Opioid prescribing patterns after hepatectomy: opportunities for minimizing variation and dissemination

Background: Optimal strategies to limit postoperative opioid use after hepatectomy have not been delineated. We aimed to characterize variations in both inpatient administration and discharge prescriptions of opioids following hepatectomy to identify targetable predictors of patient use and provider prescription. Methods: Clinical characteristics and total inpatient oral morphine equivalent (OME) use and discharge prescription amounts were downloaded from electronic records for patients who underwent hepatectomy (excluding combination cases) at a single institution between 3/2016-12/2017. Logistic regression analyses were performed to identify predictors of the lowest quartiles of inpatient use and discharge prescription volumes. Results: In total, 305 patients underwent hepatectomy: 95 (31%) open major, 130 (43%) open minor, and 80 (26%) laparoscopic. Median length of stay (LOS) was 4 days (range 0-22). Patients used a median 95mg total OME while inpatient with a wide range (0–1,552mg). At discharge, patients received median prescription of 200mg (range 0–3,600). A total of 64 (21%) patients used zero OME in the last 24 hours of inpatient admission, yet these opioid-free patients still received a median 150mg OME (range 0–500) at discharge. Lowest quartiles of total inpatient OME and discharge prescription OME were 50mg and 150mg, respectively. Older age (p < 0.01), shorter LOS (p < 0.01), and laparoscopic hepatectomy (p = 0.02) independently predicted total inpatient OME ≤50mg. Older age (p = 0.01), lower OME use in the last 24 hours of inpatient stay (p < 0.01), and laparoscopic hepatectomy (p = 0.01) independently predicted discharge prescriptions ≤150mg. Conclusion: Wide variation in opioid use occurred following hepatectomy, and patients who underwent minimally invasive procedures and had shorter LOS used the least opioids. Lower last-24-hour inpatient opioid use was associated with lower discharge prescription OME. To reduce outpatient opioid dissemination, realistically modifiable measures include increasing rates of minimally-invasive approaches and continuing current efforts on multimodal strategies for opioid weaning to minimal levels in the last 24 hours before discharge.