the Accreditation Council for Graduate Medical Education mandated that all residency programs begin to “provide instruction and experience in pain management if applicable for the specialty including recognition of the signs of addiction.”6  This mandate included resident education on chronic pain management, for which there are Centers for Disease Control and Prevention guidelines.7  It was a critical step in the right direction for better opioid prescribing among residents overall. However, progress on improving appropriate opioid prescribing within the field of surgery lags behind; no similar coordinated national effort exists to improve the management of acute pain among opioid-naïve and opioid-exposed patients after surgery.8  Few resources exist to provide surgical residents with awareness of their patients' typical opioid consumption patterns or the number of unused opioids leftover due to their prescribing decisions.3 

Fortunately, the scientific and policy communities have developed several resources to address this problem. We are in a unique time during which recent advances in national policy, information technology, and data have the potential to significantly improve evidence-based opioid prescribing practices. The responsibility now falls on surgical residency programs to integrate these tools and make them accessible to their residents. The Leapfrog Group, a health care safety nonprofit rating group, has recently begun collecting annual quality metrics from health systems on post-surgical opioid prescribing, heightening the urgency of action on the part of residency programs to ensure their residents are engaging in evidence-based prescribing practices.9 

In this piece, we highlight some of the existing resources that may help with appropriate opioid prescribing for post-surgical management of acute pain (Table). We also suggest how surgical residency programs might go about adopting and leveraging these rapidly growing bodies of evidence, real-world data, and national policies so that their residents are no longer working in a vacuum of opioid prescribing guidance.

Table

Recent Advances in National Policy, Technology, and Data That Can Be Leveraged by Surgical Training Programs to Promote Responsible Post-Surgical Opioid Prescribing for Acute Pain

Recent Advances in National Policy, Technology, and Data That Can Be Leveraged by Surgical Training Programs to Promote Responsible Post-Surgical Opioid Prescribing for Acute Pain
Recent Advances in National Policy, Technology, and Data That Can Be Leveraged by Surgical Training Programs to Promote Responsible Post-Surgical Opioid Prescribing for Acute Pain

As others have previously emphasized, efforts to improve post-surgical opioid prescribing must be evidence-based.20  To that end, in recent years several research groups have collected post-discharge opioid consumption data from surgical patients and used that data to put forth evidence-based procedure-specific prescribing recommendations.21,22  Making these recommendations accessible to residents at the point-of-care represents an important opportunity to improve the appropriateness of opioid prescription amounts. Post-surgical opioid prescribing is often left to junior residents who have little data on which to guide their prescribing decisions and few clear restrictions on how much they are allowed to prescribe. To fully realize the potential of these excellent evidence-based recommendations, efforts must be made to put them in front of residents when they are making prescribing decisions.

Widespread adoption of evidence-based educational materials by surgical residency programs for their residents, advanced practice providers, and other prescribers might be one way to address this problem. Studies by Yorkgitis et al,2  Hill et al,18  and Linder et al23  have all designed educational interventions within surgical residency programs that use actual opioid consumption data to give residents concrete quantitative recommendations at the point-of-care on quantities to prescribe for specific procedures. These interventions all resulted in clinically significant reductions in opioid prescribing, no change in patient-reported satisfaction or worsened pain control, and increased use of nonnarcotic alternatives for pain. Hill et al emphasized the importance of giving prescribers actual patient opioid consumption data in their study, stating that simply providing prescribers with these consumption-based guidelines was sufficient to change their prescribing behaviors. Similarly, at our institution, evidence-based educational materials are developed annually for residents using a prospective database of patient opioid consumption data that is continuously updated. Educational seminars, prescribing guidance cards, feedback emails, and an online prescribing guidance dashboard24  for residents are all informed by this consumption data.19  We have chosen to use consumption data gathered at our institution to build these resources, since we have previously shown that most national consensus guidelines for post-surgical opioid prescribing significantly overestimate patients' opioid needs.25  After a year of consumption-based feedback on resident opioid prescribing, the size of the largest opioid prescriptions at our institution fell by over 50%. These studies are encouraging and suggest that more surgical residents should be equipped with easily accessible patient opioid consumption data to use as a reference when deciding how much to prescribe for their patients.

Resident education is merely one small way to address the herculean challenge of curbing excess post-surgical opioid prescribing. Thankfully, there are many other concurrent trends in medicine that surgical residency programs can leverage to make progress on promoting responsible opioid prescribing practices. One is a shift toward personalized prescribing. Pain is an intricate, subjective experience in which patients who undergo the same surgery may need vastly different quantities of narcotics. Use of personalized opioid prescribing tools—tools that use patient-specific characteristics and machine learning techniques to predict individual post-surgical pain control needs—is an important next step to address overprescribing. Several research groups, including ours, have developing robust models that provide prescribing guidance tailored to patient needs and can be made available to prescribers.12,24,26 

Electronic Prescriptions for Controlled Substances (EPCS) is another important new technology that is removing barriers to reduced prescribing and should be embraced as a tool for mitigating opioid overprescribing by surgical residency programs. Legislation passed by Congress in 2018 promoted the use of EPCS for opioids to combat the opioid crisis: it encouraged providers to prescribe opioids through their electronic health record by transmitting these electronic prescriptions securely and automatically to pharmacies. Doing so makes it easier for physicians to prescribe opioid refills when appropriate, so their patients can access smaller, safer amounts of additional opioids if needed for pain control.13  Integration of EPCS within existing workflows at surgical residency programs would allow residents to feel comfortable with smaller opioid prescriptions while more easily meeting the needs of patients who require refills. Widespread adoption of EPCS in some states has indeed been associated with significant declines in opioid prescribing.27 

Since 2017, multiple states, insurance companies, and pharmacies have developed regulations on opioid prescribing.14,28  A 7-day limit on opioid prescriptions is a common policy across most states and institutions.29  In 2018, Walmart limited initial acute opioid prescriptions to 7 days in length and doses of 50 morphine milligram equivalents per day.30  These blanket restrictions on duration and daily dose of opioid analgesia have faced some criticism for being imprecise tools that do not meet the needs of all patients and have had little impact so far on curbing opioid prescribing.29,31  Nonetheless, educating surgical residents on these restrictions is important: it will make them aware that many of their patients may have opioid requirements that exceed these limits, and that these patients should have carefully crafted pain management plans upon discharge, close outpatient follow-up, and the potential need for refills.

Electronic feedback systems represent an important shift toward designing processes of continual improvement around opioid prescribing. Prescription drug monitoring programs (PDMPs)—state-level databases that can track a patient's opioid prescriptions from multiple sources—are the most common existing feedback systems. While most states maintain PDMPs, results have been mixed regarding their ability to improve opioid prescribing practices.15  This may be because they are not typically updated in real time; they are useful only if the provider checks them prior to prescribing opioids, and not all PDMPs have been integrated into electronic heath records for easy access. Better feedback tools will likely soon be available; in the meantime, encouraging use of PDMPs by residents as well as other health care team members such as pharmacists and advanced practice providers is still important as it remains one of the only existing tools that provides feedback to the prescriber. The recent acquisition of PatientPing (a care coordination company) by Appriss (a prescription drug monitoring analytics company) highlights the growing national interest in using electronic systems of feedback to improve opioid prescribing and suggests that many more tools will be available soon.32 

One final trend working in our favor is the general public's heightened awareness of the dangers of opioids. In the experience of the authors, it is increasingly common to see patients avoid opioids and request nonnarcotic alternatives for pain. As physicians struggle to find ways to quell the ongoing epidemic, some patients are clearly taking these important decisions into their own hands. But we cannot rely on this culture change alone to solve the problem. Residents should be trained to have care conversations with their patients around pain management and to set goals with them for post-surgical pain levels and functional status.

As the educators of our future surgeons, surgical residency programs should take full advantage of the growing number of policies, technologies, and other resources that will help their surgical residents become responsible prescribers of opioids while treating the real pain of surgery.

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Author notes

Funding: Dr Marwaha is supported by a grant from the National Library of Medicine/National Institutes of Health (T15LM007092) and Biomedical Informatics and Data Science Research Training Program of Harvard University. Dr Brat is funded by grants from the CRICO/Risk Management Foundation of the Harvard Medical Institutions and Blavatnik Biomedical Accelerator Pilot Grant of Harvard University.