Presented again from the American Hernia Society by Dr. Jeremy Warren, and the paper is entitled Predictors of Low and High Opioid Tablet Consumption After Inguinal Hernia Repair, an ACHQC Opioid Reduction Task Force Analysis. So let's hear that paper. Hello, everyone. I first want to thank Drs. Rosen and Ponsky for putting together this session and allowing me to participate. I will be presenting work recently completed by the ACHQC Opioid Task Force on Patient Opioid Consumption After Inguinal Hernia Repair. These are my disclosures. I am a speaker and proctor for Intuitive, which should have no bearing on this presentation, and I'm also a board member of the ACHQC. I first want to acknowledge the Opioid Task Force, and in particular, Mickey Reinhorn, who started this whole initiative, and Ariel Perez and Clayton Petro for really doing all the work on this study and allowing me to present it. At this point, we're all familiar with the impact of opioids. There have been over half a million opioid-related deaths in the last 20 years. Prescription opioid-related deaths increased by 17% this last year, and a concurrent, much larger increase was seen in deaths related to synthetic opioids, and it's really critical for us to understand that the transition to synthetic opioids and heroin often begins with exposure to prescribed opioids. This key study published back in 2017 from Dartmouth was really instrumental in bringing this issue to the fore for general surgeons. This study demonstrated both a wide range of surgeon prescribing patterns for common procedures, as well as the fact that patients typically consume dramatically less opioid than prescribed. Focusing on inguinal hernias, we can see here that patients were prescribed between 15 and 120 opioid tablets after inguinal hernia repair, with an average of over 30 pills prescribed, and all patients in the study receiving a narcotic prescription. In contrast, patients reported taking only 15 to 30 percent of the prescribed tablets after inguinal hernia repair, and in fact, a study we did here in Greenville of more than 60 percent of our inguinal hernia patients actually required no opioid consumption. We know that overprescribing increases the risk of opioid misuse and abuse, so it's really imperative that we as surgeons recognize our role in helping to fix this problem. And this is where we saw an opportunity to leverage the QC to impact opioid use and prescribing. The QC is a national hernia-specific registry now containing over 100,000 patients. Because the QC captures very granular data on these patients, we have the opportunity to evaluate factors that may truly matter in patient quality of life and opioid consumption after surgery. The opioid task force was conceived by Mickey Reinhorn back in 2017 and culminated in the creation of an opioid module built into the QC that captures potential patient risk factors for opioid use, surgeon opioid prescribing, patient consumption, and patient-reported quality outcomes. Preliminary data analyzed after our initial rollout of the opioid module demonstrated the disparity in opioid prescribing to patient-reported consumption. Over 80 percent of patients reported taking less than 10 pills compared to 56 percent of patients who were prescribed more than 10 pills. Over 50 percent actually reported taking no opioids at all after inguinal hernia repair. For this study, we wanted to take the next step to see if we could identify any patient, surgery, or surgeon-specific factors that predict which patients may be high or low opioid consumers. We identified all patients undergoing elective, clean inguinal hernia repair with completed 30-day follow-up and complete opioid data. This left us with 1,937 patients for analysis. 59 percent of cases were minimally invasive inguinal hernia repairs, including both lap and robotic, 35 percent open mesh repairs, and 6 percent open tissue repairs. Overall, patients reported consuming zero narcotics in 50 percent of cases, with only 8 percent reporting more than 10 tablets consumed. We then ran two separate multivariate analyses. The first analysis was for patients reporting zero opioid use, and we identified patients with an older age, ASA 1 or 2, use of local anesthetic, use of sedation versus general anesthetic, and shorter operative time, as all increasing the chances that patients would use zero narcotics post-op. Most significant was the prescribing patterns. Patients with no opioid use prior to surgery or prescribed fewer than seven pills were the most likely to consume zero narcotics post-operatively. The second analysis focused on high consumers, and here we saw essentially the inverse of the zero users. We saw younger age, smokers, ASA 3 or 4, preoperative opioid use, open mesh repairs, longer operative times, and worse baseline quality of life as significant factors that increased the risk of high opioid consumption post-op. And again, we saw a significant impact on physician prescribing with patients at a significantly higher risk of opioid consumption when they were prescribed a higher volume of pills. In summary, there are several patient and surgeon-specific factors that influence and predict patient opioid consumption after inginal hernia repair. Modifiable patient factors are most notably a history of smoking, which increases the risk of opioid consumption. Patients with a prior or recent opioid use are also at a higher risk, and this supports the avoidance of prescribing opioids for hernia-related pain prior to surgery. Surgeon-modifiable factors include the use of anesthetic and the choice of surgical technique, which favors minimally invasive approach in the use of local anesthetic. Most importantly is the avoidance of preoperative opioid prescribing and reducing the volume of prescribed opioids post-operatively. We can see empirically that patients just do not need a just-in-case medication and that this in fact increases their risk of higher consumption. Patient-reported opioid use is significantly impacted by surgeon prescribing. We hope that using this type of data and giving this information back to the surgeons who enter the data, we can begin to change position behavior and reduce opioid prescribing. More studies need to further correlate these findings with patient quality of life, and we don't yet know if these factors will similarly impact opioid consumption for ventral and incisional hernia repairs, but we feel that this is a key step in the right direction. Thank you so much for your time today. Thank you, Dr. Warren. Dr. Warren is unable to be with us today, but I know that Dr. Todd Ponsky wants to ask a question that maybe Dr. Rosen, who uses all these opioids we've heard about, can answer that question. Well, it's actually just a theoretical. So, you know, the reason I prescribe narcotics, and I sometimes prescribe more than I think the patient even needs, is I know that you can't call it in. That you, right? So you have to, so you can't, hold on, maybe I'm wrong, but Michael, correct me, but at least my understanding is you can't call it in. So I just give them more than I think they need, because otherwise it's a huge headache for them to come back to the hospital, to get a written prescription. And I think the reason that we have this rule of you can't call in narcotics is for safety, is for safety of having too many people illegally getting narcotics and abusing narcotics. I think we're causing the wrong, I think we're, we're causing the problem in the opposite way, that by having this restriction, we're over prescribing. If you remove that restriction and allow us to call in controlled substances, I'll prescribe zero to three pills and say, well, we'll just call it in tomorrow if you need more. So Mike, I'm curious what your thoughts are on that. Yeah. So first of all, Todd, that's a great point. So full disclosure, I'm part of the collaborative and I'm on that opioid task force too. So I know this data quite well and you bring up a lot of great points. So the first point is just to kind of summarize it is it's the fear of refills is you know, how hard it's get refills. Actually, most of the legislation has changed. You can now actually prescribe without having to hand off that through, you know, EMRs and whatnot, or call in limited opioids. So almost every state has reversed that for particularly this reason, number one, but, but it actually begs the other question. And to me, this is what the quality collaborative and all these registries and what all surgeons kind of need to realize is we need that data, right? You need the data to answer your question, which is the balance between your concern of, of having to call in refills and the hassles, no matter there will still be hassles associated with that versus the balance of, you know, potentially somebody abusing the narcotics. So actually there's subsequent data. I think it's being presented to AHS right now that the rate of inguinal hernias, if you follow these guidelines, the rate of refill calls is 4%. So it's actually quite low. It's certainly not zero. And the predictors of that are also the predictors of people who, you know, potentially use more, but probably the biggest finding in this is, um, the, the number one predictor of how many opioid tablets a patient takes is how many they are prescribed. Um, and, and I will just wrap up my comments about this, that actually of all the things I've been involved in my life and surgery and trying to make things better. Um, I took a hard line. I'll just full disclosure. Um, three years ago, I actually, every single patient that was discharged from an inguinal hernia for me got 50 oxycodones. They were, it's only a $3 prescription and it cost $23 to FedEx the prescription. If not, and I made the resonance, if you wrote less and you needed a refill, you had to pay that to get it FedEx. And that's how I handled it. And then as I started to see this data and I started to see, Hey, look, my patients weren't taking that much. I've actually, since our last collaborative meeting in March, this is, I mean, it blows my mind to say this. I actually send people home with, for, for laparoscopic inguinal hernias. I'm not so sure if we're open yet, but lap, which is the majority of my practice, zero narcotics, zero six months. I have not written a script. I send them with ice and scheduled Motrin and Tylenol. And I know in six months, cause I keep track of it. I've had one refill and it was in a physician who just tortured me about it. It wasn't Jeff Ponsky, but it, but it was a physician. Uh, and so I think this is something that we have to realize as surgeons that we have created. Let me just say that as somebody who's standing by watching all this stuff, I think that the days of narcotics are going away. I've watched other specialties use drugs like gabapentin and Tylenol and get effective pain relief without narcotics. I think we're learning a lot about alternative ways of managing pain. And we have to keep our eyes open on this. I think opioids are going by the wayside in the future.
