The Current State of Fat Grafting in the Hand: A Systematic Review for Hand Diseases

Autologous fat grafting (AFG) has traditionally been used for facial rejuvenation and soft tissue augmentation, but in recent years, its use has expanded to treat diseases of the hand. Autologous fat grafting is ideal for use in the hand because it is minimally invasive, can restore volume, and has regenerative capabilities. This review summarizes the emerging evidence regarding the safety and efficacy of AFG to the hand in several conditions, including systemic sclerosis, Dupuytren disease, osteoarthritis, burns, and traumatic fingertip injuries. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search on the use of AFG in hand pathologies was performed on October 8, 2020, in Ovid MEDLINE, Elsevier Embase, Clarivate Web of Science, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by 2 independent reviewers and a third reviewer adjudicated when required. Reviewers identified 919 unique hits. Screening of the abstracts identified 22 manuscripts which described the use of AFG to treat an identified hand condition. Studies suggest AFG in the hands is a safe, noninvasive option for the management of systemic sclerosis, Dupuytren contracture, osteoarthritis, burns, and traumatic fingertip injuries. While AFG is a promising therapeutic option for autoimmune, inflammatory, and fibrotic disease manifestations in the hand, further studies are warranted to understand its efficacy and to establish more robust clinical guidelines. Studies to date show the regenerative, immunomodulatory, and volume-filling properties of AFG that facilitate wound healing and restoration of hand function with limited complications.

Trust and Distrust in Opioid Decision-Making: A Qualitative Assessment of Patient-Doctor Relationship

PURPOSE

Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients' decision-making process on postoperative opioid use.

METHODS

We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data.

RESULTS

We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons "know," thereby, reinforcing their trust in surgeons' postoperative opioid prescribing to be in the participants' best interest. Moreover, the positive reputation of the institution strengthened the participants' trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as "suspicious," and the pharmaceutical companies, that were "despised." Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders.

CONCLUSIONS

Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms.

CLINICAL RELEVANCE

Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

Preoperative Opioid Use and Readmissions Following Surgery

OBJECTIVE

To assess the association between preoperative opioid exposure and readmissions following common surgery.

SUMMARY BACKGROUND DATA

Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown.

METHODS

We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type.

RESULTS

Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29).

CONCLUSIONS

Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.

Predictors of Discharge Home Without Opioids After Cardiac Surgery: A Multicenter Analysis

BACKGROUND

Whether all patients will require an opioid prescription after cardiac surgery is unknown. We performed a multicenter analysis to identify patient predictors of not receiving an opioid prescription at the time of discharge home after cardiac surgery.

METHODS

Opioid-naïve patients undergoing coronary artery bypass grafting and/or valve surgery through a sternotomy at 10 centers from January to December 2019 were identified retrospectively from a prospectively maintained data set. Opioid-naïve was defined as not taking opioids at the time of admission. The primary outcome was discharge without an opioid prescription. Mixed-effects logistic regression was performed to identify predictors of discharge without an opioid prescription, and postdischarge opioid prescribing was monitored to assess patient tolerance of discharge without an opioid prescription.

RESULTS

Among 1924 eligible opioid-naïve patients, mean age was 64 ± 11 years, and 25% were women. In total, 28% of all patients were discharged without an opioid prescription. On multivariable analysis, older age, longer length of hospital stay, and undergoing surgery during the last 3 months of the study were independent predictors of discharge without an opioid prescription, whereas depression, non-Black and non-White race, and using more opioid pills on the day before discharge were independent predictors of receiving an opioid prescription. Among patients discharged without an opioid prescription, 1.8% (10 of 547) were subsequently prescribed an opioid.

CONCLUSIONS

Discharging select patients without an opioid prescription after cardiac surgery appears well tolerated, with a low incidence of postdischarge opioid prescriptions. Increasing the number of patients discharged without an opioid prescription may be an area for quality improvement.

Association of State Opioid Prescription Duration Limits With Changes in Opioid Prescribing for Medicare Beneficiaries

This cohort study uses Medicare Part D data to examine whether there is an association between the implementation of state limits on opioid prescription duration and changes in prescribing.

Computed Tomography in Patients With Craniosynostosis: A Survey to Ascertain Practice Patterns Among Craniofacial Surgeons

BACKGROUND

In patients with craniosynostosis, imaging remains up to the discretion of the plastic surgeon or neurosurgeon. To inform best practice guidelines, we sought to obtain data surrounding the frequency at which craniofacial surgeons order computed tomography (CT), as well as indications. We hypothesized that we would identify considerable variation in both imaging and associated indications.

METHODS

We surveyed members of the American Society of Maxillofacial Surgeons and the American Society of Craniofacial Surgeons to measure the frequency of preoperative and postoperative head CTs, as well as indications. Initial items were piloted with 2 craniofacial surgeons and 1 neurosurgeon, using interviews to ensure content validity. χ2 Tests were used to measure associations between operative volume, years in practice, and imaging.

RESULTS

Eighty-five craniofacial surgeons responded (13.8% response rate), with the majority (63.5%) having performed a craniosynostosis operation in the last month. Only 9.4% of surgeons never order preoperative CTs. Of those who do, the most common indications included diagnosis confirmation (31.2%) and preoperative planning (27.3%). About 25% of surgeons always obtain postoperative head CTs, usually to evaluate surgical outcomes (46.7%). Only 13.3% of respondents order 2 or more postoperative scans. Higher operative volume was associated with a lower likelihood of ordering preoperative head CTs (P = 0.008).

CONCLUSIONS

The majority of surgeons obtain preoperative head CTs, whereas only 25% obtain CTs postoperatively, often to evaluate outcomes. Because outcomes may be evaluated clinically, this is a poor use of resources and exposes children to radiation. Consensus guidelines are needed to create best practices and limit unnecessary studies.

Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study

PURPOSE

The rates of upper extremity reconstruction for patients with tetraplegia remain low. We performed a retrospective study to assess recent reconstruction rates and delineate factors associated with the occurrence of reconstruction.

METHODS

We examined the National Inpatient Sample database (2012-2017) for the rate of reconstruction for patients with tetraplegia. The details of provider distribution characteristics and neighborhood attributes were obtained from the American Medical Association Physician Masterfile and based on the area deprivation index, respectively. We calculated the mean reconstruction rate per year and generated multivariable logistic regression models to examine the influence of patient factors, hospital characteristics, and provider distribution on the odds of undergoing functional reconstruction for tetraplegia patients.

RESULTS

Among 404,660 encounters with patients with tetraplegia, only 1,430 (0.4%) patients underwent upper extremity reconstruction from 2012 to 2017, with a mean rate of 238 procedures per year. We identified 5,450 hand surgeons, 12,751 physiatrists, and 444 spinal cord injury specialists, with variation in their national distribution. A greater number of surgeons near SCIS was associated with increased probability of reconstruction (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.12). The odds of surgery were greater for patients receiving care at urban teaching (OR 5.00, 95% CI 3.35-7.47) or urban nonteaching (OR 1.71, 95% CI 1.11-2.63) hospitals, whereas those at private nonprofit (OR 0.67, 95% CI 0.58-0.78) or investor-owned (OR 0.65, 95% CI 0.52-0.82) hospitals had lower odds. Although most patients had insurance coverage, patients with a higher income or those who received subsidized care had greater odds of undergoing reconstruction.

CONCLUSIONS

Reconstruction rates remain low and are correlated with the environment of care, financial factors, and provider availability. Policies that focus on reducing these factors in addition to increasing interspecialty collaboration could improve access to surgery for patients with tetraplegia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use

OBJECTIVE

To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery.

BACKGROUND

Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use.

METHODS

We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates.

RESULTS

In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90].

CONCLUSIONS

Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.

Establishment and Implementation of Evidence-Based Opioid Prescribing Guidelines in Cardiac Surgery

BACKGROUND

Despite the risk of new persistent opioid use after cardiac surgery, postdischarge opioid use has not been quantified and evidence-based prescribing guidelines have not been established.

METHODS

Opioid-naive patients undergoing primary cardiac surgery via median sternotomy between January and December 2019 at 10 hospitals participating in a statewide collaborative were selected. Clinical data were linked to patient-reported outcomes collected at 30-day follow-up. An opioid prescribing recommendation stratified by inpatient opioid use on the day before discharge (0, 1-3, or ≥4 pills) was implemented in July 2019. Interrupted time-series analyses were performed for prescription size and postdischarge opioid use before (January to June) and after (July to December) guideline implementation.

RESULTS

Among 1495 patients (729 prerecommendation and 766 postrecommendation), median prescription size decreased from 20 pills to 12 pills after recommendation release (P < .001), while opioid use decreased from 3 pills to 0 pills (P < .001). Change in prescription size over time was +0.6 pill/month before and -0.8 pill/month after the recommendation (difference = -1.4 pills/month; P = .036). Change in patient use was +0.6 pill/month before and -0.4 pill/month after the recommendation (difference = -1.0 pills/month; P = .017). Pain levels during the first week after surgery and refills were unchanged. Patients using 0 pills before discharge (n = 710) were prescribed a median of 0 pills and used 0 pills, while those using 1 to 3 pills (n = 536) were prescribed 20 pills and used 7 pills, and those using greater than or equal to 4 pills (n = 249) were prescribed 32 pills and used 24 pills.

CONCLUSIONS

An opioid prescribing recommendation was effective, and prescribing after cardiac surgery should be guided by inpatient use.

Persistent Opioid Use after Ophthalmic Surgery in Opioid-Naive Patients and Associated Risk Factors

PURPOSE

To determine the rate and risk factors for new persistent opioid use after ophthalmic surgery in the United States.

DESIGN

Retrospective claims-based cohort analysis.

PARTICIPANTS

Opioid-naive patients 13 years of age and older who underwent incisional ophthalmic surgery between January 1, 2012, and June 30, 2017, and were included in Optum's de-identified Clinformatics Data Mart database.

METHODS

New persistent opioid use was defined as filling an opioid prescription in the 90-day and the 91- to 180-day periods after the surgical procedure. The outcome variable was an initial perioperative opioid prescription fill. Rates of new persistent opioid use were calculated, and multivariate logistic regression models were used to identify variables increasing the risk of new persistent use and refill of an opioid prescription after the initial perioperative prescription in first 30 days.

MAIN OUTCOME MEASURES

New persistent opioid use and refill.

RESULTS

A total of 327 379 opioid-naive patients (mean age, 67 years [standard deviation, 16 years]; 178 067 women [54.4%]) who underwent ophthalmic surgery were examined. Among these patients, 14 841 (4.5%) had an initial perioperative opioid fill. The rate of new persistent opioid use was 3.4% (498 of 14 841 patients) compared with 0.6% (1833 of 312 538 patients) in patients who did not have an initial perioperative opioid fill. After adjusting for patient characteristics, initial perioperative opioid fill was associated independently with increased odds of new persistent use (adjusted odds ratio [OR], 6.21; 95% confidence interval [CI], 5.57-6.91; P < 0.001). Among patients who had filled an initial perioperative prescription, a prescription size of 150 morphine milligram equivalents or more was associated with an increased odds of refill (adjusted OR, 1.87; 95% CI, 1.58-2.22; P < 0.001).

CONCLUSIONS

Exposure to opioids in the perioperative period is associated with new persistent use in patients who were previously opioid-naive. This suggests that exposure to opioids is an independent risk factor for persistent use in patients undergoing incisional ophthalmic surgery. Surgeons should be aware of those risks to identify at-risk patients given the current national opioid crisis and to minimize prescribing opioids when possible.

Dental Opioid Prescriptions and Overdose Risk in Patients and Their Families

INTRODUCTION

It is unknown whether dental opioid prescriptions are associated with opioid overdose in patients or their family members, who may have access to patients' opioids.

METHODS

During July-October 2020, the 2011-2018 IBM MarketScan Dental, IBM MarketScan Commercial, and Medicaid Multi-State Databases were analyzed. Two analyses were conducted. In the patient analysis, dental procedures for privately and publicly insured patients aged 13-64 years were identified. The exposure was ≥1 initial prescription (dispensed opioid prescription within 3 days of the procedure). The association between the exposure and ≥1 overdose within 90 days of the procedure was evaluated using logistic regression. In the family analysis, procedures for privately insured patients in family plans were identified. The association between the exposure and ≥1 overdose in a family member within 90 days was evaluated using logistic regression. In both analyses, the average marginal effect of the exposure was calculated, representing the change in the probability of the outcome if all versus if no procedures were associated with ≥1 initial prescription.

RESULTS

The patient analysis included 8,544,098 procedures. When ≥1 initial prescription did and did not occur, the 90-day risk of overdose was 5.8 versus 2.2 per 10,000 procedures (average marginal effect=1.5, 95% CI=1.2, 1.8). The family analysis included 3,461,469 procedures. When ≥1 initial prescription did and did not occur, the 90-day risk of overdose in a family member was 1.7 versus 1.0 per 10,000 procedures (average marginal effect=0.4, 95% CI=0.1, 0.7).

CONCLUSIONS

Findings further highlight the importance of avoiding unnecessary dental opioid prescribing.

Association between timing of kyphoplasty and opioid prescribing risk after vertebral fracture

OBJECTIVE

Approximately 550,000 Americans experience vertebral fracture annually, and most receive opioids to treat the resulting pain. Kyphoplasty of the fractured vertebra is a procedural alternative that may mitigate risks of even short-term opioid use. While reports of kyphoplasty's impact on pain scores are mixed, no large-scale data exist regarding opioid prescribing before and after the procedure. This study was conducted to determine whether timing of kyphoplasty following vertebral fracture is associated with duration or intensity of opioid prescribing.

METHODS

This retrospective cohort study used 2001-2014 insurance claims data from a single, large private insurer in the US across multiple care settings. Patients were adults with vertebral fractures who were prescribed opioids and underwent balloon-assisted kyphoplasty within 4 months of fracture. Opioid overdose risk was stratified by prescribed average daily morphine milligram equivalents using CDC guidelines. Filled prescriptions and risk categories were evaluated at baseline and 90 days following kyphoplasty.

RESULTS

Inclusion criteria were met by 7119 patients (median age 77 years, 71.7% female). Among included patients, 3505 (49.2%) were opioid naïve before fracture. Of these patients, 31.1% had new persistent opioid prescribing beyond 90 days after kyphoplasty, and multivariable logistic regression identified kyphoplasty after 8 weeks as a predictor (OR 1.34, 95% CI 1.02-1.76). For patients previously receiving opioids, kyphoplasty > 4 weeks after fracture was associated with persistently elevated prescribing risk (OR 1.84, 95% CI 1.23-2.74).

CONCLUSIONS

New persistent opioid prescribing occurred in nearly one-third of patients undergoing kyphoplasty after vertebral fracture, although early treatment was associated with a reduction in this risk. For patients not naïve to opioids before fracture diagnosis, early kyphoplasty was associated with less persistent elevation of opioid overdose risk. Subsequent trials must compare opioid use by vertebral fracture patients treated via operative (kyphoplasty) and nonoperative (ongoing opioid) strategies before concluding that kyphoplasty lacks value, and early referral for kyphoplasty may be appropriate to avoid missing a window of efficacy.

Effect of injury location and severity on opioid use after trauma

OBJECTIVE

Recent data have suggested that persistent opioid use is prevalent following trauma. The effect of type of injury and total injury burden is not known. We sought to characterize the relationship between injury location and severity and risk of persistent opioid use.

METHODS

We investigated postdischarge opioid utilization among patients who were admitted for trauma between January 2010 and June 2017 using the Optum Clinformatics Database. New persistent opioid use (NPOU) was defined as one of the following scenarios: (1) two separate opioid prescription fills between 0 and 14 days postdischarge and having 1+ fills in the 91 to 180 days following discharge or (2) filling a prescription in the 15 to 90 days following discharge in addition to a filling in the 91 to 180 day postdischarge period. Multivariable logistic regression was used to assess the relationship between injury type and severity with new persistent opioid use development.

RESULTS

A total of 26,437 opioid-naive patients were included in the analysis. Overall, 2,277 patients (8.6%) met the criteria for NPOU. After adjustment for confounding, NPOU was significantly more common for patients with injury to the extremities (adjusted odds ratio [aOR], 1.75; 95% confidence interval [CI], 1.57-1.94) or abdomen (adjusted odds ratio [aOR], 1.42; 95% CI, 1.22-1.64). Importantly, patients with maximum Abbreviated Injury Scale score of ≥2 for any body region had 1.49-fold odds of NPOU compared with patients with score of 1 (95% CI, 1.28-1.73), while no difference was seen across groupings of total injury burden based on Injury Severity Score.

CONCLUSION

New persistent opioid use is common among patients suffering from trauma. In addition, patients suffering from extremity and abdominal injuries are at highest risk. Maximum individual region injury severity predicts development of new persistent use, whereas total injury severity does not.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Endovascular surgery is not protective against new persistent opioid use development compared to open vascular surgery

OBJECTIVE

Endovascular techniques continue to be increasingly utilized to treat vascular disease, but the effect of these minimally invasive techniques on opioid use following surgery is not known.

METHODS

Using Medicare data, we identified opioid-naive patients undergoing vascular procedures between 2009 and 2017. We selected patients ≥65 years old with continuous enrollment 12 months before and 6 months after surgery and had no additional operations. We defined new persistent opioid use (NPOU) as one or more opioid prescription fills both between 4-90 and 91-180 days postoperatively. Multivariable regression was performed for risk adjustment, and frequencies of NPOU were estimated between endovascular and open techniques to compare surgical approach.

RESULTS

A total of 77,767 patients were identified, with 2.6% of all patients developing new persistent use. In addition to the identification of several risk factors for new persistent use, patients undergoing endovascular carotid or vertebral interventions were found to have higher adjusted frequencies of persistent use compared to those undergoing open interventions (3.0% vs. 1.8%, p < 0.001) as did those undergoing endovenous compared to open vein procedures (2.2%, vs. 1.6%, p = 0.019). We found no difference for peripheral vascular or aortic/iliac procedures.

CONCLUSIONS

Patients undergoing vascular surgery are at high risk for new persistent use. Undergoing endovascular carotid or venous surgery was associated with an increased risk of NPOU, whereas no differences were found between endovascular and open approaches for peripheral arterial or aortic disease.

A Qualitative Study of Patient Protection against Postoperative Opioid Addiction: A Thematic Analysis of Self-Agency

BACKGROUND

Opioids are commonly used following outpatient surgery. However, we understand little about patients' perspectives and how patients decide on postoperative opioid use. This study seeks to investigate aspects of patients' thought processes that most impact their decisions.

METHODS

The authors conducted semistructured interviews with 30 adults undergoing minor elective hand surgery at one tertiary hospital. Narratives were content-coded to arrive at the authors' thematic analysis. The authors incorporated Bandura's concept of self-agency to interpret the data and develop a conceptual framework that best explained the implicit theory within participants' responses.

RESULTS

The authors found six themes under two domains of self-agency. Participants actively sought out protective mechanisms supporting their decision on opioid use, but sometimes did so unconsciously. They would avoid opioids postoperatively because they were "tough" and wanted to evade the risk of addiction as "good citizens." They conveyed a nuanced safety against addiction because they were "not the kind" to become addicted and because they trusted the surgeons' prescribing. However, participants felt discouraged by the stigma associated with opioids. Both intentionally and unintentionally, participants integrated a strong sense of self in their decision-making processes.

CONCLUSIONS

A robust understanding of how patients choose to take opioids for postoperative pain control is imperative to develop patient-centered strategies to treat the opioid epidemic. Effective opioid-reduction policies should consider patients as active agents who negotiate various internal and external influences in their decision-making processes. Surgeons must incorporate patients' individual goals and perspectives regarding postoperative opioid use to minimize opioid-related harm after surgery.

Persistent Opioid Use Associated With Dental Opioid Prescriptions Among Publicly and Privately Insured US Patients, 2014 to 2018

This cohort study uses data from 3 MarketScan databases to compare the association of persistent opioid use with dental opioid prescriptions among publicly and privately insured patients in the United States from 2014 through 2018.

Patient Factors Associated With Opioid Consumption in the Month Following Major Surgery

OBJECTIVE

The aim of this study was to determine preoperative patient characteristics associated with postoperative outpatient opioid use and assess the frequency of postoperative opioid overprescribing.

SUMMARY BACKGROUND DATA

Although characteristics associated with inpatient opioid use have been described, data regarding patient factors associated with opioid use after discharge are lacking. This hampers the development of individualized approaches to postoperative prescribing.

METHODS

We included opioid-naïve patients undergoing hysterectomy, thoracic surgery, and total knee and hip arthroplasty in a single-center prospective observational cohort study. Preoperative phenotyping included self-report measures to assess pain severity, fibromyalgia survey criteria score, pain catastrophizing, depression, anxiety, functional status, fatigue, and sleep disturbance. Our primary outcome measure was self-reported total opioid use in oral morphine equivalents. We constructed multivariable linear-regression models predicting opioids consumed in the first month following surgery.

RESULTS

We enrolled 1181 patients; 1001 had complete primary outcome data and 913 had complete phenotype data. Younger age, non-white race, lack of a college degree, higher anxiety, greater sleep disturbance, heavy alcohol use, current tobacco use, and larger initial opioid prescription size were significantly associated with increased opioid consumption. Median total oral morphine equivalents prescribed was 600 mg (equivalent to one hundred twenty 5-mg hydrocodone pills), whereas median opioid consumption was 188 mg (38 pills).

CONCLUSIONS

In this prospective cohort of opioid-naïve patients undergoing major surgery, we found a number of characteristics associated with greater opioid use in the first month after surgery. Future studies should address the use of non-opioid medications and behavioral therapies in the perioperative period for these higher risk patients.

Opioid prescribing patterns by dental procedure among US publicly and privately insured patients, 2013 through 2018

BACKGROUND

It is unknown which procedures account for the most US dental opioid prescriptions. Moreover, few national studies have assessed opioid prescribing patterns for these procedures. These knowledge gaps impede the optimal targeting of dental opioid stewardship initiatives.

METHODS

The authors analyzed claims data from the 2013 through 2018 IBM MarketScan Dental, Commercial, and Medicaid Multi-State Databases. Patients aged 13 through 64 years undergoing 1 of 120 procedures were identified. "Initial prescriptions" were opioid prescriptions dispensed on the date of procedures to 3 days afterward. For the procedures accounting for the 5 highest proportions of initial prescriptions, the authors fitted linear regression models assessing trends in the probability of 1 or more initial prescriptions and mean total morphine milligram equivalents prescribed-a standardized measure of opioid amount. Regressions were adjusted for demographic characteristics and comorbidities.

RESULTS

The 9,482,976 procedures in the sample were associated with 2,721,688 initial prescriptions. Of these prescriptions, 5 procedures accounted for 95.2%: tooth extraction (65.2%), problem-focused limited oral evaluation (17.2%), endodontic therapy (8.4%), alveoloplasty (2.9%), and surgical implant services (1.5%). Among the 5 procedures, the median adjusted annual change in the probability of 1 or more initial prescriptions was -1.3 percentage points. The median adjusted annual change in mean total morphine milligram equivalents was -4.5 (roughly 1 pill containing 5 mg of hydrocodone). In 2018, 45.3% of tooth extractions resulted in 1 or more initial prescriptions.

CONCLUSIONS

Five procedures accounted for 95.2% of dental opioid prescriptions, and tooth extraction accounted for almost two-thirds of those. Opioid prescribing for tooth extractions is declining but remains common, despite the availability of equally effective nonopioid alternatives.

PRACTICAL IMPLICATIONS

Eliminating routine opioid prescribing for tooth extraction could reduce dental opioid exposure substantially.

The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study

BACKGROUND

Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting.

OBJECTIVE

This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention.

METHODS

To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor's office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis.

RESULTS

This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020.

CONCLUSIONS

Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study's findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21350.

Prevalence and Patterns of Opioid Use Before and After Liver Transplantation

BACKGROUND

Opioid use in liver transplantation is poorly understood and has potential associated morbidity.

METHODS

Using a national data set of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between December 2009 and February 2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid-naive/no fills, chronic opioid use (≥120 d supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peritransplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use posttransplant.

RESULTS

Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Posttransplant, 61% of patients filled an opioid prescription 0-2 months after discharge, and 21% filled an opioid between 10-12 months after discharge. Among previously opioid-naive patients, 4% developed chronic use posttransplant. Among patients with pretransplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pretransplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased posttransplant opioid use.

CONCLUSIONS

Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use posttransplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.

Opioid prescribing exceeds consumption following common surgical oncology procedures

BACKGROUND AND OBJECTIVES

Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures.

METHODS

We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices.

RESULTS

Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them.

CONCLUSIONS

This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.

A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery

BACKGROUND

Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures.

METHODS

The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents).

RESULTS

A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P < .001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P < .001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P < .0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P < .0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P < .00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P < .0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed.

CONCLUSION

Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

Effect of Time to Hand Therapy following Zone II Flexor Tendon Repair

This population-based study aimed to define how time to hand therapy following isolated zone II flexor tendon repairs impacts complications and secondary procedures.

METHODS

Insurance claims from the Truven MarketScan Databases were used to evaluate outcomes after isolated zone II flexor tendon repairs between January 2009 and October 2015. Cohorts differing in time to hand therapy were compared to evaluate the impact on complications, reoperation, and number of therapy sessions. Secondary outcomes analyzed how the number of therapy sessions affected rates of reoperation.

RESULTS

Hand therapy was identified in 82% of patients (N = 2867) following tendon reconstruction. Therapy initiation occurred within 1 week, 1-4 weeks, and after 4 weeks in 56%, 35%, and 9% of patients, respectively. Univariate analysis showed no difference in non-tendinous complications (27%, 30%, 29%; P = 0.29) or tendon rupture rates (13%, 13%, 10%; P = 0.42) within 90 days between cohorts. Multivariable analysis showed no difference in rates of tenolysis (6.3%, 6%, 4.4%; P > 0.01). In the early initiation cohort, >23 hand therapy sessions were associated with the highest rates of tenolysis (19%).

CONCLUSIONS

Despite being a common fear of hand surgeons, early initiation of hand therapy was not associated with increased tendon rupture rates. Although delayed therapy is a concern for tendon scarring, it did not confer a higher risk of tenolysis. Complication rates do not appear to correlate with timing of hand therapy. Therefore, hand surgeons should promote early mobility following isolated flexor tendon injuries given the known functional outcome benefits.

Perioperative cannabis use: a longitudinal study of associated clinical characteristics and surgical outcomes

BACKGROUND

Despite increases in cannabis use generally and for pain management, data regarding cannabis use in patients undergoing surgery are lacking. This study examined the prevalence of cannabis use among patients undergoing elective surgery and explored differences in clinical characteristics and surgical outcomes between cannabis users and non-cannabis users.

METHODS

This prospective study included 1335 adults undergoing elective surgery. Participants completed self-report questionnaires preoperative and at 3-month and 6-month postsurgery to assess clinical characteristics and surgical outcomes.

RESULTS

Overall, 5.9% (n=79) of patients reported cannabis use (53.2% medical, 19.0% recreational and 25.3% medical and recreational). On the day of surgery, cannabis users reported worse pain, more centralized pain symptoms, greater functional impairment, higher fatigue, greater sleep disturbances and more symptoms of anxiety and depression versus non-cannabis users (all p<0.01). Additionally, a larger proportion of cannabis users reported opioid (27.9%) and benzodiazepine use (19.0%) compared with non-cannabis users (17.5% and 9.2%, respectively). At 3 and 6 months, cannabis users continued to report worse clinical symptoms; however, both groups showed improvement across most domains (p≤0.05). At 6 months, the groups did not differ on surgical outcomes, including surgical site pain (p=0.93) or treatment efficacy (p=0.88).

CONCLUSIONS

Cannabis use is relatively low in this surgical population, yet cannabis users have higher clinical pain, poorer scores on quality of life indicators, and higher opioid use before and after surgery. Cannabis users reported similar surgical outcomes, suggesting that cannabis use did not impede recovery.

Self-reported disposal of leftover opioids among US adults 50-80

OBJECTIVE

To test the association between self-reported opioid disposal education and self-reported disposal of leftover opioids among older adults.

DESIGN

Web-based survey from the National Poll on Healthy Aging (March 2018) using population-based weighting for nationally representative estimates.

SUBJECTS

Older adults aged 50-80 years who reported filling an opioid prescription within the past 2 years.

METHODS

Respondents were asked whether they received education from a prescriber or pharmacist on how to dispose of leftover opioids and whether they disposed of leftover opioids from recent prescriptions. The association between self-reported opioid disposal education and self-reported disposal of leftover opioids was estimated with multivariable logistic regression, testing for interactions with respondent demographics.

RESULTS

Among 2013 respondents (74% response rate), 596 (28.9% (26.8%-31.2%)) were prescribed opioids within the past 2 years. Education on opioid disposal was reported by 40.1% of respondents (35.8%-44.5%). Among 295 respondents with leftover medication, 19.0% (14.6%-24.5%) disposed of the leftover medications. Opioid disposal education was associated with a greater likelihood of self-reported disposal of leftover opioids among non-white respondents as compared with white non-Hispanic respondents (36.7% (16.8%-56.6%) vs 7.8% (0.1%-15.6%), p<0.01).

CONCLUSIONS

In this nationally representative survey, 49% had leftover opioids, yet only 20% of older adults reported disposal of leftover opioids. Opioid disposal education was variable in delivery, but was associated with disposal behaviors among certain populations. Strategies to promote disposal should integrate patient education on the risks of leftover opioid medications and explore additional barriers to accessing opioid disposal methods.

New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis

OBJECTIVE

To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery.

MATERIALS AND METHODS

This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates.

RESULTS

Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99).

CONCLUSION

Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.

Higher Amounts of Opioids Filled After Surgery Increase Risk of Serious Falls and Fall-Related Injuries Among Older Adults

BACKGROUND

Despite increasing numbers of older adults undergoing surgery and the known risks of opioids, little is known about the potential association between opioid prescribing and serious falls and fall-related injuries after surgery.

OBJECTIVE

To determine the incidence and risk factors of serious falls and fall-related injuries after elective, outpatient surgery.

DESIGN

Retrospective cohort study of 20% national sample of Medicare claims among beneficiaries ≥ 65 years of age with Medicare Part D claims and who underwent elective outpatient surgery from January 1, 2009, through December 31, 2014.

PARTICIPANTS

Opioid-naïve patients ≥ 65 years undergoing elective, minor, outpatient surgical procedures. The exposure was opioid prescription fills in the perioperative period (i.e., 30 days before up until 3 days after surgery) converted to total oral morphine equivalents (OME) over a period 30 days prior to and 30 days after surgery.

MAIN MEASURES

Serious falls and fall-related injuries within 30 days after surgery, examined through Poisson regression analysis with reported fall and fall-related injury rates adjusted for potential confounders.

KEY RESULTS

Among 44,247 opioid-naïve surgical patients, 76.3% filled an opioid prescription in the perioperative period. Overall, 0.62% of patients suffered a serious fall or fall-related injury within 30 days after surgery. Risk factors for serious falls or fall-related injuries after surgery included older age (80-84 years: RR 1.64, 95% CI 1.12-2.40; 85 years and older: RR 1.81, 95% CI 1.25-2.86), female sex (RR 3.04, 95% CI 2.29-4.05), Medicaid eligibility (RR 1.63, 95% CI 1.17-2.26), and higher amounts of opioids filled following surgery (≥ 225 OME: RR 2.29, 95% CI 1.72-3.07).

CONCLUSIONS

Serious falls after elective, outpatient surgery are uncommon, but correlated with age, sex, Medicaid eligibility, and the amount of opioids filled in the perioperative period. Judicious prescribing of opioids after surgery is paramount and is an opportunity to improve the safety of surgical care among older individuals.

The Opioid Epidemic

Increases in opioid prescribing over the last several decades is correlated with an alarming increase in opioid-related morbidity and mortality owing to both prescription opioid misuse and abuse as well as heroin abuse. Prescribing after surgery is commonly in excess, and leftover pills are an important driver of opioid use disorders owing to diversion and misuse. Creating evidence-based prescribing guidelines based on patient-centered outcomes and encouraging safe opioid storage and disposal is critical to curbing opioid-related morbidity and mortality going forward and to ensure safe and appropriate postoperative pain management.

Association between insurance cost-sharing subsidy and postoperative opioid prescription refills among Medicare patients

BACKGROUND

Models of health care coverage with varying degrees of patient cost-sharing have been shown to influence health care behaviors for chronic conditions including medication adherence. The effect of insurance cost-sharing subsidies on the probability of postoperative opioid refill, however, is unclear.

METHODS

This retrospective cohort study examined 100% Medicare claims data among patients (N = 21,781) ages 65 and older undergoing orthopedic procedures in Michigan between January 2013 and September 2016. Patients were classified based on the presence of low-income subsidy and on prior opioid exposure using Medicare Part D prescription files of drug events. We investigated the association of these factors with the probability of both initial and second postoperative opioid fill within 90 days from the date of discharge.

RESULTS

In this cohort, 84.6% of patients filled an initial opioid prescription, and 66.4% refilled an opioid prescription. Patients with a full low-income subsidy had greater odds of refill within the postoperative 90 days compared with those patients without a low-income subsidy (odds ratio 1.38, 95% confidence interval 1.18-1.60). Among opioid naïve patients with a full low-income subsidy, the adjusted refill rate was 61.3% (95% confidence interval 58.0-64.7%) compared with 57.6% (95% confidence interval 51.4-63.7%) among those with partial low-income subsidy and 54.2% (95% confidence interval 52.8-55.6%) among patients without low-income subsidy.

CONCLUSION

Among Medicare patients undergoing orthopedic procedures, a full medication subsidy is associated with an increased probability of opioid refill when compared with no subsidy. Going forward, it is critical to lessen financial barriers to ensure all patients have equitable access to postoperative analgesia, including both opioid and nonopioid analgesics by decreasing the patient burden of cost-sharing.

Inappropriate Preoperative Gabapentinoid Use Among Patients With Carpal Tunnel Syndrome

PURPOSE

Gabapentinoids are commonly prescribed for the treatment of neuropathic pain but are not recommended for the primary treatment of carpal tunnel syndrome (CTS). We sought (1) to investigate the preoperative use of gabapentinoids for the treatment of CTS and (2) to determine whether preoperative exposure is associated with persistent gabapentinoid and opioid use after carpal tunnel release.

METHODS

We performed a retrospective cohort study using IBM MarketScan Research Databases (2010-2017) of patients who did not fill a gabapentinoid or opioid prescription within 3 months of a new CTS diagnosis undergoing surgical release. Our primary outcomes included preoperative gabapentinoid prescription fills associated with CTS and persistent prescription fills of gabapentinoids and opioids at 91 to 180 days after surgery. Multivariable logistic regression models were used to evaluate the association between patient-level factors and persistent gabapentinoid and opioid use.

RESULTS

Of the 56,593 patients without a previous gabapentinoid or opioid prescription prior to diagnosis of CTS, 3,474 patients (6%) filled a gabapentinoid prescription before carpal tunnel release. Overall, 835 patients (24% of the preoperative users) continued to fill gabapentinoid prescriptions at 91 to 180 days after surgery. Of the preoperative gabapentinoid users, 20% (702 patients) continued to fill opioid prescriptions at 91 to 80 days after release. After adjusting for patient characteristics, preoperative gabapentinoid use was associated with increased odds of persistent postoperative gabapentinoid use (preoperative gabapentinoid, 22% adjusted probability; 95% confidence interval [95% CI], 20.3%-23.0%, no preoperative gabapentinoid use, 1%; 95% CI, 1.2%-1.4%) and persistent postoperative opioid use (preoperative gabapentinoid, 18% adjusted probability; 95% CI, 17%-20%), no preoperative gabapentinoid, 9%; 95% CI, 8.6%-9.1%).

CONCLUSIONS

Despite a lack of evidence to support the use of gabapentinoids for CTS, 6% of patients are prescribed a gabapentinoid prior to surgery, and prolonged use is common. Given the effectiveness of surgical release and the risks associated with gabapentinoids, greater attention is needed to ensure that gabapentinoids are prescribed appropriately, avoided when possible, and stopped after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Increased opioid prescription fills after dental procedures performed before weekends and holidays

BACKGROUND

Excess opioid prescriptions place patients and communities at risk of experiencing opioid-related morbidity. The authors designed a study to test the hypothesis that opioid prescription fills would be more common after dental procedures performed the day before a weekend or holiday than other weekdays.

METHODS

The authors performed a retrospective cohort study of 2,060,317 people, integrating Truven Health MarketScan insurance claims to evaluate variation in opioid fills for dental procedures performed the day before a weekend or holiday compared with other weekdays. Opioid-naïve people, aged 13 through 64 years, with eligible procedures from 2013 through 2017 were included. The primary outcome measure was a prescription opioid fill on the same date as the dental procedure.

RESULTS

Multivariable logistic regression results showed significantly higher odds of filling an opioid prescription for patients with procedures the day before weekends and holidays (adjusted odds ratio, 1.27; 95% confidence interval, 1.26 to 1.28) than for patients with procedures on other weekdays. In addition, the youngest age category, 13 through 29 years, had the highest odds of filling an opioid prescription compared with other age categories (reference category: patients aged 50-64 years, adjusted odds ratio, 1.43; 95% confidence interval, 1.41 to 1.44).

CONCLUSIONS

Outpatient dental procedures performed the day before a weekend or holiday were associated with a 27% increased adjusted odds of filling a prescription for an opioid.

PRACTICAL IMPLICATIONS

Although patients and dentists might be concerned about the challenges of unmanaged pain on weekends and holidays, opioids are not warranted for most dental procedures and should be replaced with patient education and nonopioid analgesics. Oral health care professionals concerned about postprocedural pain control should consider scheduling complex procedures earlier in the week, when emergency care is available to reduce unwarranted preemptive prescribing of opioids, which might be driving increased opioid fills before weekends and holidays.

Health Care Spending and New Persistent Opioid Use After Surgery

OBJECTIVE

We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use.

SUMMARY OF BACKGROUND DATA

Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown.

METHODS

We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates.

RESULTS

In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month.

CONCLUSION

Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.

Surgeon experience and opioid prescribing

BACKGROUND

We evaluated the effects of surgeon characteristics such as surgeon experience on differences in opioid prescribing after surgery.

METHODS

We evaluated a 20% national sample of Medicare beneficiaries ≥65 years old who underwent 15 different types of surgery to identify surgeon characteristics associated with opioid prescription size filled within seven days of discharge using a multi-level linear model.

RESULTS

174,141 patients and 13,828 surgeons met inclusion criteria. 53.8% of patients filled an opioid prescription within seven days postoperatively. The amount of opioids prescribed after surgery was highest for patients whose surgeons were early in practice (i.e. 0-7 years in practice). Surgeon credentials, type of surgery, and geographic region were associated with differing sizes of opioid fills postoperatively.

CONCLUSIONS

Surgeon characteristics such as cumulative years of practice contribute to differences in prescribing behavior after surgery. These findings can help develop strategic interventions to enhance opioid stewardship.

Classifying Preoperative Opioid Use for Surgical Care

OBJECTIVE

We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery.

BACKGROUND

Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use.

METHODS

We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group.

RESULTS

Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001).

CONCLUSION

Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.

Bringing Evidence into Practice in Hand Surgery

Despite the significant investment in scientific investigation to enhance clinical care, the uptake of new interventions and innovations into clinical care and policy remains slow. Understanding and examining the factors that influence the dissemination and implementation of best practices are critical to promote high-quality health care. This review provides an overview of the evidence base in hand surgery, the science that underlies dissemination and innovation, and the emergence of learning health systems in health care.

Association of Opioid Quantity and Caregiver Education with Pain Control after Pediatric Tonsillectomy

Objective

To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy.

Study Design

Prospective cohort study (July 2018–April 2019).

Setting

Pediatric otolaryngology service at a tertiary academic children’s hospital.

Subjects and Methods

Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics.

Results

Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation ( P < .001). Education to use nonopioids first was reported by 308 respondents (80%). In regression, prescribing guideline implementation was not associated with pain control (adjusted odds ratio, 1.3; 95% CI, 0.9-2.0; P = .22), but caregiver-reported education to use nonopioids first was associated with a higher odds of good pain control (adjusted odds ratio, 1.9; 95% CI, 1.1-3.2; P = .02).

Conclusion

Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.

Association of Opioid Use With Pain and Satisfaction After Dental Extraction

IMPORTANCE

Dentists commonly prescribe opioids to relieve pain after tooth extraction. Understanding the differences in patient-reported outcomes between opioid users and nonusers could encourage the adoption of more conservative and appropriate prescribing practices in dental medicine.

OBJECTIVE

To evaluate whether pain and satisfaction scores reported by patients who used opioids after tooth extraction were similar to the levels reported by patients with no opioid use.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was conducted in the 14 dental clinics of the University of Michigan School of Dentistry. Eligible adult patients of these clinics who underwent routine or surgical extractions between June 1, 2017, and December 31, 2017, were contacted by telephone within 6 months of the procedure. Patients were surveyed about the type of extraction, use of prescription opioid (if given), use of nonopioid analgesics, pain levels, and satisfaction with care after the procedure. Data analysis was conducted from February 1, 2018, to July 31, 2018.

MAIN OUTCOMES AND MEASURES

The primary outcome was self-reported pain as assessed by the question, "Thinking back, how would you rate your pain in the first week after your dental procedure?" with a 4-point pain scale of no pain, minimal pain, moderate pain, or severe pain. Secondary outcomes included self-reported satisfaction with care as assessed by a Likert scale ranging from 1 to 10, in which 1 was extremely dissatisfied and 10 was extremely satisfied.

RESULTS

The final cohort comprised 329 patients, of whom 155 (47.1%) underwent surgical extraction (mean [SD] age, 41.8 [18.1] years; 80 [51.6%] were men) and 174 (52.9%) underwent routine extraction (mean [SD] age, 52.4 [17.9] years; 79 [45.4%] were men). Eighty patients (51.6%) with surgical extraction and 68 (39.1%) with routine extraction used opioids after their procedure. In both extraction groups, patients who used opioids reported higher levels of pain compared with those who did not use opioids (surgical extraction group: 51 [63.8%] vs 34 [45.3%], P < .001; routine extraction group: 44 [64.7%] vs 35 [33.0%], P < .001). No statistically significant difference in satisfaction was found between groups after surgical extraction (median [interquartile range] scores: 9 [7-10] for nonopioid group vs 9 [8-10] for opioid group) and routine extraction (median [interquartile range] scores: 10 [8-10] for nonopioid group vs 9 [7-10] for opioid group).

CONCLUSIONS AND RELEVANCE

This study found that patients who used opioids after tooth extraction reported significantly higher levels of pain compared with nonusers, but no difference in satisfaction was observed.

Association of Opioid Overdose Risk Factors and Naloxone Prescribing in US Adults

BACKGROUND

Prescribing naloxone to patients is a key strategy to prevent opioid overdoses, but little is known about the reach of naloxone prescribing.

OBJECTIVE

Determine patient factors associated with receiving naloxone and trends over time in patients with key overdose risk factors.

DESIGN

Retrospective observational study.

PARTICIPANTS

Using the Clinformatics DataMart, a US-wide health insurance claims dataset, we compared adults who received opioids and naloxone (opioid+naloxone) from January 2014 to June 2017 with adults who received opioids without naloxone (opioids only), matched on gender, age ± 5 years, month/year of opioid fill, and number of opioid claims.

MAIN MEASURES

Key patient-level opioid overdose risk factors included receipt of high-dosage opioids, concurrent benzodiazepines, history of opioid and other substance use disorders, and history of opioid overdose.

RESULTS

We included 3963 opioid+naloxone and 19,815 opioid only patients. Key factors associated with naloxone fills included high opioid daily dosage (50 to < 90 morphine milligram equivalents (MME): AOR = 2.43, 95% CI 2.15-2.76 and ≥ 90 MME: AOR = 3.94, 95% CI 3.47-4.46; reference: < 50 MME), receiving concurrent benzodiazepines (AOR = 1.27, 95% CI 1.16-1.38), and having a diagnosis of opioid use disorder (AOR = 1.56, 95% CI 1.40-1.73). History of opioid overdose was not associated with naloxone (AOR = 0.92, 95% CI 0.74-1.15). The percent of patients receiving naloxone increased, yet less than 2% of patients in any of the key overdose risk factor groups received naloxone by the last 6 months of the study period.

CONCLUSIONS

Naloxone prescribing has increased and was more likely to be co-prescribed to patients with some risk factors for overdose. However, overall prescribing remains minimal. Additional efforts are needed across health systems to increase naloxone prescribing for patients at risk for opioid overdose.

Spillover Effect of Opioid Reduction Interventions From Adult to Pediatric Surgery

BACKGROUND

Procedure-specific prescribing guidelines and trainee education have reduced opioid overprescribing in adult surgical patients, but tailored interventions do not yet exist for children. It is unknown what effect these adult interventions have had on postoperative opioid prescribing in children at the same institution, where trainees rotate across both adult and pediatric services.

MATERIALS AND METHODS

This retrospective study of patients (<18 y) undergoing pediatric surgery (PS), pediatric otolaryngology (ENT), or pediatric urology (URO) procedures at a single tertiary academic center assessed opioid doses per patient before (January 01, 2015 to September 30, 2016) and after (January 01, 2017 to March 31, 2018) opioid prescribing guidelines and trainee education were instituted for adult laparoscopic cholecystectomy. Patient demographics, postoperative opioid prescribing, opioid refills, and emergency department (ED) visits <21 d after surgery were compared using chi-squared analyses and t-tests. Interrupted time-series analyses (ITSA) assessed changes in the rate of opioid prescribing pre- and postintervention for each subspecialty.

RESULTS

There were 3371 patients preintervention and 2439 patients postintervention. After the intervention, fewer patients were prescribed opioids (ENT: 97% versus 93%, P < 0.001; URO: 98% versus 94%, P < 0.001; PS: 61% versus 25%, P < 0.001) and fewer opioid doses were prescribed in each prescription (ENT: 63.8 ± 26.1 versus 50.8 ± 22.0 doses, P < 0.001; URO: 33.5 ± 23.4 versus 22.1 ± 11.3, P < 0.001; PS: 20.4 ± 12.8 versus 13.8 ± 11.4 doses, P < 0.001). There were no changes in opioid refill or ED visit rates postintervention. A decreasing rate in ENT prescribing was seen preintervention, with no significant change postintervention (-2.3 ± 1.1 versus -3.3 ± 0.7; P = 0.24). Whereas, the rate of decrease in PS and URO prescribing significantly slowed postintervention (PS: -2.0 ± 0.1 versus -0.9 ± 0.1, P < 0.001; URO: -4.2 ± 0.2 versus -2.3 ± 0.5, P = 0.005).

CONCLUSIONS

Opioid prescribing rates are decreasing, but adult interventions did not achieve reductions in pediatric opioid prescribing at the same institution. There was no concomitant rise in postoperative ED visits or opioid refills as prescribing declined, indicating that the risks of reducing opioid prescriptions may be minimal. Development of evidence-based, procedure-specific prescribing guidelines that specifically address pediatric patients are needed to effectively minimize opioid overprescribing in this population.

Association of State Opioid Duration Limits With Postoperative Opioid Prescribing

IMPORTANCE

Since the Centers for Disease Control and Prevention published opioid prescribing guidelines in March 2016, 31 states have implemented legislation to restrict the duration of opioid prescriptions for acute pain. However, the association of these policies with the amount of opioid prescribed following surgery remains unknown.

OBJECTIVE

To examine the association of opioid prescribing duration limits with postoperative opioid prescribing in Massachusetts and Connecticut, the first 2 states to implement limits after March 2016.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time series analysis and cross-sectional study examined immediate level and slope changes in monthly outcomes after prescribing limit implementation in Massachusetts and Connecticut. These states implemented 7-day limits on initial opioid prescriptions on March 14, 2016, and July 1, 2016, respectively. Using the 2014 to 2017 IBM MarketScan Research Database, 16 281 opioid-naive adults in these states who filled a prescription within 3 days of surgery between July 1, 2014, and November 30, 2017, were identified. Data were analyzed from December 2018 to June 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prescription size in oral morphine equivalents (OMEs) for the initial postoperative opioid prescription (one 5/325 mg hydrocodone-acetaminophen pill = 5 OMEs). Secondary outcomes included days supplied in the initial prescription and the proportion of initial prescriptions exceeding a 7-day supply.

RESULTS

In total, 16 281 opioid-naive patients (9708 [59.6%] female; median [interquartile range] age range, 45-54 [35-44 to 55-64] years) undergoing surgical procedures were included. In Massachusetts, there were 5340 and 5435 patients in the preimplementation and postimplementation periods, respectively. In Connecticut, there were 2869 and 2637 patients in the preimplementation and postimplementation periods, respectively. Limit implementation in Massachusetts was associated with an immediate mean level decrease in prescription size (-38 OMEs [95% CI, -44 to -32 OMEs]) and with a mean decrease in slope (-1.5 OMEs/mo [95% CI, -2.1 to -0.9 OMEs/mo]). Implementation was also associated with an immediate mean level decrease in days supplied (-0.4 days [95% CI, -0.6 to -0.2 days]) and the proportion of prescriptions exceeding a 7-day supply (-5.9 percentage points [95% CI, -7.9 to -3.9 percentage points]). In contrast, limit implementation in Connecticut was not associated with level or slope changes in any outcome.

CONCLUSIONS AND RELEVANCE

Opioid prescribing duration limits had a variable association with postoperative opioid prescribing in Massachusetts and Connecticut. The mean opioid prescription size filled, days supplied, and prescribing exceeding a 7-day supply decreased after limit implementation in Massachusetts only. Given the potential differences in policy dissemination and uptake, efforts to reduce opioid prescribing should also include surgeon education and evidence-based prescribing recommendations.