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Tuttnauer A, Atias D, Reznik O, Shomron N, Obolski U. Opioid trends and risk factors for sustained use among children and adolescents in Israel: a retrospective cohort study. Pain 2024; 165:1523-1530. [PMID: 38193827 DOI: 10.1097/j.pain.0000000000003153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/17/2023] [Indexed: 01/10/2024]
Abstract
ABSTRACT Despite growing global concern over opioids, little is known about the epidemiology of opioid use in children and adolescents. This retrospective study investigated opioid use trends and identified risk factors associated with sustained opioid use among outpatient children and adolescents in Israel. Electronic health records of 110,955 children and adolescents were used to establish opioid purchase trends in outpatient settings between 2003 and 2021. Of these, data from 2012 to 2021, n = 32,956, were included in a Cox proportional hazards analysis to identify demographic, clinical, and pharmacological risk factors for sustained opioid use. An increase in opioid use was observed, with a notable rise among strong opioids, peripheral areas, and noncancer patients. Prevalence of sustained opioid users was approximately 2.5%. Risk factors with significant adjusted hazard ratios for sustained use included history of frequent doctor visits 1.82 (95% CI [1.50-2.22]) and drug purchases 1.30 (95% CI [1.07-1.58]), malignancy 1.50 (95% CI [1.07-2.09]), history of cardiovascular (1.44 (95% CI [1.04-1.98]) and pain-related conditions 1.34 (95% CI [1.14-1.58]), and different opioid substances (relative to codeine use): tramadol 2.38 (95% CI [1.73-3.27]), oxycodone 4.29 (95% CI [3.00-6.16]), and "other strong opioids" 6.05 (95% CI [3.59-10.2]). Awareness of observed increase in opioid purchases is crucial for doctors and public health practitioners. Additional monitoring and secondary prevention of children and adolescents possessing the identified risk factors should facilitate where appropriate reducing sustained opioid use when it is unnecessary.
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Affiliation(s)
- Aviv Tuttnauer
- Department of Anesthesia, Pain Treatment Service, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Dor Atias
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Reznik
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Data Research Center, Research Authority, Schneider Children's Medical Center of Petach Tikva, Israel, Israel
| | - Noam Shomron
- Faculty of Medicine, Edmond J Safra Center for Bioinformatics, Sagol School of Neurosceince, Djerassi Institute of Oncology, Innovaiton Labs (TILabs), Tel-Aviv University, Tel Aviv, Israel
| | - Uri Obolski
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Faculty of Exact Sciences, Tel Aviv University, Tel Aviv, Israel
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Chakrani Z, Stocchi C, Alasadi H, Zubizarreta N, Stern BZ, Poeran J, Forsh DA. Prolonged Opioid Use and Associated Factors After Open Reduction and Internal Fixation of Tibial Shaft Fractures. Orthopedics 2024:1-9. [PMID: 38864647 DOI: 10.3928/01477447-20240605-02] [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] [Indexed: 06/13/2024]
Abstract
BACKGROUND The aim of this retrospective cohort study was to determine the rate of prolonged opioid use and identify associated risk factors after perioperative opioid exposure for tibial shaft fracture surgery. MATERIALS AND METHODS We used the MarketScan Commercial Claims and Encounters database (IBM) to identify patients 18 to 64 years old who filled a peri-operative opioid prescription after open reduction and internal fixation of a tibial shaft fracture from January 2016 to June 2020. Multivariable logistic regression identified factors (eg, demographics, comorbidities, medications) associated with prolonged opioid use (ie, filling an opioid prescription 91 to 180 days postoperatively); adjusted odds ratios (ORs) and 95% CIs were reported. RESULTS The rate of prolonged opioid use was 10.5% (n=259/2475) in the full cohort and 6.1% (n=119/1958) in an opioid-naive subgroup. In the full cohort, factors significantly associated with increased odds of prolonged use included preoperative opioid use (OR, 4.76; 95% CI, 3.60-6.29; P<.001); perioperative oral morphine equivalents in the 4th (vs 1st) quartile (OR, 2.68; 95% CI, 1.75-4.09; P<.001); age (OR, 1.03; 95% CI, 1.02-1.04; P<.001); and alcohol or substance-related disorder (OR, 1.66; 95% CI, 1.15-2.40; P=.01). Patients in the Northeast and North Central (vs South) regions had decreased odds of prolonged use (OR, 0.61-0.69; P=.02-.04). When removing preoperative use, findings were similar in the opioid-naive subgroup. CONCLUSION Prolonged opioid use is not uncommon in this orthopedic trauma population, with the strongest risk factor being preoperative opioid use. Nevertheless, shared risk factors exist between the opioid-naive and opioid-tolerant subgroups that can guide clinical decision-making. [Orthopedics. 202x;4x(x):xx-xx.].
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Atias D, Tuttnauer A, Shomron N, Obolski U. Prediction of sustained opioid use in children and adolescents using machine learning. Br J Anaesth 2024:S0007-0912(24)00267-8. [PMID: 38862380 DOI: 10.1016/j.bja.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/16/2024] [Accepted: 05/07/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Opioid misuse in the paediatric population is understudied. This study aimed to develop a machine learning classifier to differentiate between occasional and sustained opioid users among children and adolescents in outpatient settings. METHODS Data for 29,335 patients under 19 yr with recorded opioid purchases were collected from medical records. Machine learning methods were applied to predict sustained opioid use within 1, 2, or 3 yr after first opioid use, using sociodemographic information, medical history, and healthcare usage variables collected near the time of first prescription fulfilment. The models' performance was evaluated with classification and calibration metrics, and a decision curve analysis. An online tool was deployed for model self-exploration and visualisation. RESULTS The models demonstrated good performance, with a 1-yr follow-up model achieving a sensitivity of 0.772, a specificity of 0.703, and an ROC-AUC of 0.792 on an independent test set, with calibration intercept and slope of 0.00 and 1.02, respectively. Decision curve analysis revealed the clinical benefit of using the model relative to other strategies. SHAP analysis (SHapley Additive exPlanations) identified influential variables, including the number of diagnoses, medical images, laboratory tests, and type of opioid used. CONCLUSIONS Our model showed promising performance in predicting sustained opioid use among paediatric patients. The online risk prediction tool can facilitate compliance to such tools by clinicians. This study presents the potential of machine learning in identifying at-risk paediatric populations for sustained opioid use, potentially contributing to secondary prevention of opioid abuse.
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Affiliation(s)
- Dor Atias
- School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Aviv Tuttnauer
- Department of Anesthesia, Pain Treatment Service, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Noam Shomron
- Faculty of Medical and Health Sciences, Edmond J. Safra Center for Bioinformatics, Sagol School of Neuroscience, Djerassi Institute of Oncology, Innovation Labs (TILabs), Tel-Aviv University, Tel Aviv, Israel
| | - Uri Obolski
- School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; School of Public Health, Faculty of Medical and Health Sciences, Porter School of the Environment and Earth Sciences, Faculty of Exact Sciences, Tel Aviv University, Tel Aviv, Israel.
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Khalil M, Woldesenbet S, Munir MM, Khan MMM, Rashid Z, Altaf A, Katayama E, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery. Ann Surg Oncol 2024:10.1245/s10434-024-15435-1. [PMID: 38762641 DOI: 10.1245/s10434-024-15435-1] [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: 02/26/2024] [Accepted: 04/24/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery. METHODS Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms. RESULTS Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66). CONCLUSION Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Chen YH, Xenitidis A, Hoffmann P, Matthews L, Padmanabhan SG, Aravindan L, Ressler R, Sivam I, Sivam S, Gillispie CF, Sadhasivam S. Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia. Expert Rev Clin Pharmacol 2024; 17:455-465. [PMID: 38626303 PMCID: PMC11116045 DOI: 10.1080/17512433.2024.2343915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 04/12/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder. AREAS COVERED Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic. EXPERT OPINION The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Paul Hoffmann
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leslie Matthews
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Ruth Ressler
- Department of Biochemistry and Molecular Biology, The College of Wooster, Wooster, Ohio, USA
| | - Inesh Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Sahana Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Chase F. Gillispie
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia 25701
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Arakkal AT, Polgreen LA, Chapman CG, Simmering JE, Cavanaugh JE, Polgreen PM, Miller AC. Association between household opioid prescriptions and risk for overdose among family members not prescribed opioids. Pharmacotherapy 2024; 44:110-121. [PMID: 37926925 DOI: 10.1002/phar.2891] [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: 07/14/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Prescription opioids have contributed to the rise in opioid-related overdoses and deaths. The presence of opioids within households may increase the risk of overdose among family members who were not prescribed an opioid themselves. Larger quantities of opioids may further increase risk. OBJECTIVES To determine the risk of opioid overdose among individuals who were not prescribed an opioid but were exposed to opioids prescribed to other family members in the household, and evaluate the risk in relation to the total morphine milligram equivalents (MMEs) present in the household. METHODS We conducted a cohort study using a large database of commercial insurance claims from 2001 to 2021. For inclusion in the cohort, we identified individuals not prescribed an opioid in the prior 90 days from households with two or more family members, and determined the total MMEs prescribed to other family members. Individuals were stratified into monthly enrollment strata defined by household opioid exposure and other confounders. A generalized linear model was used to estimate incidence rate ratios (IRRs) for overdose. RESULTS Overall, the incidence of overdose among enrollees in households where a family member was prescribed an opioid was 1.73 (95% confidence interval [CI]: 1.67-1.78) times greater than households without opioid prescriptions. The risk of overdose increased continuously with the level of potential MMEs in the household from an IRR of 1.23 (95% CI: 1.16-1.32) for 1-100 MMEs to 4.67 (95% CI: 4.18-5.22) for >12,000 MMEs. The risk of overdose associated with household opioid exposure was greatest for ages 1-2 years (IRR: 3.46 [95% CI: 2.98-4.01]) and 3-5 years (IRR: 3.31 [95% CI: 2.75-3.99]). CONCLUSIONS The presence of opioids in a household significantly increases the risk of overdose among other family members who were not prescribed an opioid. Higher levels of MMEs, either in terms of opioid strength or quantity, were associated with increased levels of risk. Risk estimates may reflect accidental poisonings among younger family members.
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Affiliation(s)
- Alan T Arakkal
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | | | - Cole G Chapman
- College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
| | - Jacob E Simmering
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | - Philip M Polgreen
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Aaron C Miller
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
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Grutman AJ, Stewart C, Able C, Agrawal P, Galansky L, Gabrielson A, Haney N, Kohn TP, Crigger CB. Postoperative Opioid Prescribing in Adolescents and Young Adults After Urologic Procedures Is Associated With New Persistent Opioid Use Disorder: A Large Claims Database Analysis. Urology 2023; 182:211-217. [PMID: 37696308 DOI: 10.1016/j.urology.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To assess the risk of persistent opioid use following various urologic procedures in adolescents and young adults. MATERIALS AND METHODS The TriNetX LLC Diamond Network was queried for patients aged 13-21years who underwent pyeloplasty, hypospadias repair, inguinal hernia repair, inguinal orchiopexy, hydrocelectomy, or circumcision. Cohorts of patients prescribed and not prescribed postoperative opioids were created and propensity-matched for age, race/ethnicity, psychiatric diagnoses, and preoperative pain diagnoses. The primary outcome was new persistent opioid use, defined as new opioid use 3-9months after index procedure without another surgery requiring anesthesia during the postoperative timeframe. RESULTS Of 32,789 patients identified, 66.0% received a postoperative opioid prescription. After propensity score matching for each procedure, 18,416 patients were included: 197 for pyeloplasty, 469 for hypospadias repair, 1818 for inguinal hernia repair, 2664 for inguinal orchiopexy, 534 for hydrocelectomy, and 3526 for circumcision. Overall, 0.41% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 1.69% of patients who received postoperative opioids developed new persistent opioid use (P < .05). Patients prescribed postoperative opioids had statistically higher odds of developing new persistent opioid use for hypospadias repair (RR: 17.0; 95% CI: 2.27-127.2), inguinal orchiopexy (RR: 3.46; 95% CI: 1.87-6.4), inguinal hernia repair (RR: 2.18; 95% CI: 1.07-4.44), and circumcision (RR: 4.83; 95% CI: 2.60-8.98). CONCLUSION The use of postoperative opioids after urological procedures in adolescents and young adults is associated with a significant risk of developing new persistent opioid use.
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Affiliation(s)
| | - Courtney Stewart
- University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX
| | - Corey Able
- University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX
| | | | - Logan Galansky
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Gabrielson
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nora Haney
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Taylor P Kohn
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chad B Crigger
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Collis RW, Dry T, Ray HE, Grundlingh N, Chan G, Oswald T. Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2023; 48:1486-1491. [PMID: 37294836 DOI: 10.1097/brs.0000000000004747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/30/2023] [Indexed: 06/11/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE This project aims to evaluate the relationship between increased use of intraoperative nonopioid analgesics, muscle relaxers, and anesthetics and postoperative outcomes, including opioid utilization, time until ambulation, and hospital length of stay. SUMMARY OF BACKGROUND DATA Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine that occurs in otherwise healthy adolescents, occurring with a frequency of 1% to 3%. Up to 60% of patients receiving spinal surgeries, particularly posterior spinal fusion (PSF), experience at least 1 day of moderate-to-severe pain after surgery. PATIENTS AND METHODS This is a retrospective chart review of pediatric patients aged 10 to 17 having received PSF with >5 levels fused for AIS at a dedicated children's hospital and a regional tertiary referral center with a dedicated pediatric spine program between January 2018 and September 2022. A linear regression model was used to evaluate the influence of baseline characteristics and intraoperative medications on the total amount of postoperative morphine milligram equivalents received. RESULTS There were no significant differences in the background characteristics of the two patient populations. Patients receiving PSF at the tertiary referral center received equivalent or greater amounts of all nonopioid pain medications and demonstrated decreased time until ambulation (19.3 vs . 22.3 h), postoperative opioid use (56.1 vs . 70.1 MME), and postoperative hospital length of stay (35.9 vs . 58.3 h). Hospital location was not individually associated with a difference in postoperative opioid use. There was not a significant difference in postoperative pain ratings. When accounting for all other variables, liposomal bupivacaine had the greatest contribution to the decrease in postoperative opioid use. CONCLUSION Patients receiving greater amounts of nonopioid intraoperative medications utilized 20% fewer postoperative morphine milligram equivalents, were discharged 22.3 hours earlier and had earlier recorded evidence of mobility. Postoperatively, nonopioid analgesics were as effective as opioids in the reduction of subjective pain ratings. This study further demonstrates the efficacy of multimodal pain management regimens in pediatric patients receiving PSF for AIS.
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Affiliation(s)
- Reid W Collis
- Wellstar Kennestone Hospital, Graduate Medical Education, Marietta, GA
| | - Tonia Dry
- Department of Pediatric Orthopedics, Wellstar Health System, Marietta, GA
| | - Herman E Ray
- Kennesaw State University, School of Data Science and Analytics, Kennesaw, GA
| | - Nina Grundlingh
- Kennesaw State University, School of Data Science and Analytics, Kennesaw, GA
| | - Gilbert Chan
- Department of Pediatric Orthopedics, Wellstar Health System, Marietta, GA
| | - Timothy Oswald
- Department of Pediatric Orthopedics, Wellstar Health System, Marietta, GA
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Chua KP, Nguyen TD, Brummett CM, Bohnert AS, Gunaseelan V, Englesbe MJ, Waljee JF. Changes in Surgical Opioid Prescribing and Patient-Reported Outcomes After Implementation of an Insurer Opioid Prescribing Limit. JAMA HEALTH FORUM 2023; 4:e233541. [PMID: 37831460 PMCID: PMC10576220 DOI: 10.1001/jamahealthforum.2023.3541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/04/2023] [Indexed: 10/14/2023] Open
Abstract
Importance Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain. Objective To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan. Design, Setting, and Participants This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019. Exposure Policy limiting opioid prescriptions to a 5-day supply in February 2018. Main Outcomes and Measures Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume. Results Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone. Conclusions This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Thuy D. Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | - Amy S. Bohnert
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Vidhya Gunaseelan
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | - Michael J. Englesbe
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Jennifer F. Waljee
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
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Schultz E, Zhuang T, Shapiro LM, Hu SS, Kamal RN. Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis. Spine J 2023; 23:1451-1460. [PMID: 37355048 PMCID: PMC10538426 DOI: 10.1016/j.spinee.2023.06.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND CONTEXT Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting. PURPOSE To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures. STUDY DESIGN Retrospective analysis using national administrative claims database. PATIENT SAMPLE A total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery. OUTCOME MEASURES Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users. METHODS We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors. RESULTS A total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient. CONCLUSION Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification. LEVEL OF EVIDENCE Level III Prognostic Study. MINI ABSTRACT We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.
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Affiliation(s)
- Emily Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California San Francisco
| | - Serena S Hu
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University.
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Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg 2023:00000539-990000000-00608. [PMID: 37450650 DOI: 10.1213/ane.0000000000006623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.
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Affiliation(s)
- Jamie M Kitzman
- From the Department of Anesthesiology, Division of Pediatric Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Veronika V Mesheriakova
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
| | - Amber N Borucki
- Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California
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12
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Varady NH, Chen AF, Niu R, Chung M, Freccero DM, Smith EL. Association Between Surgical Opioid Prescriptions and Opioid Initiation by Opioid-naïve Spouses. Ann Surg 2023; 277:e1218-e1224. [PMID: 34954759 DOI: 10.1097/sla.0000000000005350] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses. SUMMARY OF BACKGROUND DATA Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown. METHODS This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from January 1, 2011 to June 30, 2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months after surgery was assessed. Secondary analyses assessed how this association varied with postoperative time. RESULTS There were 318,022 patients (mean ± standard deviation age 48.8 ±9.3 years; 49.5% women). Among the 50,833 (16.0%) patients that did not fill a surgical opioid prescription, 2152 (4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189 (84.0%) patients who filled a surgical opioid prescription, 15,026 (5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery [unadjusted P < 0.001; adjusted odds ratio (aOR) 1.37, 95% confidence interval (CI) 1.31-1.43, P < 0.001]. Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95% CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57,95% CI 1.391.76, P < 0.001). CONCLUSIONS Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Hospital of Special Surgery, New York, NY
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Ruijia Niu
- Department of Orthopaedic Surgery, Boston Medical center, Boston, MA
| | - Mei Chung
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA; and
| | - David M Freccero
- Department of Orthopaedic Surgery, Boston Medical center, Boston, MA
| | - Eric L Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA
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Bovonratwet P, Kapadia M, Chen AZ, Vaishnav AS, Song J, Sheha ED, Albert TJ, Gang CH, Qureshi SA. Opioid prescription trends after ambulatory anterior cervical discectomy and fusion. Spine J 2023; 23:448-456. [PMID: 36427653 DOI: 10.1016/j.spinee.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND CONTEXT Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown. PURPOSE To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. OUTCOME MEASURES Rate, amount, and type of perioperative opioid prescription. METHODS Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively). RESULTS A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066). CONCLUSIONS Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Milan Kapadia
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Aaron Z Chen
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Avani S Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Todd J Albert
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Catherine H Gang
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA.
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Hendricks MA, El Ibrahimi S, Ritter GA, Flores D, Fischer MA, Weiss RD, Wright DA, Weiner SG. Association of Household Opioid Availability With Opioid Overdose. JAMA Netw Open 2023; 6:e233385. [PMID: 36930154 PMCID: PMC10024199 DOI: 10.1001/jamanetworkopen.2023.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
IMPORTANCE Previous studies that examined the role of household opioid prescriptions in opioid overdose risk were limited to commercial claims, did not include fatal overdoses, and had limited inclusion of household prescription characteristics. Broader research is needed to expand understanding of the risk of overdose. OBJECTIVE To assess the role of household opioid availability and other household prescription factors associated with individuals' odds of fatal or nonfatal opioid overdose. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study assessing patient outcomes from January 1, 2015, through December 31, 2018, was conducted on adults in the Oregon Comprehensive Opioid Risk Registry database in households of at least 2 members. Data analysis was performed between October 16, 2020, and January 26, 2023. EXPOSURES Household opioid prescription availability and household prescription characteristics. MAIN OUTCOMES AND MEASURES Opioid overdoses were captured from insurance claims, death records, and hospital discharge data. Household opioid prescription availability and prescription characteristics for individuals and households were modeled as 6-month cumulative time-dependent measures, updated monthly. To assess the association between household prescription availability, household prescription characteristics, and overdose, multilevel logistic regression models were developed, adjusting for demographic, clinical, household, and prescription characteristics. RESULTS The sample included 1 691 856 individuals in 1 187 140 households, of which most were women (53.2%), White race (70.7%), living in metropolitan areas (75.8%), and having commercial insurance (51.8%), no Elixhauser comorbidities (69.5%), and no opioid prescription fills in the study period (57.0%). A total of 28 747 opioid overdose events were observed during the study period (0.0526 per 100 person-months). Relative to individuals without personal or household opioid fills, the odds of opioid-related overdose increased by 60% when another household member had an opioid fill in the past 6 months (adjusted odds ratio [aOR], 1.60; 95% CI, 1.54-1.66) and were highest when both the individual and another household member had opioid fills in the preceding 6 months (aOR, 6.25; 95% CI, 6.09-6.40). CONCLUSIONS AND RELEVANCE In this cohort study of adult Oregon residents in households of at least 2 members, the findings suggest that household prescription availability is associated with increased odds of opioid overdose for others in the household, even if they do not have their own opioid prescription. These findings underscore the importance of educating patients about proper opioid disposal and the risks of household opioids.
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Affiliation(s)
| | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas
| | - Grant A. Ritter
- Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Diana Flores
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Roger D. Weiss
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
| | - Dagan A. Wright
- Injury and Violence Prevention Program–Public Health Division–Oregon Health Authority, Portland
| | - Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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15
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Lan YT, Pagani NR, Chen YW, Niu R, Chang DC, Talmo CT, Hollenbeck BL, Mattingly DA, Smith EL. A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty. J Arthroplasty 2023; 38:18-23.e1. [PMID: 35987496 DOI: 10.1016/j.arth.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty. METHODS In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage. RESULTS For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74). CONCLUSION We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yu-Tung Lan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas R Pagani
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carl T Talmo
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Brian L Hollenbeck
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - David A Mattingly
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Eric L Smith
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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16
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Inappropriate prescribing of opioids for patients undergoing surgery. Proc Natl Acad Sci U S A 2022; 119:e2210226119. [PMID: 36442133 PMCID: PMC9894214 DOI: 10.1073/pnas.2210226119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In response to the opioid epidemic in the United States, states have passed policies aimed at regulating how opioids are prescribed by physicians. For such policies to be effective, however, opioids must be prescribed to the patients for whom they are intended. Whether opioid prescriptions are written for those who are not intended to consume them is empirically difficult to show. In a commercially insured population, we examined opioid prescriptions written for and filled by spouses of patients undergoing outpatient surgery on the day of a patient's surgery compared with the surrounding days. Because patients may be unable to fill prescriptions themselves immediately after surgery, surgeons may prescribe opioids to a patient's spouse, which would be clinically inappropriate. Among 450,125 opioid-naïve couples studied, for patients who did not fill perioperative opioid prescriptions themselves, the rate of spousal fills on the day of surgery (DOS) was 2.39 fills per 1,000 surgeries compared with 0.44 fills on all other perioperative days (adjusted odds ratio (aOR), 5.5, 95% CI, 4.6-6.5). Increases in spousal opioid fills were not present for patients that filled opioid prescriptions themselves. These findings suggest intentional, clinically inappropriate prescribing of opioids.
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17
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Abraham O, Rosenberger CA, Birstler J. Psychometric validation of the AOSL scale using confirmatory factor analysis: A nationally representative sample. J Am Pharm Assoc (2003) 2022; 62:1638-1643.e6. [PMID: 35450831 PMCID: PMC9680980 DOI: 10.1016/j.japh.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The opioid overdose epidemic has worsened during the COVID-19 pandemic. Recent data revealed a 28.5% increase in drug-related overdose deaths from 2019 to 2020. Adolescents often misuse family members' and friends' prescription opioid medications. Furthermore, adolescents may not possess the knowledge or understanding to safely manage opioid medications. There is a need for a validated scale to effectively measure adolescents' opioid misuse knowledge, attitudes, and interest in learning about prescription opioid safety. OBJECTIVE The purpose of this study was to validate the Adolescent Opioid Safety and Learning (AOSL) scale with a nationally representative sample of adolescents and confirm the factor structure of the scale using confirmatory factor analysis (CFA). METHODS Adolescent participants (aged 13-18 years) completed the 16-item AOSL scale in Qualtrics from November to December 2020. A total of 774 responses were analyzed. A CFA was performed to determine the fit of the data to the 4-factor model proposed by a prior exploratory factor analysis of the AOSL scale. Fit was assessed using the chi-square test, comparative fit index (CFI), Tucker-Lewis index (TLI), and root mean-squared error of approximation (RMSEA). RESULTS Participants were 50% male and 62% white non-Hispanic. The CFI was 0.984, TLI was 0.980, and RMSEA was 0.048 ([95% CI 0.041-0.054], P-value that RMSEA ≤ 0.05 = 0.712). The chi-square test results were χ2 = 268.752 on 98 degrees of freedom (P < 0.001). Cronbach's alpha, a measure of internal consistency, was high within each factor. CFA indicated good fit of the current study's data to the 4-factor model. CONCLUSION We found the AOSL scale measures adolescents' knowledge of opioid misuse, knowledge of opioid harm, interest in learning about prescription opioids, and likelihood to practice misuse behaviors. This scale can help researchers understand adolescent perceptions and opinions about opioid safety.
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Affiliation(s)
| | | | - Jen Birstler
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison
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18
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Hageman IC, Tien MY, Trajanovska M, Palmer GM, Corlette SJ, King SK. Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice. J Pediatr Surg 2022; 57:1249-1257. [PMID: 35397872 DOI: 10.1016/j.jpedsurg.2022.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia. MATERIAL/METHOD A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records. RESULTS Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge. CONCLUSION There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.
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Affiliation(s)
- Isabel C Hageman
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Faculty of Medicine, Utrecht University, Utrecht, the Netherland.
| | - Melissa Y Tien
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Misel Trajanovska
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Greta M Palmer
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sebastian J Corlette
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sebastian K King
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
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19
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Agniel D, Brat GA, Marwaha JS, Fox K, Knecht D, Paz HL, Bicket MC, Yorkgitis B, Palmer N, Kohane I. Association of Postsurgical Opioid Refills for Patients With Risk of Opioid Misuse and Chronic Opioid Use Among Family Members. JAMA Netw Open 2022; 5:e2221316. [PMID: 35838671 PMCID: PMC9287751 DOI: 10.1001/jamanetworkopen.2022.21316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The US health care system is experiencing a sharp increase in opioid-related adverse events and spending, and opioid overprescription may be a key factor in this crisis. Ambient opioid exposure within households is one of the known major dangers of overprescription. OBJECTIVE To quantify the association between the postsurgical initiation of prescription opioid use in opioid-naive patients and the subsequent prescription opioid misuse and chronic opioid use among opioid-naive family members. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using administrative data from the database of a US commercial insurance provider with more than 35 million covered individuals. Participants included pairs of patients who underwent surgery from January 1, 2008, to December 31, 2016, and their family members within the same household. Data were analyzed from January 1 to November 30, 2018. EXPOSURES Duration of opioid exposure and refills of opioid prescriptions received by patients after surgery. MAIN OUTCOMES AND MEASURES Risk of opioid misuse and chronic opioid use in family members were calculated using inverse probability weighted Cox proportional hazards regression models. RESULTS The final cohort included 843 531 pairs of patients and family members. Most pairs included female patients (445 456 [52.8%]) and male family members (442 992 [52.5%]), and a plurality of pairs included patients in the 45 to 54 years age group (249 369 [29.6%]) and family members in the 15 to 24 years age group (313 707 [37.2%]). A total of 3894 opioid misuse events (0.5%) and 7485 chronic opioid use events (0.9%) occurred in family members. In adjusted models, each additional opioid prescription refill for the patient was associated with a 19.2% (95% CI, 14.5%-24.0%) increase in hazard of opioid misuse in family members. The risk of opioid misuse appeared to increase only in households in which the patient obtained refills. Family members in households with any refill had a 32.9% (95% CI, 22.7%-43.8%) increased adjusted hazard of opioid misuse. When patients became chronic opioid users, the hazard ratio for opioid misuse among family members was 2.52 (95% CI, 1.68-3.80), and similar patterns were found for chronic opioid use. CONCLUSIONS AND RELEVANCE This cohort study found that opioid exposure was a household risk. Family members of a patient who received opioid prescription refills after surgery had an increased risk of opioid misuse and chronic opioid use.
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Affiliation(s)
- Denis Agniel
- RAND Corporation, Santa Monica, California
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Gabriel A. Brat
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jayson S. Marwaha
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kathe Fox
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- Aetna Inc, Hartford, Connecticut
| | | | | | - Mark C. Bicket
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Nathan Palmer
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Isaac Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
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20
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Hallowell BD, Chambers LC, Barre L, Diao N, Onyejekwe C, Banks A, Bratberg J, Weidele H, Viner-Brown S, McDonald J. Association between initial opioid prescription diagnosis type and subsequent chronic prescription opioid use in Rhode Island: a population-based cohort study. BMJ Open 2022; 12:e050540. [PMID: 34992104 PMCID: PMC8739418 DOI: 10.1136/bmjopen-2021-050540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To identify initial diagnoses associated with elevated risk of chronic prescription opioid use. DESIGN Population-based, retrospective cohort study. SETTING State of Rhode Island. PARTICIPANTS Rhode Island residents with an initial opioid prescription dispensed between 1 April 2019 and 31 March 2020. PRIMARY OUTCOME MEASURE Subsequent chronic prescription opioid use, defined as receiving 60 or more days' supply of opioids in the 90 days following an initial opioid prescription. RESULTS Among the 87 055 patients with an initial opioid prescription, 3199 (3.7%) subsequently became chronic users. Patients who become chronic users tended to receive a longer days' supply, greater quantity dispensed, but a lower morphine milligram equivalents on the initial opioid prescription. Patients prescribed an initial opioid prescription for diseases of the musculoskeletal system and connective tissue (adjusted OR (aOR): 5.9, 95% CI: 4.7 to 7.6), diseases of the nervous system (aOR: 6.3, 95% CI: 4.9 to 8.0) and neoplasms (aOR: 5.6, 95% CI: 4.2 to 7.5) had higher odds of subsequent chronic prescription opioid use, compared with a referent group that included all diagnosis types with fewer than 15 chronic opioid users, after adjusting for confounders. CONCLUSIONS By focusing interventions and prescribing guidelines on specific types of diagnoses that carry a high risk of chronic prescription opioid use and diagnoses that would benefit equally or more from alternative management approaches, states and healthcare organisations may more efficiently decrease inappropriate opioid prescribing while improving the quality of patient care.
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Affiliation(s)
| | - Laura C Chambers
- Rhode Island Department of Health, Providence, Rhode Island, USA
| | - Luke Barre
- Roger Williams Medical Center, Providence, Rhode Island, USA
| | - Nancy Diao
- Rhode Island Department of Health, Providence, Rhode Island, USA
| | | | - Alexandra Banks
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jeffery Bratberg
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Heidi Weidele
- Rhode Island Department of Health, Providence, Rhode Island, USA
| | | | - James McDonald
- Rhode Island Department of Health, Providence, Rhode Island, USA
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21
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Ahrari M, Ali S, Hartling L, Dong K, Drendel AL, Klassen TP, Schreiner K, Dyson MP. Nonmedical Opioid Use After Short-term Therapeutic Exposure in Children: A Systematic Review. Pediatrics 2021; 148:183452. [PMID: 34816280 DOI: 10.1542/peds.2021-051927] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Opioid-related harms continue to rise for children and youth. Analgesic prescribing decisions are challenging because the risk for future nonmedical opioid use or disorder is unclear. OBJECTIVE To synthesize research examining the association between short-term therapeutic opioid exposure and future nonmedical opioid use or opioid use disorder and associated risk factors. DATA SOURCES We searched 11 electronic databases. STUDY SELECTION Two reviewers screened studies. Studies were included if: they were published in English or French, participants had short-term (≤14 days) or an unknown duration of therapeutic exposure to opioids before 18 years, and reported opioid use disorder or misuse. DATA EXTRACTION Data were extracted, and methodologic quality was assessed by 2 reviewers. Data were summarized narratively. RESULTS We included 21 observational studies (49 944 602 participants). One study demonstrated that short-term therapeutic exposure may be associated with opioid abuse; 4 showed an association between medical and nonmedical opioid use without specifying duration of exposure. Other studies reported on prevalence or incidence of nonmedical use after medical exposure to opioids. Risk factors were contradictory and remain unclear. LIMITATIONS Most studies did not specify duration of exposure and were of low methodologic quality, and participants might not have been opioid naïve. CONCLUSIONS Some studies suggest an association between lifetime therapeutic opioid use and nonmedical opioid use. Given the lack of clear evidence regarding short-term therapeutic exposure, health care providers should carefully evaluate pain management options and educate patients and caregivers about safe, judicious, and appropriate use of opioids and potential signs of misuse.
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Affiliation(s)
| | - Samina Ali
- Departments of Pediatrics.,Emergency Medicine.,Women and Children's Health Research Institute
| | | | | | - Amy L Drendel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Terry P Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Kurt Schreiner
- Pediatric Parents' Advisory Group, University of Alberta, Edmonton, Alberta, Canada
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22
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Zhu CY, Schumm MA, Hu TX, Nguyen DT, Kim J, Tseng CH, Lin AY, Yeh MW, Livhits MJ, Wu JX. Patient-Centered Decision-making for Postoperative Narcotic-Free Endocrine Surgery: A Randomized Clinical Trial. JAMA Surg 2021; 156:e214287. [PMID: 34495283 DOI: 10.1001/jamasurg.2021.4287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Historically, opioid pain medications have been overprescribed following thyroid and parathyroid surgery. Many narcotic prescriptions are incompletely consumed, creating waste and opportunities for abuse. Objective To determine whether limiting opioid prescriptions after outpatient thyroid and parathyroid surgery to patients who opt in to narcotic treatment reduces opioid consumption without increasing postoperative pain compared with usual care (routine narcotic prescriptions). Design, Setting, and Participants A randomized clinical trial of Postoperative Opt-In Narcotic Treatment (POINT) or routine narcotic prescription (control) was conducted at a single tertiary referral center from June 1 to December 30, 2020. A total of 180 adults undergoing ambulatory cervical endocrine surgery, excluding patients currently receiving opioids, were assessed for eligibility. POINT patients received perioperative pain management counseling and were prescribed opioids only on patient request. Patients reported pain scores (0-10) and medication use through 7 daily postoperative surveys. Logistic regression was used to determine factors associated with opioid consumption. Interventions Patients in the POINT group were able to opt in or out of receiving prescriptions for opioid pain medication on discharge. Control patients received routine opioid prescriptions on discharge. Main Outcomes and Measures Daily peak pain score through postoperative day 7 was the primary outcome. Noninferiority was defined as a difference less than 2 on an 11-point numeric rating scale from 0 to 10. Analysis was conducted on the evaluable population. Results Of the 180 patients assessed for eligibility, the final study cohort comprised 102 patients: 48 randomized to POINT and 54 to control. Of these, 79 patients (77.5%) were women and median age was 52 (interquartile range, 43-62) years. A total of 550 opioid tablets were prescribed to the control group, and 230 tablets were prescribed to the POINT group, in which 23 patients (47.9%) opted in for an opioid prescription. None who opted out subsequently required rescue opioids. In the first postoperative week, 17 POINT patients (35.4% of survey responders in the POINT group) reported consuming opioids compared with 27 (50.0%) control patients (P = .16). Median peak outpatient pain scores were 6 (interquartile range, 4-8) in the control group vs 6 (interquartile range, 5-7) in the POINT group (P = .71). In multivariate analysis, patients with a history of narcotic use were 7.5 times more likely to opt in (95% CI, 1.61-50.11; P = .02) and 4.8 times more likely to consume opioids (95% CI, 1.04-1.52; P = .01). Higher body mass index (odds ratio, 1.11; 95% CI, 1.01-1.23; P = .03) and highest inpatient postoperative pain score (odds ratio, 1.24; 95% CI, 1.04-1.52; P = .02) were also associated with opioid consumption. Conclusions and Relevance In this trial, an opt-in strategy for postoperative narcotics reduced opioid prescription without increasing pain after cervical endocrine surgery. Trial Registration ClinicalTrials.gov Identifier: NCT04710069.
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Affiliation(s)
- Catherine Y Zhu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Max A Schumm
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Theodore X Hu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Dalena T Nguyen
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jiyoon Kim
- Department of Biostatistics, UCLA School of Public Health, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Anne Y Lin
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Michael W Yeh
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Masha J Livhits
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - James X Wu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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23
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Katzman C, Harker EC, Ahmed R, Keilin CA, Vu JV, Cron DC, Gunaseelan V, Lai YL, Brummett CM, Englesbe MJ, Waljee JF. The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use. Ann Surg 2021; 274:e410-e416. [PMID: 32427764 DOI: 10.1097/sla.0000000000003723] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery. BACKGROUND Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use. METHODS We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates. RESULTS In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90]. CONCLUSIONS Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.
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Affiliation(s)
- Charles Katzman
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Emily C Harker
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Rizwan Ahmed
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Charles A Keilin
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Joceline V Vu
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vidhya Gunaseelan
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Yen-Ling Lai
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- University of Michigan, Department of Anesthesiology, Ann Arbor, Michigan
| | - Michael J Englesbe
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Jennifer F Waljee
- University of Michigan, Department of Surgery, Ann Arbor, Michigan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
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24
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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: 4] [Impact Index Per Article: 1.3] [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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25
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Shanahan CW, Reding O, Holmdahl I, Keosaian J, Xuan Z, McAneny D, Larochelle M, Liebschutz J. Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed. BMJ Open 2021; 11:e047928. [PMID: 34385249 PMCID: PMC8362709 DOI: 10.1136/bmjopen-2020-047928] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management. DESIGN Longitudinal survey of patients 7 days before and 7-14 days after surgery. SETTING Academic urban safety-net hospital. PARTICIPANTS 181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES Total morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids. RESULTS Surgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (-2.05 to -0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (-0.09% to -0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to -104.82) total MED increase in opioid consumption, and 19% (-0.35% to -0.02%) fewer unused opioids. High-risk drug use was associated with 9% (-0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices. CONCLUSIONS Participants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.
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Affiliation(s)
- Christopher W Shanahan
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Olivia Reding
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Inga Holmdahl
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia Keosaian
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ziming Xuan
- Community Health Sciences, Boston University, Boston, Massachusetts, USA
| | - David McAneny
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Marc Larochelle
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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26
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Wackerbarth JJ, Ham SA, Aizen J, Richgels J, Faris SF. Persistent Opioid Usage After Urologic Intervention and the Impact of Tramadol. Urology 2021; 157:114-119. [PMID: 34333038 DOI: 10.1016/j.urology.2021.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine if patients who receive tramadol are as likely to develop persistent usage compared to other opioids after urologic surgery and procedures. METHODS We identified adults 18 to 64 years old who underwent a urologic procedure in the years 2014 to 2017 using the Truven MarketScan database and subsequently filled an opioid prescription within two weeks of discharge. Patients were excluded if they had any previous opioid prescriptions in the year before surgery. A multivariate logistic regression model was constructed to estimate influence of type of opioid on discharge and various comorbidities on persistent use to determine if persistent use was related to the choice of discharge opioid. We also compared these rates to a 1:3 comorbidities matched, non-surgical cohort of patients from the general population. RESULTS Overall, 115,687 patients were included. After 1 year, 14.8% of the urologic surgery cohort had persistent opioid usage compared to 10.8% in the opioid naïve matched non-surgical cohort (OR = 1.37; 95% CI 1.35-1.39). Discharge with tramadol was associated with a higher odd of persistent usage compared to class II opioids controlling for type of urologic surgery, age, gender, and pain related comorbidities (OR = 1.23 95% CI 1.13-1.35). The odds of persistent usage varied slightly by type of urologic procedure, but all were higher than matched non-surgical cohort. CONCLUSION Patients developed persistent opiate usage after urologic surgery compared to a comorbidity matched non-surgical cohort. In this model, tramadol specifically was associated with higher odds of novel persistent opioid usage compared to other opioids. Urologists should not consider tramadol to be a safer choice with regard to developing persistent usage and consider prospective validation of these results.
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Affiliation(s)
| | - Sandra A Ham
- Center for Health and the Social Services, University of Chicago, Chicago, IL
| | - Joshua Aizen
- Section of Urology, University of Chicago Medical Center, Chicago, IL
| | - John Richgels
- Section of Urology, University of Chicago Medical Center, Chicago, IL
| | - Sarah F Faris
- Section of Urology, University of Chicago Medical Center, Chicago, IL.
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27
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Worsham CM, Woo J, Jena AB, Barnett ML. Adverse Events And Emergency Department Opioid Prescriptions In Adolescents. Health Aff (Millwood) 2021; 40:970-978. [PMID: 34097510 DOI: 10.1377/hlthaff.2020.01762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, we exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transition from "child" to "adult" at age eighteen to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events. We found that adolescent patients just over age eighteen were similar to those just under age eighteen, but they were 9.7 percent more likely to be prescribed an opioid and 12.6 percent more likely to have an adverse opioid-related event, defined as overdose, diagnosis of opioid use disorder, or long-term opioid use, within one year. We estimated a 14.1 percent increased risk for an adverse outcome when "adults" just over age eighteen were prescribed opioids that would not have been prescribed if they were just under age eighteen and considered "children." Our results suggest that differences in care provided in pediatric versus adult care settings may be important to understanding prescribers' roles in the opioid epidemic.
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Affiliation(s)
- Christopher M Worsham
- Christopher M. Worsham is a clinical and research fellow in the Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, and the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Jaemin Woo
- Jaemin Woo is a research assistant in the Department of Health Care Policy, Harvard Medical School
| | - Anupam B Jena
- Anupam B. Jena is the Ruth L. Newhouse Associate Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School and a scientific adviser at Precision Health Economics, Inc., in Los Angeles, California
| | - Michael L Barnett
- Michael L. Barnett is an assistant professor in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an assistant professor of medicine at Harvard Medical School
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Abstract
This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
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29
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Cutter CM, Larson RC, Abir M. Social network theory-an underutilized opportunity to align innovative methods with the demands of the opioid epidemic. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:305-310. [PMID: 33166483 DOI: 10.1080/00952990.2020.1836186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
It has been almost 3 years since the opioid epidemic was declared a national public health emergency under federal law. Solutions have focused on supply-reduction strategies. These approaches, however, have failed to significantly curtail opioid overdose and related death. Demand for opioid use arising from social networks and environment is an important contributing factor to the current opioid epidemic. Adoption of existing underused methods is needed to drive further progress. This Perspective proposes the social contagion model as a promising framework through which to operationalize evaluation of the influence of social networks and environment in the opioid epidemic and argues for its greater application. Comparing the current epidemic with previous opioid epidemics reiterates the utility of the social contagion model. This model acknowledges social network influence on individual behavior. It leverages tools from epidemiology, permits evaluation of interpersonal influence, facilitates consideration of disproportionate and collateral effects, and overcomes limitations of traditional models and geographic assumptions inherent to many approaches surrounding the current opioid epidemic. Analyzing the opioid epidemic within a social contagion framework will enhance evaluation methods and enable the design of interventions to reflect the actual demands of the current crisis. If the influence of social networks and environment is not considered, the devastating toll of the opioid epidemic could grow.
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Affiliation(s)
- Christina M Cutter
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Department of Veterans Affairs and University of Michigan, Ann Arbor, MI, USA.,Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Richard C Larson
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mahshid Abir
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,RAND Corporation, Santa Monica, CA, USA
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Ballock RT, Seif J, Goodwin R, Lin JH, Cirillo J. Clinical and Economic Outcomes Associated With Use of Liposomal Bupivacaine Versus Standard of Care for Management of Postsurgical Pain in Pediatric Patients Undergoing Spine Surgery. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:29-35. [PMID: 33880386 PMCID: PMC8049745 DOI: 10.36469/jheor.2021.21967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
Background: Approximately 60% of hospitalized children undergoing surgery experience at least 1 day of moderate-to-severe pain after surgery. Pain following spine surgery may affect opioid exposure, length of stay (LOS), and costs in hospitalized pediatric patients. This is a retrospective cohort analysis of pediatric patients undergoing inpatient primary spine surgery. Objectives: To examine the association of opioid-related and economic outcomes with postsurgical liposomal bupivacaine (LB) or non-LB analgesia in pediatric patients who received spine surgery. Methods: Premier Healthcare Database records (January 2015-September 2019) for patients aged 1-17 years undergoing inpatient primary spine surgery were retrospectively analyzed. Outcomes included in-hospital postsurgical opioid consumption (morphine milligram equivalents [MMEs]), opioid-related adverse events (ORAEs), LOS (days), and total hospital costs. A generalized linear model adjusting for baseline characteristics was used. Results: Among 10 189 pediatric patients, the LB cohort (n=373) consumed significantly fewer postsurgical opioids than the non-LB cohort (n=9816; adjusted MME ratio, 0.53 [95% confidence interval (CI), 0.45-0.61]; P<0.0001). LOS was significantly shorter in the LB versus non-LB cohort (adjusted rate ratio, 0.86 [95% CI, 0.80-0.94]; P=0.0003). Hospital costs were significantly lower in the LB versus non-LB cohort overall (adjusted rate ratio, 0.92 [95% CI, 0.86-0.99]; P=0.0227) mostly because of decreased LOS and central supply costs. ORAEs were not significantly different between groups (adjusted rate ratio, 0.84 [95% CI, 0.65-1.08]; P=0.1791). Discussion: LB analgesia was associated with shorter LOS and lower hospital costs compared with non-LB analgesia in pediatric patients undergoing spine surgery. The LB cohort had lower adjusted room and board and central supply costs than the non-LB cohort. These data suggest that treatment with LB might reduce hospital LOS and subsequently health-care costs, and additional cost savings outside the hospital room may factor into overall health-care cost savings. LB may reduce pain and the need for supplemental postsurgical opioids, thus reducing pain and opioid-associated expenses while improving patient satisfaction with postsurgical care. Conclusions: Pediatric patients undergoing spine surgery who received LB had significantly reduced in-hospital postsurgical opioid consumption, LOS, and hospital costs compared with those who did not.
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Affiliation(s)
| | - John Seif
- Department of Pediatric Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Ryan Goodwin
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Tirotta CF, Lin JH, Tran MH. Effectiveness of Liposomal Bupivacaine Compared With Standard- of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3681-3687. [PMID: 33975790 DOI: 10.1053/j.jvca.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Accepted: 04/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery. DESIGN The authors retrospectively analyzed Premier Healthcare Database records. SETTING The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations. PARTICIPANTS The records included data from patients aged 12-to-<18 years. INTERVENTIONS The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery. MEASUREMENTS AND MAIN RESULTS Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia. CONCLUSIONS These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.
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Varady NH, Smith EL, Clarkson SJ, Niu R, Freccero DM, Chen AF. Opioid Use Following Inpatient Versus Outpatient Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:497-505. [PMID: 33439611 DOI: 10.2106/jbjs.20.01401] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the risks of continued opioid use following inpatient total joint arthroplasty (TJA) have been well-studied, these risks in the outpatient setting are not well known. The purpose of the present study was to characterize opioid use following outpatient compared with inpatient TJA. METHODS In this retrospective cohort study, opioid-naïve patients who underwent inpatient or outpatient (no overnight stay) primary, elective TJA from 2007 to 2017 were identified within a large national commercial-claims insurance database. For inclusion in the study, patients had to have been continuously enrolled in the database for ≥12 months prior to and ≥6 months after the TJA procedure. Multivariable analyses controlling for demographics, geography, procedure, year, and comorbidities were utilized to determine the association between surgical setting and risk of persistent opioid use, defined as the patient still filling new opioid prescriptions >90 days postoperatively. RESULTS We identified a total of 92,506 opioid-naïve TJA patients, of whom 57,183 (61.8%) underwent total knee arthroplasty (TKA). Overall, 7,342 patients (7.9%) underwent an outpatient TJA procedure, including 4,194 outpatient TKAs. Outpatient TJA was associated with reduced surgical opioid prescribing (78.9% compared with 87.6% for inpatient procedures; p < 0.001). Among the 80,393 patients (86.9%) who received surgical opioids, the total amount of opioids prescribed (in morphine milligram equivalents) was similar between inpatient (median, 750; interquartile range, 450 to 1,200) and outpatient procedures (median, 750; interquartile range, 450 to 1,140; p = 0.47); however, inpatient TJA patients were significantly more likely to still be taking opioids after 90 days postoperatively (11.4% compared with 9.0% for outpatient procedures; p < 0.001). These results persisted in adjusted analysis (adjusted odds ratio, 1.13; 95% confidence interval, 1.03 to 1.24; p = 0.01). CONCLUSIONS Outpatient TJA patients who received opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient TJA procedures, but were significantly less likely to become persistent opioid users, even when controlling for patient factors. Outpatient TJA, as compared with inpatient TJA, does not appear to be a risk factor for new opioid dependence, and these findings support the continued transition to the outpatient-TJA model for lower-risk patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric L Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Samuel J Clarkson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruijia Niu
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - David M Freccero
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Sandhu HK, Miller CC, Tanaka A, Estrera AL, Charlton-Ouw KM. Effectiveness of Standard Local Anesthetic Bupivacaine and Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Truncal Incisions: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e210753. [PMID: 33724391 PMCID: PMC7967071 DOI: 10.1001/jamanetworkopen.2021.0753] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations. OBJECTIVE To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018. INTERVENTION Patients were randomized to standard bupivacaine or liposomal bupivacaine. MAIN OUTCOMES AND MEASURES Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption. RESULTS A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = -0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use. CONCLUSIONS AND RELEVANCE In this randomized clinical trial involving truncal incisions for cardiovascular procedures, liposomal bupivacaine did not provide improved pain control and did not reduce adjunctive opioid use compared with conventional bupivacaine formulation over 3 postoperative days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02111746.
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Affiliation(s)
- Harleen K. Sandhu
- McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Charles C. Miller
- McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Akiko Tanaka
- McGovern Medical School at the University of Texas Health Science Center at Houston
- Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Anthony L. Estrera
- McGovern Medical School at the University of Texas Health Science Center at Houston
- Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Kristofer M. Charlton-Ouw
- McGovern Medical School at the University of Texas Health Science Center at Houston
- HCA Houston Healthcare, Gulf Coast Division, Houston, Texas
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Texas
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Griesler PC, Hu MC, Wall MM, Kandel DB. Assessment of Prescription Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring in the US. JAMA Netw Open 2021; 4:e2031073. [PMID: 33410876 PMCID: PMC7791357 DOI: 10.1001/jamanetworkopen.2020.31073] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Limited information is available regarding the association between parental and adolescent medical prescription opioid use and misuse in the US. Objective To examine the associations between parental and adolescent prescription opioid medical use and misuse. Design, Setting, and Participants This cross-sectional, nationally representative study included 15 200 parent-adolescent dyads from the annual 2015-2017 National Survey on Drug Use and Health. Data were collected from January 6, 2015, to December 20, 2017, and analyzed from October 4, 2019, to October 15, 2020. Exposures Parental past 12-month exclusive medical prescription opioid use and any misuse (ie, using without a prescription or in any way not directed by a physician). Main Outcomes and Measures Adolescent past 12-month medical prescription opioid use or misuse. Multivariable regressions estimated associations between parental and offspring medical prescription opioid use or misuse, controlling for sociodemographic and psychosocial variables. Results Respondents included 9400 mother-child and 5800 father-child dyads in the same household; children were aged 12 to 17 years (52.8% male; mean [SD] age, 14.5 [1.7] years). Controlling for other factors, parental medical prescription opioid use was associated with adolescent prescription opioid medical use (adjusted odds ratio [aOR], 1.28; 95% CI, 1.06-1.53) and misuse (aOR, 1.53; 95% CI, 1.07-2.25), whereas parental misuse was not. Parental medical prescription stimulant use was associated with adolescent medical prescription opioid use (aOR, 1.40; 95% CI, 1.02-1.91). Parental marijuana use (aOR, 1.84; 95% CI, 1.13-2.99), parent-adolescent conflict (aOR, 1.26; 95% CI, 1.05-1.52), and adolescent depression (aOR, 1.75; 95% CI, 1.26-2.44) were associated with adolescent prescription opioid misuse. Adolescent delinquency (aOR, 1.55; 95% CI, 1.38-1.74) and perceived schoolmates' drug use (aOR, 2.87; 95% CI, 1.95-4.23) were also associated with adolescent misuse and more weakly with medical use (aORs, 1.13 [95% CI, 1.05-1.22] and 1.61 [95% CI, 1.32-1.96], respectively). Conclusions and Relevance Youth use of prescription opioids is in part a structural/environmental issue. The findings of this study suggest that parental medical prescription opioid use is associated with offspring prescription opioid use, whereas parental misuse is not. Restricting physicians' opioid prescribing to parents is a crucial public health goal. In addition, parents could be educated on the risks of their prescription opioid use for offspring and on practices to mitigate risk, including safe medication storage and disposal. Screening for parental prescription opioid use could be part of pediatric practice. Addressing adolescent mental health could also reduce adolescent prescription opioid misuse.
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Affiliation(s)
- Pamela C. Griesler
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- New York State Psychiatric Institute, New York, New York
| | - Mei-Chen Hu
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Melanie M. Wall
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- New York State Psychiatric Institute, New York, New York
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York
- Research Foundation for Mental Hygiene, New York, New York
| | - Denise B. Kandel
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- New York State Psychiatric Institute, New York, New York
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York
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Ludwig A, Monico LB, Lertch E, Schwartz RP, Fishman M, Mitchell SG. Until there's nothing left: Caregiver resource provision to youth with opioid use disorders. Subst Abuse 2021; 42:990-997. [PMID: 33759732 PMCID: PMC9813860 DOI: 10.1080/08897077.2021.1901178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background and Aims: Despite the considerable literature associating certain characteristics of caregivers and family structures with risks of adolescent/young adult (youth) substance use, there has been little study of the role of caregivers in opioid use disorder (OUD) treatment outcomes. This qualitative study sought to understand and contextualize the factors that influenced the resources caregivers provided their youth after residential treatment. Methods: In order to improve understandings of the role caregivers play both during and after residential OUD treatment, 31 caregivers of youth who were in a residential substance use disorder treatment center were interviewed at baseline, three-months, and six-months following their youth's discharge. Results: This analysis focused on the provision of caregiver resources and identified three key influences - OUD understandings and expectations, relationships with youth, and the emotional toll on caregivers. This has important implications as residential treatment success rates are relatively low among this population. Conclusions: These findings suggest that engagement of caregivers and families in outpatient care following residential treatment could offer an important opportunity for interventions that promote youth recovery.
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Affiliation(s)
- Ariel Ludwig
- Friends Research Institute, Inc, Baltimore, Maryland, USA
| | | | | | | | - Marc Fishman
- Mountain Manor Treatment Center, Baltimore, Maryland, USA
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Studer A, Billings K, Thompson D, Ida J, Rastatter J, Patel M, Huetteman P, Hoeman E, Duggan S, Mudahar S, Birmingham P, King M, Lavin J. Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy. Laryngoscope 2020; 131:E2337-E2343. [PMID: 33314128 DOI: 10.1002/lary.29314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools. STUDY DESIGN Prospective quality improvement initiative. METHODS Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED). RESULTS In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED. CONCLUSIONS Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2337-E2343, 2021.
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Affiliation(s)
- Abbey Studer
- Center for Quality and Safety, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Kathleen Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Dana Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Jonathan Ida
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Jeff Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Manisha Patel
- Center for Quality and Safety, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Patricia Huetteman
- Data, Analytics and Reporting, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Erin Hoeman
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sarah Duggan
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sukhraj Mudahar
- Department of Pharmacy, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Patrick Birmingham
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A.,Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Michael King
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A.,Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
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Quinn PD, Fine KL, Rickert ME, Sujan AC, Boersma K, Chang Z, Franck J, Lichtenstein P, Larsson H, D’Onofrio BM. Association of Opioid Prescription Initiation During Adolescence and Young Adulthood With Subsequent Substance-Related Morbidity. JAMA Pediatr 2020; 174:1048-1055. [PMID: 32797146 PMCID: PMC7418042 DOI: 10.1001/jamapediatrics.2020.2539] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Concerns about adverse outcomes associated with opioid analgesic prescription have led to major guideline and policy changes. Substantial uncertainty remains, however, regarding the association between opioid prescription initiation and increased risk of subsequent substance-related morbidity. OBJECTIVE To examine the association of opioid initiation among adolescents and young adults with subsequent broadly defined substance-related morbidity. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed population-register data from January 1, 2007, to December 31, 2013, on Swedish individuals aged 13 to 29 years by January 1, 2013, who were naive to opioid prescription. To account for confounding, the analysis compared opioid prescription recipients with recipients of nonsteroidal anti-inflammatory drugs as an active comparator, compared opioid-recipient twins and other multiple birth individuals with their nonrecipient co-multiple birth offspring (co-twin control), examined dental prescription as a specific indication, and included individual, parental, and socioeconomic covariates. Data were analyzed from March 30, 2019, to January 22, 2020. EXPOSURES Opioid prescription initiation, defined as first dispensed opioid analgesic prescription. MAIN OUTCOMES AND MEASURES Substance-related morbidity, assessed as clinically diagnosed substance use disorder or overdose identified from inpatient or outpatient specialist records, substance use disorder or overdose cause of death, dispensed pharmacotherapy for alcohol use disorder, or conviction for substance-related crime. RESULTS Among the included cohort (n = 1 541 862; 793 933 male [51.5%]), 193 922 individuals initiated opioid therapy by December 31, 2013 (median age at initiation, 20.9 years [interquartile range, 18.2-23.6 years]). The active comparator design included 77 143 opioid recipients without preexisting substance-related morbidity and 229 461 nonsteroidal anti-inflammatory drug recipients. The adjusted cumulative incidence of substance-related morbidity within 5 years was 6.2% (95% CI, 5.9%-6.5%) for opioid recipients and 4.9% (95% CI, 4.8%-5.1%) for nonsteroidal anti-inflammatory drug recipients (hazard ratio, 1.29; 95% CI, 1.23-1.35). The co-twin control design produced comparable results (3013 opioid recipients and 3107 nonrecipients; adjusted hazard ratio, 1.43; 95% CI, 1.02-2.01), as did restriction to analgesics prescribed for dental indications and additional sensitivity analyses. CONCLUSIONS AND RELEVANCE Among adolescents and young adults analyzed in this study, initial opioid prescription receipt was associated with an approximately 30% to 40% relative increase in risk of subsequent substance-related morbidity in multiple designs that adjusted for confounding. These findings suggest that this increase may be smaller than previously estimated in some other studies.
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Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Kimberly L. Fine
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Ayesha C. Sujan
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Katja Boersma
- Center for Health and Medical Psychology, School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Johan Franck
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Brian M. D’Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Shen Y, Bhagwandass H, Branchcomb T, Galvez SA, Grande I, Lessing J, Mollanazar M, Ourhaan N, Oueini R, Sasser M, Valdes IL, Jadubans A, Hollmann J, Maguire M, Usmani S, Vouri SM, Hincapie-Castillo JM, Adkins LE, Goodin AJ. Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions. THE JOURNAL OF PAIN 2020; 22:246-262. [PMID: 33031943 DOI: 10.1016/j.jpain.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/24/2023]
Abstract
The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.
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Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Hemita Bhagwandass
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Tychell Branchcomb
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Sophia A Galvez
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivanna Grande
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Julia Lessing
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Mikela Mollanazar
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Razanne Oueini
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Sasser
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ashmita Jadubans
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Josef Hollmann
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Maguire
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Silken Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Lauren E Adkins
- University of Florida Health Science Center Libraries, Gainesville, Florida
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida.
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Abstract
Increases in opioid prescribing over the last several decades is correlated with an alarming increase in opioid-related morbidity and mortality owing to both prescription opioid misuse and abuse as well as heroin abuse. Prescribing after surgery is commonly in excess, and leftover pills are an important driver of opioid use disorders owing to diversion and misuse. Creating evidence-based prescribing guidelines based on patient-centered outcomes and encouraging safe opioid storage and disposal is critical to curbing opioid-related morbidity and mortality going forward and to ensure safe and appropriate postoperative pain management.
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Affiliation(s)
- Lily A Upp
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA
| | - Jennifer F Waljee
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA; Department of Plastic Surgery, University of Michigan Medical School, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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40
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Tyan P, Klebanoff JS, Smith S, Amdur R, North A, Maassen MS, Moawad GN. Perioperative Narcotic Trends in Women Undergoing Minimally Invasive Myomectomy. J Minim Invasive Gynecol 2020; 27:1383-1388.e1. [DOI: 10.1016/j.jmig.2019.09.787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 01/27/2023]
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41
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Carris NW, Coon SA, Moseley MG. Searching for the lowest effective opioid dose: A framework for acute pain from the National Academies. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nicholas W. Carris
- Division of Ambulatory Care, Department of Pharmacotherapeutics & Clinical Research, USF Health Taneja College of Pharmacy University of South Florida Tampa Florida USA
| | - Scott A. Coon
- Division of Ambulatory Care, Department of Pharmacotherapeutics & Clinical Research, USF Health Taneja College of Pharmacy University of South Florida Tampa Florida USA
| | - Mark G. Moseley
- Division of Emergency Medicine, Department of Internal Medicine, USF Health Morsani College of Medicine University of South Florida Tampa Florida USA
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42
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Warner NS, Habermann EB, Hooten WM, Hanson AC, Schroeder DR, St. Sauver JL, Huddleston PM, Bydon M, Cunningham JL, Gazelka HM, Warner DO. Association Between Spine Surgery and Availability of Opioid Medication. JAMA Netw Open 2020; 3:e208974. [PMID: 32584410 PMCID: PMC7317600 DOI: 10.1001/jamanetworkopen.2020.8974] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Prolonged prescribing of opioids after spine surgery is often perceived as a negative outcome, but successful opioid reduction may occur despite continued prescribing. Improved characterization of opioid availability before and after surgery is necessary to identify these successes. OBJECTIVE To evaluate the association between spine surgery and modification of opioid availability postoperatively by using consistent definitions to classify opioid availability before and after surgery. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study included 2223 adults (age ≥18 years) who underwent spine surgery in Olmsted County, Minnesota, from January 1, 2005, through December 31, 2016. Data were analyzed from April 1, 2019, to December 1, 2019. EXPOSURES Preoperative opioid availability based on prescription data in the 180 days before surgery in accordance with Consortium to Study Opioid Risks and Trends (CONSORT) definitions. MAIN OUTCOMES AND MEASURES Successful modification of opioid availability, defined as an improvement in CONSORT status postoperatively (assessed from 181 to 365 days after surgery) compared with preoperative status, or continued absence of opioid availability for patients with no preoperative availability. Multivariable logistic regression was used to assess the association between preoperative opioid availability and successful modification by 1 year after undergoing surgery. RESULTS Of 2223 patients included in the study, 1214 were male (54.6%), with a median age of 55 years (interquartile range, 43-68) years. Patients were classified as having no (778 [35.0%]), short-term (1118 [50.3%]), episodic (227 [10.2%]), or long-term (100 [4.5%]) preoperative opioid availability. Of the 2148 patients (96.6%) who were alive at 1 year, postoperative opioid availability was classified as no (1583 [73.7%]), short-term (398 [18.5%]), episodic (104 [4.8%]), and long-term (63 [2.9%]). A total of 1672 patients (77.8%) had successful modification of opioid availability, with success of 83.0% for those with no preoperative availability, 74.9% for those with short-term preoperative availability, 79.8% for those with episodic preoperative availability, and 64.4% for those with long-term preoperative opioid availability. In multivariable analysis, success was significantly associated with preoperative opioid availability (odds ratio [OR] for short term, 0.61 [95% CI, 0.48-0.77]; OR for episodic, 0.95 [95% CI, 0.64-1.40]; OR long term, 0.49 [95% CI, 0.30-0.82]; P < .001 overall vs no availability). CONCLUSIONS AND RELEVANCE In this study, when following standardized CONSORT definitions, 4 of 5 adults undergoing spine surgery in a population-based cohort met the criteria for a successful pattern of postoperative opioid prescribing. Similar methods to objectively assess changes in opioid prescribing may be clinically useful in other perioperative settings.
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Affiliation(s)
- Nafisseh S. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B. Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - W. Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew C. Hanson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Halena M. Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - David O. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Schepis TS, Klare DL, Ford JA, McCabe SE. Prescription Drug Misuse: Taking a Lifespan Perspective. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2020; 14:1178221820909352. [PMID: 32214819 PMCID: PMC7065295 DOI: 10.1177/1178221820909352] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 11/16/2022]
Abstract
Prescription drug misuse (PDM), or medication use without a prescription or in ways not intended by the prescriber, is a notable public health concern, especially in the United States. Accumulating research has characterized PDM prevalence and processes, but age-based or lifespan changes in PDM are understudied. Given age-based differences in the medical or developmental concerns that often underlie PDM, it is likely that PDM varies by age. This review summarizes the literature on PDM across the lifespan, examining lifespan changes in prevalence, sources, motives and correlates for opioid, stimulant, and tranquilizer/sedative (or benzodiazepine) PDM. In all, prevalence rates, sources and motives vary considerably by age group, with fewer age-based differences in correlates or risk factors. PDM prevalence rates tend to decline with aging, with greater use of physician sources and greater endorsement of self-treatment motives in older groups. Recreational motives (such as to get high) tend to peak in young adulthood, with greater use of peer sources or purchases to obtain medication for PDM in younger groups. PDM co-occurs with other substance use and psychopathology, including suicidality, across age groups. The evidence for lifespan variation in PDM is strongest for opioid PDM, with a need for more research on tranquilizer/sedative and stimulant PDM. The current literature is limited by the few studies of lifespan changes in PDM within a single sample, a lack of longitudinal research, little research addressing PDM in the context of polysubstance use, and little research on minority groups, such as sexual and gender minorities.
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Affiliation(s)
- Ty S Schepis
- Department of Psychology, Texas State University, San Marcos, TX, USA
| | - Dalton L Klare
- Department of Psychology, Texas State University, San Marcos, TX, USA
| | - Jason A Ford
- Department of Sociology, University of Central Florida, Orlando, FL, USA
| | - Sean Esteban McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, School of Nursing, University of MI, Ann Arbor, Michigan, USA.,Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI, USA.,Center for Human Growth and Development, University of Michigan, Ann Arbor, Michigan, USA.,Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
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44
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Affiliation(s)
- Christopher M Worsham
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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45
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Nguyen AP, Glanz JM, Narwaney KJ, Binswanger IA. Association of Opioids Prescribed to Family Members With Opioid Overdose Among Adolescents and Young Adults. JAMA Netw Open 2020; 3:e201018. [PMID: 32219404 PMCID: PMC7462253 DOI: 10.1001/jamanetworkopen.2020.1018] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Family members are cited as a common source of prescription opioids used for nonmedical reasons. However, the overdose risk associated with exposure to opioids prescribed to family members among adolescents and young adults is not well established. OBJECTIVE To assess the association of opioids prescribed to family members with pharmaceutical opioid overdose among youth. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 45 145 family units with a total of 72 040 adolescents and young adults aged 11 to 26 years enrolled in a Kaiser Permanente Colorado health plan in 2006 and observed through June 2018. EXPOSURES Opioid prescriptions and dosage dispensed to family members and youth in the past month. MAIN OUTCOMES AND MEASURES Fatal pharmaceutical opioid overdoses identified in vital records and nonfatal pharmaceutical opioid overdoses identified in emergency department and inpatient settings. Time to first overdose was modeled using Cox regression. RESULTS The study population consisted of 72 040 adolescents and young adults (mean [SD] age across follow-up, 19.3 [3.7] years; 36 646 [50.9%] girls and women) nested in 45 145 family units. Youth were more commonly exposed to prescription opioids dispensed to a family member than through their own prescriptions. During follow-up, 26 284 youth (36.5%) filled at least 1 opioid prescription, and 47 461 youth (65.9%) had at least 1 family member with a prescription. Exposure to family members with opioid prescriptions in the past month was associated with increased risk of pharmaceutical opioid overdose (adjusted hazard ratio [aHR], 2.17; 95% CI, 1.24-3.79) independent of opioids prescribed to youth (aHR, 6.62; 95% CI, 3.39-12.91). Concurrent exposure to opioid prescriptions from youth and family members was associated with substantially increased overdose risk (aHR, 12.99; 95% CI, 5.08-33.25). High dosage of total morphine milligram equivalents (MME) prescribed to family members in the past month was associated with youth overdose (0 MME vs >0 to <200 MME: aHR, 1.39; 95% CI, 0.51-3.81; 0 MME vs 200 to <600 MME: aHR, 1.49; 95% CI, 0.59-3.77; 0 MME vs ≥600 MME: aHR, 2.93; 95% CI, 1.55-5.56). CONCLUSIONS AND RELEVANCE In this study of youth linked to family members, exposure to family members' prescribed opioids was associated with increased risk of pharmaceutical opioid overdose, independent of opioids prescribed to youth. Further interventions targeting youth and families are needed, including counseling patients about the risks of opioids to youth in their families.
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Affiliation(s)
- Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | - Komal J. Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Colorado Permanente Medical Group, Aurora, CO
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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46
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Chua KP, Brummett CM, Conti RM, Bohnert A. Association of Opioid Prescribing Patterns With Prescription Opioid Overdose in Adolescents and Young Adults. JAMA Pediatr 2020; 174:141-148. [PMID: 31841589 PMCID: PMC6990690 DOI: 10.1001/jamapediatrics.2019.4878] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Safe opioid prescribing practices are critical to mitigate the risk of prescription opioid overdose in adolescents and young adults. However, studies that examine opioid prescribing patterns associated with prescription opioid overdose have mostly focused on older adults. The generalizability of these studies to adolescents and young adults is unclear. OBJECTIVE To identify opioid prescribing patterns associated with prescription opioid overdose in adolescents and young adults. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed privately insured patients aged 12 to 21 years with opioid prescription claims in the IBM MarketScan Commercial Claims and Encounters database between July 1, 2009, and October 1, 2017, and no cancer diagnosis. Data analysis was performed from January 1 to April 30, 2019. MAIN OUTCOMES AND MEASURES The outcome was a treated opioid overdose as indicated by diagnosis codes. On the basis of days supplied, opioid prescription claims were converted to person-days (the unit of analysis) on which opioid exposure would occur if patients took medications as prescribed. Logistic regression with clustered SEs at the patient level was used to model the occurrence of overdose on a person-day as a function of daily opioid dosage category (<30, 30-59, 60-89, 90-119, or ≥120 morphine milligram equivalents), concurrent benzodiazepine use, and extended-release or long-acting opioid use. Regressions controlled for demographic characteristics, year, opioid use within 180 days, and comorbidities (mental health disorder, substance use disorder, and other chronic condition). RESULTS A total of 2 752 612 patients (mean [SD] age at cohort entry, 17.2 [2.5] years; 1 451 918 [52.8%] female) participated in the study. Patients had 4 686 355 opioid prescription claims, corresponding to 21 605 444 person-days. Overdose occurred on 255 person-days among 249 patients (0.01% of the sample). Each increase in daily opioid dosage category was associated with higher overdose risk (adjusted odds ratio [AOR], 1.18; 95% CI, 1.05-1.31). Compared with no use, both concurrent benzodiazepine use (AOR, 1.83; 95% CI, 1.24-2.71) and extended-release or long-acting opioid use (AOR, 2.01; 95% CI, 1.16-3.46) were associated with increased overdose risk. CONCLUSIONS AND RELEVANCE The findings suggest that when prescribing opioids to adolescents and young adults, practitioners could potentially mitigate overdose risk by using the lowest effective daily dosage, avoiding concurrent opioid and benzodiazepine prescribing, and relying on short-acting opioids. Findings are broadly consistent with prior opioid safety studies focused on older adults.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
| | - Chad M. Brummett
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | - Rena M. Conti
- Questrom School of Business, Institute for Health System Innovation and Policy, Department of Markets, Public Policy, and Law, Boston University, Boston, Massachusetts
| | - Amy Bohnert
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
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47
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Al-Kaisy A, Van Buyten JP, Amirdelfan K, Gliner B, Caraway D, Subbaroyan J, Rotte A, Kapural L. Opioid-sparing effects of 10 kHz spinal cord stimulation: a review of clinical evidence. Ann N Y Acad Sci 2019; 1462:53-64. [PMID: 31578744 PMCID: PMC7065058 DOI: 10.1111/nyas.14236] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/26/2019] [Accepted: 08/29/2019] [Indexed: 01/01/2023]
Abstract
Chronic pain is a common condition that affects the physical, emotional, and mental well‐being of patients and can significantly diminish their quality of life. Due to growing concerns about the substantial risks of long‐term opioid use, both governmental agencies and professional societies have recommended prioritizing the use of nonpharmacologic treatments, when suitable, in order to reduce or eliminate the need for opioid use. The use of 10 kHz spinal cord stimulation (10 kHz SCS) is one such nonpharmacologic alternative for the treatment of chronic, intractable pain of the trunk and limbs. This review examines published clinical data regarding the efficacy of 10 kHz SCS for decreasing chronic pain in patients and its potential to reduce or eliminate opioid usage. Multiple prospective and retrospective studies in patients with intractable pain demonstrated that 10 kHz SCS treatment provided ≥50% pain relief in >70% patients after at least 1 year of treatment. Pain relief with 10 kHz SCS therapy ranged from 54% to 87% in the studies. More importantly, the mean daily dose of opioids required by patients in these studies was reduced after 10 kHz SCS treatment, and on average over 60% patients in studies either reduced or eliminated opioids at the last follow‐up.
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Affiliation(s)
- Adnan Al-Kaisy
- The Pain Management and Neuromodulation Centre, Guy's and St. Thomas' Hospital, London, United Kingdom
| | | | | | | | | | | | | | - Leonardo Kapural
- Carolina's Pain Institute, Winston-Salem, North Carolina.,University of North Carolina, Chapel Hill, North Carolina.,Department of Anesthesiology and Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, Chapel Hill, North Carolina
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48
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10 kHz SCS therapy for chronic pain, effects on opioid usage: Post hoc analysis of data from two prospective studies. Sci Rep 2019; 9:11441. [PMID: 31391503 PMCID: PMC6686020 DOI: 10.1038/s41598-019-47792-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/24/2019] [Indexed: 12/29/2022] Open
Abstract
Chronic pain, including chronic low back and leg pain are prominent causes of disability worldwide. While patient management aims to reduce pain and improve daily function, prescription of opioids remains widespread despite significant adverse effects. This study pooled data from two large prospective trials on 10 kHz spinal cord stimulation (10 kHz SCS) in subjects with chronic low back pain and/or leg pain and performed post hoc analysis on changes in opioid dosage 12 months post 10 kHz SCS treatment. Patient-reported back and leg pain using the visual analog scale (VAS) and opioid dose (milligrams morphine equivalent/day, MME/day) were compared at 12 months post-10 kHz SCS therapy to baseline. Results showed that in the combined dataset, 39.3% of subjects were taking >90 MME dose of opioids at baseline compared to 23.0% at 12 months post-10 kHz SCS therapy (p = 0.007). The average dose of opioids in >90 MME group was significantly reduced by 46% following 10 kHz SCS therapy (p < 0.001), which was paralleled by significant pain relief (P < 0.001). In conclusion, current analysis demonstrates the benefits of 10 kHz SCS therapy and offers an evidence-based, non-pharmaceutical alternative to opioid therapy and/or an adjunctive therapy to facilitate opioid dose reduction whilst delivering significant pain relief. Healthcare providers involved in management of chronic non-cancer pain can include reduction or elimination of opioid use as part of treatment plan when contemplating 10 kHz SCS.
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