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Chen SY, Ourshalimian S, Hijaz D, Odegard MN, Kim E, Andras L, Kelley-Quon LI. Opioid consumption before discharge predicts outpatient opioid use in adolescents undergoing surgery. Surgery 2024; 176:462-468. [PMID: 38763792 PMCID: PMC11246811 DOI: 10.1016/j.surg.2024.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/10/2024] [Accepted: 03/25/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND The majority of adolescents undergoing surgery report unused prescription opioids after surgery, increasing the risk of diversion, misuse, and addiction. Adult studies have demonstrated that opioid use 24 hours before discharge corresponds with opioid use at home. We hypothesized that inpatient opioid consumption is associated with outpatient opioid use in adolescents. METHODS Adolescents aged 13-20 years undergoing elective surgery associated with an opioid prescription were prospectively recruited. Parent-adolescent dyads were surveyed preoperatively to assess sociodemographics, health literacy, and baseline substance use, and opioid use was measured at 30- and 90-days postoperatively. Medical records were reviewed to calculate cumulative opioid use during hospitalization. Inpatient and postoperative opioid use was converted to oral morphine equivalents. Adjusting for age, sex, race, health literacy, alcohol use, pain score, and surgery, multivariable linear regression identified factors associated with outpatient oral morphine equivalent use 90 days postoperatively. RESULTS Overall, 103 adolescents were enrolled. Median oral morphine equivalents used from 24 and 48 hours before discharge and throughout the hospitalization were 30.8 (interquartile range:11.7-45.0), 67.5 (interquartile range:37.5-94.3), and 97.5 (interquartile range:18.0-152.7), respectively. Regression analysis demonstrated that adolescent-reported pain at discharge (P = .028) and cumulative oral morphine equivalents used 24 hours (P < .001) and 48 hours (P = .003) before discharge were significantly associated with postoperative oral morphine equivalents use at home. Oral morphine equivalents consumption 24 hours before discharge estimated cumulative oral morphine equivalents use 90 days postoperatively at a 1-to-5 ratio in 94.1% of patients. CONCLUSION For adolescents undergoing surgery, patient-reported pain at discharge and oral morphine equivalents administered 24 hours before discharge are associated with cumulative outpatient opioid use. Tailoring outpatient prescriptions to total oral morphine equivalent consumption 24 hours before discharge could reduce excess opioid prescribing.
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Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA. https://twitter.com/steph_y_chen
| | | | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjorie N Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA. https://twitter.com/MarjorieOdegard
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lindsay Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery & Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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McKenzie CP, Straube LE, Webster CM, Nielsen ME, Stuebe AM. Reducing Opioid Prescribing after Cesarean Delivery by Utilizing a Tailored Opioid Prescribing Algorithm. Am J Perinatol 2024; 41:e2934-e2940. [PMID: 37774746 DOI: 10.1055/a-2184-0423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
OBJECTIVE There are increasing efforts among health care systems to promote safe opioid prescribing; however, best practice for minimizing overprescription is not established. Our study aimed to evaluate the effect of a tailored opioid prescribing algorithm on opioid prescription quantities. STUDY DESIGN A tailored opioid prescribing algorithm was developed to provide a recommended prescription quantity based on inpatient opioid use. A retrospective analysis of opioid prescribing 3 months before and after implementation was performed. Our primary outcome was the number of oxycodone 5-mg tablets prescribed. Subgroup analysis by oxycodone consumption in the 24 hour prior to discharge was performed. Patient satisfaction and unused opioid tablets were assessed by text message survey 2 weeks' postpartum. RESULTS We included 627 (n = 313 preimplementation; n = 314 postimplementation) patients who underwent cesarean delivery. Clinical characteristics were similar between groups. The median number of oxycodone 5-mg tablets prescribed in the baseline group was 20 (interquartile range [IQR]: 20-30), compared with 5 (IQR: 0-10) in the tailored prescribing group (p < 0.0001). For patients with no opioid use in the 24 hours prior to discharge, the median number of tablets prescribed decreased from 20 (IQR: 10-20) to 0 (IQR: 0-5) following the intervention (p < 0.0001). The proportion of patients discharged without an opioid prescription increased from 7% (23/313) in the baseline group to 35% (111/314) in the tailored prescribing group (odds ratio: 6.9, 95% confidence interval [4.3, 11.1]). CONCLUSION Tailored opioid prescribing reduced the number of opioid tablets prescribed and increased the proportion of patients who were discharged without an opioid prescription. KEY POINTS · Opioid prescribing should be tailored by inpatient use.. · Tailored prescribing reduced opioid prescription amounts.. · Many patients do not require an opioid prescription..
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Affiliation(s)
- Christine P McKenzie
- Division of Obstetric Anesthesia, Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Lacey E Straube
- Division of Obstetric Anesthesia, Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Carolyn M Webster
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina, Chapel Hill, North Carolina
| | - Alison M Stuebe
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Bjornson S, Grindeland CJ, Werremeyer AB. Impact of Implementing Screening and Interventions to Target Prevention of Opioid Misuse and Accidental Overdose in the Inpatient Setting. J Pharm Pract 2024; 37:442-447. [PMID: 36472932 DOI: 10.1177/08971900221144183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Introduction: There are limited publications supporting the use of screening tools to implement upstream prevention of opioid-related problems. Opioid and Naloxone Education (ONE) is utilized in outpatient pharmacies to screen and identify patients at risk of opioid-related problems and make interventions. Objectives: To implement ONE in the inpatient setting to promote prevention of opioid-related problems and overdose risk mitigation. Methods: For this pilot, ONE screening tool was completed via chart review and patient interview for inpatients prescribed an opioid. Risk scores were calculated and recommendations were provided. Outcomes evaluated included morphine milligram equivalents (MME) prior to hospitalization, inpatient screening pre-, post-, and at discharge; naloxone orders at discharge; and comparison of overdose risk from different sources. Results: The control group (n = 44) had a mean MME decrease of 1.5, and following implementation of pharmacist interventions, the experimental group (n = 45) observed a mean MME decrease of 28.6 (P = .0001). For the threshold of 50 MME, 8.6% of patients in the control group had a change from >50 MME to <50 MME at 24 hour follow up. This change occurred in 29% of patients in the experimental group (P = .03). For non-opioid analgesics, 6.8% of patients in the control group had non-opioid analgesic orders added or increased compared to 26.6% in the experimental group (P = .01). Conclusion: Screening for opioid misuse and accidental overdose risk appears impactful in the inpatient setting. Screening and appropriate risk-based intervention was associated with decreases in total daily MME and increased non-opioid analgesics.
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Affiliation(s)
- Siri Bjornson
- Department of Pharmacy, Sanford Medical Center, Fargo, ND, USA
| | | | - Amy B Werremeyer
- Department of Pharmacy, Sanford Medical Center, Fargo, ND, USA
- School of Pharmacy, North Dakota State University, Fargo, ND, USA
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Watters JA, Banaag A, Massengill JC, Koehlmoos TP, Staat BC. Postpartum Opioid Use among Military Health System Beneficiaries. Am J Perinatol 2024; 41:60-66. [PMID: 34784618 DOI: 10.1055/s-0041-1740006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of the study is to evaluate the prevalence and factors associated with opioid prescriptions to postpartum patients among TRICARE beneficiaries receiving care in the civilian health care system versus a military health care facility. STUDY DESIGN We evaluated postpartum opioid prescriptions filled at discharge among patients insured by TRICARE Prime/Prime Plus using the Military Health System Data Repository between fiscal years 2010 to 2015. We included women aged 15 to 49 years old and excluded abortive pregnancy outcomes and incomplete datasets. The primary outcome investigated mode of delivery and demographics for those filling an opioid prescription. Secondary outcomes compared prevalence of filled opioid prescription at discharge for postpartum patients within civilian care and military care. RESULTS Of a total of 508,258 postpartum beneficiaries, those in civilian health care were more likely to fill a discharge opioid prescription compared with those in military health care (OR 3.9, 95% CI 3.8-3.99). Cesarean deliveries occurred less frequently in military care (26%) compared with civilian care (30%), and forceps deliveries occurred more frequently in military care (1.38%) compared with civilian care (0.75%). Women identified as Asian race were least likely to fill an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Women aged 15 to 19 years had a lower odds of filling an opioid prescription (OR 0.83, 95% CI 0.80-0.86). Women associated with a senior officer rank were less likely to fill an opioid prescription postpartum (OR 0.83, 95% CI 0.73-0.91), while those associated with warrant officer rank were more likely to fill an opioid prescription (OR 1.14, 95% CI 1.06-1.23). CONCLUSION Our data indicates that women who received care in civilian facilities were more likely to fill an opioid prescription at discharge when compared with military facilities. Factors such as race and age were associated with opioid prescription at discharge. This study highlights areas for improvement for potential further studies. KEY POINTS · Opioid prescription patterns for postpartum women may vary across the country.. · Our study indicates postpartum patients in civilian care are more likely to fill opioids postpartum.. · This study highlights a population which may have an improved opioid prescribing pattern..
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Affiliation(s)
- Julie A Watters
- Department of Obstetrics and Gynecology, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, California
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Amanda Banaag
- Center for Health Services Research, Henry M. Jackson Foundation, Bethesda, Maryland
| | - Jason C Massengill
- Department of Obstetrics and Gynecology, Wright-Patterson United States Air Force Medical Center, Dayton, Ohio
| | - Tracey P Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barton C Staat
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Boyev A, Jain AJ, Newhook TE, Prakash LR, Chiang YJ, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm. JAMA Surg 2023; 158:e234154. [PMID: 37672236 PMCID: PMC10483385 DOI: 10.1001/jamasurg.2023.4154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/16/2023] [Indexed: 09/07/2023]
Abstract
Importance Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Krebsbach MN, Alexander KM, Miller JJ, Doll EL, Lee YL, Simmons JD. Implementing a Discharge Opioid Bundle in Adult Trauma Patients Decreases the Amount of Opioids Prescribed at Discharge. Am Surg 2023; 89:4281-4287. [PMID: 35622969 DOI: 10.1177/00031348221101483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioids remain the mainstay treatment of acute pain caused by trauma. The lack of evidence driven prescribing creates a challenging situation for providers. We hypothesized that the implementation of a trauma discharge opioid bundle (TDOB) would decrease the total morphine milligram equivalents (MME) prescribed at discharge while maintaining pain control. METHODS This was a pre-post study of adult trauma patients before and after implementation of a TDOB to guide the prescription of opioids and discharge prescription education in patients discharged from a level one trauma center. The pre-group and post-group, included consecutively discharged patients from September through November in 2018 and 2019. The primary outcome was the total MME prescribed at discharge. RESULTS A total of 377 patients met inclusion criteria. One hundred and fifty-one patients were included in the pre-group and 226 in the post-group. The total MME prescribed at discharge (225 ± [150-300] pre vs 200 ± [100-225] post, P = < .001) and maximum MME/day (45 ± [30-45] vs 30 ± [20-45], P = .004) were significantly less in the post-group. Incidence of outpatient refills within fourteen days were similar. More non-opioid pain adjuncts were prescribed post-intervention and discharge pain education was provided more frequently. CONCLUSION The implementation of a TDOB significantly reduced the MME prescribed at discharge without increasing the number of opioid refills.
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Affiliation(s)
- Mackenzie N Krebsbach
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | | | - Jennifer J Miller
- College of Nursing, Department of Adult Health Nursing, University of South Alabama, Mobile, AL, USA
| | - Elizabeth L Doll
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | - Yann-Leei Lee
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | - Jon D Simmons
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
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Herzig SJ, Anderson TS, Urman RD, Jung Y, Ngo LH, McCarthy EP. Risk Factors for Opioid-Related Adverse Drug Events Among Older Adults After Hospitalization for Major Orthopedic Procedures. J Patient Saf 2023; 19:379-385. [PMID: 37589954 PMCID: PMC10525019 DOI: 10.1097/pts.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Older adults undergoing orthopedic procedures are commonly discharged from the hospital on opioids, but risk factors for postdischarge opioid-related adverse drug events (ORADEs) have not been previously examined. We aimed to identify risk factors for ORADEs after hospital discharge following orthopedic procedures. METHODS This is a retrospective cohort study of a national sample of Medicare beneficiaries 65 years or older, who underwent major orthopedic surgery during hospitalization in 2016 and had an opioid fill within 2 days of discharge. We excluded beneficiaries with hospice claims and those admitted from or discharged to a facility. We used billing codes and medication claims to define potential ORADEs requiring a hospital revisit within 30 days of discharge. RESULTS Among 30,514 hospitalizations with a major orthopedic procedure (89.7% arthroplasty, 5.6% treatment of fracture of dislocation, 4.7% other) and an opioid claim, a potential ORADE requiring hospital revisit occurred in 750 (2.5%). Independent risk factors included age of 80 years or older (hazard ratio [HR], 1.65; 95% confidence interval, 1.38-1.97), female sex (HR, 1.34 [1.16-1.56]), and clinical conditions, including heart failure (HR, 1.34 [1.10-1.62]), respiratory illness (HR, 1.23 [1.03-1.46]), kidney disease (HR, 1.23 [1.04-1.47]), dementia/delirium (HR, 1.63 [1.26-2.10]), anxiety disorder (HR, 1.42 [1.18-1.71]), and musculoskeletal/nervous system injuries (HR, 1.54 [1.24-1.90]). Prior opioid use, coprescribed sedating medications, and opioid prescription characteristics were not associated with ORADEs after adjustment for patient characteristics. CONCLUSIONS Potential ORADEs occurred in 2.5% of older adults discharged with opioids after orthopedic surgery. These risk factors can inform clinician decision making, conversations with older adults, and targeting of harm reduction strategies.
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Affiliation(s)
- Shoshana J. Herzig
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy S. Anderson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Richard D. Urman
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H. Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ellen P. McCarthy
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
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Tsai SHL, Hu CW, El Sammak S, Durrani S, Ghaith AK, Lin CCJ, Krzyż EZ, Bydon M, Fu TS, Lin TY. Different Gabapentin and Pregabalin Dosages for Perioperative Pain Control in Patients Undergoing Spine Surgery: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2023; 6:e2328121. [PMID: 37556139 PMCID: PMC10413173 DOI: 10.1001/jamanetworkopen.2023.28121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/20/2023] [Indexed: 08/10/2023] Open
Abstract
IMPORTANCE Patients undergoing spine surgery often experience severe pain. The optimal dosage of pregabalin and gabapentin for pain control and safety in these patients has not been well established. OBJECTIVE To evaluate the associations of pain, opioid consumption, and adverse events with different dosages of pregabalin and gabapentin in patients undergoing spine surgery. DATA SOURCES PubMed/MEDLINE, Embase, Web of Science, Cochrane library, and Scopus databases were searched for articles until August 7, 2021. STUDY SELECTION Randomized clinical trials conducted among patients who received pregabalin or gabapentin while undergoing spine surgery were included. DATA EXTRACTION AND SYNTHESIS Two investigators independently performed data extraction following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guideline. The network meta-analysis was conducted from August 2022 to February 2023 using a random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was pain intensity measured using the Visual Analog Scale (VAS), and secondary outcomes included opioid consumption and adverse events. RESULTS Twenty-seven randomized clinical trials with 1861 patients (median age, 45.99 years [range, 20.00-70.00 years]; 759 women [40.8%]) were included in the systematic review and network meta-analysis. Compared with placebo, the VAS pain score was lowest with gabapentin 900 mg per day, followed by gabapentin 1200 mg per day, gabapentin 600 mg per day, gabapentin 300 mg per day, pregabalin 300 mg per day, pregabalin 150 mg per day, and pregabalin 75 mg per day. Additionally, gabapentin 900 mg per day was found to be associated with the lowest opioid consumption among all dosages of gabapentin and pregabalin, with a mean difference of -22.07% (95% CI, -33.22% to -10.92%) for the surface under the cumulative ranking curve compared with placebo. There was no statistically significant difference in adverse events (nausea, vomiting, and dizziness) among all treatments. No substantial inconsistency between direct and indirect evidence was detected for all outcomes. CONCLUSIONS AND RELEVANCE These findings suggest that gabapentin 900 mg per day before spine surgery is associated with the lowest VAS pain score among all dosages. In addition, no differences in adverse events were noted among all treatments.
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Affiliation(s)
- Sung Huang Laurent Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Wei Hu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Sally El Sammak
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sulaman Durrani
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Che Chung Justin Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ewa Zuzanna Krzyż
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tsai Sheng Fu
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Tung Yi Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
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9
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Rolfzen ML, Wick A, Mascha EJ, Shah K, Krause M, Fernandez-Bustamante A, Kutner JS, Michael Ho P, Sessler DI, Bartels K. Best Practice Alerts Informed by Inpatient Opioid Intake to Reduce Opioid Prescribing after Surgery (PRIOR): A Cluster Randomized Multiple Crossover Trial. Anesthesiology 2023; 139:186-196. [PMID: 37155372 PMCID: PMC10602614 DOI: 10.1097/aln.0000000000004607] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Overprescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. This study therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery. METHODS This study included 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating 8-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on previous inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid and nonopioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial. RESULTS The total postdischarge opioid prescription was a median [quartile 1, quartile 3] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI, 0.80 to 1.13; P = 0.586). The alert was displayed in 28% (3,074 of 11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid and nonopioid combination medications or additional opioid prescriptions written after discharge. CONCLUSIONS A decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.(Anesthesiology 2023; 139:186-96). EDITOR’S PERSPECTIVE
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Affiliation(s)
- Megan L. Rolfzen
- Department of Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA
| | - Abraham Wick
- UCHealth, Pharmacy Analytics Core, Aurora, CO, USA
| | - Edward J. Mascha
- Department of Quantitative Health Sciences, Cleveland
Clinic, Cleveland, OH, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Karan Shah
- Department of Quantitative Health Sciences, Cleveland
Clinic, Cleveland, OH, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Martin Krause
- Department of Anesthesiology, University of California San
Diego, San Diego, CA, USA
| | | | - Jean S. Kutner
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, USA
| | - P. Michael Ho
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, USA
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA
- Department of Anesthesiology, University of Colorado School
of Medicine, Aurora, CO, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Parker DJ, Geist H, Yazdanyar A, Rosentel J, McCambridge M, Chestnut V, Matthews A, Liptak ME, Lebby EB, Beauchamp GA. Surgical Opioid Stewardship for Orthopedic Surgery: A Quality Improvement Initiative. Orthopedics 2023; 46:e230-e236. [PMID: 36779731 DOI: 10.3928/01477447-20230207-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
The aim of this quality improvement initiative was to reduce unnecessary opioid prescribing by sharing data with prescribers on opioid use by patients. In our study, transition of care clinicians performed follow-up phone calls to select postoperative orthopedic patients to determine opioid use. We implemented a standardized postoperative 7-day opioid wean and designed a dashboard to track the information gathered. We calculated descriptive statistics for continuous and categorical variables. In the initial assessment of opioid use by orthopedic patients, the study consisted of 296 patients with a mean age of 64.8±11.4 years, 147 females (49.7%) and 149 males (50.3%), 59.1% joint replacements (hip, knee, shoulder), and 40.9% spine surgeries (lumbar decompression, cervical fusion, hemilaminectomy). Among those prescribed an opioid, 50% received a prescription for 30 pills or less and 52.4% reported taking more than 80% of the opioid pills, while 35.1% reported taking less than 60%. In the prescribing quality improvement assessment, there were a total of 1547 hospitalizations for joint replacement surgeries from June 2018 to June 2020: 774 (50.0%) hips and 773 (50.0%) knees. There was a significant difference in morphine milligram equivalents per day and quantity prescribed when comparing the preintervention period with the postintervention period without significant increases in opioid refill requests or return visit rates. In our study, sharing data around patient opioid use and provider-facing prescribing metrics reduced postoperative opioid prescribing without significantly increasing opioid refill or emergency department return visit rates. [Orthopedics. 2023;46(4):e230-e236.].
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11
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Hurley ET, Danilkowicz RM, Toth AP. Editorial Commentary: Postoperative Pain Management After Anterior Cruciate Ligament Reconstruction Can Minimize Opioid Use and Allow Early Rehabilitation. Arthroscopy 2023; 39:1296-1298. [PMID: 37019539 DOI: 10.1016/j.arthro.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 04/07/2023]
Abstract
Effective analgesia is essential after anterior cruciate ligament (ACL) reconstruction to control pain while minimizing opioid consumption and allowing early rehabilitation. Orthopaedic surgeons write the third-largest number of opioid prescriptions, which are responsible for 1/10th of all opioid prescriptions, and one-third of patients with ACL injury use opioids preoperatively, a risk factor for postoperative abuse. Pain management after ACL reconstruction using variety of analgesic regimens including various permutations of nerve blocks, nerve block adjuncts, intra-articular injections, intravenous and oral medications, cryotherapy, compression stockings, and transcutaneous electrical nerve stimulation units, based on multidisciplinary collaboration between surgeons and anesthesiologists, can minimize opioid consumption. A recent meta-analysis shows that combined femoral-sciatic nerve block may be a top-ranked analgesic technique. Femoral and adductor canal nerve blocks are also effective alternatives and most common. Femoral and femoral sciatic nerve blocks may risk quadriceps strength deficits, whereas an advantage of adductor canal nerve is that the saphenous nerve is purely sensory. We recommend longer-acting nerve blockade (72 hours) using continuous anesthetic delivery via a pump/catheter with ropivacaine or the use of a slow-release preparation such as bupivacaine liposome injectable suspension.
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Morgan K, Solomon LM, Jones N, Picco L, Nielsen S. Building knowledge in opioid prescribing in post-operative treatment. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023:7142871. [PMID: 37186142 DOI: 10.1093/ijpp/riad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 04/02/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Opioids prescribed in hospital are a key risk factor for harm in the community. This study aimed to gain an in-depth understanding of factors affecting post-operative opioid prescribing amongst clinicians using the capability, opportunity, motivation generate behaviour framework, more commonly known as COM-B. METHODS Focus groups and semi-structured interviews were used to gain an in-depth understanding of factors affecting optimal practice when prescribing opioids for post-operative patients at discharge. A topic guide was written using the COM-B behaviour change model to ensure the full range of possible factors influencing prescribing behaviours were explored. RESULTS We found barriers and facilitators of optimal opioid prescribing practice across all three domains of capability, opportunity and motivation. Capability among junior doctors could be increased in the areas of risk assessment and prescribing appropriate discharge analgesia, though education and training were not key barriers to improving practice. Findings indicated that opportunity to practice optimal prescribing was hindered by a lack of time at discharge and technology. Beliefs about one's own and others' responsibilities also impacted motivation to practice optimal prescribing behaviours. Pharmacists were identified as key supports for patient education and appropriate prescribing. CONCLUSIONS Educating prescribers about opioid risks and clinical practice guidelines are necessary interventions, however, our findings indicate that if implemented in isolation, they may not have the desired impact. Interventions also need to address discharge time pressures and presumptions that GPs are aware of whether opioids should be ceased or continued after surgical discharge.
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Affiliation(s)
- Kirsty Morgan
- Peninsula Health, Frankston, Victoria, Australia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | | | | | - Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
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13
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Adams TJ, Aljohani DM, Forget P. Perioperative opioids: a narrative review contextualising new avenues to improve prescribing. Br J Anaesth 2023; 130:709-718. [PMID: 37059626 DOI: 10.1016/j.bja.2023.02.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 04/16/2023] Open
Abstract
Opioids have dominated the management of perioperative pain in recent decades with higher doses than ever before used in some circumstances. Through the expanding use of opioids, growing research has highlighted their associated side-effects and the intertwined phenomena of acute withdrawal syndrome, opioid tolerance, and opioid-induced hyperalgesia. With multiple clinical guidelines now endorsing multimodal analgesia, a diverse array of opioid-sparing agents emerges and has been studied to variable degrees, including techniques of opioid-free anaesthesia. It remains unclear to what extent such methods should be adopted, yet current evidence does suggest dependence on opioids as the primary perioperative analgesic might not meet the principles of 'rational prescribing' as described by Maxwell. In this narrative review we describe how, using current evidence, a patient-centred rational-prescribing approach can be applied to opioids in the perioperative period. To contextualise this approach, we discuss the historical adoption of opioids in anaesthesia, our growing understanding of associated side-effects and emerging strategies of opioid-sparing and opioid-free anaesthesia. We discuss avenues and challenges for improving opioid prescribing to limit persistent postoperative opioid use and how these may be incorporated into a rational-prescribing approach.
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Affiliation(s)
- Tobias J Adams
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK.
| | - Dalia Mohammed Aljohani
- Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK; Department of Anesthesia Technology, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Patrice Forget
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
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14
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Boudrias C, Migneault B, Plante F, Carrier FM. Postoperative opioid consumption and prescription in major abdominal surgery. Can J Anaesth 2023; 70:451-452. [PMID: 36536156 DOI: 10.1007/s12630-022-02383-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Catherine Boudrias
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
| | - Brigitte Migneault
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - François Plante
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - François M Carrier
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada.
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
- Carrefour de l'innovation et santé des populations, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.
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15
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Berkley E, Takhar S, Wilson M, Fine J, Ho T, Dray J. Effectiveness of an Opioid Stewardship Guideline in Renal Transplant Recipients Post-Discharge. J Pain Palliat Care Pharmacother 2023; 37:44-51. [PMID: 36519299 DOI: 10.1080/15360288.2022.2149672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Previous literature suggests that kidney transplant recipients (KTRs) do not use the majority of opioid tablets prescribed after transplant surgery. This study analyzed the effectiveness of a new pain management guidance in KTRs after discharge from transplant surgery at a renal transplant center. The single center pre-, post- study compared the number of opioid refill requests, patient-reported pain control, multimodal analgesic agents, and opioid tablets prescribed at discharge in both pre- and post- cohorts. A total of 127 patients were included. Data was collected through standardized patient interviews and chart review from electronic medical records. The pre-guidance and post-guidance cohorts had no detectable difference in refill requests (p = 0.365) nor pain control (p = 0.324) post-discharge. The post-group had a significant reduction in opioid tablets prescribed at discharge (22 tablets ± 10 vs 10 tablets ± 2, p = <0.0001) with a significant increase in acetaminophen (p = 0.005) and lidocaine patches (p = <0.0001) prescribed at discharge. Both groups used a mean of three opioid tablets within the first week after discharge. The guidance resulted in 700 fewer opioid tablets in the community during the study time frame, with no difference in pain control nor refill requests after discharge.
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16
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Marziali ME, Giordano M, Gleit Z, Prigoff J, Landau R, Martins SS. Development and design of a mobile application for prescription opioid clinical decision-making: a feasibility study in New York City, USA. BMJ Open 2023; 13:e066427. [PMID: 36854603 PMCID: PMC9980329 DOI: 10.1136/bmjopen-2022-066427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 02/19/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVES Excessive opioid prescribing is a contributing factor to the opioid epidemic in the USA. We aimed to develop, implement and evaluate the usability of a clinical decision-making mobile application (app) for opioid prescription after surgery. METHODS We developed two clinical decision trees, one for opioid prescription after adult laparoscopic cholecystectomy and one for posterior spinal fusion surgery in adolescents. We developed a mobile app incorporating the two algorithms with embedded clinical decision-making, which was tested by opioid prescribers. A survey collected prescription intention prior to app use and participants' evaluation. Participants included opioid prescribers for patients undergoing (1) laparoscopic cholecystectomy in adults or (2) posterior spinal fusion in adolescents with idiopathic scoliosis. RESULTS Eighteen healthcare providers were included in this study (General Surgery: 8, Paediatrics: 10). Intended opioid prescription before app use varied between departments (General Surgery: 0-10 pills (mean=5.9); Paediatrics: 6-30 pills (mean=20.8)). Intention to continue using the app after using the app multiple times varied between departments (General Surgery: N=3/8; Paediatrics: N=7/10). The most reported reason for not using the app is lack of time. CONCLUSIONS In this project evaluating the development and implementation of an app for opioid prescription after two common surgeries with different prescription patterns, the surgical procedure with higher intended and variable opioid prescription (adolescent posterior spinal fusion surgery) was associated with participants more willing to use the app. Future iterations of this opioid prescribing intervention should target surgical procedures with high variability in both patients' opioid use and providers' prescription patterns.
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Affiliation(s)
- Megan E Marziali
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Mirna Giordano
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Zachary Gleit
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jake Prigoff
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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Kukushliev VV, Sherman KA, Kurylo CM, Ortmann SD, Scheidt RA, Scheidt KB. Tapered Dose Postoperative Opioid Prescriptions Following Inpatient Total Hip and Knee Arthroplasty: Quality Improvement Study and Retrospective Review. J Arthroplasty 2023; 38:239-244. [PMID: 36075313 DOI: 10.1016/j.arth.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Overprescription of pain medications directly fuels the opioid epidemic. Veterans are profoundly impacted. Tapered dose protocols may reduce excessive prescribing. METHODS A retrospective study of adult veterans who presented to our institution for primary total knee arthroplasty or total hip arthroplasty (THA) was performed. Postdischarge opioid use was reviewed before and after an opioid taper prescription protocol. The preprotocol and postprotocol groups had 299 and 89 veterans, respectively. Total Morphine Milligram Equivalent (MME) prescribed postdischarge, number of tablets prescribed, number of refills issued, 30-day emergency department visits, and 30-day readmissions were compared. Opioid naïve and chronic opioid users were both included. RESULTS Preprotocol and postprotocol implementation group, in combination with surgery type (total knee arthroplasty versus THA) and opioid naïve status, predicted MME. On average, the postprotocol group received 224 MME less, THA patients received 177 MME less, and nonopioid naïve patients received 152 MME more. CONCLUSION The opioid taper protocol led to less opioid administration after discharge. Taper protocols should be considered for postoperative pain management. LEVEL OF EVIDENCE III, retrospective comparison study.
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Affiliation(s)
- Vasil V Kukushliev
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Christopher M Kurylo
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephen D Ortmann
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert A Scheidt
- Washington University in St. Louis School of Medicine, Saint Louis, Missouri
| | - Karl B Scheidt
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
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18
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Melucci AD, Dave YA, Lynch OF, Hsu S, Erlick MR, Linehan DC, Moalem J. Predictors of opioid-free discharge after laparoscopic cholecystectomy. Am J Surg 2023; 225:206-211. [PMID: 35948514 DOI: 10.1016/j.amjsurg.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA. https://twitter.com/AlexaMelucci
| | - Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Olivia F Lynch
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - Shawn Hsu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mariah R Erlick
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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19
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Madsen AM, Martin JM, Linder BJ, Gebhart JB. Perioperative opioid management for minimally invasive hysterectomy. Best Pract Res Clin Obstet Gynaecol 2022; 85:68-80. [PMID: 35752553 DOI: 10.1016/j.bpobgyn.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
Given the high volume of hysterectomies performed, the contribution of gynecologists to the opioid crisis is potentially significant. Following a hysterectomy, most patients are over-prescribed opioids, are vulnerable to developing new persistent opioid use, and can be the source of misuse, diversion, or accidental exposure. People who misuse opioids are at risk of an overdose related death, which is now one of the leading causes of death in the United States and is rising in other countries. It is the physician's responsibility to reduce opioid use by making impactful practice changes, such as 1) using pre-emptive opioid sparing strategies, 2) optimizing multimodal nonopioid pain management, 3) restricting postoperative opioid prescribing, and 4) educating patients on proper disposal of unused opioids. These changes can be implemented with an enhanced recovery after surgery protocol, shared decision-making, and patient education strategies related to opioids.
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Affiliation(s)
- Annetta M Madsen
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jessica M Martin
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Brian J Linder
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John B Gebhart
- Department of Obstetrics & Gynecology, Division of Urogynecology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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20
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Lorentzen WJ, Perez N, Galet C, Allan LD. The butterfly effect: How an outpatient quality improvement project affected inpatient opioid‘s prescribing habits. SURGERY IN PRACTICE AND SCIENCE 2022; 11. [DOI: 10.1016/j.sipas.2022.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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21
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Lentine B, Beesley H, Dicken Q, Niu R, Freccero DM, Smith EL. Reduced Narcotic Utilization in Total Joint Arthroplasty Patients in an Urban Tertiary Care Center. Arthroplast Today 2022; 18:125-129. [PMID: 36325518 PMCID: PMC9619144 DOI: 10.1016/j.artd.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 08/07/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient characteristics and discharge opioid use after the initiation of a preoperative and postoperative institutional opioid prescription protocol in a population with a high prevalence of opioid dependence and substance use. Methods Data on 1004 patients undergoing total joint arthroplasties from July 1, 2017, to June 30, 2019, were retrospectively reviewed. Demographics were collected, and data were grouped into high- and low-discharge opioid groups based on 1 standard deviation above or below the mean. Patient characteristics of the high and low groups were compared using one-way analysis of variance and Pearson chi-square test. Results The prevalence of preoperative opioid dependence was 21.8%. The mean discharge opioid prescription was 264 morphine milligram equivalents (MMEs). The cutoffs of high- and low-use groups were above 424 MMEs and below 104.5 MMEs. The high-discharge opioid group was more likely to be male, younger, to have a history of preoperative opioid use, to undergo general anesthesia, and to be uninsured. The lower-discharge opioid group was more likely to be older, female, to have Medicare, and to stay approximately 1 day longer in the hospital. Body mass index, intraoperative opioid requirement, American Society of Anesthesiologists Classification score, race, total knee vs total hip arthroplasty, or surgical approach for total hip arthroplasty did not affect discharge opioid prescriptions. Conclusions Reduction of opioid prescriptions at discharge in total joint arthroplasty patients may be possible with the use of preoperative and postoperative protocols, optimizing patient risk factors for opioid use and utilizing a patient-specific opioid taper regimen.
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Affiliation(s)
- Brandon Lentine
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | | | | | - Ruijia Niu
- New England Baptist Hospital, Boston, MA, USA
| | - David M. Freccero
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Eric L. Smith
- New England Baptist Hospital, Boston, MA, USA,Corresponding author. New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120, USA. Tel.: +1 617 754 6609.
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Kay AB, White T, Baldwin M, Gardner S, Daley LM, Majercik S. Less Is More: A Multimodal Pain Management Strategy Is Associated With Reduced Opioid Use in Hospitalized Trauma Patients. J Surg Res 2022; 278:161-168. [DOI: 10.1016/j.jss.2022.04.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 03/22/2022] [Accepted: 04/13/2022] [Indexed: 01/09/2023]
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Effects of Intraoperative Opioid Administration on Postoperative Pain and Pain Threshold: A Randomized Controlled Study. J Clin Med 2022; 11:jcm11195587. [PMID: 36233454 PMCID: PMC9572642 DOI: 10.3390/jcm11195587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 12/05/2022] Open
Abstract
Fentanyl and short-acting remifentanil are often used in combination. We evaluated the effect of intraoperative opioid administration on postoperative pain and pain thresholds when the two drugs were used. Patients who underwent gynecological laparoscopic surgery were randomly assigned into two groups (15 patients each) to receive either sufficient (group A) or minimum (group B) fentanyl (maximum estimated effect site concentration: A: 7.86 ng/mL, B: 1.5 ng/mL). The estimated effect site concentration at the end of surgery was adjusted to the same level (1 ng/mL). Patients in both groups also received continuous intravenous remifentanil during surgery. The primary outcome was the pressure pain threshold, as evaluated by a pressure algometer 3 h postoperatively. The pressure pain threshold at 3 h postoperatively was 51.1% (95% CI: [44.4–57.8]) in group A and 56.6% [49.5–63.6] in group B, assuming a preoperative value of 100% (p = 0.298). There were no significant differences in pressure pain threshold and numeric rating scale scores between the groups after surgery. The pain threshold decreased significantly in both groups at 3 h postoperatively compared to preoperative values, and recovered at 24 h. Co-administration of both opioids caused hyperalgesia regardless of fentanyl dose.
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Bedene A, Dahan A, Rosendaal FR, van Dorp ELA. Opioid epidemic: lessons learned and updated recommendations for misuse involving prescription versus non-prescription opioids. Expert Rev Clin Pharmacol 2022; 15:1081-1094. [PMID: 36068971 DOI: 10.1080/17512433.2022.2114898] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION In the past decades, the opioid crisis has heavily impacted parts of the US society and has been followed by an increase in the use of opioids worldwide. It is of paramount importance that we explore the origins of the US opioid epidemic to develop best practices to tackle the rising tide of opioid overdoses. AREAS COVERED In this expert review, we discuss opioid (over)prescription, change in perception of pain, and false advertisement of opioid safety as the leading causes of the US opioid epidemic. Then, we review the evidence about opioid dependence and addiction potential and provide current knowledge about predictors of aberrant opioid-related behavior. Lastly, we discuss different approaches that were considered or undertaken to combat the rising tide of opioid-related deaths by regulatory bodies, pharmaceutical companies, and health-care professionals. For this expert review, we considered published articles relevant to the topic under investigation that we retrieved from Medline or Google scholar electronic database. EXPERT OPINION The opioid epidemic is a dynamic process with many underlying mechanisms. Therefore, no single approach may be best suited to combat it. In our opinion, the best way forward is to employ multiple strategies to tackle different underlying mechanisms.
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Affiliation(s)
- Ajda Bedene
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eveline L A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Odegard M, Kelley-Quon LI. Postoperative Opioid Prescribing, Use, and Disposal in Children. Adv Pediatr 2022; 69:259-271. [PMID: 35985715 DOI: 10.1016/j.yapd.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article provides an overview of postoperative opioid prescribing, use, and disposal patterns in children and also identifies gaps in knowledge and areas for improvement. We present evidence that there is a need to tailor prescriptions to specific procedures to reduce the number of excess, unused prescription opioid pills in the home. We also explain the need to provide culturally competent care when managing a child's pain after surgery. Finally, we discuss the need for widespread provider and caregiver education about safe prescription opioid use, storage, and disposal.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA.
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA 90033, USA
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DiPeri TP, Newhook TE, Day RW, Chiang YJ, Dewhurst WL, Arvide EM, Bruno ML, Scally CP, Roland CL, Katz MH, Vauthey JN, Chang GJ, Badgwell BD, Perrier ND, Grubbs EG, Lee JE, Tzeng CWD. A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients. Surg Open Sci 2022; 9:51-57. [PMID: 35663797 PMCID: PMC9161107 DOI: 10.1016/j.sopen.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care. Methods Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates. Results Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742). Conclusion The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.
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Affiliation(s)
- Timothy P. DiPeri
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy E. Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ryan W. Day
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney L. Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elsa M. Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Morgan L. Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher P. Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christina L. Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H.G. Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J. Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy D. Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G. Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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DiPeri TP, Newhook TE, Tran Cao HS, Ikoma N, Dewhurst WL, Arvide EM, Bruno ML, Katz MHG, Vauthey JN, Lee JE, Tzeng CWD. Opioid Discharge Prescriptions After Inpatient Surgery: Risks of Rebound Refills by Length of Stay. J Surg Res 2022; 278:111-118. [PMID: 35597025 DOI: 10.1016/j.jss.2022.04.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/02/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION As inpatient stays become shorter, one concern with standardizing discharge opioid prescriptions is the potential risk of "rebound refills." We sought to compare opioid prescription refill rates and volumes for surgical patients discharged on postoperative day (POD) 2-3, 4-7, and 8+. METHODS In a prospective quality improvement protocol, faculty volunteered to use either a 5x-multiplier (5x) or usual care (UC) for discharge prescriptions after inpatient (≥48 h stay) surgery from Sep-Dec 2019. The 5x-multiplier is 5-times the patient's last 24-h opioid use (by oral morphine equivalents, OME). Cohorts were compared by POD of discharge: POD 2-3 ("SHORT"), POD 4-7 ("INTERMEDIATE"), and POD 8+ ("LONG"). The primary endpoint was 30-d refill rates. Secondary endpoints included 30-d refill OME and inpatient opioid weaning/discharge metrics. RESULTS From 22 faculty, 409 patients were included. When stratified by POD, 154 (37.7%) were discharged SHORT, 176 (43.0%) INTERMEDIATE, and 79 (19.3%) LONG. SHORT stay patients had a median last 24-h OME of 10 mg (versus 5 mg INTERMEDIATE, 5 mg LONG; P = 0.268), and a median discharge OME of 55 mg (versus 75 mg INTERMEDIATE, 100 mg LONG; P = 0.221). Patients with SHORT stays did not have higher refill rates (11.7% versus 18.2% INTERMEDIATE, 19.0% LONG; P = 0.193) or higher median refill OME (150 mg versus 300 mg INTERMEDAITE, 339 mg LONG; P = 0.154). CONCLUSIONS Despite concerns of increased refills, patients discharged by POD 2-3 were not associated with "rebound refills." A patient-centered 5x-multiplier standardization of discharge opioid prescriptions is feasible in all inpatient surgery patients, even those discharged following a short inpatient stay.
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Affiliation(s)
- Timothy P DiPeri
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Hospital opioid use predicts the need for discharge opioid prescriptions following laparoscopic bariatric surgery. Surg Endosc 2022; 36:6312-6318. [PMID: 35024936 DOI: 10.1007/s00464-022-09035-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/03/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Overprescribing of opioids after surgery increases new persistent opioid use and diversion contributing to the opioid epidemic. There is a paucity of evidence regarding discharge opioid prescribing after bariatric surgery. METHODS We conducted a retrospective, cohort study analyzing post-operative opioid use at a single institution in patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LGB) from July 2019 thru February 2020. Multimodal analgesia was used including 5 mg oxycodone pills as needed during hospitalization with five prescribed on discharge if requested after discussion. Opioid use was determined from medical record review and post-operative data collected from patients at a 2-week follow-up visit. The Michigan Automated Prescription System (MAPS) was used as an adjunct to evaluate perioperative opioid prescriptions. RESULTS The cohort of 84 patients included those having LSG (72) and LGB (12). Fifty-five patients (65%) received a prescription for opioids on discharge and 91% filled their prescription. Only 44% (22/50) of those filling their opioid prescription took any opioids with 24% (65/275) of the total pills prescribed actually consumed. Opioid use on the surgical ward had the strongest correlation with discharge opioid use (rho = 0.65, CI 0.494, 0.770). The number of opioid pills taken on the surgical ward was positively associated with the number of pills taken after discharge. Those who took none, 1 to 3, or 4 or more opioid pills consumed 0.14 ± 0.48, 0.95 ± 1.71, and 3.14 ± 1.86 pills after discharge (p < 0.001). No patients required an additional opioid prescription within 90 days of surgery with MAPS confirmation. CONCLUSION Postoperative in-hospital opioid use following laparoscopic bariatric surgery predicts opioid use after discharge. This knowledge can guide patient-specific discharge opioid prescribing with the potential to mitigate diversion and reduce chronic opioid use.
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Rautalin I, Kallio M, Korja M. In-hospital postoperative opioid use and its trends in neurosurgery between 2007 and 2018. Acta Neurochir (Wien) 2022; 164:107-116. [PMID: 34664095 PMCID: PMC8761135 DOI: 10.1007/s00701-021-05021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/02/2021] [Indexed: 12/01/2022]
Abstract
Background Postoperative opioid use plays an important role in the global opioid crisis, but little is known about in-hospital opioid use trends of large surgical units. We investigated whether postoperative in-hospital opioid consumption changed in a large academic neurosurgical unit between 2007 and 2018. Methods We extracted the data of consumed opioids in the neurosurgical intensive care unit and two bed wards between 2007 and 2018. Besides overall consumption, we analyzed the trends for weak (tramadol and codeine), strong, and the most commonly used opioids. The use of various opioids was standardized using the defined daily doses (DDDs) of each opioid agent. A linear regression analysis was performed to estimate annual treatment day-adjusted changes with 95% confidence intervals. Results Overall, 121 361 opioid DDDs were consumed during the 196 199 treatment days. Oxycodone was the most commonly used postoperative opioid (49% of all used opioids) in neurosurgery. In the bed wards, the use of oral oxycodone increased 375% (on average 13% (9–17%) per year), and the use of transdermal buprenorphine 930% (on average 26% (9–45%) per year) over the 12-year period. Despite the increased use of strong opioids in the bed wards (on average 3% (1–4%) per year), overall opioid use decreased 39% (on average 6% (4–7%) per year) between 2007 and 2018. Conclusions Due to the increase of strong opioid use in the surgical bed wards, we encourage other large teaching hospitals and surgical units to investigate whether their opioid use trends are similarly worrisome and whether the opioid consumption changes in the hospital setting are transferred to opioid use patterns or opioid-related harms after discharge. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05021-9.
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Affiliation(s)
- Ilari Rautalin
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, P.O. Box 266, 00029, Helsinki, Finland.
| | - Miia Kallio
- HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS), P.O. Box 440, 00029, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, P.O. Box 266, 00029, Helsinki, Finland
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Langnas E, Rodriguez-Monguio R, Luo Y, Croci R, Dudley RA, Chen CL. The association of multimodal analgesia and high-risk opioid discharge prescriptions in opioid-naive surgical patients. Perioper Med (Lond) 2021; 10:60. [PMID: 34906217 PMCID: PMC8672612 DOI: 10.1186/s13741-021-00230-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioids and multimodal analgesia are widely administered to manage postoperative pain. However, little is known on how improvements in inpatient pain control are correlated with high-risk (> 90 daily OME) discharge opioid prescriptions for opioid naïve surgical patients. METHODS We conducted a retrospective observational study of adult opioid-naïve patients undergoing surgery from June 2012 through December 2018 at a large academic medical center. We used multivariate logistic regression to assess whether multimodal analgesic drugs consumed in the 24 h prior to discharge was associated with a reduction in high-risk opioid discharge prescriptions. We identified other risk factors for receiving a high-risk discharge opioid prescription. RESULTS Among the 32,511 patients, 83% of patients were discharged with an opioid prescription. In 2013, 34.1% of patients with a discharge opioid prescription received a high-risk prescription and this declined to 17.7% by 2018. Use of multimodal analgesic agents during the final 24 h of hospitalization increased each year, with over 80% receiving at least one multimodal analgesic agent by 2018. The median OME consumed in the 24 h prior to discharge peaked in 2013 at 31 and steadily decreased to 19.8 by 2018. There was a significant association between the use of acetaminophen in the 24 h prior to discharge and a high-risk prescription at discharge (p < 0.01). OMEs consumed in the 24 h prior to discharge was a significant predictor of receiving a high-risk discharge prescription, even at low doses. Other factors associated with receipt of a high-risk discharge opioid prescription included male gender, race, history of anxiety disorder, and discharge service. DISCUSSION Use of multimodal analgesia regimens in hospitalized surgical patients in the 24 h prior to hospital discharge increased between 2012 and 2018. Simultaneously, opioid use prior to hospital discharge decreased. Despite these gains, approximately one in five discharge prescriptions was high-risk (> 90 daily OME). In addition, we found that prescribing of discharge opioids above inpatient opioid requirements remains common in opioid naive surgical patients. CONCLUSION Providers should account for pre-discharge opioid consumption and use of multimodal analgesia when considering the total and daily OME's that may be appropriate for an individual surgical patient on the discharge opioid prescription.
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Affiliation(s)
- Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.
| | - Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, USA.,Medication Outcomes Center, University of California, San Francisco, San Francisco, USA.,Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
| | - Yanting Luo
- Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
| | - Rhiannon Croci
- UCSF Health Informatics, University of California, San Francisco, San Francisco, USA
| | - R Adams Dudley
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Catherine L Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.,Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, San Francisco, USA
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Bleicher J, Fender Z, Johnson JE, Cain BT, Phan K, Powers D, Wei G, Presson AP, Kwok A, Pickron TB, Scaife CL, Huang LC. Use of post-discharge opioid consumption patterns as a tool for evaluating opioid prescribing guidelines. Am J Surg 2021; 224:58-63. [DOI: 10.1016/j.amjsurg.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/08/2021] [Accepted: 12/18/2021] [Indexed: 12/15/2022]
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Hassan MM, Rahman OF, Hussain ZB, Burgess SL, Yen YM, Kocher MS. Opioid overprescription in adolescents and young adults undergoing hip arthroscopy. J Hip Preserv Surg 2021; 8:75-82. [PMID: 34567603 PMCID: PMC8460166 DOI: 10.1093/jhps/hnab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/03/2021] [Indexed: 12/16/2022] Open
Abstract
Few studies have examined factors related to the increased consumption of opioids after hip arthroscopy in adolescents and young adults. This study sought to determine prescription patterns following hip arthroscopy in this population, and to determine clinical or surgical factors associated with increased post-operative opioid use. Daily post-operative opioid intake was obtained from pain-control logbooks of adolescents and young adults who underwent hip arthroscopy between January 2017 and 2020. Study outcomes were defined as the median total number of opioid tablets consumed, total days opioids were consumed, mean daily opioid consumption and the ratio of opioids prescribed post-operatively to consumed. Clinical and surgical factors were analyzed to determine any association with opioid consumption. Fifty-eight (20%) patients returned completed logbooks. Most patients (73%) were prescribed 30 oxycodone tablets. The median number of tablets consumed was 7 (range 0–41) over a median duration of 7 days (range 1–22). The median ratio of tablets consumed to prescribed was 20%. Increasing patient age at surgery was associated with increased total number of tablets consumed (r = 0.28, P = 0.04) and to the ratio of tablets consumed to prescribed (r = 0.30, P = 0.03). Patients who were prescribed more than 30 tablets consumed on average 7.8 more tablets than patients prescribed fewer (P = 0.003). Patients who underwent regional anesthesia consumed tablets for longer compared with those who did not (median, 10 versus 4 days; P = 0.03). After undergoing hip arthroscopy, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed.
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Affiliation(s)
- Mahad M Hassan
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Omar F Rahman
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 100 E 77th St, New York, NY 10075, USA
| | - Zaamin B Hussain
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Orthopaedic Surgery, Emory University School of Medicine, 1364 E Clifton Rd NE, Atlanta, GA 30322, USA
| | - Stephanie L Burgess
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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Bible L, Obaid O, Khurrum M, Goh M, Hammad A, Kitts DJ, Anand T, Kapadia M, Joseph B. Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes? J Surg Res 2021; 268:634-642. [PMID: 34474212 DOI: 10.1016/j.jss.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/28/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients. METHODS We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed. RESULTS In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality. CONCLUSION Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.
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Affiliation(s)
- Letitia Bible
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Omar Obaid
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Khurrum
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Mei Goh
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Ahmad Hammad
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Daniel James Kitts
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Tanya Anand
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Meera Kapadia
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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Kodia K, Stephens-McDonnough JA, Alnajar A, Villamizar NR, Nguyen DM. Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients-achieving better pain control with less (schedule II) opioid utilization. J Thorac Dis 2021; 13:3948-3959. [PMID: 34422325 PMCID: PMC8339763 DOI: 10.21037/jtd-21-552] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/20/2021] [Indexed: 01/22/2023]
Abstract
Background Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra- and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy. Methods This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record. Results A total of 98 patients (43 pre- and 55 post-protocol implementation) were included in this study. There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5–16.5) (ERATS) vs. 19.5 (12.6–36.0) (pre-ERATS), P<0.0001]. More importantly, a drastic reduction of total and schedule II opioids dispensed at discharge was noted in the ERATS group [total MME: 150 (100.0–330.0) vs. 800.0 (450.0–975.0), P<0.0001 and schedule II MME: 90.0 (0–242.2) vs. 800.0 (450.0–975.0), P<0.0001; ERATS vs. pre-ERATS respectively]. A shorter hospital stay (median difference of 1 day, P=0.0012 and a mean difference of 2.4 days, P=0.0054) was observed in the enhanced recovery group. Conclusions Implementation of an enhanced recovery protocol for thoracotomy patients is safe and associated with elimination of thoracic epidural analgesia, decreased postoperative pain, shorter hospitalization, drastic reduction of post-discharge opioid dispensed and decreased dependence on addiction-prone schedule II narcotics.
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Affiliation(s)
- Karishma Kodia
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Joy A Stephens-McDonnough
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ahmed Alnajar
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Nestor R Villamizar
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Dao M Nguyen
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
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Ashrafi AN, Yip W, Graham JN, Yu V, Titus M, Widjaja W, Dickerson S, Berger AK, Desai MM, Gill IS, Aron M, Kim MP. Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy. J Robot Surg 2021; 16:715-721. [PMID: 34431025 DOI: 10.1007/s11701-021-01268-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/13/2021] [Indexed: 12/24/2022]
Abstract
The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.
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Affiliation(s)
- Akbar N Ashrafi
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA. .,Department of Urology, Northern Adelaide Local Health Network, South Australia Health, Adelaide, Australia. .,Adelaide Medical School, The University of Adelaide, Adelaide, Australia. .,College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Wesley Yip
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - John N Graham
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Valerie Yu
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Micha Titus
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William Widjaja
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shane Dickerson
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andre K Berger
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Mihir M Desai
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Inderbir S Gill
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Michael P Kim
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Macintyre PE. The opioid epidemic from the acute care hospital front line. Anaesth Intensive Care 2021; 50:29-43. [PMID: 34348484 DOI: 10.1177/0310057x211018211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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Bleicher J, Stokes SM, Brooke BS, Glasgow RE, Huang LC. Patient-centered Opioid Prescribing: Breaking Away From One-Size-Fits-All Prescribing Guidelines. J Surg Res 2021; 264:1-7. [PMID: 33744772 PMCID: PMC8222090 DOI: 10.1016/j.jss.2021.01.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Procedure-based opioid-prescribing guidelines have reduced the amount of opioids prescribed after surgery; however, many patients are still overprescribed opioids. The 24-h predischarge opioid consumption (PDOC) metric has been proposed to guide patient-centered prescribing. MATERIALS AND METHODS This is a single-institution, retrospective study of patients who underwent major abdominal surgery. We assessed the correlation between inpatient opioid use and discharge prescriptions using morphine milligram equivalents (MMEs). The adequacy of discharge prescriptions for individual patients was assessed using 2 models, one assuming constant opioid use (based on 24-h PDOC) and the other assuming a linear taper. RESULTS Of 596 included patients, gastric bypass and colectomy were the most common operations. Median length of stay was 3.5 d. Inpatient opioid use and discharge prescriptions were weakly correlated (r = 0.35). Patients with no opioid use 24 h before discharge (n = 133, 22.3%) were frequently discharged with opioid prescriptions. Patients with high opioid use (24-h PDOC >60 MME) were often discharged with prescriptions that would have lasted <48 h (164/200, 82%). Assuming constant opioid use, discharge prescriptions would have lasted patients a median of 5.1 d. With linear opioid tapering, 440 (72.9%) patients would have had leftover pills. A theoretical discharge prescription of 4 times 24-h PDOC would reduce the median prescription by 130 MMEs and allow a linear taper for 97.6% of patients. CONCLUSIONS At our institution, opioid prescribing was rarely patient-centered, with little correlation between patient's inpatient opioid use and discharge prescriptions. This leads to overprescribing for most patients and underprescribing for others.
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Affiliation(s)
- Josh Bleicher
- Department of Surgery, University of Utah, Salt Lake City, Utah.
| | - Sean M Stokes
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | | | | | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah
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Patient and surgical factors affect postoperative opioid prescription for orthopaedic trauma patients undergoing single-admission, single-surgery fracture fixation: a retrospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tucker DW, Homere AJ, Wier JR, Bougioukli S, Carney JJ, Wong M, Inaba K, Marecek GS. Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use. Injury 2021; 52:1234-1238. [PMID: 32948328 DOI: 10.1016/j.injury.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries. DESIGN Retrospective Cohort Study. SETTING Academic Level-1 Trauma Center. PATIENTS 96 Patients with blunt or ballistic fractures. INTERVENTION Inpatient narcotic pain management after orthopaedic fracture management. MAIN OUTCOME MEASUREMENTS Morphine equivalent units (MEU). RESULTS Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption. CONCLUSION Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Andrew J Homere
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Julien R Wier
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Sofia Bougioukli
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - John J Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Monica Wong
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
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Horodyski L, Ball B, Emile C, Rhodes A, Miao F, Reis IM, Carrasquillo MZ, Livingstone J, Matadial C, Ritch CR, Deane LA. Safe transition to opioid-free pathway after robotic-assisted laparoscopic prostatectomy. J Robot Surg 2021; 16:307-314. [PMID: 33855681 DOI: 10.1007/s11701-021-01237-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/03/2021] [Indexed: 11/27/2022]
Abstract
To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control.
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Affiliation(s)
- Laura Horodyski
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA.
| | - Brittany Ball
- Miami Veteran's Affairs Medical Center, Miami, FL, USA
| | - Clarence Emile
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
| | | | - Feng Miao
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
| | - Isildinha M Reis
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
| | | | - Joshua Livingstone
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
- Miami Veteran's Affairs Medical Center, Miami, FL, USA
| | - Christina Matadial
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
- Miami Veteran's Affairs Medical Center, Miami, FL, USA
| | - Chad R Ritch
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
- Miami Veteran's Affairs Medical Center, Miami, FL, USA
| | - Leslie A Deane
- University of Miami, 1120 NW 14th Street Suite 1551C, Miami, FL, USA
- Miami Veteran's Affairs Medical Center, Miami, FL, USA
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An Interactive Pain Application (MServ) Improves Postoperative Pain Management. Pain Res Manag 2021; 2021:8898170. [PMID: 33868524 PMCID: PMC8035036 DOI: 10.1155/2021/8898170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/25/2021] [Accepted: 03/01/2021] [Indexed: 11/21/2022]
Abstract
Background Most patients have moderate or severe pain after surgery. Opioids are the cornerstone of treating severe pain after surgery but cause problems when continued long after discharge. We investigated the efficacy of multifunction pain management software (MServ) in improving postoperative pain control and reducing opioid prescription at discharge. Methods We recruited 234 patients to a prospective cohort study into sequential groups in a nonrandomised manner, one day after major thoracic or urological surgery. Group 1 received standard care (SC, n = 102), group 2 were given a multifunctional device that fed back to the nursing staff alone (DN, n = 66), and group 3 were given the same device that fed back to both the nursing staff and the acute pain team (DNPT, n = 66). Patient-reported pain scores at 24 and 48 hours and patient-reported time in severe pain, medications, and satisfaction were recorded on trial discharge. Findings. Odds of having poor pain control (>1 on 0–4 pain scale) were calculated between standard care (SC) and device groups (DN and DNPT). Patients with a device were significantly less likely to have poor pain control at 24 hours (OR 0.45, 95% CI 0.25, 0.81) and to report time in severe pain at 48 hours (OR 0.62, 95% CI 0.47–0.80). Patients with a device were three times less likely to be prescribed strong opioids on discharge (OR 0.35, 95% CI 0.13 to 0.95). Interpretation. Using an mHealth device designed for pain management, rather than standard care, reduced the incidence of poor pain control in the postoperative period and reduced opioid prescription on discharge from hospital.
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Davey MS, Hurley ET, Anil U, Moses A, Thompson K, Alaia M, Strauss EJ, Campbell KA. Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis. Arthroscopy 2021; 37:1290-1300.e6. [PMID: 33515736 DOI: 10.1016/j.arthro.2021.01.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable. RESULTS Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. CONCLUSIONS Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of RCTs.
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Affiliation(s)
- Martin S Davey
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eoghan T Hurley
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Utkarsh Anil
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Akini Moses
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kamali Thompson
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Michael Alaia
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kirk A Campbell
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
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Calderon T, Hedges E, Livingston MH, Gitzelmann C, Pegoli W, Wakeman D. Opioid stewardship in pediatric surgery: Approaching zero. J Pediatr Surg 2021; 56:573-579. [PMID: 33008639 DOI: 10.1016/j.jpedsurg.2020.08.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/07/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In response to the opioid epidemic, we hypothesized that adequate pain control can be achieved with few, if any, opioid prescriptions at discharge following pediatric surgical procedures. METHODS All records for patients 0-15 years old who underwent pediatric surgical operations from December 2017 through May 2018 were reviewed. Opioids prescriptions, emergency department (ED) visits, and hospital readmissions were recorded. Postoperative pain was assessed on a scale from 0 to 10 via phone call within three days of discharge. RESULTS 352 patients underwent 394 surgical procedures. Three patients were prescribed opioids at discharge. There were no pain-related readmissions. One patient returned to the ED owing to pain. 116 unique pain scores were obtained from 114 patients: score 0 (n = 69, 59%), 1-3 (n = 31, 27%), 4-5 (n = 11, 9%), 6-8 (n = 5, 4%), and 9-10 (n = 0, 0%). There was a positive association between pain and increasing age (r = 0.26, p = 0.005). No patients who underwent hernia repair reported a pain score greater than 3. CONCLUSIONS Adequate pain control at discharge after pediatric general surgical procedures can be achieved for most children with scheduled nonopioid medications only. A limited supply of opioids for analgesia after discharge may benefit small subset of patients. This strategy would help reduce opioid prevalence in the community. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Thais Calderon
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Elizabeth Hedges
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael H Livingston
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY
| | - Christopher Gitzelmann
- Division of Pediatric Surgery, Rutgers Robert Wood Johnson Medical School, Saint Barnabas Medical Center, Livingston, NJ
| | - Walter Pegoli
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY
| | - Derek Wakeman
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY.
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Kurteva S, Habib B, Moraga T, Tamblyn R. Incidence and Variables Associated With Inconsistencies in Opioid Prescribing at Hospital Discharge and Its Associated Adverse Drug Outcomes. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:147-157. [PMID: 33518021 DOI: 10.1016/j.jval.2020.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/02/2020] [Accepted: 07/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Opioid-related medication errors (MEs) can have a significant impact on patient health and contribute to opioid misuse. The objective of this study was to estimate the incidence of and variables associated with the receipt of an opioid prescription and opioid-related MEs (omissions, duplications, or dose changes) at hospital discharge. We also determined rates of adverse drug events and risks of emergency department visits, readmissions, or death 30 days and 90 days post discharge associated with MEs. METHODS A cohort of hospitalized patients discharged from the McGill University Health Centre between 2014 and 2016 was assembled. The impact of opioid-related MEs was assessed in a propensity score-adjusted logistic regression models. Multivariable logistic regression was used to determine characteristics associated with MEs and discharge opioid prescription. RESULTS A total of 1530 (43.9%) of 3486 patients were prescribed opioids, of which 13.4% (n = 205) of patients had at least 1 opioid-related ME. Rates of MEs were higher in handwritten prescriptions compared to the electronic reconciliation discharge prescription group (20.6% vs 1.2%). Computer-based prescriptions were associated with a 69% lower risk of opioid-related MEs (adjusted odds ratio: 0.31, 95% confidence interval: 0.14-0.65) as well as 63% lower risk of receiving an opioid prescription. Opioid-related MEs were associated with a 2.3 times increased risk of healthcare utilization in the 30 days postdischarge period (adjusted odds ratio: 2.32, 95% confidence interval: 1.24-4.32). CONCLUSIONS Opioid-related MEs are common in handwritten discharge prescriptions. Our findings highlight the need for computer-based prescribing platforms and careful review of medications during critical periods of care such as hospital transitions.
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Affiliation(s)
- Siyana Kurteva
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Canada.
| | - Bettina Habib
- Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Canada
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Canada; Department of Medicine, McGill University Health Center, Montreal, Canada
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Paredes AZ, Hyer JM, Tsilimigras DI, Dillhoff ME, Ejaz A, Cloyd JM, Tsung A, Pawlik TM. Wide variation in inpatient opioid utilization following hepatopancreatic surgery. HPB (Oxford) 2021; 23:212-219. [PMID: 32561176 DOI: 10.1016/j.hpb.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inpatient opioid utilization following major surgery remains relatively unknown. We sought to characterize inpatient opioid consumption following hepatopancreatic surgery and determine factors associated with the variability in opioid utilization. METHODS Adult patients who underwent hepatopancreatic surgery at a single institution were identified. Multimodal pain management strategies assessed included opioids (oral morphine equivalents, OME), acetaminophen, ibuprofen and ketorolac. RESULTS Among 2,054 patients, the median total OME utilized was 465 (129-815) during a patient's hospitalization following hepatopancreatic surgery. The interquartile range for total OMEs administered following hepatopancreatic surgery was as high as 940 OMEs (125 oxycodone-5mg pills) following a pancreaticoduodenectomy versus 520 OMEs (69 oxycodone-5mg pills) following a hemi-hepatectomy. Despite relatively high use of acetaminophen post-operatively (n = 1,588, 77.0%), multimodal pain control with acetaminophen and ibuprofen was infrequent (n = 175, 8.5%). Furthermore, individuals with high opioid utilization used on average 147 OMEs (20 oxycodone-5mg pills) the day before discharge versus 44 OME (6 oxycodone-5mg pills) among patients with expected opioid utilization. CONCLUSIONS Marked variability in inpatient opioid consumption following hepatopancreatic surgery was noted. Future work is necessary to decrease the variability in inpatient opioid prescribing practices to promote the safe and effective management of pain.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Smith CR, Fox WC, Robinson CP, Garvan C, Babi MA, Pizzi MA, Lobmeyer E, Bursian A, Maciel CB, Busl KM. Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 2021; 35:241-248. [PMID: 33403584 DOI: 10.1007/s12028-020-01157-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal. METHODS This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement. RESULTS Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6-11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min. CONCLUSIONS PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.
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Affiliation(s)
- Cameron R Smith
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - W Christopher Fox
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA
| | - Christopher P Robinson
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Cynthia Garvan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Marc-Alain Babi
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael A Pizzi
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Erica Lobmeyer
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Alberto Bursian
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Carolina B Maciel
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Katharina M Busl
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA.
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Lee S, Wei S, White V, Bain PA, Baker C, Li J. Classification of Opioid Usage Through Semi-Supervised Learning for Total Joint Replacement Patients. IEEE J Biomed Health Inform 2021; 25:189-200. [PMID: 32386170 DOI: 10.1109/jbhi.2020.2992973] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Opioid misuse and overdose have become a public health hazard and caused drug addiction and death in the United States due to rapid increase in prescribed and non-prescribed opioid usage. The misuse and overdose are highly related to opioid over-prescription for chronic and acute pain treatment, where a one-size-fits-all prescription plan is often adopted but can lead to substantial leftovers for patients who only consume a few. To reduce over-prescription and opioid overdose, each patient's opioid usage pattern should be taken into account. As opioids are often prescribed for patients after total joint replacement surgeries, this study introduces a machine learning model to predict each patient's opioid usage level in the first 2 weeks after discharge. Specifically, the electronic health records, patient prescription history, and consumption survey data are collected to investigate the level of short-term opioid usage after joint replacement surgeries. However, there are a considerable number of answers missing in the surveys, which degrades data quality. To overcome this difficulty, a semi-supervised learning model that assigns pseudo labels via Bayesian regression is proposed. Using this model, the missing survey answers of opioids amount taken by the patients are predicted first. Then, based on the prediction, pseudo labels are assigned to those patients to improve classification performance. Extensive experiments indicate that such a semi-supervised learning model has shown a better performance in the resulting patients classification. It is expected that by using such a model the providers can adjust the amount of prescribed opioids to meet each patient's actual need, which can benefit the management of opioid prescription and pain intervention.
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Pena JJ, Chen CJ, Clifford H, Xue Z, Wang S, Argenziano M, Landau R, Meng ML. Introduction of an Analgesia Prescription Guideline Can Reduce Unused Opioids After Cardiac Surgery: A Before and After Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:1704-1711. [PMID: 33455887 DOI: 10.1053/j.jvca.2020.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE(S) The authors aimed to assess whether the introduction of a tailored Analgesia Prescription Guideline would decrease the amount of unused opioid following discharge from cardiac surgery. DESIGN Prospective, observational, before and after study. SETTING Quaternary care university hospital. PARTICIPANTS A total of 191 participants who underwent cardiac surgery requiring midline sternotomy and cardiopulmonary bypass. There were 99 participants in the before cohort (prior to introduction of the Analgesia Prescription Guideline), and 92 participants in the after cohort (after introduction of the Analgesia Prescription Guideline). INTERVENTIONS Using prospectively collected observational data on participant opioid consumption in the before cohort, a tailored Analgesia Prescription Guideline was developed. This guideline then was introduced to all opioid-prescribing providers in the cardiothoracic surgery department. Prospective data then were collected in the after cohort of participants. Opioid prescription practices and opioid consumption between the two groups then were compared. MEASUREMENTS AND MAIN RESULTS Opioid prescriptions were given to 62/99 participants (63%) in the before cohort, and 48/92 (52%) in the after cohort (rate difference 0.1, CI 95% -0.26, 0.046). In the before cohort, the mean (± standard deviation) number of opioid tablets prescribed, used, and leftover was 26 (±10), 11 (±10), and 15 (±12), respectively. In the after cohort, the mean number of opioid tablets prescribed, used, and leftover was 18 (mean difference -8, CI 95% -12, -5), 10 (mean difference -1, CI 95% -5, 3), and 8 (mean difference -7, CI 95% -11, -3), respectively. There were 110/191 (58%) participants using no opioids following discharge, and 10/191 (5%) still using opioids two weeks after discharge. There were no differences between groups with regard to demographics, opioid-related side effects, pain scores, satisfaction, opioid storage. and disposal practices. CONCLUSIONS The development and implementation of a tailored Analgesia Prescription Guideline decreased the amount of opioids prescribed after cardiac surgery and resulted in lower numbers of unused leftover opioid tablets in the community. Patient comfort and satisfaction scores remained high.
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Affiliation(s)
- Joseph J Pena
- Columbia University Irving Medical Center, Department of Anesthesiology, New York, NY.
| | - Chung Jen Chen
- Columbia University Irving Medical Center, Department of Anesthesiology, New York, NY
| | - Hugo Clifford
- Columbia University Irving Medical Center, Department of Anesthesiology, New York, NY
| | - Zenghui Xue
- Mailman School of Public Health, Department of Biostatistics, Columbia University, New York, NY
| | - Shuang Wang
- Mailman School of Public Health, Department of Biostatistics, Columbia University, New York, NY
| | - Michael Argenziano
- Columbia University Irving Medical Center, Department of Cardiothoracic Surgery, New York, NY
| | - Ruth Landau
- Columbia University Irving Medical Center, Department of Anesthesiology, New York, NY
| | - Marie-Louise Meng
- Duke University Medical Center, Department of Anesthesiology, Durham, NC
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50
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Montiel Ishino FA, McNab PR, Gilreath T, Salmeron B, Williams F. A comprehensive multivariate model of biopsychosocial factors associated with opioid misuse and use disorder in a 2017-2018 United States national survey. BMC Public Health 2020; 20:1740. [PMID: 33208132 PMCID: PMC7672927 DOI: 10.1186/s12889-020-09856-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have comprehensively and contextually examined the relationship of variables associated with opioid use. Our purpose was to fill a critical gap in comprehensive risk models of opioid misuse and use disorder in the United States by identifying the most salient predictors. METHODS A multivariate logistic regression was used on the 2017 and 2018 National Survey on Drug Use and Health, which included all 50 states and the District of Columbia of the United States. The sample included all noninstitutionalized civilian adults aged 18 and older (N = 85,580; weighted N = 248,008,986). The outcome of opioid misuse and/or use disorder was based on reported prescription pain reliever and/or heroin use dependence, abuse, or misuse. Biopsychosocial predictors of opioid misuse and use disorder in addition to sociodemographic characteristics and other substance dependence or abuse were examined in our comprehensive model. Biopsychosocial characteristics included socioecological and health indicators. Criminality was the socioecological indicator. Health indicators included self-reported health, private health insurance, psychological distress, and suicidality. Sociodemographic variables included age, sex/gender, race/ethnicity, sexual identity, education, residence, income, and employment status. Substance dependence or abuse included both licit and illicit substances (i.e., nicotine, alcohol, marijuana, cocaine, inhalants, methamphetamine, tranquilizers, stimulants, sedatives). RESULTS The comprehensive model found that criminality (adjusted odds ratio [AOR] = 2.58, 95% confidence interval [CI] = 1.98-3.37, p < 0.001), self-reported health (i.e., excellent compared to fair/poor [AOR = 3.71, 95% CI = 2.19-6.29, p < 0.001], good [AOR = 3.43, 95% CI = 2.20-5.34, p < 0.001], and very good [AOR = 2.75, 95% CI = 1.90-3.98, p < 0.001]), no private health insurance (AOR = 2.12, 95% CI = 1.55-2.89, p < 0.001), serious psychological distress (AOR = 2.12, 95% CI = 1.55-2.89, p < 0.001), suicidality (AOR = 1.58, 95% CI = 1.17-2.14, p = 0.004), and other substance dependence or abuse were significant predictors of opioid misuse and/or use disorder. Substances associated were nicotine (AOR = 3.01, 95% CI = 2.30-3.93, p < 0.001), alcohol (AOR = 1.40, 95% CI = 1.02-1.92, p = 0.038), marijuana (AOR = 2.24, 95% CI = 1.40-3.58, p = 0.001), cocaine (AOR = 3.92, 95% CI = 2.14-7.17, p < 0.001), methamphetamine (AOR = 3.32, 95% CI = 1.96-5.64, p < 0.001), tranquilizers (AOR = 16.72, 95% CI = 9.75-28.65, p < 0.001), and stimulants (AOR = 2.45, 95% CI = 1.03-5.87, p = 0.044). CONCLUSIONS Biopsychosocial characteristics such as socioecological and health indicators, as well as other substance dependence or abuse were stronger predictors of opioid misuse and use disorder than sociodemographic characteristics.
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Affiliation(s)
- Francisco A Montiel Ishino
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, 7201 Wisconsin Ave Ste. 533, Bethesda, MD, 20814, USA. .,Transdisciplinary Center for Health Equity Research, College of Education and Human Development, Texas A&M University, 4243 TAMU, 311 Blocker, College Station, TX, 77843, USA.
| | - Philip R McNab
- Center for a Livable Future, Department of Environmental Health & Engineering, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 840, Baltimore, MD, 21202, USA
| | - Tamika Gilreath
- Transdisciplinary Center for Health Equity Research, College of Education and Human Development, Texas A&M University, 4243 TAMU, 311 Blocker, College Station, TX, 77843, USA
| | - Bonita Salmeron
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, 7201 Wisconsin Ave Ste. 533, Bethesda, MD, 20814, USA
| | - Faustine Williams
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, 7201 Wisconsin Ave Ste. 533, Bethesda, MD, 20814, USA
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