Opioid dispensing based on hysterectomy route

Opioid dispensing based on hysterectomy route | Image Credit: © Darwin Brandis - © Darwin Brandis - stock.adobe.com.

According to a recent study published in the American Journal of Obstetrics & Gynecology, perioperative opioid dispensing is significantly dependent on hysterectomy route.

Opioids are often used in medicine for pain relief but have led to severe rates of overdose and mortality. From 1999 to 2019, there were 250,000 overdose deaths from prescription opioids in the United States. Long-term use of opioids within a year of first prescription is seen in about 15% of patients prescribed opioids.

Opioids are often prescribed for the first time in a surgical center, including hysterectomies, which are the second most common surgical procedure in women. An opioid prescription is given to about 82% of women receiving a hysterectomy.

Studies have evaluated the risk of opioid use after hysterectomy, but there is little concise data on risk factors of opioid use related to hysterectomy. To determine the association between patterns of perioperative opioid dispensing during hysterectomy and subsequent opioid use, investigators conducted a systematic review and meta-analysis.

Two independent authors conducted a systematic literature search of Embase, Pubmed, and Web of Science. Literature from study inception to March 25, 2022, was eligible for inclusion.

Key words included opioid, analgesics, narcot, methadone, tramadol, codeine, morphine, buprenorphine, oxycodone, fentanyl, tapentadol, oxymorphone, hydrocodone, levorphanol, sufentanil, remifentanil, R-dihydroetorphine, Morphine-6-glucuronide, oliceridine, naloxone, naltrexone, opium, hysterect, uterine, uterus, excision, remov, and resec.

Eligibility criteria included being an observational study and reporting opioid dispensing for patients receiving hysterectomy. Exclusion criteria included incomplete data, data duplication or major overlap, and hysterectomy for malignancy. Eligibility review was performed by 2 independent reviewers, with a third consulted for disagreements.

The dosage of opioid dispensing during the perioperative period, reported as morphine milligram equivalents (MME), was measured as the primary outcome of the study. Perioperative opioid dispensing was considered opioid dispensing from 30 preoperative days to 21 postoperative days.

Assessment of risk factors linked to perioperative persistent opioid use, defined as opioid use from 3 months to 3 years following surgery, was measured as the secondary outcome of the study.

Data extraction was completed by 2 independent authors, with extracted data including first author’s name, publication year, country, study design, study period, sample size, hysterectomy route, participant eligibility criteria, definition, and rates of perioperative opioid dispensing and persistent opioid use. Quality assessment was performed using the Joanna Briggs Institutecritical appraisal checklist.

There were 8 articles included in the final analysis, half of which were retrospective designs and the other half prospective designs. Study publication dates were from 2017 to 2022. Of the studies, 3 contained data on persistent opioid use and 5 on perioperative opioid dispensing. Overall risk of bias was low, with 5 studies having low risk and 3 having moderate risk.

Perioperative opioids were given to 83% of patients undergoing hysterectomy, with an average 143.5 MME dispensed per patient. This is equal to about 19 5-mg oxycodone tablets. 

The average MME was 157 for patients receiving abdominal hysterectomy, 127.5 for laparoscopic, and 87.6 for vaginal. This indicated a significant reduction in MME for patients receiving vaginal hysterectomy compared to laparoscopic and abdominal. A significant reduction was also seen for MME in laparoscopic hysterectomy compared to abdominal.

Overall, 5% of patients with hysterectomy experienced persistent opioid use. However, persistent use occurrence was not significantly impacted by hysterectomy route or surgical complications. Rather, increased risk of persistent use was seen in patients aged under 45 years, alongside those with smoking history, alcohol use, fibromyalgia, and back pain.

These results indicated impacts in opioid dispensing, but not persistent opioid use, from hysterectomy route. Investigators recommended this information be considered when prescribing opioids to patients undergoing hysterectomy.

Reference

Hessami K, Welch J, Frost A. Perioperative opioid dispensing and persistent use after benign hysterectomy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology. 2023;229(1).doi:10.1016/j.ajog.2022.12.015