Surgeons prescribe pain medications, makes sense; pain is a frequent “adverse” effect of surgical care. And with the drumbeats of concern over opioid addiction, physicians have reassessed our prescribing habits. But, in today’s world, physicians and more frequently, their employers are increasingly concerned about “satisfaction” scores. A new study looks at how a reduction in opioid pain prescriptions may influence those scores.
One of the beneficial effects of our societal concern about opioid use and addiction has been in that reassessment where we found significant variations in prescribing patterns among surgeons, patterns that had more historical experiential evidence than scientific. Many health systems using physician education and triggers in electronic health records standardized pain prescriptions, including Dartmouth, where the researchers performed their study. They looked at five commonly performed out-patient procedures  correlated prescribing behavior with subsequent patient satisfaction. The considered a period before “educational intervention” (is it me or does that sound vaguely like Cultural Revolution’s re-education) and a similar period after the new prescribing standards were in place.
The patients in each period were very similar; the most significant difference was a larger number of men in the post-education period. The percentage of patients prescribed opioids after their procedures was reduced by roughly 18% (from 90% to 72%), and the number of pills prescribed dropped by over half. And these reductions were seen for all each surgeon, as well as in the aggregate.
The satisfaction scores were obtained from survey’s performed by an outside agency, employed by the health system, mailed to patients after their care. The anonymous nature of the survey prevented matching responses to a specific patient; more importantly, it made the determination of the response rate impossible. The satisfaction scores reflect 10% of the patients treated during that period, a percentage that was about half that of overall patient responses during that period — so small numbers, and possibly bias reporting ahead.
There was no change in patient satisfaction. On a 10-point scale where ten is most satisfied, the median was 10 in both periods – makes you wonder about the degree to which these patient’s satisfaction was truly stratified.
The bottom line is that we can significantly reduce the amounts of opioids we prescribe for postoperative pain without impacting patient “satisfaction.” That makes for one less argument from physicians about altering their prescribing behavior. Unfortunately, it is an argument that has been more a research hypothesis than an actual belief.
One last thought, and perhaps this is too much of an “insider” point of view. This study, like so many, makes use of data already being gathered. That reduces the cost of doing research and eliminates a lot of concern over the approval of the study by institutional review boards.  But it also limits what we can ask, and more and more studies take that approach. We do know, in this case, that overall satisfaction with the surgeons was unchanged, but we don’t know specifically about the patient’s experience of postoperative pain. That would have required patient consent and more work.
 The procedures included partial removal of the breast, partial removal of the breast with sampling of the lymph nodes in the armpit, open hernia repair, and minimally invasive hernia repair or removal of the gall bladder.
 Dartmouth’s IRB rightly determined that no specific consent from patients was required because the information was being routinely collected.
Source: Association of Decreased Postsurgical Opioid Prescribing with Patients’ Satisfaction with Surgeons JAMA Surgery DOI: 10.1001/jamasurg.2019.2875