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Vincent R, Gert R, Eric P, Salah-Eddine A, Sacha M, Maarten W, Sven B, Steven V, De Ridder D, Tomas M, Mark P. Prolonged opioid use after single-level lumbar spinal fusion surgery in a Belgian population: a multicentric observational study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08448-7. [PMID: 39168891 DOI: 10.1007/s00586-024-08448-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/14/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE Lumbar spinal fusion surgeries are increasingly being performed in spinal degenerative disease, often accompanied by perioperative opioid prescriptions. The aim of this study is to analyze prolonged postoperative opioid use following a standardized opioid prescription after single-level lumbar spinal fusion surgery in a Belgian population. METHODS This prospective, multicentric observational study included patients undergoing single-level lumbar fusion surgery for degenerative disease. A standardized postoperative opioid protocol (Targinact 2 × 10 mg/5 mg, Paracetamol 4 × 1 g and Ibuprofen 3 × 600 mg) was applied uniformly. Prolonged opioid use was defined as continued opioid use six months after surgery. Patient data were collected using the Back-App®. RESULTS Among 198 participants, 32.8% continued opioid use six months post-surgery, with 8% utilizing strong opioids. Prolonged opioid use correlated with lower pre-operative back pain. Patients with prolonged opioid use and strong opioid use at six months show less improvement in disability compared to patients without prolonged opioid use. Moreover, patients with prolonged strong opioid use tend to have lesser improvement of the low back pain. The odds for prolonged opioid use decrease with the increase of the improvement in ODI. CONCLUSION 1 in 3 patients undergoing single-level lumbar spinal fusion surgery is at risk for prolonged opioid use. The study underscores the importance of tailored pain management strategies, particularly given the rising prevalence of spinal fusion surgeries. The association between pre-operative low back pain, post-operative improvement in functionality (ODI), and prolonged opioid use emphasizes the need for judicious opioid prescribing practices and highlights the role of functional outcomes in treatment goals.
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Affiliation(s)
- Raymaekers Vincent
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Roosen Gert
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Put Eric
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Achahbar Salah-Eddine
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Meeuws Sacha
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Wissels Maarten
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Bamps Sven
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Vanvolsem Steven
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Menovsky Tomas
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Plazier Mark
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
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Nelson CL, Sheth NP, Higuera Rueda CA, Redfern RE, Van Andel DC, Anderson MB, Cholewa JM, Israelite CL. Impact of Chronic Opioid Use on Postoperative Mobility Recovery and Patient-Reported Outcomes: A Propensity-Matched Study. J Arthroplasty 2024; 39:S148-S153. [PMID: 38401614 DOI: 10.1016/j.arth.2024.02.032] [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: 11/13/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Opioid use prior to total joint arthroplasty may be associated with poorer postoperative outcomes. However, few studies have reported the impact on postoperative recovery of mobility. We hypothesized that chronic opioid users would demonstrate impaired objective and subjective mobility recovery compared to nonusers. METHODS A secondary data analysis of a multicenter, prospective observational cohort study in which patients used a smartphone-based care management platform with a smartwatch for self-directed rehabilitation following hip or knee arthroplasty was performed. Patients were matched 2:1 based on age, body mass index, sex, procedure, Charnley class, ambulatory status, orthopedic procedure history, and anxiety. Postoperative mobility outcomes were measured by patient-reported ability to walk unassisted at 90 days, step counts, and responses to the 5-level EuroQol-5 dimension 5-level, compared by Chi-square and student's t-tests. Unmatched cohorts were also compared to investigate the impact of matching. RESULTS A total of 153 preoperative chronic opioid users were matched to 306 opioid-naïve patients. Age (61.9 ± 10.5 versus 62.1 ± 10.3, P = .90) and sex (53.6 versus 53.3% women, P = .95) were similar between groups. The proportion of people who reported walking unassisted for 90 days did not vary in the matched cohort (87.8 versus 90.7%, P = .26). Step counts were similar preoperatively and 1-month postoperatively but were lower in opioid users at 3 and 6 months postoperatively (4,823 versus 5,848, P = .03). More opioid users reported moderate to extreme problems with ambulation preoperatively on the 5-level EuroQol-5 dimension 5-level (80.6 versus 69.0%, P = .02), and at 6 months (19.2 versus 9.3%, P = .01). CONCLUSIONS Subjective and objective measures of postoperative mobility were significantly reduced in patients who chronically used opioid medications preoperatively. Even after considering baseline factors that may affect ambulation, objective mobility metrics following arthroplasty were negatively impacted by preoperative chronic opioid use.
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Affiliation(s)
- Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Craig L Israelite
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Rocca MS, Honig EL, Tran A, Kolevar MP, Kaveeshwar S, Aneizi A, Leong NL, Packer JD, Henn RF, Meredith SJ. Preoperative opioid use is associated with worse preoperative patient-reported outcomes in hip arthroscopy patients. J ISAKOS 2024; 9:581-586. [PMID: 38692433 DOI: 10.1016/j.jisako.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/08/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES The purpose of this study was to define the rate of preoperative opioid use among patients undergoing hip arthroscopy, ascertain which clinical factors are associated with opioid use, and assess the effect of preoperative opioid usage on preoperative patient-reported outcome (PRO) measures. METHODS A single institution orthopedic registry was retrospectively analyzed for patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) syndrome with or without labral tear between 2015 and 2022. Patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Scores (NPS), and Musculoskeletal Outcomes Data Evaluation and Management System expectations domain preoperatively. Patients' charts were reviewed to determine demographic factors and identify any active opioid prescription within 6 weeks before surgery. Bivariate analysis was used to determine associations between preoperative opioid use and baseline PROs. Statistically significant bivariate associations were further tested by multivariate analysis to determine independent predictors. RESULTS A total of 123 patients were included (age 39.7 ± 12.0 years; 87 females; body mass index 27.4 ± 5.7 kg/m2). There were 21 patients (17%) using opioids preoperatively. Prior orthopedic or other surgery and lower education level were associated with preoperative opioid use. Patients with preoperative opioid use scored statistically significantly worse compared with those without preoperative opioid use on baseline PROMIS Physical Function (38.6 vs 40.5, p = 0.01), Pain Interference (65.9 vs 60.2, p = 0.001), Fatigue (60.7 vs 51.6, p = 0.005), Social Satisfaction (38.2 vs 43.2, p = 0.007), and Depression (54.2 vs 48.8, p = 0.01). Preoperative opioid use was also associated with statistically significantly worse preoperative NPS for both the operative hip (6.3 vs 4.6, p = 0.003) and whole body (3.0 vs 1.4, p = 0.008). Preoperative opioid use was an independent predictor of worse baseline PROMIS Pain Interference, Fatigue, Social Satisfaction, and NPS for the operative hip. CONCLUSION Patients using opioids preoperatively had worse baseline PROs for physical function, pain, social satisfaction, and depression than those not using opioids preoperatively. When controlling for confounding variables, preoperative opioid use was independently predictive of worse baseline pain, fatigue, and social satisfaction. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Michael S Rocca
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Evan L Honig
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Andrew Tran
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Matthew P Kolevar
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Samir Kaveeshwar
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Natalie L Leong
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
| | - Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
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Khoraminejad B, Sakowitz S, Gao Z, Chervu N, Curry J, Ali K, Bakhtiyar SS, Benharash P. Association of substance-use disorder with outcomes of major elective abdominal operations: A contemporary national analysis. Surg Open Sci 2024; 19:44-49. [PMID: 38585038 PMCID: PMC10995883 DOI: 10.1016/j.sopen.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/15/2024] [Indexed: 04/09/2024] Open
Abstract
Background Affecting >20million people in the U.S., including 4 % of all hospitalized patients, substance use disorder (SUD) represents a growing public health crisis. Evaluating a national cohort, we aimed to characterize the association of concurrent SUD with perioperative outcomes and resource utilization following elective abdominal operations. Methods All adult hospitalizations entailing elective colectomy, gastrectomy, esophagectomy, hepatectomy, and pancreatectomy were tabulated from the 2016-2020 National Inpatient Sample. Patients with concurrent substance use disorder, comprising alcohol, opioid, marijuana, sedative, cocaine, inhalant, hallucinogen, or other psychoactive/stimulant use, were considered the SUD cohort (others: nSUD). Multivariable regression models were constructed to evaluate the independent association between SUD and key outcomes. Results Of ∼1,088,145 patients, 32,865 (3.0 %) comprised the SUD cohort. On average, SUD patients were younger, more commonly male, of lowest quartile income, and of Black race. SUD patients less frequently underwent colectomy, but more often pancreatectomy, relative to nSUD.Following risk adjustment and with nSUD as reference, SUD demonstrated similar likelihood of in-hospital mortality, but remained associated with increased odds of any perioperative complication (Adjusted Odds Ratio [AOR] 1.17, CI 1.09-1.25). Further, SUD was linked with incremental increases in adjusted length of stay (β + 0.90 days, CI +0.68-1.12) and costs (β + $3630, CI +2650-4610), as well as greater likelihood of non-home discharge (AOR 1.54, CI 1.40-1.70). Conclusions Concurrent substance use disorder was associated with increased complications, resource utilization, and non-home discharge following major elective abdominal operations. Novel interventions are warranted to address increased risk among this vulnerable population and address significant disparities in postoperative outcomes.
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Affiliation(s)
- Baran Khoraminejad
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Boston University, Boston, MA, United States of America
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Zihan Gao
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Joanna Curry
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Konmal Ali
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Denver, Aurora, CO, United States of America
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
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Johnson A, Nguyen F, Richardson M, Rabi S, Mann S, Gilron I, Yach J, Milne B, Evans G, Parlow J. Postdischarge opioid use after lumbar spine surgery among older adults in Ontario: a population-based cohort study. Can J Surg 2024; 67:E252-E260. [PMID: 38925858 PMCID: PMC11230664 DOI: 10.1503/cjs.003723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Prescription opioid use places a considerable economic burden on health care systems. Older patients undergoing surgical procedures for painful conditions commonly receive opioids pre- and postoperatively, and are susceptible to adverse reactions. This study explores predictors of prolonged postoperative opioid use among older patients after lumbar spine surgery and the consequences in terms of health care utilization and costs. METHODS We conducted a retrospective population-based cohort study using Ontario administrative data from older adults undergoing spine surgery between 2006 and 2017. Data were analyzed from 90 days preoperatively to 1 year after hospital discharge, with last postoperative opioid prescriptions stratified into 90-day increments. We used multivariable ordinal logistic regression to identify predictors of long-term opioid use and generalized linear modelling to examine resource utilization and health care costs (2021 Canadian dollars). RESULTS Of 15 109 patients included, 40.8% received preoperative opioid prescriptions. Preoperative opioid use strongly predicted prolonged postoperative use (odds ratio [OR] 4.47, 95% confidence interval [CI] 4.16-4.79), with 48.3% of patients who received preoperative opioids continuing to use opioids for longer than 9 months, relative to 12.7% of those without preoperative use. Several other risk factors for prolonged use were identified. Patients receiving long-term postoperative opioids incurred greater health care costs relative to those with opioids prescribed for fewer than 90 days (OR 1.49, 95% CI 1.44-1.54). CONCLUSION Among older adults undergoing spine surgery, preoperative opioid use was a strong predictor of prolonged postoperative use, which was associated with increased health care costs. These results form an important baseline for future studies evaluating strategies to reduce opioid use targeting older surgical populations.
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Affiliation(s)
- Ana Johnson
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Francis Nguyen
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Melissa Richardson
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Sarah Rabi
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Steve Mann
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Ian Gilron
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Jeff Yach
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Brian Milne
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Gerald Evans
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
| | - Joel Parlow
- From the Department of Public Health Sciences, Queen's University, Kingston, Ont. (Johnson); ICES Queen's (Johnson), Queen's University, Kingston, Ont.; ICES McMaster, McMaster University, Hamilton, Ont. (Nguyen); the School of Rehabilitation Therapy, Queen's University, Kingston, Ont. (Richardson); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Rabi); the Department of Surgery, Queen's University, Kingston, Ont. (Mann, Yach); the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ont. (Gilron, Milne, Parlow); the Department of Medicine, Queen's University, Kingston, Ont. (Evans)
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Farronato DM, Pezzulo JD, Paulik J, Miltenberg B, Johns WL, Davis DE. The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00222-2. [PMID: 38548094 DOI: 10.1016/j.jse.2024.02.021] [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: 09/07/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Miltenberg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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7
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Selznick A, Kruse C, Al-Mohrej OA, Valente G, Khan M, Al-Asiri J, Petrisor B. The Role of Preoperative Opioid Use in Foot and Ankle Surgery: A Systematic Review. J Foot Ankle Surg 2024; 63:305-311. [PMID: 37923116 DOI: 10.1053/j.jfas.2023.10.003] [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: 12/07/2022] [Revised: 09/18/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023]
Abstract
Prescription opioids, particularly for treating musculoskeletal pain, are a significant contributor to the opioid epidemic in North America. There is also evidence to suggest that chronic use of opioids is associated with poor outcomes after orthopedic surgery. However, whether this association is relevant in foot and ankle surgery is still unclear. Accordingly, a systematic review of the literature was undertaken to assess the impact of preoperative opioid use in patients undergoing foot and ankle surgery concerning postoperative pain, complications, and postoperative opioid dependence. Four databases, including EMBASE, MEDLINE, PubMed, and CINAHL, were searched to March 2022 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use after foot and ankle surgery. A total of 22,092 patients were included in the final synthesis of 8 studies. Most of which were level 3 evidence (5 studies). Around 18% of the patients used opioids preoperatively. Preoperative opioid use was associated with more quantities and prolonged use of opioids postoperatively. Two studies showed an increased risk of complications postoperatively in patients who used opioids preoperatively compared to the nonopioid group. Preoperative opioid use in patients undergoing foot and ankle surgeries is associated with increased and prolonged use of opioids postoperatively and may therefore predict the potential for misuse.
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Affiliation(s)
- Asher Selznick
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton ON, Canada
| | - Colin Kruse
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton ON, Canada
| | - Omar A Al-Mohrej
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada; Section of Orthopedic Surgery, Department of Surgery, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia.
| | - Giuseppe Valente
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
| | - Moin Khan
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
| | - Jamal Al-Asiri
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
| | - Bradley Petrisor
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
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8
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Marek RJ, Le JT, Hapenciuc G, Philip MA, Chiu J, Block AR, Ben-Porath YS. Incremental Contribution of the Minnesota Multiphasic Personality Inventory - 3 to Predicting One-Year Postoperative Spinal Cord Surgery/Spinal Cord Stimulation Outcomes. J Clin Psychol Med Settings 2024; 31:77-90. [PMID: 37642803 DOI: 10.1007/s10880-023-09971-3] [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] [Accepted: 08/10/2023] [Indexed: 08/31/2023]
Abstract
Pre-surgical psychological assessments are becoming common in the United States and are recommended or required prior to surgical/spinal cord stimulator intervention for chronic back pain. Psychological testing is often recommended for these evaluations and the various versions of the Minnesota Multiphasic Personality Inventory (MMPI) have demonstrated utility for predicting outcomes in this setting. This investigation sought to extend that literature with the newest version of the MMPI, the MMPI-3. The sample comprised of 909 patients (50.5% men, 49.5% women) who consented to participating in an outcome study and took the MMPI-3 along with other self-report measures of pain, functional disability, and emotional functioning prior to surgery as part of their pre-surgical psychological assessment. Self-report measures of pain, functional disability, and emotional functioning were administered again one-year following the intervention. MMPI-3 scale scores accounted for up to 9% of additional variance in the outcomes after controlling for pre-surgical measures. Measures of emotional/internalizing dysfunction, somatic dysfunction, and, to a lesser extent, behavioral/externalizing dysfunction contributed the most to the prediction of poorer outcomes.
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Affiliation(s)
- Ryan J Marek
- Department of Psychology and Philosophy, Sam Houston State University, 1905 University Ave, Huntsville, TX, 77340, USA.
| | - Janet T Le
- Department of Primary Care & Clinical Medicine, Sam Houston State University, Conroe, TX, USA
| | - Gabriel Hapenciuc
- Department of Primary Care & Clinical Medicine, Sam Houston State University, Conroe, TX, USA
| | - Michelle A Philip
- Department of Primary Care & Clinical Medicine, Sam Houston State University, Conroe, TX, USA
| | - Josephine Chiu
- Department of Primary Care & Clinical Medicine, Sam Houston State University, Conroe, TX, USA
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9
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D'Antonio ND, Lambrechts MJ, Heard JC, Siegel N, Karamian BA, Huang A, Canseco JA, Woods B, Kaye ID, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Preoperative Marijuana Use on Surgical Outcomes, Patient-Reported Outcomes, and Opioid Consumption Following Lumbar Fusion. Global Spine J 2024; 14:568-576. [PMID: 35849499 PMCID: PMC10802534 DOI: 10.1177/21925682221116819] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVES To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed. METHODS Patients > 18 years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively. RESULTS Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, P = .041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, P > .05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, P > .05). CONCLUSIONS Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Angela Huang
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Barrett Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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10
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Singh M, Bajaj A, Shlimak A, Kanekar S, Rampichini M, Gokaslan ZL, Scarfo KA, Leary OP, Guglielmo MA. Short-Term Pain Outcomes and Pain Medication Utilization Among Urine Toxicology-Identified Opioid and Marijuana Users After Elective Spine Surgery. Neurosurgery 2024; 94:622-629. [PMID: 37861310 DOI: 10.1227/neu.0000000000002727] [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: 04/27/2023] [Accepted: 08/27/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Postoperative pain outcomes may be influenced by preoperative substance use, which is often underreported due to associated stigma. This study examined the impact of urine toxicology-identified preoperative opioid and marijuana use on pain outcomes after elective spinal surgery. METHODS Patients undergoing elective spinal surgery between September 2020 and May 2022 were recruited for this prospective cohort study. Detailed chart review was completed to collect demographic, urine toxicology, Visual Analog Scale (VAS), and pain medication data. Comparisons between self-reported and urine toxicology-identified substance use, preoperative/postoperative VAS ratings, and postoperative pain medication use were made using χ 2 tests, Student t -tests, and logistic regression, respectively. Models were adjusted for age, sex, and race. RESULTS Among 111 participants (mean age 58 years, 59% female, 95% with ≥1 comorbidity), urine toxicology overestimated drug use (47% vs 16%, P < .001) and underestimated alcohol use (16% vs 56%, P < .001) at preoperative baseline relative to patient reports. Two weeks postoperatively, participants with preoperative opioid metabolites reported no significant improvements in pain from baseline (6.67 preoperative vs 5.92 postoperative, P = .288) unlike nonusers (6.56 preoperative vs 4.61 postoperative, P < .001). They also had worse postoperative VAS (5.92 vs 4.61, P = .030) and heavier reliance on opioid medications (odds ratio = 3.09, 95% CI = 1.21-7.89, P = .019). Conversely, participants with preoperative marijuana reported similar improvements in pain from baseline (users: 6.88 preoperative vs 4.36 postoperative, P = .001; nonusers: 6.49 preoperative vs 5.07 postoperative, P = .001), similar postoperative pain (4.36 vs 5.07, P = .238), and similar postoperative reliance on opioid medications (odds ratio = 0.96, 95% CI = 0.38-2.44, P = .928). Trends were maintained among the 83 patients who returned for the 3-month follow-up. CONCLUSION Although urine toxicology-identified preoperative opioid use was associated with poor postoperative pain relief and reliance on postoperative opioids for pain management after elective spinal surgery, preoperative marijuana use was not. Preoperative marijuana use, hence, should not delay or be a contraindication to elective spinal surgery.
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Affiliation(s)
- Manjot Singh
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence , Rhode Island , USA
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11
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Lin Z, Chen Z, Li Y. Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial. World J Surg Oncol 2024; 22:54. [PMID: 38360661 PMCID: PMC10868092 DOI: 10.1186/s12957-023-03298-x] [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: 10/09/2023] [Accepted: 12/29/2023] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE In patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence. METHODS This study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications. RESULTS After exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, - 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, - 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, - 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, - 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001). CONCLUSIONS After laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model. TRIAL REGISTRATION ChiCTR2100051784.
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Affiliation(s)
- Zhimin Lin
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China
- The 900th, Hospital of Joint Logistic Support Force, PLA, Fuzhou, 350001, People's Republic of China
- Affiliated Hospital of Putian University, 999th Dongzhen East Road, Licheng District, Putian, 351100, People's Republic of China
| | - Zhongbiao Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China
- The 900th, Hospital of Joint Logistic Support Force, PLA, Fuzhou, 350001, People's Republic of China
| | - Yongliang Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
- Affiliated Hospital of Putian University, 999th Dongzhen East Road, Licheng District, Putian, 351100, People's Republic of China.
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12
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Luo M, Shi F, Wang H, Chen Z, Dai H, Shi Y, Chen J, Tang S, Huang J, Xiao Z. The impact of perioperative opioid use on postoperative outcomes following spinal surgery: a meta-analysis of 60 cohort studies with 13 million participants. Spine J 2024; 24:278-296. [PMID: 37844626 DOI: 10.1016/j.spinee.2023.09.027] [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: 03/16/2023] [Revised: 09/01/2023] [Accepted: 09/30/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND CONTEXT An important factor for the prognosis of spinal surgery is the perioperative use of opioids. However, the relationship is not clear. PURPOSE The purpose of this study was to evaluate the effect of perioperative opioid use on the prognosis of patients following spinal surgery. STUDY DESIGN/SETTING Systematic review and meta-analysis. OUTCOME MEASURES A meta-analysis was conducted using the random-effects method to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). METHODS The PubMed, Embase, and Cochrane Library databases were systematically searched to find relevant articles that were published until September 2, 2022. The primary outcome was prolonged postoperative opioid use, and secondary outcomes included the length of stay (LOS), reoperation, the time to return to work (RTW), postoperative complications, gastrointestinal complications, new permanent disability, central nervous system events and infection. In addition, subgroup analysis of the primary outcome was conducted to explore the main sources of heterogeneity, and sensitivity analysis of all outcomes was performed to evaluate the stability of the results. RESULTS A total of 60 cohort studies involving 13,219,228 individuals met the inclusion criteria. Meta-analysis showed that perioperative opioid use was specifically related to prolonged postoperative opioid use (OR 6.91, 95% CI 6.09 to 7.84, p<.01). Furthermore, the results also showed that perioperative opioid use was significantly associated with prolonged LOS (OR 1.74, 95% CI 1.39 to 2.18, p<.01), postoperative complications (OR 1.72, 95% CI 1.26 to 2.36, p<.01), reoperation (OR 2.38, 95% CI 1.85 to 3.07, p<.01), the time to RTW (OR 0.45, 95% CI 0.39 to 0.52, p<.01), gastrointestinal complications (OR 1.39, 95% CI 1.30 to 1.48, p<.01), central nervous system events (OR 1.99, 95% CI 1.21 to 3.27, p=.07) and infection (OR 1.22, 95% CI 1.09 to 1.36, p=.01). These results were corroborated by the trim-and-fill procedure and leave-one-out sensitivity analyses. CONCLUSIONS Based on the current evidence, patients with perioperative opioid use, in comparison to controls, appear to have prolonged postoperative opioid use, which may increase the risk of poor outcomes including prolonged LOS, complications, reoperation, RTW and so on. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous. These findings may help clinicians to realize the harmfulness of perioperative use of opioids, reduce the use of prescription opioids, necessarily withdraw before operation or significantly wean to the lowest tolerable preoperative amount, and provide some inspiration for standardizing the use of opioids in the future.
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Affiliation(s)
- Mingjiang Luo
- Department of spinal Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Fuwen Shi
- Department of spinal Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China; Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Hongxu Wang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Zuoxuan Chen
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Huijie Dai
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Yuxin Shi
- Department of Pediatric Dentistry, First Affiliated Hospital (Affiliated Stomatological Hospital) of Xinjiang Medical University, Urumqi 830054, China
| | - Jiang Chen
- Department of spinal Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Siliang Tang
- Department of spinal Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Jingshan Huang
- Department of spinal Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Zhihong Xiao
- Department of spinal Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China.
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13
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Ballatori AM, Shahrestani S, Ton A, Chen X, Gettleman BS, Buser Z, Wang JC. Post-Operative Complications Associated with Long-Term NSAID or Long-Term Opioid Use Prior to Lumbar Spinal Fusion Surgery. Clin Neurol Neurosurg 2024; 236:108093. [PMID: 38183953 DOI: 10.1016/j.clineuro.2023.108093] [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: 11/08/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE Lower back pain (LBP) has been implicated as a significant cause of chronic pain in the United States, often requiring analgesic use. In this study, we investigate the trends in long-term preoperative NSAID (LTN) and Opioid (LTO) use in patients with low back pain in the United States, and the resultant postoperative complications following lumbar fusion. METHODS In this retrospective cohort study of patients with lumbar pathologies, multivariate population-based regression models were developed using the 2010-2017 National Readmission Database. Short-term complications (30-, 90-day) and long-term complications (180-, 300-day) were analyzed at readmission. RESULTS Of patients diagnosed with LBP (N = 1427,190) we found a rise in LTO users and a fall in LTN users following 2015. We identified 654,264 individuals who received a lumbar spine fusion, of which 22,975 were LTN users and 11,213 were LTO users. LTO users had significantly higher total inpatient charges (p-value<0.0001) and LOS (p-value<0.0001), while LTN users had lower rates of acute infection (OR: 0.993, 95% CI: 0.987-0.999, p = 0.017) and acute posthemorrhagic anemia (OR: 0.957, 95% CI: 0.935-0.979, p < 0.001) at primary admission. Readmission analysis showed that LTN use had significantly lower odds of readmission compared to LTO use at all time points (p < 0.01 for all). LTN use had significantly higher odds of hardware failure (OR: 1.134, 95% CI: 1.039-1.237, p = 0.005) within 300-days of receiving a lumbar fusion. CONCLUSIONS LTO users had significantly higher readmission rates compared to LTN. In addition, we found that LTN use was associated with significantly higher odds of hardware failure at long-term follow-up in patients receiving lumbar fusion surgery.
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Affiliation(s)
- Alexander M Ballatori
- Keck School of Medicine of University of Southern California Department of Orthopedics, Los Angeles, California
| | - Shane Shahrestani
- Keck School of Medicine of University of Southern California Department of Orthopedics, Los Angeles, California; Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | - Andy Ton
- Keck School of Medicine of University of Southern California Department of Orthopedics, Los Angeles, California
| | - Xiao Chen
- Keck School of Medicine of University of Southern California Department of Orthopedics, Los Angeles, California
| | - Brandon S Gettleman
- University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Zorica Buser
- Keck School of Medicine of University of Southern California Department of Orthopedics, Los Angeles, California.
| | - Jeffrey C Wang
- Keck School of Medicine of University of Southern California Department of Orthopedics, Los Angeles, California
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Chen SF, Su CC, Huang CC, Ogink PT, Yen HK, Groot OQ, Hu MH. External validation of machine learning algorithm predicting prolonged opioid prescriptions in opioid-naïve lumbar spine surgery patients using a Taiwanese cohort. J Formos Med Assoc 2023; 122:1321-1330. [PMID: 37453900 DOI: 10.1016/j.jfma.2023.06.027] [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: 11/24/2022] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND/PURPOSE Identifying patients at risk of prolonged opioid use after surgery prompts appropriate prescription and personalized treatment plans. The Skeletal Oncology Research Group machine learning algorithm (SORG-MLA) was developed to predict the risk of prolonged opioid use in opioid-naive patients after lumbar spine surgery. However, its utility in a distinct country remains unknown. METHODS A Taiwanese cohort containing 2795 patients who were 20 years or older undergoing primary surgery for lumbar decompression from 2010 to 2018 were used to validate the SORG-MLA. Discrimination (area under receiver operating characteristic curve [AUROC] and area under precision-recall curve [AUPRC]), calibration, overall performance (Brier score), and decision curve analysis were applied. RESULTS Among 2795 patients, the prolonged opioid prescription rate was 5.2%. The validation cohort were older, more inpatient disposition, and more common pharmaceutical history of NSAIDs. Despite the differences, the SORG-MLA provided a good discriminative ability (AUROC of 0.71 and AURPC of 0.36), a good overall performance (Brier score of 0.044 compared to that of 0.039 in the developmental cohort). However, the probability of prolonged opioid prescription tended to be overestimated (calibration intercept of -0.07 and calibration slope of 1.45). Decision curve analysis suggested greater clinical net benefit in a wide range of clinical scenarios. CONCLUSION The SORG-MLA retained good discriminative abilities and overall performances in a geologically and medicolegally different region. It was suitable for predicting patients in risk of prolonged postoperative opioid use in Taiwan.
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Affiliation(s)
- Shin-Fu Chen
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan; Department of Medical Education, National Taiwan University Hospital, Taiwan.
| | - Chih-Chi Su
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan; Department of Medical Education, National Taiwan University Hospital, Taiwan.
| | - Chuan-Ching Huang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan; Department of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan.
| | - Paul T Ogink
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Hung-Kuan Yen
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Taiwan; Department of Medical Education, National Taiwan University Hospital, Hsin-Chu Branch, Taiwan.
| | - Olivier Q Groot
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, USA.
| | - Ming-Hsiao Hu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan; Department of Orthopedics, National Taiwan University College of Medicine, Taiwan.
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Mohammed H, Parks M, Ibrahim S, Magnus M, Ma Y. Impact of Pre-operative Opioid Use on Racial Disparities in Adverse Outcomes Post Total Knee and Hip Arthroplasty. J Racial Ethn Health Disparities 2023; 10:3051-3061. [PMID: 36478270 DOI: 10.1007/s40615-022-01479-0] [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: 09/09/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The growing opioid epidemic in the USA has underlying racial disparities dimensions. Also, studies have shown that patients from minority racial groups are at higher risk of adverse events following major orthopedic surgery. The aim of our study was to determine whether pre-operative opioid-use disorders (OUDs) impacted racial disparities in the likelihood of patients experiencing adverse post-operative outcomes following TKA and THA. METHODS Data about patients undergoing TKA and THA were collected from the 2005-2014 National Inpatient Sample databases. Regression modeling was used to assess the impact of OUDs on odds of adverse outcomes comparing racial groups. The adverse outcomes included any in-hospital post-surgical complications, prolonged length of stay (LOS), and nonhome discharge. RESULTS In our fully adjusted regression models using White patients as the reference group, we found that OUDs were associated with racial disparities in prolonged LOS and nonhome discharge. In the non-OUD group, Black patients had significantly higher odds of longer LOS (OR: 1.35, 95% CI: 1.26-1.46, p-value: < 0.0001), whereas those with history of OUD had non-significantly lower odds of longer LOS (OR: 0.94, 95% CI: 0.69-1.29, p-value: 0.71). Similarly, for the outcome of nonhome discharges, Black patients in the non-OUD group had significantly higher odds (OR: 1.31, 95% CI: 1.21-1.43, p-value: < 0.0001) and those with a history of OUD had non-significantly lower odds (OR: 0.91, 95% CI: 0.64-1.29, p-value: 0.59). CONCLUSIONS Significant racial disparities are present in adverse events among patients in the non-OUD group, but those disparities attenuated in the OUD group.
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Affiliation(s)
- Hina Mohammed
- Syapse Inc., San Francisco, CA, USA
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Michael Parks
- Hospital for Special Surgery, New York City, NY, USA
- Weill Cornell Medical College, Cornell University, New York City, NY, USA
| | - Said Ibrahim
- Donal and Barbara Zucker School of Medicine, Northwell Health/ Hofstra University, Long Island, NY, USA
| | - Manya Magnus
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Yan Ma
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Moore M, Shendrik I, Roof MA, Sicat CS, Meftah M, Schwarzkopf R, Rozell JC. Outcomes of medicaid patients undergoing TJA with previous positive urine toxicology screens. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3555-3560. [PMID: 37225946 DOI: 10.1007/s00590-023-03591-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Previous studies have demonstrated that patients with positive preoperative urine toxicology (utox) screens prior to total joint arthroplasty (TJA) have higher readmission rates, greater complication rates, and longer hospital stays compared to patients with negative screens. The aim of this study was to investigate the effect of postponing surgery for patients with positive preoperative utox in the Medicaid population. METHODS This retrospective, observational study reviewed the Medicaid ambulatory database at a large, academic orthopedic specialty hospital for patients with a utox screen prior to TJA from 2012 to 2020. Patients were categorized into three groups: (1) controls with negative preoperative utox or a utox consistent with prescription medications (Utox-) with TJA completed as scheduled; (2) positive preoperative utox with TJA rescheduled and surgery completed on a later date (R-utox+); (3) positive preoperative utox inconsistent with prescription medications with TJA completed as scheduled (S-utox+). Primary outcomes included mortality, 90-day readmission rate, complication rate, and length of stay. RESULTS Of the 300 records reviewed, 185 did not meet inclusion criteria. The remaining 115 patients included 80 (69.6%) Utox-, 5 (6.3%) R-utox+, and 30 (37.5%) S-utox+. Mean follow-up time was 49.6 months. Hospital stays trended longer in the Utox- group (3.7 ± 2.0 days vs. 3.1 ± 1.6 S-utox+ vs.2.5 ± 0.4 R-utox+, p = 0.20). Compared to the R-utox+group, the S-utox+ group trended toward lower home discharge rates (p = 0.20), higher in-hospital complication rates (p = 0.85), and more all-cause 90-day emergency department visits (p = 0.57). There were no differences in postoperative opioid utilization between groups (p = 0.319). Duration of postoperative narcotic use trended toward being longer in the Utox- patients (820.7 ± 1073.8 days vs. 684.6 ± 1491.8 S-utox+ vs. 585.1 ± 948.3 R-utox+, p = 0.585). Surgical time (p = 0.045) and revision rates (p = 0.72) trended toward being higher in the S-utox+ group. CONCLUSIONS Medicaid patients with positive preoperative utox who had surgeries postponed trended towards shorter hospital stays and greater home discharge rates. Larger studies should be conducted to analyze the implications of a positive preoperative utox on risk profiles and outcomes following TJA in the Medicaid population. Study design Retrospective cohort study.
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Affiliation(s)
- Michael Moore
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA.
| | - Irina Shendrik
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Mackenzie A Roof
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Chelsea Sue Sicat
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Morteza Meftah
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
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Cozowicz C, Zhong H, Poeran J, Illescas A, Liu J, Poultsides LA, Avgerinos DV, Memtsoudis SG. The impact of multimodal analgesia in coronary artery bypass graft surgery-a population-based analysis. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01111-X. [PMID: 38042402 DOI: 10.1016/j.jtcvs.2023.11.035] [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: 04/20/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Multimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS), and opioid consumption among patients undergoing coronary artery bypass graft surgery. METHODS This retrospective cohort study included 349,940 adult patients undergoing elective coronary artery bypass graft surgery (January 2006 to December 2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of nonopioid analgesic modalities. These included, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids only and multimodal analgesia with the addition of 1, 2 or ≥3 nonopioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in milligram oral morphine equivalents. RESULTS Multimodal analgesia was associated with a beneficial dose response pattern. With increasing nonopioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed, eg, with the addition of 1, 2, or ≥3 nonopioid modalities the odds for any complication decreased by 8% (odds ratio [OR], 0.92; confidence interval [CI], 0.90-0.94), 17% (OR, 0.83; CI, 0.81-0.86), and 22% (OR, 0.78; CI 0.69-0.79), respectively. This stepwise pattern was consistent in respiratory, cardiac, and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities. CONCLUSIONS These nationally representative data indicate that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.
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Affiliation(s)
- Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Jashvant Poeran
- Department of Orthopaedic Surgery, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alex Illescas
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Lazaros A Poultsides
- Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece; Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Stavros G Memtsoudis
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY.
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18
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Du AL, Rishel CA, Sun EC. Association Between Naloxone Coprescription Mandates and Postoperative Outcomes. Ann Surg 2023; 278:e995-e1002. [PMID: 36805578 PMCID: PMC10439975 DOI: 10.1097/sla.0000000000005821] [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] [Indexed: 02/22/2023]
Abstract
INTRODUCTION The opioid epidemic is a public health issue in the United States. The objective of this study was to evaluate the association between naloxone coprescription mandates and postoperative outcomes. BACKGROUND Data on naloxone coprescription mandates show mixed evidence for fatal overdoses in the broader population. How these mandates have impacted surgical patients has not been fully explored. METHODS Healthcare claims data were used to identify all patients undergoing 1 of 50 common procedures between January 1, 2004, and June 30, 2019, and categorized as high risk for opioid overdose. The primary outcomes were an emergency department visit or hospital admission within 30 postoperative days. To reduce confounding, the association between this outcome and the implementation of naloxone coprescription mandates was estimated using a difference-in-differences approach. RESULTS The study included 429,878 surgical patients with an average age of 54.8 years (SD=15.9 years) and with 257,728 females (60.0%). There was no significant association between naloxone prescribing mandates and the primary outcomes. After adjustment for potential confounders, the incidence of hospital admission was 3.26% after implementation of a naloxone coprescription mandate compared with 3.33% before (difference change: -0.08%, 95% CI: -0.44% to 0.29%, P =0.68). The incidence of an emergency department visit was 7.06% after implementation of a naloxone coprescription mandate compared with 7.73% before (difference: -0.67%, 95% CI: -1.39% to 0.05%, P =0.07). These results were robust to a variety of sensitivity and subgroup analyses. CONCLUSIONS Naloxone coprescription mandates were not associated with a statistically or clinically significant change in emergency department visits or hospital admissions within 30 postoperative days.
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Affiliation(s)
- Austin L Du
- School of Medicine, University of California, San Diego, La Jolla, CA
| | - Chris A Rishel
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA
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19
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Hansen CW, Carlino EK, Saunee LA, Dasa V, Bhandutia AK. Modern Perioperative Pain Management Strategies to Minimize Opioids after Total Knee Arthroplasty. Orthop Clin North Am 2023; 54:359-368. [PMID: 37718075 DOI: 10.1016/j.ocl.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Total Knee Arthroplasty is associated with significant postoperative pain that can limit functional outcomes and patient satisfaction. In recent years, the standard of care for postoperative pain management has reduced reliance on opioids in favor of multimodal analgesia. These regimens consist of systemic medications such as COX-2 inhibitors, acetaminophen, corticosteroids, and gabapentinoids, as well as regional and local approaches such as peripheral nerve blocks and local infiltrative analgesics. Newer therapies, such as cryoneurolysis, are still being studied but have shown promising results. Additional studies are needed to determine the ideal pain regimen that will optimize pain control and eliminate the need for postoperative opioids.
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Affiliation(s)
- Charles W Hansen
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Elizabeth K Carlino
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA.
| | - Lauren A Saunee
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Amit K Bhandutia
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
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Trenchfield D, Lee Y, Brush P, McCurdy M, Lambrechts M, Narayanan R, Christianson A, Deez A, Wiafe B, Kaye ID, Canseco J, Hilibrand AS, Vaccaro AR, Kepler C, Schroeder G. Effect of Preoperative Marijuana on Patient Outcomes and Opioid Use after Lumbar Decompression. Global Spine J 2023:21925682231203650. [PMID: 37728558 DOI: 10.1177/21925682231203650] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVES Our study aims to analyze the effect of preoperative marijuana use on outcomes and postoperative opioid use in patients who have undergone lumbar decompression without fusion. METHODS All patients >18 years of age who underwent lumbar decompression from 2017-2022 with documented preoperative marijuana use at our academic institution were retrospectively identified. A 3:1 propensity match incorporating demographics, procedure type, and levels decompressed was performed to compare preoperative marijuana users and non-users. 1-year preoperative and postoperative opioid consumption in milligrams of morphine equivalents and postoperative outcomes including readmissions, reoperations, and complications, were obtained. A multivariate regression model was performed to measure the effect of marijuana use on the likelihood of a spine reoperation. RESULTS Of the 340 included patients, 85 were preoperative marijuana users. There were no significant differences in medical complications, 90-day readmissions, or opioid consumption preoperatively or postoperatively (P > .05). We identified a trend towards patients who used marijuana having more reoperations for any cause (20.0% vs 11.37%, P = .067). Multivariate logistic regression analysis suggested that preoperative marijuana use was a significant predictor of all-spine reoperations (OR = 2.06, P = .036). CONCLUSIONS In lumbar decompression patients, preoperative marijuana use does not impact opioid consumption, readmissions, or medical complications, but is a significant predictor of future postoperative reoperations. Additional research is necessary to further explore the role of marijuana use in spine surgery.
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Affiliation(s)
- Delano Trenchfield
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Parker Brush
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael McCurdy
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, MO, USA
| | - Rajkishen Narayanan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alex Christianson
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Azra Deez
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Bright Wiafe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Azimi A, Hooshmand E, Mafi AA, Tabatabaei FS. Effect of duloxetine on opioid consumption and pain after total knee and hip arthroplasty: a systematic review and meta-analysis of randomized clinical trials. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1035-1045. [PMID: 37027215 DOI: 10.1093/pm/pnad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the analgesic effects of duloxetine, specifically on postoperative pain, opioid consumption, and related side effects following total hip or knee arthroplasty. METHODS In this systematic review and meta-analysis, Medline, Cochrane, EMBASE, Scopus, and Web of Science were searched until November 2022 for studies which compared duloxetine with placebo when added to routine pain management protocols. Individual study risk of bias assessment was conducted based on Cochrane risk of bias tool 2. Random effect model meta-analysis was done on mean differences, to evaluate the outcomes. RESULTS Nine randomized clinical trials (RCT) were included in the final analysis, totaling 806 patients. Duloxetine reduced opioid consumption (oral morphine milligram equivalents) on postoperative days (POD) 2 (mean difference (MD): -14.35, P = .02), POD 3 (MD: -13.6, P < .001), POD 7 (MD: -7.81, P < .001), and POD 14 (MD: -12.72, P < .001). Duloxetine decreased pain with activity on POD 1, 3, 7, 14, 90 (All P < .05), and pain at rest on POD 2, 3, 7, 14, and 90 (all P < .05). There was no significant difference in the prevalence of the side effects, except for increased risk of somnolence/drowsiness (risk ratio: 1.87, P = .007). CONCLUSION Current evidence shows low to moderate opioid sparing effects of perioperative duloxetine and a statistically but not clinically significant reduction in pain scores. Patients treated with duloxetine had an increased risk for somnolence and drowsiness.
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Affiliation(s)
- Amirali Azimi
- Department of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Hooshmand
- Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Amir Ali Mafi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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22
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Liu X, Wong CKH, Wu T, Tang EHM, Au ICH, Li L, Cheung CW, Lang BHH. Discharge of postoperative patients with an opioid prescription is associated with increased persistent opioid use, healthcare expenditures and mortality: a retrospective cohort study. Br J Anaesth 2023; 131:586-597. [PMID: 37474420 DOI: 10.1016/j.bja.2023.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/07/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND The risk factors for persistent opioid use after surgical discharge and the association between opioid prescription at discharge and postoperative emergency department visits, readmission, and mortality are unclear. METHODS This population-based retrospective cohort study involved opioid-naive patients who underwent surgical procedures from January 1, 2000 to November 30, 2020. The data source was Hong Kong Hospital Authority Clinical Management System electronic health record. The primary outcome was the incidence of new persistent opioid use. Other study outcomes included 30-day emergency department visits, 30-day readmission, and 30-day all-cause mortality. Multivariable logistic regression models were used to estimate the association between opioid prescription at discharge and persistent opioid use, emergency department visits, readmission, and all-cause mortality. RESULTS Over a median follow-up of 1 month with 36 104 person-years, 438 128 patients (opioid prescription: 32 932, no opioid prescription: 405 196) who underwent surgical procedures were analysed, of whom 15 112 (3.45%) had persistent opioid use after discharge. Prescribing opioids on discharge was associated with increased risks of developing persistent opioid use (odds ratio [OR]: 2.30, 95% confidence interval [CI]: 2.19-2.40, P<0.001), 30-day emergency department visits (OR: 1.28, 95% CI: 1.23-1.33, P<0.001), 30-day readmission (OR: 1.17, 95% CI: 1.13-1.20, P<0.001), and 30-day all-cause mortality (OR: 1.68, 95% CI: 1.53-1.86, P<0.001). CONCLUSIONS In this large cohort of patients undergoing surgery, an opioid prescription on discharge was associated with a higher chance of persistent opioid use and increased risks of postoperative emergency department visits, readmission, and mortality. Minimising opioid prescriptions on discharge could improve perioperative patient outcomes.
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Affiliation(s)
- Xiaodong Liu
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Carlos K H Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health Limited (D2(4)H), Hong Kong Special Administrative Region, China.
| | - Tingting Wu
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric H M Tang
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ivan C H Au
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lanlan Li
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chi W Cheung
- Department of Anaesthesiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Brian H-H Lang
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China.
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23
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Meade PJ, Matzko CN, Stamm MA, Mulcahey MK. Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100758. [PMID: 37645396 PMCID: PMC10461209 DOI: 10.1016/j.asmr.2023.100758] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/25/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR). Methods Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users. Results Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively. Conclusions This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Patrick J. Meade
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | | | - Michaela A. Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Mary K. Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
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Knapik DM, Tanenbaum JE, Salata MJ, Victoroff BN, Voos JE, Gillespie RJ. Increase in Deltoid Compartment Pressures Immediately After Arthroscopic Rotator Cuff Repair Does Not Significantly Affect Postoperative Opioid Consumption. Arthrosc Sports Med Rehabil 2023; 5:100760. [PMID: 37492561 PMCID: PMC10365942 DOI: 10.1016/j.asmr.2023.100760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/12/2023] [Indexed: 07/27/2023] Open
Abstract
Purpose To investigate the association between changes in individual (anterior, lateral, and posterior) and overall deltoid compartment pressures and postoperative opioid consumption up to 14 days after primary double-row arthroscopic rotator cuff repair (ARCR). Methods In 113 consecutive patients undergoing primary double-row ARCR, anterior, lateral, and posterior deltoid compartment pressures were measured prior to incision and immediately after closure with a manometer. Postoperatively, all patients were provided with an identical rehabilitation protocol, quantity and dose of opioid tablets, and pain journal in which to record daily opioid consumption and visual analog scale pain scores for 14 days after surgery. The pain journals were collected at the first postoperative visit, and opioid consumption was calculated based on morphine equivalents. Statistical analysis was performed to determine the association between deltoid compartment pressures and opioid consumption postoperatively. Results Sixty-nine percent of patients who met the inclusion criteria (74 of 107) returned the pain journals. The mean age at the time of surgery was 57.4 ± 8.8 years (range, 30-75 years), with female patients being significantly older (P = .03). The mean length of surgery was 71.7 ± 16.3 minutes. No significant association between increase in individual (anterior, lateral, or posterior) or mean overall compartment pressures and morphine equivalents of opioid consumption was appreciated on any postoperative day. Conclusions No significant correlation between increase in individual or overall deltoid compartment pressures after ARCR and postoperative opioid consumption in the immediate postoperative period was found in this study. Level of Evidence Level II, prospective cohort study.
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Affiliation(s)
- Derrick M. Knapik
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | | | - Michael J. Salata
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Brian N. Victoroff
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - James E. Voos
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Robert J. Gillespie
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
- University Hospitals Sports Medicine Institute, Cleveland, Ohio, U.S.A
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, U.S.A
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25
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Fernandez AC, Aslesen H, Golmirzaie G, Stanton S, Gunaseelan V, Waljee J, Brummett CM, Englesbe M, Bicket MC. Patient Responses to Surgery-relevant Screening for Opioid and Other Risky Substance Use Before Surgery: A Pretest-posttest Study. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:896-899. [PMID: 36478099 PMCID: PMC10321761 DOI: 10.1093/pm/pnac190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/02/2022] [Accepted: 12/01/2022] [Indexed: 07/20/2023]
Affiliation(s)
- Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Heidi Aslesen
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Goodardz Golmirzaie
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sofea Stanton
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Englesbe
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark C Bicket
- Correspondence to: Mark Bicket, MD, PhD, Department of Anesthesiology, University of Michigan School of Medicine, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA. E-mail:
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Kagan R, Welling S, Mildren ME, Smith S, Philipp T, Yoo J. It is the Opioids Not the Spine Surgeon; Dislocation After Total Hip Arthroplasty is Associated With Opioid Use in Patients Who Have Prior Lumbar Spine Fusion. J Arthroplasty 2023; 38:S336-S339. [PMID: 36889529 DOI: 10.1016/j.arth.2023.02.080] [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: 11/19/2022] [Revised: 02/23/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not. METHODS This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics. RESULTS There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001). CONCLUSION Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA.
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Affiliation(s)
- Ryland Kagan
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Sebastian Welling
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | | | - Spencer Smith
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Travis Philipp
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Jung Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
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Kim NS, Lam AW, Golub IJ, Sheth BK, Vakharia RM, Saleh A, Razi AE. Opioid Use Disorder in Patients Undergoing Primary 1- to 2-Level Anterior Cervical Discectomy and Fusion Is Associated With Longer In-Hospital Lengths of Stay and Higher Rates of Readmissions, Complications, and Costs of Care. Global Spine J 2023; 13:1467-1473. [PMID: 34409880 PMCID: PMC10448104 DOI: 10.1177/21925682211037265] [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] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To determine whether opioid use disorder (OUD) patients undergoing 1- to 2-level anterior cervical discectomy and fusion (1-2ACDF) have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) complications; and 4) costs. METHODS OUD patients undergoing primary 1-2ACDF were identified within the Medicare database and matched to a control cohort in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 80,683 patients who underwent 1-2 ACDF with (n = 13,448) and without (n = 67,235) OUD. Outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, and costs. Multivariate logistic regression analyses were used to calculate odds-ratios (OR) for medical complications and readmissions. Welch's t-test was used to test for significance for LOS and cost between the cohorts. An alpha value less than 0.002 was considered statistically significant. RESULTS OUD patients were found to have significantly longer in-hospital LOS compared to their counterparts (3.41 vs. 2.23-days, P < .0001), in addition to higher frequency and odds of requiring readmissions (21.62 vs. 11.57%; OR: 1.38, P < .0001). Study group patients were found to have higher frequency and odds of developing medical complications (0.88 vs. 0.19%, OR: 2.80, P < .0001) and incurred higher episode of care costs ($20,399.62 vs. $16,812.14, P < .0001). CONCLUSION The study can help to push orthopaedic surgeons in better managing OUD patients pre-operatively in terms of safe discontinuation and education of opioid drugs and their effects on complications, leading to more satisfactory outcomes.
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Affiliation(s)
- Nathan S. Kim
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
- State University of New York (SUNY) Downstate, School of Medicine, Brooklyn, New York, NY, USA
| | - Aaron W. Lam
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - Ivan J. Golub
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - Bhavya K. Sheth
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - Rushabh M. Vakharia
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - Ahmed Saleh
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - Afshin E. Razi
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, NY, USA
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Stonner MM, Skladman R, Bettlach CLR, Kennedy C, Mackinnon SE. Recruiting hand therapists improves disposal of unused opioid medication. J Hand Ther 2023; 36:507-513. [PMID: 35909068 DOI: 10.1016/j.jht.2022.06.005] [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: 07/27/2021] [Revised: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Opioids often remain unused after upper extremity surgery, and leftover prescriptions are frequently diverted. When administered in a hand surgery clinic, an educational brochure outlining a simple method of opioid disposal has been shown to improve disposal rates after surgery. PURPOSE To understand whether administration of an opioid disposal educational brochure in a hand therapy clinic would increase opioid disposal rates, compared to a hand surgery clinic. STUDY DESIGN Prospective cohort study. METHODS Patients who presented to a hand therapy clinic postoperatively were recruited to participate in this prospective cohort study. An educational brochure outlining a simple method of opioid disposal was made available at the hand therapy and surgery clinics. A questionnaire was later issued to obtain: location of brochure receipt, demographic information, pre- and post-operative opioid use history, and opioid disposal patterns. Chi-square tests and multivariable binary logistic regression assessed associations between medication disposal and explanatory variables. RESULTS Patients who received the brochure were significantly more likely to dispose of excess opioid medication, compared to those who did not receive the brochure (57.1% vs 10.8%, p < .001). Patients who received the brochure at the hand therapy clinic were significantly more likely to dispose of excess opioids (86.4%) compared to those who received the brochure at the surgery clinic (25.0%). Older age was predictive of increased disposal (p =.028*). There were no significant associations between gender, length of follow-up, or surgery type with the incidence of opioid disposal. CONCLUSION Recruiting both hand therapists and surgeons in the distribution of a simple, educational brochure on opioid disposal can increase disposal rates. Patients who received the brochure from the hand therapist were more likely to dispose of excess opioids. The longstanding patient-therapist relationship creates an opportunity for educational initiatives and discussion of stigmatized topics, such as opioid use.
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Affiliation(s)
- Macyn M Stonner
- Program in Occupational Therapy, Milliken Hand Rehabilitation Center, Washington University School of Medicine, St. Louis, MO, USA.
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carrie L Roth Bettlach
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carie Kennedy
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Yu HC, Kleiman V, Kojic K, Slepian PM, Cortes H, McRae K, Katznelson R, Huang A, Tamir D, Fiorellino J, Ganty P, Cote N, Kahn M, Mucsi I, Selzner N, Rozenberg D, Chaparro C, Rao V, Cypel M, Ghanekar A, Kona S, McCluskey S, Ladak S, Santa Mina D, Karkouti K, Katz J, Clarke H. Prevention and Management of Chronic Postsurgical Pain and Persistent Opioid Use Following Solid Organ Transplantation: Experiences From the Toronto General Hospital Transitional Pain Service. Transplantation 2023; 107:1398-1405. [PMID: 36482750 DOI: 10.1097/tp.0000000000004441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND With >700 transplant surgeries performed each year, Toronto General Hospital (TGH) is currently one of the largest adult transplant centers in North America. There is a lack of literature regarding both the identification and management of chronic postsurgical pain (CPSP) after organ transplantation. Since 2014, the TGH Transitional Pain Service (TPS) has helped manage patients who developed CPSP after solid organ transplantation (SOT), including heart, lung, liver, and renal transplants. METHODS In this retrospective cohort study, we describe the association between opioid consumption, psychological characteristics of pain, and demographic characteristics of 140 SOT patients who participated in the multidisciplinary treatment at the TGH TPS, incorporating psychology and physiotherapy as key parts of our multimodal pain management regimen. RESULTS Treatment by the multidisciplinary TPS team was associated with significant improvement in pain severity and a reduction in opioid consumption. CONCLUSIONS Given the risk of CPSP after SOT, robust follow-up and management by a multidisciplinary team should be considered to prevent CPSP, help guide opioid weaning, and provide psychological support to these patients to improve their recovery trajectory and quality of life postoperatively.
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Affiliation(s)
- Hai Chuan Yu
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Valery Kleiman
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Katarina Kojic
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, Providence Health Care/St. Paul's Hospital, Vancouver, BC, Canada
| | - P Maxwell Slepian
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | - Henry Cortes
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Alex Huang
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Diana Tamir
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Joseph Fiorellino
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Praveen Ganty
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Nathalie Cote
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Michael Kahn
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Istvan Mucsi
- Ajmera Transplant Center, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Nazia Selzner
- Ajmera Transplant Center, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Dmitry Rozenberg
- Temerty Faculty of Medicine, Division of Respirology, Ajmera Transplant Program, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Cecilia Chaparro
- Division of Respirology, Department of Medicine, Lung Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Vivek Rao
- Peter Munk Cardiac Centre of the University Health Network, Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Department of Cardiovascular Surgery, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Anand Ghanekar
- Ajmera Transplant Center, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Sharath Kona
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Salima Ladak
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Joel Katz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
- University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
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Tierney S, Magnan MC, Zahrai A, McIsaac D, Poulin P, Stratton A. Feasibility of a multidisciplinary Transitional Pain Service in spine surgery patients to minimise opioid use and improve perioperative outcomes: a quality improvement study. BMJ Open Qual 2023; 12:e002278. [PMID: 37336575 DOI: 10.1136/bmjoq-2023-002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023] Open
Abstract
INTRODUCTION Spine surgery patients have high rates of perioperative opioid consumption, with a chronic opioid use prevalence of 20%. A proposed solution is the implementation of a Transitional Pain Service (TPS), which provides patient-tailored multidisciplinary care. Its feasibility has not been demonstrated in spine surgery. The main objective of this study was to evaluate the feasibility of a TPS programme in patients undergoing spine surgery. METHODS Patients were recruited between July 2020 and November 2021 at a single, tertiary care academic centre. Success of our study was defined as: (1) enrolment: ability to enrol ≥80% of eligible patients, (2) data collection: ability to collect data for ≥80% of participants, including effectiveness measures (oral morphine equivalent (OME) and Visual Analogue Scale (VAS)-perceived analgesic management and overall health) and programme resource requirements measures (appointment attendance, 60-day return to emergency and length of stay), and (3) efficacy: estimate potential programme effectiveness defined as ≥80% of patients weaned back to their intake OME requirements at programme discharge. RESULTS Thirty out of 36 (83.3%) eligible patients were enrolled and 26 completed the TPS programme. The main programme outcomes and resource measures were successfully tracked for >80% of patients. All 26 patients had the same or lower OME at programme discharge than at intake (intake 38.75 mg vs discharge 12.50 mg; p<0.001). At TPS discharge, patients reported similar overall health VAS (pre 60.0 vs post 70.0; p=0.14), improved scores for VAS-perceived analgesic management (pre 47.6 vs post 75.6; p<0.001) and improved Brief Pain Inventory pain intensity (pre 39.1 vs post 25.0; p=0.02). CONCLUSION Our feasibility study successfully met or exceeded our three main objectives. Based on this success and the defined clinical need for a TPS programme, we plan to expand our TPS care model to include other surgical procedures at our centre.
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Affiliation(s)
- Sarah Tierney
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marie-Claude Magnan
- Department of Orthopedics, Spine Division, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amin Zahrai
- Department of Clinical Psychology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniel McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Patricia Poulin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Clinical Psychology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexandra Stratton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Orthopedics, Spine Division, Ottawa Hospital, Ottawa, Ontario, Canada
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Stone AB, Iban YC, Zhong H, Poeran J, Liu J, Cozowicz C, Wong J, Illescas A, Memtsoudis SG. Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study. J Clin Anesth 2023; 86:111074. [PMID: 36758393 DOI: 10.1016/j.jclinane.2023.111074] [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: 09/19/2022] [Revised: 01/13/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
STUDY OBJECTIVE Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects. DESIGN Retrospective study of population-based database. PATIENTS The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery. INTERVENTIONS None. MEASUREMENTS The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes. MAIN RESULTS In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP. CONCLUSIONS In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.
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Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Yhan Colon Iban
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy/ Department of Orthopedics / Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy/ Department of Orthopedics / Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jean Wong
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Alex Illescas
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA.
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Cheah MA, Sarmiento S, Lesko RP, El Eter L, Siotos C, McColl MA, Manahan MA, Sacks JM, Maher DP, Rosson GD, Cooney CM. Association of preoperative opioid use and postoperative complications following breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 83:258-265. [PMID: 37285777 DOI: 10.1016/j.bjps.2023.05.007] [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: 09/28/2021] [Revised: 03/14/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.
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Affiliation(s)
- Michael A Cheah
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA; Department of Plastic and Reconstructive Surgery, UT Southwestern, Dallas, TX 75390, USA
| | - Samuel Sarmiento
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Robert P Lesko
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Leen El Eter
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michael A McColl
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO 63110, USA
| | - Dermot P Maher
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Oya R, Ogawa S, Oya K, Hirakawa Y, Maeda C, Amaya F. Prevalence of preoperative opioid usage and its impact on postoperative outcomes: a retrospective cohort study. J Anesth 2023:10.1007/s00540-023-03198-0. [PMID: 37160444 DOI: 10.1007/s00540-023-03198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE Preoperative opioid treatment increases postoperative adverse events. This study was aimed to analyze preoperative opioid prevalence in countries with low opioid consumption. Additionally, the effect of low opioid usage on postoperative outcomes was also investigated. METHODS We conducted this single center retrospective cohort analysis in a Japanese university-affiliated hospital to investigate opioid usage and its impact on the duration of postoperative hospitalization and in-hospital mortality. Adult patients who underwent general anesthesia between 2015 and 2020 were included. We extracted the patients' characteristics, surgical information and postoperative outcomes. Subgroup analysis to address opioid dose effect was performed in high and low dose opioid subgroups. RESULTS Among 20,306 inpatients, 535 (2.63%) patients used opioids preoperatively. Tramadol was the most frequently used opioid. The median morphine equivalent (MME) dose was 15 mg/day. Median duration of hospitalization was 18 and 9 days in the opioid and non-opioid groups, and in-hospital mortality was 2.06% and 0.42%. Multivariable regression analysis demonstrated that preoperative opioid use was associated with a longer duration of hospitalization and in-hospital mortality. Subgroup analysis demonstrated longer durations of hospitalization in both high (> 30 mg/day MME) and low (≤ 30 mg/day MME) dose opioid groups, while higher in-hospital mortality was seen only in the high dose opioid group. CONCLUSIONS Preoperative opioid usage was one-tenth of the United States average. Despite its low prevalence and small dosage, preoperative opioid usage was associated with poor postoperative outcomes. Dedicated perioperative interventions to prevent opioid-associated adverse events should be developed even in countries with low opioid consumption.
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Affiliation(s)
- Rina Oya
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-ku, Kyoto, 602-0841, Japan
| | - Satoru Ogawa
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-ku, Kyoto, 602-0841, Japan
| | - Kiyofumi Oya
- Peace Home Care Clinic, 16-21 Oiwake-cho, Otsu, Shiga, 520-0064, Japan
| | - Yuka Hirakawa
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-ku, Kyoto, 602-0841, Japan
| | - Chika Maeda
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-ku, Kyoto, 602-0841, Japan
| | - Fumimasa Amaya
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kajiicho 465, Kamigyo-ku, Kyoto, 602-0841, Japan.
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Dickerson DM, Mariano ER, Szokol JW, Harned M, Clark RM, Mueller JT, Shilling AM, Udoji MA, Mukkamala SB, Doan L, Wyatt KEK, Schwalb JM, Elkassabany NM, Eloy JD, Beck SL, Wiechmann L, Chiao F, Halle SG, Krishnan DG, Cramer JD, Ali Sakr Esa W, Muse IO, Baratta J, Rosenquist R, Gulur P, Shah S, Kohan L, Robles J, Schwenk ES, Allen BFS, Yang S, Hadeed JG, Schwartz G, Englesbe MJ, Sprintz M, Urish KL, Walton A, Keith L, Buvanendran A. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med 2023:rapm-2023-104435. [PMID: 37185214 DOI: 10.1136/rapm-2023-104435] [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: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.
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Affiliation(s)
- David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Randall M Clark
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mercy A Udoji
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Health Care System, Decatur, Georgia, USA
| | | | - Lisa Doan
- Department of Anesthesiology, PerioperativeCare and Pain Medicine, New York University School of Medicine, New York, New York, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperativeand Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Stacy L Beck
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Maternal Fetal Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, USA
| | - Steven G Halle
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Wael Ali Sakr Esa
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
- Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Jaime Baratta
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | | | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shalini Shah
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer Robles
- Department of Urology Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian F S Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Yang
- Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | | | - Gary Schwartz
- AABP Integrative Pain Care, Melville, New York, USA
- Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Michael Sprintz
- Sprintz Center for Pain and Recovery, Shenandoah, Texas, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Lauren Keith
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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A Retrospective Cohort Study on Chronic Opioid Use After Geriatric Hip Fracture Surgery-Risk Factors, Trends, and Outcomes. J Am Acad Orthop Surg 2023; 31:312-318. [PMID: 36595589 DOI: 10.5435/jaaos-d-22-00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 11/19/2022] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The purpose of this study is to identify the risk factors for prolonged opioid use after surgery in geriatric hip fracture patients and the effects of prolonged use on mortality and readmission rates. METHODS An institutional registry was queried for all patients older than 65 years who underwent surgical treatment of a hip fracture between January 2016 and June 2017. Using the Controlled Substance Utilization Review and Evaluation System (CURES), we identified patients who had filled an opioid prescription within 3 months of hospital admission as opioid exposed and patients without a history of opioid use as opioid naïve (ON). RESULTS Of 500 patients who underwent hip-fracture surgery during the study period, a total of 322 had complete Controlled Substance Utilization Review and Evaluation System data. 36.0% (116) were OE, and 64.0% (206) were ON. 23.0% (74) patients filled an opioid prescription 6 months after surgery, 59.5% (44) were OE, and 40.5% (30) were ON. OE and patients on antidepressants were more likely to continue opioids at 6 months. Age, sex, fracture pattern, implant, benzodiazepine use, smoking, and alcohol status were not notable risk factors for prolonged opioid use. Antidepressant use was a risk factor for readmission within 90 days. Previous opioid exposure predicted mortality within 6 months. DISCUSSION Opioid use in geriatric hip fracture patients is high both preoperatively and postoperatively. Opioid exposed patients and patients on antidepressants are more likely to continue opioids at 6 months. A substantial proportion of ON patients became prolonged opioid users. Although prolonged opioid use postoperatively did not increase the risk of readmission or death, antidepressant use predicted readmission and previous opioid exposure predicted mortality. By identifying predictors of prolonged postoperative opioid use in geriatric hip fracture patients, we can better prepare physicians and their patients on what to expect in the postoperative period. LEVEL OF EVIDENCE Level III.
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Elsamadicy AA, Sandhu MRS, Reeves BC, Freedman IG, Koo AB, Jayaraj C, Hengartner AC, Havlik J, Hersh AM, Pennington Z, Lo SFL, Shin JH, Mendel E, Sciubba DM. Association of inpatient opioid consumption on postoperative outcomes after open posterior spinal fusion for adult spine deformity. Spine Deform 2023; 11:439-453. [PMID: 36350557 DOI: 10.1007/s43390-022-00609-2] [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: 04/25/2022] [Accepted: 10/29/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Opioids are the most commonly used analgesic in the postoperative setting. However, few studies have analyzed the impact of high inpatient opioid use on outcomes following surgery, with no current studies assessing its effect on patients undergoing spinal fusion for an adult spinal deformity (ASD). Thus, the aim of this study was to investigate risk factors for high inpatient opioid use, as well as to determine the impact of high opioid use on outcomes such as adverse events (AEs), hospital length of stay (LOS), cost of hospital admission, discharge disposition, and readmission rates in patients undergoing spinal fusion for ASD. METHODS A retrospective cohort study was performed using the Premier healthcare database from the years 2016 and 2017. All adult patients > 40 years old who underwent thoracic or thoracolumbar fusion for ASD were identified using the ICD-10-CM diagnostic and procedural coding system. Patients were then categorized into three cohorts based on inpatient opioid use: Low MME (morphine milligram equivalents), Medium MME, and High MME. Patient demographics, comorbidities, treating hospital characteristics, intraoperative variables, postoperative AEs, LOS, discharge disposition, and total cost of hospital admission were assessed in the analysis. Multivariate regression analysis was done to determine independent predictors of high inpatient MME, prolonged LOS, and increased hospital cost. RESULTS Of 1673 patients included, 417 (24.9%) were classified as Low MME, 840 (50.2%) as Medium MME, and 416 (24.9%) as High MME. Age significantly decreased with increasing MME (Low: 71.0% 65 + years vs Medium: 62.0% 65 + years vs High: 47.4% 65 + years, p < 0.001), while the proportions of patients presenting with three or more comorbidities were similar across the cohorts (Low: 20.1% with 3 + comorbidities vs Medium: 18.0% with 3 + comorbidities vs High: 24.3% with 3 + comorbidities, p = 0.070). With respect to postoperative outcomes, the proportion of patients who experienced any AE (Low: 60.2% vs Medium: 68.8% vs High: 70.9%, p = 0.002), extended LOS (Low: 6.7% vs Medium: 20.7% vs High: 45.4%, p < 0.001), or non-routine discharge (Low: 66.6% vs Medium: 73.5% vs High: 80.1%, p = 0.003) each increased along with total MME. In addition, rates of 30-day readmission were greatest among the High MME cohort (Low: 8.4% vs Medium: 7.9% vs High: 12.5%, p = 0.022). On multivariate analysis, medium and high MME were associated with prolonged LOS [Medium: OR 4.41, CI (2.90, 6.97); High: OR 13.99, CI (8.99, 22.51), p < 0.001] and increased hospital cost [Medium: OR 1.69, CI (1.21, 2.39), p = 0.002; High: OR 1.66, CI (1.12, 2.46), p = 0.011]. Preadmission long-term opioid use [OR 1.71, CI (1.07, 2.7), p = 0.022], a prior opioid-related disorder [OR 11.32, CI (5.92, 23.49), p < 0.001], and chronic pulmonary disease [OR 1.39, CI (1.06, 1.82), p = 0.018] were each associated with a high inpatient MME on multivariate analysis. CONCLUSION Our study demonstrated that increasing inpatient MME consumption was associated with extended LOS and increased hospital cost in patients undergoing spinal fusion for ASD. Further studies identifying risk factors for increased MME consumption may provide better risk stratification for postoperative opioid use and healthcare resource utilization.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
| | - Mani Ratnesh S Sandhu
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Christina Jayaraj
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Andrew M Hersh
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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Levy HA, Karamian BA, Canseco JA, Henstenburg J, Larwa J, Haislup B, Kaye ID, Woods BI, Radcliff KE, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF? World Neurosurg 2023; 171:e686-e692. [PMID: 36566977 DOI: 10.1016/j.wneu.2022.12.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The purpose of this study is to determine if increased postoperative prescription opioid dosing is an isolated predictor of chronic opioid use after anterior cervical diskectomy and fusion (ACDF). METHODS A retrospective cohort analysis of patients undergoing ACDF for degenerative diseases from 2016-2019 at a single institution was performed. Preoperative and postoperative opioid and benzodiazepine prescriptions, including morphine milligram equivalents (MMEs) and duration of use, were obtained from the Pennsylvania Prescription Drug Monitoring Program. Univariate analysis compared patient demographics and surgical factors across groups on the basis of postoperative opioid dose (high: MME ≥90, low: MME <90) and chronicity of use (chronic: ≥120 days or >10 prescriptions). Logistic regressions identified predictors of high opioid dose and chronic use. RESULTS A total of 385 patients were included. Preoperative opioid tolerance and tobacco use were associated with high postoperative opioid dose and chronic usage. Younger age correlated with high-dose prescriptions. Increased body mass index and preoperative benzodiazepine use were associated with chronic opioid use. Chronic postoperative opioid use correlated with high-dose prescriptions, change in opioid prescribed, private pay scripts, and more than 1 prescriber and pharmacy. Logistic regression identified high postoperative opioid dose, opioid tolerance, increased body mass index, and no prior cervical surgery as predictors of chronic opioid use. Regression analysis determined younger age, increased medical comorbidities, and opioid tolerance to be predictors for high MME prescriptions. CONCLUSIONS High postoperative opioid dose independently predicted chronic opioid use after ACDF regardless of preoperative opioid tolerance.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA.
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffrey Henstenburg
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph Larwa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brett Haislup
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - I David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kris E Radcliff
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Jones IA, Talehakimi A, Murphy LS, Wang JC, Piple AS, Christ AB, Heckmann ND. Duloxetine for Postoperative Pain Control Following Knee or Hip Replacement: A Systematic Review and Meta-Analysis. Arthroplast Today 2023; 20:101097. [PMID: 36852213 PMCID: PMC9957748 DOI: 10.1016/j.artd.2023.101097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/08/2022] [Accepted: 01/02/2023] [Indexed: 03/01/2023] Open
Abstract
Background Duloxetine is a Food and Drug Administration-approved selective norepinephrine reuptake inhibitor for treating depression, anxiety, fibromyalgia, and neuropathic and chronic musculoskeletal pain. This meta-analysis aims to evaluate the efficacy of duloxetine in reducing pain and postoperative opioid use following lower extremity total joint arthroplasty. Methods A literature search was performed, identifying randomized controlled trials investigating duloxetine for pain management after total hip and total knee arthroplasty. Data from the visual analog scale (VAS) for pain during movement and at rest were extracted for postoperative days (PODs) 1, 3, 7, and 14, as well as postoperative week 6 and postoperative month 3. Opioid use data were obtained at 24, 48 and 72 hours. All data were analyzed using inverse variance with random effects and presented as weighted mean difference. Results Eight unique studies were identified and included, 7 of which were analyzed quantitatively. Duloxetine decreased postoperative opioid consumption at 48 and 72 hours. For VAS for pain at rest, significantly reduced pain was reported by duloxetine-treated patients at POD 3, POD 7, and postoperative week 6. For VAS for pain at movement, significantly reduced pain was reported by duloxetine-treated patients at POD1, POD 3, POD 7, POD 14, postoperative week 6, and postoperative month 3. Conclusions Duloxetine appears to decrease postoperative pain and opioid consumption following total joint arthroplasty. However, definitive conclusions are limited by small sample size and study heterogeneity. While there is a need for follow-up studies to determine the optimal dose, duration, and patient population, strong preliminary data provide robust support for future large-scale efficacy studies.
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Affiliation(s)
- Ian A. Jones
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Arad Talehakimi
- Kansas City University College of Osteopathic Medicine, Kansas City, MO, USA
| | - Linda S. Murphy
- Irvine Libraries Reference Department, University of California, Irvine, CA, USA
| | - Jennifer C. Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Amit S. Piple
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Alexander B. Christ
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Nathanael D. Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
- Corresponding author. Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1520 San Pablo Street, Ste 2000, Los Angeles, CA 90333. Tel.: +1 323 704 6363.
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Impact of Perioperative Ketamine on Postoperative Bariatric Surgery Opioid Use and Length of Stay. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:50-54. [PMID: 36729562 DOI: 10.1097/sle.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/24/2022] [Indexed: 02/03/2023]
Abstract
SETTINGS Postoperative pain management is an ever-growing challenge with the rise of the opioid crisis. Ketamine is an NMDA channel blocker, considered an alternative to perioperative opioid use; small concentrations are safe. Objective: The primary objective of this study was to evaluate the impact of perioperative ketamine administration on postoperative opioid use and the length of hospital stay in bariatric patients. METHODS Four hundred (366) charts were retrospectively reviewed; of those, 187 received ketamine and were placed in the Ketamine group, 179 received standard-of-care pain management and were part of the No-Ketamine group. Data was collected using medical databases from July 2020 to January 2021. RESULTS A greater length of stay was recorded in the No-Ketamine group (45.67±20.6 hours) when compared with the Ketamine group (40.6±14.3 hours); P <0.05. The Ketamine group had a mean MME of 17.5±16.5 whereas the No-Ketamine had a mean MME of 22.3±17.7, P <0.05. CONCLUSIONS Ketamine may be a feasible alternative to reduce opioid use and hospital length of stay. We believe that ketamine can be an important contribution to ERABS pathways, being responsible for improved outcomes after bariatric/metabolic surgical procedures.
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Komatsu R, Nash MG, Wu J, Dinges EM, Delgado CM, Bollag LA. Prediction of postoperative respiratory depression and respiratory complications in patients on preoperative methadone. J Anesth 2023; 37:79-91. [PMID: 36352048 DOI: 10.1007/s00540-022-03134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/29/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE We developed prediction models for postoperative respiratory depression and respiratory complications for 958 patients who were on methadone preoperatively. METHODS The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/min, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. Secondary outcome was the composite of postoperative respiratory complications. Prediction models for postoperative respiratory depression and respiratory complications were constructed using multivariate logistic regression with preoperative and intraoperative characteristics as the predictors. RESULTS For the multivariate logistic regression model for postoperative respiratory depression, surgery duration (P = 0.005), body mass index (BMI) (P = 0.008), surgery involving digestive system (P = 0.031), and American Society of Anesthesiologists (ASA) physical status ≥ 4 (P = 0.038) were statistically significant predictors. The area under the receiver operating characteristic curve (AUROC) of the model was 0.581 (0.558-0.601) [median (95% confidence interval (CI))] with fivefold cross-validation. For the model for postoperative respiratory complications, surgery duration (P = 0.001), history of hypertension (P = 0.028), surgery involving musculoskeletal system (P < 0.001), surgery involving integumental system (P = 0.034), surgery categorized to miscellaneous therapeutic procedures (P = 0.028), combined general and regional anesthesia (P = 0.033), ASA physical status 3 (P < 0.001), and ASA physical status ≥ 4 (P < 0.001) were statistically significant predictors, and AUROC of the model was 0.726 (0.712-0.737). CONCLUSIONS Multivariate logistic regression models including preoperative, and intraoperative characteristics as the predictors performed poorly to predict postoperative respiratory depression, and moderately for postoperative respiratory complications. Neither model is accurate enough to be subject to clinical use.
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Affiliation(s)
- Ryu Komatsu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA. .,Department of General Anesthesiology, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Michael G Nash
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Jiang Wu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Emily M Dinges
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Carlos M Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Laurent A Bollag
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Kim Y, Pacor JM, Do A, Brennan J, Fiellin DA, Edelman EJ. Outcomes of Patients with Opioid-Related Diagnoses in Acute Coronary Syndrome: a National Inpatient Sample-Based Analysis. J Gen Intern Med 2023; 38:563-570. [PMID: 36376632 PMCID: PMC9971420 DOI: 10.1007/s11606-022-07399-3] [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: 10/20/2020] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) and opioid use are both major causes of morbidity and mortality globally. Although epidemiological studies point to increased risk of ACS in opioid users, in-hospital management and outcomes are unknown for this population when presenting with ACS. We sought to determine whether there are differences for in-hospital outcomes and management of ACS for those with and without opioid-related diagnoses (ORD). METHODS AND RESULTS From the National Inpatient Sample database, we extracted patients hospitalized between 2012 and 2016 for ACS. The primary independent variable was ORD by International Classification of Diseases, 9th and 10th Revision, codes. The primary outcome was in-hospital mortality; secondary outcomes were cardiac arrest, receipt of angiogram, and percutaneous coronary intervention (PCI). Statistical comparisons were performed using χ2 test and Student's t test. Multivariable logistic regression was performed to determine the independent association between ORD and outcomes of interest. Among the estimated 5.8 million admissions for ACS, the proportion of patients with ORD increased over the study period (p for trend < 0.01). Compared to patients without ORD presenting with ACS, patients with ORD were younger with fewer cardiovascular risk factors. Yet, in-hospital mortality was higher in patients with ORD presenting with ACS (AOR 1.36, 95% CI 1.26-1.48). Patients with ORD were more likely to experience in-hospital cardiac arrest (AOR 1.42, 95% CI 1.23-1.63) and less likely to undergo angiogram (AOR 0.42, 95% CI 0.38-0.45) or PCI (AOR 0.30, 95% CI 0.28-0.32). CONCLUSION Despite evidence of increased risk of mortality and cardiac arrest, patients with ORD admitted for ACS are less likely to receive ACS management.
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Affiliation(s)
- Yeunjung Kim
- Division of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Justin M. Pacor
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Albert Do
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Joseph Brennan
- Division of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - David A. Fiellin
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT USA
| | - E. Jennifer Edelman
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT USA
- Department of Social and Behavioral Medicine, Yale School of Public Health, New Haven, CT USA
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Kugelman DN, Mahure SA, Feng JE, Rozell JC, Schwarzkopf R, Long WJ. Total knee arthroplasty is associated with greater immediate post-surgical pain and opioid use than total hip arthroplasty. Arch Orthop Trauma Surg 2022; 142:3575-3580. [PMID: 33991234 DOI: 10.1007/s00402-021-03951-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA. METHODS A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution's standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress. RESULTS A total of 11,693 cases were identified: 5,909 THA (50.53%) and 5784 (49.47%) TKA. THA patients tended to be slightly younger (63.38 years, SD 11.61 years, vs 65.72 years, SD 9.56 years; p < 0.01) and have lower BMIs (28.92 kg/m2 vs 32.52 kg/m2; p < 0.01). THA patients had lower ASA scores in comparison to TKA patients (p < 0.01). Aggregate opioid consumption (93.76 MME vs 147.55 MME; p < 0.01) along with first 24-h and 48-h usage was significantly less for THA as compared to TKA. Similarly, mean pain scores (4.15 vs 5.08; p < 0.01) were lower for THA, while AMPAC mobilization scores were higher (20.88 vs 19.29; p < 0.01) when compared to TKA. CONCLUSION THA patients reported lower pain scores and were found to require less opioid medication in the immediate post-surgical period than TKA patients.
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Affiliation(s)
- David N Kugelman
- New York University Langone Orthopaedic Hospital, 301 East 17 St, Manhattan, New York, NY, 10003, USA
| | - Siddharth A Mahure
- New York University Langone Orthopaedic Hospital, 301 East 17 St, Manhattan, New York, NY, 10003, USA
| | - James E Feng
- New York University Langone Orthopaedic Hospital, 301 East 17 St, Manhattan, New York, NY, 10003, USA
| | - Joshua C Rozell
- New York University Langone Orthopaedic Hospital, 301 East 17 St, Manhattan, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- New York University Langone Orthopaedic Hospital, 301 East 17 St, Manhattan, New York, NY, 10003, USA
| | - William J Long
- New York University Langone Orthopaedic Hospital, 301 East 17 St, Manhattan, New York, NY, 10003, USA.
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Use of Hand Therapy After Distal Radius Fracture: A National Perspective. J Hand Surg Am 2022; 47:1117.e1-1117.e9. [PMID: 34666936 DOI: 10.1016/j.jhsa.2021.08.018] [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: 03/06/2020] [Revised: 06/29/2021] [Accepted: 08/25/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy. METHODS Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest. RESULTS In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use. CONCLUSIONS This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy. CLINICAL RELEVANCE Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.
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Li M, Sun W, Zhou R, Huang Y, Meng F, Luo L, Yan Z, Shi X, Huang F, Fan C, Jiang Z. Non-pharmaceutical treatments to relieve pain or reduce opioid analgesic intake and improve quality of life after total hip replacement: a meta analysis. Am J Transl Res 2022; 14:6828-6845. [PMID: 36398259 PMCID: PMC9641482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/30/2022] [Indexed: 06/16/2023]
Abstract
To reduce pain after total hip replacement (THR), researchers are interested in drug-free interventions. However, there is still a lack of consensus on their prevention efficacy. We performed a meta-analysis to evaluate the use of nonpharmaceutical interventions for postoperative pain management after THR. We searched the Cochrane Library, MEDLINE, EMBASE, Web of Science, PEDRO, and ClinicalTrials.gov databases for articles published between and 1991 and 2020. The main outcome measures were postoperative pain, opioid consumption, and quality of life (QoL). In total, 1,942 patients were studied. We found moderate evidence indicating postoperative pain relief measured by the Western Ontario and McMaster Universities Arthritis Index Scale, with mean differences (MDs) of -0.28 (95% confidence interval [CI], -0.49 to -0.07; P=0.01; I2 =0%) within three months, -0.19 (95% CI, -0.40 to 0.02; P=0.07; I2 =0%) between 3-6 months, and -0.13 (95% CI, -0.35 to 0.08; P=0.21; I2 =0%) between 6-12 months. Additionally, we found that acupuncture therapy could reduce opioid analgesic consumption (MD, -0.98; 95% CI, -1.18 to -0.79; fentanyl [mg/h]; P<0.01; I2 =72.2%) and significantly improve pain relief with an MD of 0.90 (95% CI, 0.47 to 1.33; P<0.01; I2 =0%) measured using the visual analog scale. Electrotherapy slightly improved perceived pain with an MD of 0.22 (95% CI, -0.27 to 0.70; P=0.37; I2 =0%). Moreover, moderate evidence has shown that preoperative exercises improve QoL. This meta-analysis suggested that continuous passive motion did not improve pain or QoL. Postoperative exercise was associated with pain relief and improved QoL. Acupuncture therapy after THR has been shown to reduce opioid analgesic consumption.
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Affiliation(s)
- Minying Li
- Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Weipeng Sun
- First Clinical College, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Ruoyu Zhou
- First Clinical College, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Yingjie Huang
- Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Fanhang Meng
- Department of Organ Transplantation, The Second Affiliated Hospital of Guangzhou University of Chinese MedicineGuangzhou 510000, Guangdong, China
| | - Lieliang Luo
- First Clinical College, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Zijian Yan
- First Clinical College, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Xiaofan Shi
- Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese MedicineGuangzhou 510006, Guangdong, China
| | - Feng Huang
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese MedicineGuangzhou 510405, Guangdong, China
| | - Chun Fan
- Guangzhou University of Chinese MedicineGuangzhou 510000, Guangdong, China
| | - Ziwei Jiang
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese MedicineGuangzhou 510405, Guangdong, China
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Bakewell BK, Townsend CB, Ly JA, Sherman M, Abdelfattah HM, Solarz M, Woozley K, Ilyas AM. The Effect of Preoperative Benzodiazepine Usage on Postoperative Opioid Consumption After Hand Surgery: A Multicenter Analysis. Cureus 2022; 14:e29609. [PMID: 36321037 PMCID: PMC9601921 DOI: 10.7759/cureus.29609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/01/2022] Open
Abstract
Background Prescription rates of opioids and benzodiazepines have steadily increased in the last decade with the percentage of prescription opioid overdose deaths involving benzodiazepines more than doubling during that time. Orthopaedic surgery is one of the highest-volume opioid prescribing medical specialties, but the effects of benzodiazepine use on orthopaedic surgery patient outcomes are not well understood. The purpose of the study was to utilize the state Prescription Drug Monitoring Program (PDMP) database to investigate if perioperative benzodiazepine use predisposes patients to prolonged opioid use following hand and upper extremity orthopaedic surgery. Methods This study was retrospective and conducted at three urban academic institutions. All patients who underwent carpal tunnel release, thumb basal joint arthroplasty, and distal radius fracture open reduction internal fixation performed by 14 board-certified, fellowship-trained orthopaedic hand and upper extremity surgeons between April 2018 and August 2019, were collected via a database query. All opioid and benzodiazepine prescriptions were collected from three months preoperatively to six months postoperatively. Results In this study, 634 patients met the inclusion criteria presented to one of the three institutions during the 18-month study period. Patients consisted of 276 carpal tunnel releases, 217 distal radius fracture open reduction internal fixations, and 141 thumb basal joint arthroplasties. Benzodiazepine users were 14.6% more likely to fill an additional opioid prescription (p<0.005) and were 10.8% more likely to experience prolonged three to six-month postoperative opioid use (p<0.005). Conclusion This study found that patients who use benzodiazepines are at a higher risk of filling additional opioid prescriptions and prolonged opioid use following hand and upper extremity surgery. Prescribers should take this into account when prescribing opioids after upper extremity orthopaedic surgery.
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Martin CE, Thakkar B, Cox L, Johnson E, Jones HE, Connolly A. Beyond opioid prescribing: Evaluation of a substance use disorder curriculum for OBGYN residents. PLoS One 2022; 17:e0274563. [PMID: 36107914 PMCID: PMC9477269 DOI: 10.1371/journal.pone.0274563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/30/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Amidst the current opioid crisis, there is a need for better integration of substance use disorder screening and treatment across specialties. However, there is no consensus regarding how to best instruct OBGYN trainees in the clinical skills related to opioid and other substance use disorders (SUD). Study objectives were (1) to assess the effectiveness a SUD curriculum to improve self-reported competence among OBGYN residents and (2) to explore its effectiveness to improve attending evaluations of residents’ clinical skills as well as its feasibility and acceptability from the resident perspective. Methods A pilot 3-session curriculum was developed and adapted to SUD screening and treatment which included readings, didactics, and supervised outpatient clinical experiences for OBGYN post-graduate year 1 (PGY-1) residents rotating through an integrated OBGYN-SUD clinic. Eighteen residents completed pre and post clinical skills self-assessments (SUD screening, counseling, referring, Motivational Interviewing) using an adapted Zwisch Rating Scale (range 1–5). Scores were compared between time points using paired t-tests. Sub-samples also (a) were evaluated by the attending on three relevant Accreditation Council for Graduate Medical Education Milestones (ACGME) milestone sets using the web-based feedback program, myTIPreport (n = 10) and (b) completed a qualitative interview (n = 4). Results All PGY-1s (18/18) across three academic years completed the 3-session SUD curriculum. Clinical skill self-assessments improved significantly in all areas [SUD Screening (2.44 (0.98) vs 3.56 (0.62), p = <0.01); Counseling (1.81 (0.71) vs 3.56 (0.51), p = < .01; Referring (2.03 (0.74) vs 3.17 (0.71), p = < .01; Motivational Interviewing (1.94 (1.06) vs 3.33 (0.69), p = < .01)]. Milestone set levels assigned by attending evaluations (n = 10) also improved. Qualitative data (n = 4) revealed high acceptability; all curriculum components were viewed positively, and feedback was provided (e.g., desire for more patient exposures). Conclusion A pilot SUD curriculum tailored for OBGYN PGY-1 residents that goes beyond opioid prescribing to encompass SUD management is feasible, acceptable and likely effective at improving SUD core clinical skills.
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Affiliation(s)
- Caitlin E. Martin
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- Institute of Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- * E-mail:
| | - Bhushan Thakkar
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Lauren Cox
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Elisabeth Johnson
- Department of Obstetrics and Gynecology, UNC Horizons, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Hendrée E. Jones
- Department of Obstetrics and Gynecology, UNC Horizons, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - AnnaMarie Connolly
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
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Roy S, Bruehl S, Feng X, Shotwell MS, Van De Ven T, Shaw AD, Kertai MD. Developing a risk stratification tool for predicting opioid-related respiratory depression after non-cardiac surgery: a retrospective study. BMJ Open 2022; 12:e064089. [PMID: 36219738 PMCID: PMC9445779 DOI: 10.1136/bmjopen-2022-064089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Accurately assessing the probability of significant respiratory depression following opioid administration can potentially enhance perioperative risk assessment and pain management. We developed and validated a risk prediction tool to estimate the probability of significant respiratory depression (indexed by naloxone administration) in patients undergoing noncardiac surgery. DESIGN Retrospective cohort study. SETTING Single academic centre. PARTICIPANTS We studied n=63 084 patients (mean age 47.1±18.2 years; 50% men) who underwent emergency or elective non-cardiac surgery between 1 January 2007 and 30 October 2017. INTERVENTIONS A derivation subsample reflecting two-thirds of available patients (n=42 082) was randomly selected for model development, and associations were identified between predictor variables and naloxone administration occurring within 5 days following surgery. The resulting probability model for predicting naloxone administration was then cross-validated in a separate validation cohort reflecting the remaining one-third of patients (n=21 002). RESULTS The rate of naloxone administration was identical in the derivation (n=2720 (6.5%)) and validation (n=1360 (6.5%)) cohorts. The risk prediction model identified female sex (OR: 3.01; 95% CI: 2.73 to 3.32), high-risk surgical procedures (OR: 4.16; 95% CI: 3.78 to 4.58), history of drug abuse (OR: 1.81; 95% CI: 1.52 to 2.16) and any opioids being administered on a scheduled rather than as-needed basis (OR: 8.31; 95% CI: 7.26 to 9.51) as risk factors for naloxone administration. Advanced age (OR: 0.971; 95% CI: 0.968 to 0.973), opioids administered via patient-controlled analgesia pump (OR: 0.55; 95% CI: 0.49 to 0.62) and any scheduled non-opioids (OR: 0.63; 95% CI: 0.58 to 0.69) were associated with decreased risk of naloxone administration. An overall risk prediction model incorporating the common clinically available variables above displayed excellent discriminative ability in both the derivation and validation cohorts (c-index=0.820 and 0.814, respectively). CONCLUSION Our cross-validated clinical predictive model accurately estimates the risk of serious opioid-related respiratory depression requiring naloxone administration in postoperative patients.
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Affiliation(s)
- Sounak Roy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas Van De Ven
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Aneizi A, Gelmann D, Ventimiglia DJ, Sajak PMJ, Nadarajah V, Foster MJ, Weir TB, Akabudike NM, Pensy RA, Henn RF. Preoperative Opioid Use in Patients Undergoing Common Hand Surgeries. Hand (N Y) 2022; 17:905-912. [PMID: 33467941 PMCID: PMC9465804 DOI: 10.1177/1558944720974122] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The objectives of this study were to determine the baseline patient characteristics associated with preoperative opioid use and to establish whether preoperative opioid use is associated with baseline patient-reported outcome measures in patients undergoing common hand surgeries. METHODS Patients undergoing common hand surgeries from 2015 to 2018 were retrospectively reviewed from a prospective orthopedic registry at a single academic institution. Medical records were reviewed to determine whether patients were opioid users versus nonusers. On enrollment in the registry, patients completed 6 Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function, Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression), the Brief Michigan Hand Questionnaire (BMHQ), a surgical expectations questionnaire, and Numeric Pain Scale (NPS). Statistical analysis included multivariable regression to determine whether preoperative opioid use was associated with patient characteristics and preoperative scores on patient-reported outcome measures. RESULTS After controlling for covariates, an analysis of 353 patients (opioid users, n = 122; nonusers, n = 231) showed that preoperative opioid use was associated with higher American Society of Anesthesiologists class (odds ratio [OR], 2.88), current smoking (OR, 1.91), and lower body mass index (OR, 0.95). Preoperative opioid use was also associated with significantly worse baseline PROMIS scores across 6 domains, lower BMHQ scores, and NPS hand scores. CONCLUSIONS Preoperative opioid use is common in hand surgery patients with a rate of 35%. Preoperative opioid use is associated with multiple baseline patient characteristics and is predictive of worse baseline scores on patient-reported outcome measures. Future studies should determine whether such associations persist in the postoperative setting between opioid users and nonusers.
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Affiliation(s)
- Ali Aneizi
- University of Maryland School of
Medicine, Baltimore, USA
| | | | | | | | | | | | | | | | | | - R. Frank Henn
- University of Maryland School of
Medicine, Baltimore, USA
- University of Maryland School of
Medicine and University of Maryland Rehabilitation & Orthopaedic Institute,
Baltimore, USA
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Levy HA, Karamian BA, Larwa J, Henstenburg J, Canseco JA, Haislup B, Chang M, Patel P, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Is Patient Geography a Risk Factor for Chronic Opioid Use After ACDF? Am J Med Qual 2022; 37:464-471. [PMID: 35951341 DOI: 10.1097/jmq.0000000000000077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The social and medical implications intrinsic to patient zip codes with high opioid fatality may reveal residence in these locations to be a risk factor predicting chronic opioid use after anterior cervical discectomy and fusion (ACDF). The purpose of this study is to determine if residence in Pennsylvania zip codes with high incidence of opioid overdose deaths is a risk factor for chronic postoperative opioid use after ACDF. Preoperative opioid usage did not vary meaningfully between high- and low-risk zip code groups. Patients in high-risk opioid overdose zip codes were significantly more likely to exhibit chronic postoperative opioid use. The Kaplan-Meier curve demonstrated that opioid discontinuation was less probable at any postoperative time for patients residing in high opioid fatality zip codes. Logistic regression found opioid tolerance, smoking, and depression to predict extended opioid use.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Evidenced-Based Opioid Prescribing Recommendations Following Hand and Upper-Extremity Surgery. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:276-282. [PMID: 36157302 PMCID: PMC9492791 DOI: 10.1016/j.jhsg.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/28/2022] [Indexed: 12/03/2022] Open
Abstract
The United States’ opioid epidemic has taken an immense toll over the past 2 decades when assessed by morbidities, mortalities, and economic costs. Prescription opioids are a substantial contribution to this public health emergency, and it is critical for health care providers to practice good analgesic stewardship. Interventions have effectively curtailed opioid overuse, including prescription drug monitoring programs, educational initiatives, and multimodal analgesia strategies. Surgeons, particularly hand surgeons or those who perform musculoskeletal procedures, have been implicated as high-volume opioid prescribers. Guidelines for appropriate opioid dosing and analgesic management strategies after common hand and upper-extremity surgeries are sparse and offer an area for meaningful improvement. We sought to generate comprehensive, evidence-based recommendations for postoperative analgesia regimens for common hand and upper-extremity procedures.
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