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Priest KC, Merlin JS, Lai J, Sorbero M, Taylor EA, Dick AW, Stein BD. A Longitudinal Multivariable Analysis: State Policies and Opioid Dispensing in Medicare Beneficiaries Undergoing Surgery. J Gen Intern Med 2024:10.1007/s11606-024-08888-3. [PMID: 39020230 DOI: 10.1007/s11606-024-08888-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 06/12/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND States have implemented policies to decrease clinically unnecessary opioid prescribing, but few studies have examined how state policies affect opioid dispensing rate trends for surgical patients. OBJECTIVE To examine trends in the perioperative opioid dispensing rates for fee-for-service Medicare beneficiaries and the effects of select state policies. DESIGN AND PARTICIPANTS A retrospective cohort study using 2006 to 2018 Medicare claims data for individuals undergoing surgical procedures for which opioid analgesic treatment is common. EXPOSURES State policies mandating prescription drug monitoring program (PDMP; PDMP policies) use, initial opioid prescription duration limit (duration limit policies), and mandated continuing medical education (CME; CME pain policies) on pain management. MAIN MEASURES Opioid dispensing rates, days' supply, and the daily morphine milligram equivalent dose (MMED). KEY RESULTS The percentage of Medicare beneficiaries dispensed opioids in the perioperative period increased from 2007 to 2018; MMED and days' supply decreased over the same period, with significant variation by age, sex, and race. None of the three state policies affected the likelihood of Medicare beneficiaries being dispensed perioperative opioids. However, CME pain policies and duration limit policies were associated with decreased days' supply and decreased MMED in the several years following implementation, respectively. CONCLUSION While we observed a slight increase in the rate of Medicare beneficiaries dispensed opioids perioperatively and a substantial decrease in MMED and days' supply for those receiving opioids, state policies examined had relatively modest effects on the main measures. Our findings suggest that these state policies may have a limited impact on opioid dispensing for a patient population that is commonly dispensed opioid analgesics to help control surgical pain, and as a result may have little direct effect on clinical outcomes for this population. Changes in opioid dispensing for this population may be the result of broader societal trends than such state policies.
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Affiliation(s)
- Kelsey C Priest
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jessica S Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie Lai
- RAND Corporation, Santa Monica, CA, USA
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Changes in opioid prescription duration for musculoskeletal injury associated with the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:926-932. [PMID: 36943361 DOI: 10.1093/pm/pnad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/20/2023] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES To assess whether implementation of the Strengthen Opioid Misuse Prevention (STOP) Act was associated with an increase in the percentage of opioid prescriptions written for 7 days or fewer among patients with acute or postsurgical musculoskeletal conditions. DESIGN An interrupted time-series study was conducted to determine the change in duration of opioid prescriptions associated with the STOP Act. SETTING Data were extracted from the electronic health record of a large health care system in North Carolina. SUBJECTS Patients presenting from 2016 to 2020 with an acute musculoskeletal injury and the clinicians treating them were included in an interrupted time-series study (n = 12 839). METHODS Trends were assessed over time, including the change in trend associated with implementation of the STOP Act, for the percentage of prescriptions written for ≤7 days. RESULTS Among patients with acute musculoskeletal injury, less than 30% of prescriptions were written for ≤7 days in January of 2016; by December of 2020, almost 90% of prescriptions were written for ≤7 days. Prescriptions written for ≤7 days increased 17.7% after the STOP Act was implemented (P < .001), after adjustment for the existing trend. CONCLUSIONS These results demonstrate significant potential for legislation to influence opioid prescribing behavior.
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Affiliation(s)
- Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Michael E Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Donna M Kazemi
- College of Health and Human Services, School of Nursing, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
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Adalbert JR, Syal A, Varshney K, George B, Hom J, Ilyas AM. The prescription drug monitoring program in a multifactorial approach to the opioid crisis: PDMP data, Pennsylvania, 2016-2020. BMC Health Serv Res 2023; 23:364. [PMID: 37046254 PMCID: PMC10100464 DOI: 10.1186/s12913-023-09272-3] [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: 04/08/2022] [Accepted: 03/09/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Prescription opioids remain an important contributor to the United States opioid crisis and to the development of opioid use disorder for opioid-naïve individuals. Recent legislative actions, such as the implementation of state prescription drug monitoring programs (PDMPs), aim to reduce opioid morbidity and mortality through enhanced tracking and reporting of prescription data. The primary objective of our study was to describe the opioid prescribing trends in the state of Pennsylvania (PA) as recorded by the PA PDMP following legislative changes in reporting guidelines, and discuss the PDMP's role in a multifactorial approach to opioid harm reduction. METHODS State-level opioid prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. Data for oxycodone, hydrocodone, and morphine were analyzed by quarter for total prescription numbers and refills. Prescription lengths, pill quantities, and average morphine milliequivalents (MMEs) were analyzed by quarter for all 14 opioid prescription variants recorded by the PA PDMP. Linear regression was conducted for each group of variables to identify significant differences in prescribing trends. RESULTS For total prescriptions dispensed, the number of oxycodone, hydrocodone, and morphine prescriptions decreased by 34.4, 44.6, and 22.3% respectively (p < 0.0001). Refills fluctuated less consistently with general peaks in Q3 of 2017 and Q3 of 2018 (p = 0.2878). The rate of prescribing for all opioid prescription lengths decreased, ranging in frequency from 22 to 30 days (47.5% of prescriptions) to 31+ days of opioids (0.8% of prescriptions) (p < 0.0001). Similarly, decreased prescribing was observed for all prescription amounts, ranging in frequency from 22 to 60 pills (36.6% of prescriptions) to 60-90 pills (14.2% of prescriptions) (p < 0.0001). Overall, the average MME per opioid prescription decreased by 18.9%. CONCLUSIONS Per the PA PDMP database, opioid prescribing has decreased significantly in PA from 2016 to 2020. The PDMP database is an important tool for tracking opioid prescribing trends in PA, and PDMPs structured similarly in other states may enhance our ability to understand and influence the trajectory of the U.S. opioid crisis. Further research is needed to determine optimal PDMP policies and practices nationwide.
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Affiliation(s)
- Jenna R Adalbert
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
- Jefferson College of Population Health, Philadelphia, PA, USA.
| | - Amit Syal
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Karan Varshney
- Jefferson College of Population Health, Philadelphia, PA, USA
- Deakin University School of Medicine, Geelong, VIC, USA
| | - Brandon George
- Jefferson College of Population Health, Philadelphia, PA, USA
| | - Jeffrey Hom
- Jefferson College of Population Health, Philadelphia, PA, USA
- Philadelphia Department of Public Health, Philadelphia, PA, USA
| | - Asif M Ilyas
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopaedic Institute Foundation for Opioid Research & Education, Philadelphia, PA, USA
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Straubhar AM, Stroup C, de Bear O, Dalton L, Rolston A, McCool K, Reynolds RK, McLean K, Siedel JH, Uppal S. Provider compliance with a tailored opioid prescribing calculator in gynecologic surgery. Gynecol Oncol 2023; 170:229-233. [PMID: 36716511 DOI: 10.1016/j.ygyno.2023.01.018] [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] [Received: 12/06/2022] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the impact a tailored opioid prescription calculator has on meeting individual patient opioid needs while avoiding opioid over prescriptions. METHODS Our group previously developed and published an opioid prescribing calculator incorporating patient risk factors (history of depression, anxiety, chronic opioid use, substance abuse disorder, and/or chronic pain) and type of surgery (laparotomy or laparoscopy). This calculator was implemented on 1/1/2021 and its impact on opioid prescriptions was evaluated until 12/31/21. The primary outcome of the present study is to determine prescriber compliance with the calculator (defined as not overprescribing from the number of pills indicated by the calculator). The secondary outcome is to determine the excess prescription rate (defined as proportion of patients reporting more than 3 pills remaining at 30 days post-surgery). Refill rates and pain related patient phone calls were collected. Descriptive statistics were used to summarize the cohort. RESULTS Of the 355 patients included, 54.7% (N = 194) underwent laparoscopy and 45.4% (N = 161) underwent laparotomy. One hundred and forty-two patients (40%) had at least one risk factor for opioid usage. The median number of opioid pills prescribed following laparoscopy was 3 (range 0-15) and 6 (0-20) after laparotomy. The prescriber compliance was 88.2% and the excess prescription rate was 25.1% (N = 89 patients). CONCLUSIONS Our tailored opioid calculator has a high prescriber compliance. Implementation of this calculator led to a standardization of tailored opioid prescribing, while limiting the number of over prescriptions. A free web version of the calculator can be easily accessed at www.opioidcalculator.org.
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Affiliation(s)
- Alli M Straubhar
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.
| | - Cynthia Stroup
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Olivia de Bear
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Liam Dalton
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Aimee Rolston
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Kevin McCool
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - R Kevin Reynolds
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Karen McLean
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Jean H Siedel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Shitanshu Uppal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
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The Effect of Online Prescription Drug Monitoring on Opioid Prescription Habits After Elective Single-level Lumbar Fusion. J Am Acad Orthop Surg 2022; 30:e1411-e1418. [PMID: 35947832 DOI: 10.5435/jaaos-d-22-00433] [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: 04/29/2022] [Accepted: 06/12/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The United States opioid epidemic is a well-documented crisis stemming from increased prescriptions of narcotics. Online prescription drug monitoring programs (PDMPs) are a potential resource to mitigate narcotic misuse by tracking controlled substance prescriptions. Therefore, the purpose of this study was to evaluate opioid prescription trends after implementation of an online PDMP in patients who underwent single-level lumbar fusion. METHODS Patients who underwent a single-level lumbar fusion between August 27, 2017, and August 31, 2020, were identified and placed categorically into one of two cohorts: an "early adoption" cohort, September 1, 2017, to August 31, 2018, and a "late adoption" cohort, September 1, 2019, to August 31, 2020. This allowed for a 1-year washout period after Pennsylvania PDMP implementation on August 26, 2016. Opioid use data were obtained by searching for each patient in the state government's online PDMP and recording data from the year before and the year after the patient's procedure. RESULTS No significant difference was observed in preoperative opioid prescriptions between the early and late adoption cohorts. The late adoption group independently predicted decreased postoperative opioid prescriptions (β, 0.78; 95% confidence interval [CI], 0.65 to 0.93; P = 0.007), opioid prescribers (β, 0.81; 95% CI, 0.72 to 0.90; P < 0.001), pharmacies used (β, 0.90; 95% CI, 0.83 to 0.97; P = 0.006), opioid pills (β, 0.61; 95% CI, 0.50 to 0.74; P < 0.001), days of opioid prescription (β, 0.57; 95% CI, 0.45 to 0.72; P < 0.001), and morphine milligram equivalents prescribed (β, 0.53; 95% CI, 0.43 to 0.66; P < 0.001). CONCLUSIONS PDMP implementation was associated with decreased postoperative opioid prescription patterns but not preoperative opioid prescribing behaviors. LEVELS OF EVIDENCE 4.
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Adalbert JR, Varshney K, Hom J, Ilyas AM. Methadone Prescribing for Pain Management in Pennsylvania per the Prescription Drug Monitoring Program, 2016–2020. Cureus 2022; 14:e28583. [PMID: 36185908 PMCID: PMC9521395 DOI: 10.7759/cureus.28583] [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] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Methadone is a schedule II opioid traditionally used to treat opioid use disorder (OUD) and chronic pain. However, following the identification of its contribution to opioid overdose deaths, methadone has become less commonly used for chronic pain indications. In Pennsylvania (PA), prescribers are required to report methadone prescriptions written for pain indications to the prescription drug monitoring program (PDMP), which is an electronic database that enhances the tracking and reporting of prescription data. The primary objective of our study was to describe the geographic methadone prescribing trends recorded by the PA PDMP in order to report methadone’s current use for only pain indications. Methods State- and county-level methadone prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. The metric reported per quarter consisted of the total number of methadone prescriptions dispensed for pain indications unrelated to OUD. Results A total of 341,949 methadone prescriptions were dispensed in PA from the third quarter (Q3) of 2016 to the first quarter (Q1) of 2020 (range = 1106) with an overall 38.7% decrease in methadone prescriptions and a change in the rate of 85.97 per 100,000 population. The counties with the five highest prescription totals were Philadelphia, Allegheny, Bucks, Montgomery, and York (range = 46,969), and the counties with the five highest rates per 100,000 were Montour, Green, Columbia, Northumberland, and Forest (range = 964). Conclusions Methadone prescribing for pain management unrelated to OUD has decreased in PA from 2016 to 2020 per the PA PDMP. However, it is still prescribed in appreciable amounts for pain management. Further studies are required to understand the prescribing rationale and potential areas for harm reduction interventions.
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Bicket MC, Gunaseelan V, Lagisetty P, Fernandez AC, Bohnert A, Assenmacher E, Sequeira M, Englesbe MJ, Brummett CM, Waljee JF. Association of opioid exposure before surgery with opioid consumption after surgery. Reg Anesth Pain Med 2022; 47:346-352. [PMID: 35241626 PMCID: PMC9035103 DOI: 10.1136/rapm-2021-103388] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 02/20/2022] [Indexed: 12/14/2022]
Abstract
ObjectiveTo determine the effect of prescription opioid use in the year before surgery on opioid consumption after surgery.BackgroundRecently developed postoperative opioid prescribing guidelines rely on data from opioid-naïve patients. However, opioid use in the USA is common, and the impact of prior opioid exposure on the consumption of opioids after surgery is unclear.MethodsPopulation-based cohort study of 26,001 adults 18 years of age and older who underwent one of nine elective general or gynecologic surgical procedures between January 1, 2017 and October 31, 2019, with prospectively collected patient-reported data from the Michigan Surgical Quality Collaborative (MSQC) linked to state prescription drug monitoring program at 70 MSQC-participating hospitals on 30-day patient-reported opioid consumption in oral morphine equivalents (OME) (primary outcome).ResultsCompared with opioid-naïve participants, opioid-exposed participants (26% of sample) consumed more prescription opioids after surgery (adjusted OME difference 12, 95% CI 10 to 14). Greater opioid exposure was associated with higher postoperative consumption in a dose-dependent manner, with chronic users reporting the greatest consumption (additional OMEs 32, 95% CI 21 to 42). However, for eight of nine procedures, 90% of opioid-exposed participants consumed ≤150 OMEs. Among those receiving perioperative prescriptions, opioid-exposed participants had higher likelihood of refill (adjusted OR 4.7, 95% CI 4.4 to 5.1), number of refills (adjusted incidence rate ratio 4.0, 95% CI 3.7 to 4.3), and average refill amount (adjusted OME difference 333, 95% CI 292 to 374)).ConclusionsPreoperative opioid use is associated with small increases in patient-reported opioid consumption after surgery for most patients, though greater differences exist for patients with chronic use. For most patients with preoperative opioid exposure, existing guidelines may meet their postoperative needs. However, guidelines may need tailoring for patients with chronic use, and providers should anticipate a higher likelihood of postoperative refills for all opioid-exposed patients.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Pooja Lagisetty
- Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy Bohnert
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | | | - Melwyn Sequeira
- Department of Surgery, MidMichigan Medical Center, Midland, Texas, USA
| | - Michael J Englesbe
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Ellyson AM, Grooms J, Ortega A. Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior. HEALTH ECONOMICS 2022; 31:297-341. [PMID: 34773311 DOI: 10.1002/hec.4446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.
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Affiliation(s)
- Alice M Ellyson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jevay Grooms
- Department of Economics, Howard University, Washington, District of Columbia, USA
| | - Alberto Ortega
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
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Hoppe D, Karimi L, Khalil H. Mapping the research addressing prescription drug monitoring programs: A scoping review. Drug Alcohol Rev 2022; 41:803-817. [PMID: 35106867 DOI: 10.1111/dar.13431] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/19/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
ISSUES Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice. APPROACH A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021. KEY FINDINGS A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use. IMPLICATIONS Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement. CONCLUSION Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.
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Affiliation(s)
- Dimi Hoppe
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Leila Karimi
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Hanan Khalil
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Langnas EM, Matthay ZA, Lin A, Harbell MW, Croci R, Rodriguez-Monguio R, Chen CL. Enhanced recovery after surgery protocol and postoperative opioid prescribing for cesarean delivery: an interrupted time series analysis. Perioper Med (Lond) 2021; 10:38. [PMID: 34775985 PMCID: PMC8591895 DOI: 10.1186/s13741-021-00209-0] [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: 04/26/2021] [Accepted: 07/18/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear. STUDY DESIGN We conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends. RESULTS Among the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01). CONCLUSION Although ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.
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Affiliation(s)
- E M Langnas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.
| | - Z A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, USA
| | - A Lin
- UCSF School of Medicine, University of California, San Francisco, San Francisco, USA
| | - M W Harbell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - R Croci
- UCSF Health Informatics, University of California, San Francisco, San Francisco, USA
| | - R 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
| | - C 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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Shenoy R, Wagner Z, Kirkegaard A, Romanelli RJ, Mudiganti S, Mariano L, Martinez M, Zanocco K, Watkins KE. Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program. JAMA HEALTH FORUM 2021; 2:e212924. [PMID: 35977161 PMCID: PMC8725834 DOI: 10.1001/jamahealthforum.2021.2924] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/04/2021] [Indexed: 11/21/2022] Open
Abstract
Importance Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)-based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation. Objective To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge. Design Setting and Participants This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included. Exposures Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively. Main Outcomes and Measures The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days. Results Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = -10.00 [95% CI, -19.52 to -0.48]; obstetric/gynecologic surgery: β = -18.65 [95% CI, -22.00 to -15.30]; and orthopedic surgery: β = -30.59 [95% CI, -40.19 to -21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = -3.02 [95% CI, -3.47 to -2.57]; obstetric/gynecologic surgery: β = -4.86 [95% CI, -5.38 to -4.34]; and orthopedic surgery: β = -4.06 [95% CI, -5.07 to -3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = -10.00; 95% CI, -10.10 to -9.90), but median MMEs did not (β = 0; 95% CI, -9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = -33.33 [95% CI, -38.48 to -28.19]; tablets: β = -10.00 [95% CI, -11.17 to -8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, -22.33 to 42.33; tablets: β = 0.83; 95% CI, -3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties. Conclusions and Relevance In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers' attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing.
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Affiliation(s)
- Rivfka Shenoy
- David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles,Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California,National Clinician Scholars Program, University of California, Los Angeles, Los Angeles
| | | | | | - Robert J. Romanelli
- Center for Health Systems Research, Division of Research, Development and Dissemination, Sutter Health, Walnut Creek, California
| | - Satish Mudiganti
- Center for Health Systems Research, Division of Research, Development and Dissemination, Sutter Health, Walnut Creek, California
| | | | - Meghan Martinez
- Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, California
| | - Kyle Zanocco
- David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles
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12
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Wang LX. The complementarity of drug monitoring programs and health IT for reducing opioid-related mortality and morbidity. HEALTH ECONOMICS 2021; 30:2026-2046. [PMID: 34046967 DOI: 10.1002/hec.4360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 03/10/2021] [Accepted: 05/05/2021] [Indexed: 06/12/2023]
Abstract
In response to the opioid crisis, each US state has implemented a prescription drug monitoring program (PDMP) to collect data on controlled substances prescribed and dispensed in the state. I study whether health information technology (HIT) complements patient prescription data in PDMPs to reduce opioid-related mortality and morbidity. A novel dataset is constructed that records state policies that integrate PDMP with HIT and facilitate interstate data sharing. Using difference-in-differences models, I find that PDMP-HIT integration policies reduce opioid-related inpatient morbidity. The reductions are substantial in states that established integration without ever mandating the use of a PDMP. A mechanism test suggests that PDMP integration works mainly through the hospital system while a mandate affects legal opioids prescription. The impacts from integration are strongest for the vulnerable groups-middle-aged, low-to middle-income patients, and those with public insurance. There is suggestive evidence that interstate data sharing further complements integration despite not having a significant impact independently. The results are robust to a set of tests using alternative specifications and measures. The total benefits from integration far exceed the associated costs.
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Affiliation(s)
- Lucy Xiaolu Wang
- Department of Economics, Cornell University, New York, New York, USA
- Department of Innovation and Entrepreneurship Research, Max Planck Institute for Innovation and Competition, Munich, Germany
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13
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Winkelman RD, Kavanagh MD, Tanenbaum JE, Pelle DW, Benzel EC, Mroz TE, Steinmetz MP. The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform. J Neurosurg Spine 2021; 35:275-283. [PMID: 34243163 DOI: 10.3171/2020.11.spine201046] [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: 06/09/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. METHODS This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. RESULTS A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. CONCLUSIONS Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.
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Affiliation(s)
- Robert D Winkelman
- 1Center for Spine Health, Neurological Institute, and
- 2Case Western Reserve University School of Medicine; and
- Departments of3Neurosurgery and
| | - Michael D Kavanagh
- 1Center for Spine Health, Neurological Institute, and
- 2Case Western Reserve University School of Medicine; and
| | - Joseph E Tanenbaum
- 1Center for Spine Health, Neurological Institute, and
- 2Case Western Reserve University School of Medicine; and
- 4Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Dominic W Pelle
- 1Center for Spine Health, Neurological Institute, and
- 5Orthopaedic Surgery, Cleveland Clinic
| | - Edward C Benzel
- 1Center for Spine Health, Neurological Institute, and
- Departments of3Neurosurgery and
| | - Thomas E Mroz
- 1Center for Spine Health, Neurological Institute, and
- 5Orthopaedic Surgery, Cleveland Clinic
| | - Michael P Steinmetz
- 1Center for Spine Health, Neurological Institute, and
- Departments of3Neurosurgery and
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Primary Care Implementation of a Mandatory Prescription Drug Monitoring Program in New York City. J Behav Health Serv Res 2021; 49:122-133. [PMID: 34426933 DOI: 10.1007/s11414-021-09766-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
The ways in which prescription drug monitoring programs (PDMPs) have been integrated into clinical practice remain understudied, and research into PDMP implementation in states where PDMP use by providers is mandated remains scant. This qualitative study describes how use of a state-mandated PDMP influenced clinical practice and opioid analgesic prescribing. We conducted face-to-face, in-depth interviews with 53 New York State-licensed primary care physicians who reported that they currently prescribed opioid analgesic medication, including those providers who reported consistent use of the PDMP (n = 38) in this sample. We used a thematic analytic approach to identify patterns of PDMP implementation into practice following enactment of the New York State legislative usage mandate. Among physicians who consistently used the PDMP, we found two distinct groups: (1) physicians who reported no change in their clinical practice and (2) physicians who acknowledged changes to both clinical practice and administrative management. In the latter group, most physicians felt the PDMP had benefited their patient relationships by fostering dialogue around patient substance use; however, some used the PDMP to dismiss patients from care. Findings suggest that increased education for providers relating to judicious prescribing, opioid use disorder, and best practice for PDMP utilization are needed.
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15
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Query mandates in prescription drug monitoring programs reduce opioid use among commercially insured patients with cancer. J Am Pharm Assoc (2003) 2021; 62:363-369. [PMID: 34246576 DOI: 10.1016/j.japh.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/29/2021] [Accepted: 06/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) have been shown to reduce opioid use in the general and noncancer populations. However, evidence of PDMP impacts on patients with cancer remains limited. OBJECTIVE The aim of the study was to examine the impact of PDMP mandates on individual-level opioid use among patients with cancer. METHODS This is a retrospective cohort study of patients with newly diagnosed cancer aged 18-65 years in the IQVIA PharMetrics Plus database (IQVIA Inc; nationally representative data of the U.S. commercially insured population in 49 states) between 2013 and 2015. The primary exposure was PDMP rigor (ranked from highest to lowest rigor): provider query + registration, query only, registration only, and unexposed. The study outcomes included (1) prevalent use among all individuals; and among opioid users (2) total days supplied, (3) daily morphine equivalent dose (MED), and (4) cumulative MED. RESULTS Of the eligible cohort (n=28,353), 37.5% (10,656) received opioids after a cancer diagnosis. The individuals exposed to these mandates were as follows: query + registration: 3899 (13.8%); query only: 3459 (12.2%); registration only: 2764 (9.7%); and no mandates: 18,231 (64.3%). The PDMP mandates had no effect on prevalent opioid use. Compared with unexposed patients, those subject to query mandates-alone or with registration mandates-experienced 12 fewer opioid days supplied and a lower mean cumulative MED (-662 mg and -702 mg, respectively), P < 0.01. Registration-only mandates were associated with 21 days more (P < 0.01) total days supplied and lower daily MED (1.1 mg; P < 0.05) but had no statistically significant effect on cumulative MED (-46 mg, P > 0.05). CONCLUSION Query mandates are a stronger PDMP tool than registration mandates in reducing opioid days supplied and cumulative MED. Initiatives should target PDMP mandates toward intended patient groups to reduce high-risk opioid use without compromising adequate pain treatment.
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16
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Ferrell JK, Shindo ML, Stack BC, Angelos P, Bloom G, Chen AY, Davies L, Irish JC, Kroeker T, McCammon SD, Meltzer C, Orloff LA, Panwar A, Shin JJ, Sinclair CF, Singer MC, Wang TV, Randolph GW. Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement. Head Neck 2021; 43:2281-2294. [PMID: 34080732 DOI: 10.1002/hed.26774] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking. METHODS An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements. CONCLUSIONS This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.
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Affiliation(s)
- Jay K Ferrell
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Maisie L Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Gary Bloom
- Thyroid Cancer Survivors' Association (ThyCa), Olney, Maryland, USA
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Louise Davies
- Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Susan D McCammon
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, Alabama, USA
| | - Charles Meltzer
- Department of Head and Neck Surgery, Kaiser Permanente Northern California, Santa Rosa, California, USA
| | - Lisa A Orloff
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Aru Panwar
- Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, USA
| | - Michael C Singer
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Tiffany V Wang
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W Randolph
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Theodorou CM, Jackson JE, Rajasekar G, Nuño M, Yamashiro KJ, Farmer DL, Hirose S, Brown EG. Impact of prescription drug monitoring program mandate on postoperative opioid prescriptions in children. Pediatr Surg Int 2021; 37:659-665. [PMID: 33433663 PMCID: PMC8026407 DOI: 10.1007/s00383-020-04846-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Prescription drug monitoring programs (PDMPs) have been established to combat the opioid epidemic, but there is no data on their efficacy in children. We hypothesized that a statewide PDMP mandate would be associated with fewer opioid prescriptions in pediatric surgical patients. METHODS Patients < 18 undergoing inguinal hernia repair, orchiopexy, orchiectomy, appendectomy, or cholecystectomy at a tertiary children's hospital were included. The primary outcome, discharge opioid prescription, was compared for 10 months pre-PDMP (n = 158) to 10 months post-PDMP (n = 228). Interrupted time series analysis was performed to determine the effect of the PDMP on opioid prescribing. RESULTS Over the 20-month study period, there was an overall decrease in the rate of opioid prescriptions per month (- 3.6% change, p < 0.001). On interrupted time series analysis, PDMP implementation was not associated with a significant decrease in the monthly rate of opioid prescriptions (1.27% change post-PDMP, p = 0.4). However, PDMP implementation was associated with a reduction in opioid prescriptions of greater than 5 days' supply (- 2.7% per month, p = 0.03). CONCLUSION Opioid prescriptions declined in pediatric surgical patients over the study time period. State-wide PDMP implementation was associated with a reduction in postoperative opioid prescriptions of more than 5 days' duration.
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Affiliation(s)
- Christina M. Theodorou
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
| | - Jordan E. Jackson
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
| | - Ganesh Rajasekar
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Sacramento, USA
| | - Miriam Nuño
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Sacramento, USA
| | - Kaeli J. Yamashiro
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
| | - Diana L. Farmer
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
| | - Shinjiro Hirose
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
| | - Erin G. Brown
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
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Talwar R, Joshi SS. Minimizing opioid consumption following robotic surgery. Transl Androl Urol 2021; 10:2289-2296. [PMID: 34159111 PMCID: PMC8185686 DOI: 10.21037/tau.2019.08.11] [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: 04/12/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022] Open
Abstract
The American opioid epidemic has led to one of the worse public health crises in recent history, and emerging evidence has highlighted the role of healthcare professionals in exposing patients and communities to potent opioid drugs. Surgeons, in treating postoperative pain, are at the forefront of this epidemic. In Urology, investigators are beginning to establish how patients handle and consume opioids following common urologic procedures in an effort to limit excess prescribing. However, there is a paucity of data to define acceptable amounts of opioid medications to adequately treat postoperative pain after urologic surgery. Many common urologic procedures are now routinely performed with robotic technology. Robotic, minimally-invasive approaches decrease incision size and accelerate postoperative recovery, thereby presenting a unique opportunity to curb excessive opioid prescribing in the postoperative patient. Herein, we explore the roots of the current crisis, outline current literature guiding pain control after surgery, and review the current, though sparse, literature that may guide urologists in decreasing opioid use after robotic surgery.
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Affiliation(s)
- Ruchika Talwar
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Shreyas S. Joshi
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Huynh V, Colborn K, Rojas KE, Christian N, Ahrendt G, Cumbler E, Schulick R, Tevis S. Evaluation of opioid prescribing preferences among surgical residents and faculty. Surgery 2021; 170:1066-1073. [PMID: 33858683 DOI: 10.1016/j.surg.2021.02.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. METHODS Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. RESULTS Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. CONCLUSION There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/THuynhMD
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/ColbornKathryn
| | - Kristin E Rojas
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, FL. https://twitter.com/kristinrojasMD
| | - Nicole Christian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Gretchen Ahrendt
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/@ahrendt50
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Richard Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Tevis
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO.
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20
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Juprasert JM, Obeid L, Yeo HL. Public perception on opioids & pain management after major surgery. Am J Surg 2021; 223:280-286. [PMID: 33781511 DOI: 10.1016/j.amjsurg.2021.03.044] [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: 12/02/2020] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND In the US, opioids are overprescribed after surgery contributing to the opioid epidemic. Patients' expectations regarding postoperative opioids remains unclear. METHODS A representative survey using random-digit dial telephone sampling of English-speaking adults in US was conducted from August 28 to December 11, 2019. RESULTS Of the 1533 eligible persons contacted, 1000 completed the interviews yielding a cooperation rate of 65%. The mean age was 47 (±18) years, half were men, and most were non-Hispanic white (73%). Forty-eight percent expected an opioid prescription after major surgery, 50% worry about addiction, and 61% believe they contribute to the opioid epidemic. Interestingly, 31% assume that opioid-dependent users were first exposed to opioids following surgery. CONCLUSION Many Americans surveyed expect to receive an opioid containing pain medication after major surgery, but fear the risk of addiction and believe that they are contributing to the opioid epidemic. They do not think that opioid-dependent users were first exposed to opioids after surgery. This discordance may represent an area of policy action and education.
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Affiliation(s)
- Jackly M Juprasert
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, 525 E 68th St, New York, NY, 10065, USA.
| | - Lama Obeid
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, 525 E 68th St, New York, NY, 10065, USA.
| | - Heather L Yeo
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, 525 E 68th St, New York, NY, 10065, USA; Weill Cornell Medicine, Department of Healthcare Policy and Research, 1300 York Ave, New York, NY, 10065, USA.
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21
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Wang TT, Tong J, Hersh EV, Chuang SK, Panchal N. Does prescription drug monitoring program usage affect opioid analgesic prescriptions by oral and maxillofacial surgeons after third molar surgery? Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:26-31. [PMID: 33741285 DOI: 10.1016/j.oooo.2021.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/08/2020] [Accepted: 01/13/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To curb opioid overprescription and diversion, 49 states have implemented mandatory prescription drug monitoring programs (PDMPs). This study aims to examine the changes in analgesic prescription patterns associated with mandatory PDMP usage by oral and maxillofacial surgeons. DESIGN This retrospective observational cohort study analyzed analgesic prescriptions after third molar surgeries from the University of Pennsylvania from July 2016 to December 2019. Because Pennsylvania mandated PDMP usage on January 1, 2017, we analyzed prescriptions 6 months prior to and for each 6-month interval after implementation. RESULTS Prescriptions after 13,430 procedures on 6437 patients across 7 6-month periods were analyzed. Patients in all study periods had an average age of 40 years and there was a slight majority of females. After PDMP implementation, patients who received analgesics had an 80% lower odds of receiving an opioid option after adjusting for age, sex, and procedural severity. When an opioid was prescribed, the mean pills per script decreased from 20.18 to 10.96 1 year after PDMP implementation. CONCLUSIONS Mandatory PDMP usage was associated with decreased odds of a patient receiving an opioid analgesic and with a decrease in mean opioid pills per script. PDMPs may be helpful in reducing opioid prescriptions by oral and maxillofacial surgeons after third molar surgery.
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Affiliation(s)
- Tim T Wang
- DMD Candidate, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA; MPH Candidate, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Associate Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Tong
- DMD Candidate, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elliot V Hersh
- Professor, Department of Oral & Maxillofacial Surgery/Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - Sung-Kiang Chuang
- Clinical Professor, Department of Oral and Maxillofacial Surgery/Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA; Private Practice, Brockton Oral and Maxillofacial Surgery Inc.; Attending, Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA, USA
| | - Neeraj Panchal
- Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA.
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22
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Levinsky NC, Byrne MM, Hanseman DJ, Cortez AR, Guitron J, Starnes SL, Van Haren RM. Opioid Dependence After Lung Cancer Resection: Institutional Analysis of State Prescription Drug Database. World J Surg 2020; 45:887-896. [PMID: 33221948 DOI: 10.1007/s00268-020-05865-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The national opioid epidemic is a public health crisis. Thoracic surgery has also been associated with high incidence of new persistent opioid use. Our purpose was to describe the incidence and predictors of opioid use after lung cancer resection. METHODS Retrospective review of lung cancer resections from 2015 to 2018 was performed using the Ohio Automated Rx Reporting System. Opioid dosing was recorded as milligram morphine equivalents (MME). Patients were stratified by preoperative opioid use. Chronic preoperative opioid users (opioid dependent) filled > 120 days supply of opioid pain medication in the 12 months prior to surgery; intermittent opioid users filled < 120 days. Chronic postoperative opioid users continued monthly use after 180 days postoperatively. RESULTS 137 patients underwent resection. 16.1% (n = 22) were opioid dependent preoperatively, 29.2% (n = 40) were intermittent opioid users, and 54.7% (n = 75) were opioid naïve. Opioid dependent patients had higher daily inpatient opioid use compared to intermittent users and opioid naïve (43[30.0-118.1] MME vs 17.9[3.5-48.8] MME vs 8.8[2.1-25.0] MME, p < 0.001). Twenty-six percent (n = 35) of all patients were opioid users beyond 180 days postoperatively. Variables associated with opioid use > 180 days were: chronic preoperative opioid use (OR 23.8, p < 0.01), daily inpatient opioid requirement (1.02, p < 0.01), and neoadjuvant chemotherapy (28.2, p < 0.01). CONCLUSIONS A quarter of patients are opioid dependent after lung cancer resection. This is due to both preexisting and new persistent opioid use. Improved strategies are needed to prevent chronic pain and opioid dependence after lung cancer resection.
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Affiliation(s)
- Nick C Levinsky
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew M Byrne
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | | | - Julian Guitron
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML-0558, Medical Sciences Building, Room 2472, Cincinnati, OH, USA
| | - Sandra L Starnes
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML-0558, Medical Sciences Building, Room 2472, Cincinnati, OH, USA
| | - Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way ML-0558, Medical Sciences Building, Room 2472, Cincinnati, OH, USA.
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23
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Serrell EC, Greenberg CC, Borza T. Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic. Cancer 2020; 127:184-187. [PMID: 33002194 DOI: 10.1002/cncr.33199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Emily C Serrell
- Department of Urology, University of Wisconsin, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
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24
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Ansari B, Tote KM, Rosenberg ES, Martin EG. A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018. Public Health Rep 2020; 135:100S-127S. [PMID: 32735190 PMCID: PMC7407056 DOI: 10.1177/0033354920922975] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies. METHODS We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings. RESULTS The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed. CONCLUSIONS Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.
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Affiliation(s)
- Bahareh Ansari
- Department of Information Science, University at Albany–State University of New York, Albany, NY, USA
| | - Katherine M. Tote
- Department of Epidemiology and Biostatistics, University at Albany–State University of New York, Albany, NY, USA
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Eli S. Rosenberg
- Department of Epidemiology and Biostatistics, University at Albany–State University of New York, Albany, NY, USA
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Erika G. Martin
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
- Department of Public Administration and Policy, University at Albany–State University of New York, Albany, NY, USA
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25
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Delcher C, Pauly N, Moyo P. Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019). Curr Opin Psychiatry 2020; 33:326-333. [PMID: 32250984 PMCID: PMC7409839 DOI: 10.1097/yco.0000000000000608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field. RECENT FINDINGS The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science. SUMMARY There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.
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Affiliation(s)
- Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Nathan Pauly
- Department of Health Policy Management and Leadership, West Virginia University School of Public Health, Morgantown, West Virginia
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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26
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Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery. Plast Reconstr Surg 2020; 145:687-695. [PMID: 32097308 DOI: 10.1097/prs.0000000000006570] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery. METHODS A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events. RESULTS Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days' hospital length of stay. CONCLUSIONS Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
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27
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Puac-Polanco V, Chihuri S, Fink DS, Cerdá M, Keyes KM, Li G. Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States. Epidemiol Rev 2020; 42:134-153. [PMID: 32242239 DOI: 10.1093/epirev/mxaa002] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.
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Affiliation(s)
- Victor Puac-Polanco
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Stanford Chihuri
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - David S Fink
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Magdalena Cerdá
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Katherine M Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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28
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Myrga JM, Macleod LC, Bandari J, Jacobs BL, Davies BJ. Decrease in Urologic Discharge Opioid Prescribing after Mandatory Query of Statewide Prescription Drug Monitoring Program. Urology 2020; 139:84-89. [PMID: 32061826 DOI: 10.1016/j.urology.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the effectiveness of the introduction of the Pennsylvania Prescription Drug Monitoring Program (PDMP) on discharge postoperative opioid prescriptions in patients undergoing major urologic procedures within a large single tertiary care hospital. Opioids have historically been prescribed to control postoperative pain, but with growing concern regarding opioid overdose, misuse, and diversion, measures have been introduced to curb opioid prescribing. Numerous states have introduced PDMP programs as a method to search patients' prior opioid prescriptions. These programs have reduced opioid prescriptions in emergency department and outpatient settings, but their effectiveness, and the use of a prescriber query mandate, in reducing postoperative opioid prescribing has not been established. METHODS We identified 582 patients who underwent major prostate or renal surgery between July 1st 2016 and June 30th 2017 at a single large academic hospital. We examined prescribing trends in both opioid naive and opioid tolerant patients measuring 5mg oxycodone equivalents before and after a PDMP query was mandated on January 1st 2017. RESULTS There was no significant difference is the number of opioid prescriptions given after introduction of the required PDMP query, but there was an 18% decrease in the median number of 5mg oxycodone equivalents prescribed before and after the PDMP query (P < .001). This was consistent in both an opioid naive and opioid exposed population. CONCLUSION This is the first study to establish that required PDMP queries may reduce the number of discharge opioid pills prescribed in a surgical setting. Required PDMP queries may help reduce the harm associated with opioid overprescribing.
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Affiliation(s)
- John M Myrga
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA.
| | | | - Jathin Bandari
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - Bruce L Jacobs
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - Benjamin J Davies
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
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29
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30
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Strickler GK, Zhang K, Halpin JF, Bohnert ASB, Baldwin GT, Kreiner PW. Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribing. Drug Alcohol Depend 2019; 199:1-9. [PMID: 30954863 DOI: 10.1016/j.drugalcdep.2019.02.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 01/30/2019] [Accepted: 02/03/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Comprehensive mandatory use laws for prescription drug monitoring programs (PDMPs) have been implemented in a number of states to help address the opioid overdose epidemic. These laws may reduce opioid-related overdose deaths by increasing prescribers' use of PDMPs and reducing high-risk prescribing behaviors. METHODS We used state PDMP data to examine the effect of these mandates on prescriber registration, use of the PDMP, and on prescription-based measures of patient risk in three states-Kentucky, Ohio, and West Virginia-that implemented mandates between 2010 and 2015. We conducted comparative interrupted time series analyses to examine changes in outcome measures after the implementation of mandates in the mandate states compared to control states. RESULTS Mandatory use laws increased prescriber registration and utilization of the PDMP in the mandate states compared to controls. The multiple provider episode rate, rate of opioid prescribing, rate of overlapping opioid prescriptions, and rate of overlapping opioid/benzodiazepine prescriptions decreased in Kentucky and Ohio. Nevertheless, the magnitude of changes in these measures varied among mandates states. CONCLUSIONS These findings indicate that PDMP mandates have the potential to reduce risky opioid prescribing practices. Variation in the laws may explain why the effectiveness varied between states.
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Affiliation(s)
- Gail K Strickler
- Institute for Behavioral Health, Brandeis University, Waltham, MA, USA.
| | - Kun Zhang
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John F Halpin
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Amy S B Bohnert
- Department of Psychiatry, University of Michigan and VA Center for Clinical Management Research, University of Michigan North Campus Research Complex, 2800 Rd., Bldg. 16, Room 227W, Ann Arbor, MI, 48109, USA
| | - Grant T Baldwin
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Peter W Kreiner
- Institute for Behavioral Health, Brandeis University, Waltham, MA, USA
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31
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Lin HC, Wang Z, Simoni-Wastila L, Boyd C, Buu A. Interstate data sharing of prescription drug monitoring programs and associated opioid prescriptions among patients with non-cancer chronic pain. Prev Med 2019; 118:59-65. [PMID: 30316875 DOI: 10.1016/j.ypmed.2018.10.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/18/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022]
Abstract
All fifty states have implemented prescription drug monitoring programs (PDMPs) to reduce misuse and diversion of controlled drugs. Interstate PDMP data sharing has been called for by clinical practitioners, but evidence to support the effectiveness of PDMP data sharing is lacking. This study examined whether PDMP interstate data sharing with bordering states was associated with prescriptions of opioids. This was a cross-sectional study that included patients with non-cancer chronic pain from the 2014 National Ambulatory Medical Care Survey (weighted N = 66,198,751; unweighted N = 2846). Multinomial logistic regression was performed to examine the association between PDMP interstate data sharing status and patients' being prescribed opioids for pain treatment, controlling for covariates guided by the Eisenberg's model of physician decision-making. Findings indicated that patients residing in states with interstate PDMP data sharing with all or partial bordering states were not less likely to be prescribed opioids compared to those living in states without interstate data sharing. Other factors such as patient age, health insurance type, new patient status, and physician adoption of electronic medical records were associated with the likelihood of patients' being prescribed opioids. This study concluded that current practice of interstate PDMP data sharing with bordering states was not associated with patients' being prescribed opioids for non-cancer chronic pain treatment. Future studies and policy efforts that unravel technological, legal, and political barriers to reciprocal and equal interstate data sharing with bordering states should be warranted to inform PDMP redesign and in turn, augment overall PDMP effectiveness in reducing misuse of prescription opioids.
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Affiliation(s)
- Hsien-Chang Lin
- Department of Applied Health Science, School of Public Health, Indiana University, 1025 E. 7th Street, SPH 116, Bloomington, IN 47405, USA.
| | - Zhi Wang
- Department of Applied Health Science, School of Public Health, Indiana University, 1025 E. 7th Street, SPH 116, Bloomington, IN 47405, USA.
| | - Linda Simoni-Wastila
- Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, 20 North Pine Street, Baltimore, MD 21201, USA.
| | - Carol Boyd
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 North Ingalls, Ann Arbor, MI 48109, USA.
| | - Anne Buu
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 North Ingalls, Ann Arbor, MI 48109, USA.
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