The persistent benefits of decreasing default pill counts for postoperative narcotic prescriptions

Nathan Coppersmith; Joshua Sznol; Andrew Esposito; Emily Flom; Alexander Chiu; Peter Yoo

doi:10.1371/journal.pone.0304100

Peer Review History

Original SubmissionJanuary 16, 2024
5 Mar 2024 Decision Letter - Guilherme Antonio Moreira de Barros, Editor PONE-D-23-43929The Persistent Benefits of Decreasing Default Pill Counts for Postoperative Narcotic PrescriptionsPLOS ONE Dear Dr. Coppersmith, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. This is an interesting piece of work demonstrating how simple attitudes, such as reducing the number of prescribed opioid tablets in the postoperative period, can result in lower long-term usage risks. I find the study to be well-designed and presented; however, there is a need to enhance the discussion by comparing the obtained results with factors determining postoperative chronic opioid usage, as well as local characteristics of opioid abuse found in official local statistics and any available literature. I believe the discussion is incomplete and does not fully reflect the interesting findings demonstrated. I also request that you pay attention to the reviewers' comments and respond to all queries if you agree to resubmit the study for review. Please submit your revised manuscript by Apr 19 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Dear author, although this work is very interesting and important to the scientific community, specially dealing with opioid addiction, there are some considerations that I would like to highlight: Opioid consumption must be related to the type of surgery. I have not seen, in the table, this variable. Probably, would be a heterogeneous group, and tissue trauma can vary as well as the intensity of pain . In addition, there was no control of the use of other analgesics that could increase or reduce opioid consumption. Besides that, gender, race, social, educational and economic level, anxiety and other psychological and psychiatric comorbidities and other variables were not controlled. There was no mention of risk stratification and the impact on opioid consumption I think that the use of opioid have to be a rational, based on specific circumstances, and you have to discuss and suggest how to deal with a well done postoperative analgesia . Reducing the number of pills, or the the need for more over time can not be seen as an isolated event nor as a solution to the opioid crisis Reviewer #2: The manuscript describes a practical synthesis of effect simply reducing the number of opioid analgesic pills in the treatment of postoperative pain in the period 2017 until 2021. Some questions about this paper Any rational for reducing 30 pills to 12 pills? why not reduces 30-50% to opioids pill? Can you explain us more? Page 5: Did not mention the calculation for converting each analgesic to morphine (MME), as depending on the reference, the values vary for the calculations. Page 6: Some studies/papers report a cut off of 80-90 MME, why did they choose 90 MME? There is no consensus among the opioids guidelines as to which dose of morphine would be a cut off, most cite 90 mme Page 6: It was not mentioned which surgeries were included in the research, we know that there are surgeries that have greater painful potential than others As a suggestion too, include the percentages of outpatient surgeries or separate them by surgical specialty ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. 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Revision 1
24 Apr 2024 Author Response Yale School of Medicine 333 Cedar Street New Haven, CT 06510 April 1, 2024 Guilherme Antonio Moreira de Barros, M.D., M.Sc., Ph.D Academic Editor PLOS ONE Dear Dr. Moreira de Barros, Thank you for the opportunity to submit revisions to this manuscript, entitled “The Persistent Benefits of Decreasing Default Pill Counts for Postoperative Narcotics Prescriptions.” The review provided very helpful thoughts and suggestions, we are grateful for the excellent comments and feedback. Based on the reviews, we have made several important improvements to the manuscript which are outlined individually below. We hope you will find that the manuscript addresses the concerns of the reviewers satisfactorily. Once again, our research team is grateful for the ongoing interest of the PLOS ONE in our work. Best wishes, Nathan Coppersmith, MD, MHS Yale School of Medicine Yale University New Haven, CT Editor: This is an interesting piece of work demonstrating how simple attitudes, such as reducing the number of prescribed opioid tablets in the postoperative period, can result in lower long-term usage risks. • Thank you for this feedback. I find the study to be well-designed and presented; however, there is a need to enhance the discussion by comparing the obtained results with factors determining postoperative chronic opioid usage, as well as local characteristics of opioid abuse found in official local statistics and any available literature. I believe the discussion is incomplete and does not fully reflect the interesting findings demonstrated. • Thank you for this feedback. A discussion has been added regarding the risks of developing chronic postoperative opioid usage. Furthermore, the discussion has been enhanced to look at the local and regional trends regarding opioid prescribing habits. Reviewer #1: Dear author, although this work is very interesting and important to the scientific community, specially dealing with opioid addiction, there are some considerations that I would like to highlight: Opioid consumption must be related to the type of surgery. I have not seen, in the table, this variable. Probably, would be a heterogeneous group, and tissue trauma can vary as well as the intensity of pain. • Thank you for this feedback. Due to the heterogeneity of surgeries performed across the 191,379 surgical procedures performed during this time period we did not break the data down by type of procedure performed. With such a large variety of surgeries performed, we were more interested in the overall trend of opioid prescription across the healthcare system because change in volume or prescription habits to one or a few particular types of surgeries would not influence the overall trend of such a large volume of surgeries. In addition, there was no control of the use of other analgesics that could increase or reduce opioid consumption. Besides that, gender, race, social, educational and economic level, anxiety and other psychological and psychiatric comorbidities and other variables were not controlled. • Thank you for this feedback. The trend over time of use of other analgesics that could influence post-op opioid consumption is a very interesting and valuable idea. This data was not included in our data pull. There were not large changes in the demographics of gender and race in the population over the study period as demonstrated in the supplementary table 1. The influence of other psychological and psychiatric comorbidities in the population is an interesting point and a data point that was not collected in our data pull. There was no mention of risk stratification and the impact on opioid consumption • Thank you for this feedback. We have incorporated a discussion of patients who are higher risk for developing persistent postoperative opioid use into the discussion as well as risk of worse postoperative outcomes based on prior opioid use. I think that the use of opioid have to be a rational, based on specific circumstances, and you have to discuss and suggest how to deal with a well done postoperative analgesia . Reducing the number of pills, or the the need for more over time can not be seen as an isolated event nor as a solution to the opioid crisis • Thank you for this feedback. We concur that reducing the number of pills is not in isolation a solution to the opioid crisis. The discussion has been enriched to further elaborate on multi-modal pain control strategies, intra-operative pain control strategies, and targeting pill counts to specific procedures that can all be combined in order to potentially reduce the use of post-operative opioids. Reviewer #2: The manuscript describes a practical synthesis of effect simply reducing the number of opioid analgesic pills in the treatment of postoperative pain in the period 2017 until 2021. Any rational for reducing 30 pills to 12 pills? why not reduces 30-50% to opioids pill? Can you explain us more? • Thank you for this feedback. 12 pills was chosen as a quantity to provide one tablet every six hours for three days. This decision was made in 2017 by the healthcare system opioid stewardship committee. This has been added to the manuscript. Page 5: Did not mention the calculation for converting each analgesic to morphine (MME), as depending on the reference, the values vary for the calculations. • Thank you for this feedback. The calculation for converting each analgesic to morphine (MME) was based on the United States Centers for Disease Control and Prevention morphine milligram equivalent doses for commonly prescribed opioids for pain management (https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#T1_down). This has been added to the manuscript. Page 6: Some studies/papers report a cut off of 80-90 MME, why did they choose 90 MME? There is no consensus among the opioids guidelines as to which dose of morphine would be a cut off, most cite 90 mme. • Thank you for this feedback. The cutoff of 90 MME was used as it is the equivalent of the default quantity of 12 oxycodone 5 mg immediate-release tablets using the MME conversion of factor of 1.5 for oxycodone based on the CDC MME table. Page 6: It was not mentioned which surgeries were included in the research, we know that there are surgeries that have greater painful potential than others. As a suggestion too, include the percentages of outpatient surgeries or separate them by surgical specialty • Thank you for this feedback. As this included all surgeries performed in the healthcare system, we evaluated the data at a macro level, and we did not evaluate particular surgeries as we felt that the quantity of surgeries is large enough that individual types of surgeries would not influence the overall trend significantly. An interesting follow up study would be to interrogate the trends in prescribing habits of the most frequently performed surgeries, which surgeries had the greatest decrease in post-op opioids prescribed, if any actually had an increase, and which may not have had a decrease. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0304100.r002
7 May 2024 Decision Letter - Guilherme Antonio Moreira de Barros, Editor The persistent benefits of decreasing default pill counts for postoperative narcotic prescriptions PONE-D-23-43929R1 Dear Dr. Coppersmith, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Guilherme Antonio Moreira de Barros, M.D., M.Sc., Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): Dear Dr. Coppersmith, Congratulation for the great improvement and for the answers to the questions formulated by the reviewers. Reviewers' comments: https://doi.org/10.1371/journal.pone.0304100.r003
Formally Accepted
24 May 2024 Acceptance Letter - Guilherme Antonio Moreira de Barros, Editor PONE-D-23-43929R1 PLOS ONE Dear Dr. Coppersmith, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Guilherme Antonio Moreira de Barros Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0304100.r004

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