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Babino JM, Thornton JD, Putney K, Bethany Taylor R, Wanat MA. Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers. J Pharm Pract 2023; 36:1077-1084. [PMID: 35410543 DOI: 10.1177/08971900221088797] [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: 09/22/2023]
Abstract
Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.
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Affiliation(s)
- Justin M Babino
- Department of Pharmacy, Baylor St Luke's Medical Center, Houston, TX, USA
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX, USA
- Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kimberly Putney
- Department of Pharmacy, Baylor St Luke's Medical Center, Houston, TX, USA
| | | | - Matthew A Wanat
- Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, Houston, TX, USA
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
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McCorquodale CL, Greening R, Tulloch R, Forget P. Opioid prescribing for acute postoperative pain: an overview of systematic reviews related to two consensus statements relevant at patient, prescriber, system and public health levels. BMC Anesthesiol 2023; 23:294. [PMID: 37648969 PMCID: PMC10468854 DOI: 10.1186/s12871-023-02243-5] [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: 04/28/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND National guidelines for rational opioid prescribing for acute postoperative pain are needed to optimise postoperative pain control and function whilst minimising opioid-related harm. OBJECTIVES This overview of systematic reviews aims to summarise and critically assess the quality of systematic reviews related to the 20 recommendations from two previously published consensus guideline papers (ten relevant at patient and prescriber levels and ten at a system / Public Health level). It also aims to identify gaps in research that require further efforts to fill these in order to augment the evidence behind creating national guidelines for rational opioid prescribing for acute postoperative pain. METHODS A systematic database search using PubMed/MEDLINE and Cochrane was conducted in November 2022. Furthermore, reference lists were reviewed. All identified systematic reviews were assessed for eligibility. Data from each study was extracted using a pre-standardised data extraction form. The methodological quality of the included reviews was assessed by two independent reviewers using the AMSTAR 2 checklist. Descriptive synthesis of the results was performed. RESULTS A total of 12 papers were eligible for analysis. Only eight out of the total 20 prioritised recommendations had systematic reviews that provided evidence related to them. These systematic reviews were most commonly of critically low quality. CONCLUSION The consensus papers provide guidance and recommendations based on the consensus of expert opinion that is based on the best available evidence. However, there is a lack of evidence supporting many of these consensus statements. Efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should therefore continue.
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Affiliation(s)
- C L McCorquodale
- University of Aberdeen School of Medicine, Medical Sciences and Nutrition, Aberdeen, Scotland, UK.
| | - R Greening
- NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - R Tulloch
- University of Aberdeen School of Medicine, Medical Sciences and Nutrition, Aberdeen, Scotland, UK
| | - P Forget
- University of Aberdeen School of Medicine, Medical Sciences and Nutrition, Aberdeen, Scotland, UK
- Department of Anaesthetics, NHS Grampian, Aberdeen, Scotland, UK
- Pain AND Opioid After Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Brussels, Belgium
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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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Adams TJ, Aljohani DM, Forget P. Perioperative opioids: a narrative review contextualising new avenues to improve prescribing. Br J Anaesth 2023; 130:709-718. [PMID: 37059626 DOI: 10.1016/j.bja.2023.02.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 04/16/2023] Open
Abstract
Opioids have dominated the management of perioperative pain in recent decades with higher doses than ever before used in some circumstances. Through the expanding use of opioids, growing research has highlighted their associated side-effects and the intertwined phenomena of acute withdrawal syndrome, opioid tolerance, and opioid-induced hyperalgesia. With multiple clinical guidelines now endorsing multimodal analgesia, a diverse array of opioid-sparing agents emerges and has been studied to variable degrees, including techniques of opioid-free anaesthesia. It remains unclear to what extent such methods should be adopted, yet current evidence does suggest dependence on opioids as the primary perioperative analgesic might not meet the principles of 'rational prescribing' as described by Maxwell. In this narrative review we describe how, using current evidence, a patient-centred rational-prescribing approach can be applied to opioids in the perioperative period. To contextualise this approach, we discuss the historical adoption of opioids in anaesthesia, our growing understanding of associated side-effects and emerging strategies of opioid-sparing and opioid-free anaesthesia. We discuss avenues and challenges for improving opioid prescribing to limit persistent postoperative opioid use and how these may be incorporated into a rational-prescribing approach.
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Affiliation(s)
- Tobias J Adams
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK.
| | - Dalia Mohammed Aljohani
- Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK; Department of Anesthesia Technology, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Patrice Forget
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
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Opioid PrEscRiptions and usage After Surgery (OPERAS): protocol for a prospective multicentre observational cohort study of opioid use after surgery. BMJ Open 2022; 12:e063577. [PMID: 36332960 PMCID: PMC9639103 DOI: 10.1136/bmjopen-2022-063577] [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: 11/06/2022] Open
Abstract
INTRODUCTION Postoperative pain is common and frequently addressed through opioid analgesia. This practice must balance the benefits of achieving adequate pain relief against the harms of adverse effects such as opioid-induced ventilatory impairment and opioid use disorder. This student and trainee-led collaborative study aims to investigate and compare the prescription versus consumption of opioids at 7 days postdischarge after common surgical procedures and their impact on patient-reported outcomes regarding postoperative pain. METHODS AND ANALYSIS This is a prospective multicentre observational cohort study of surgical patients in Australia, Aotearoa New Zealand and select international sites, conducted by networks of students, trainees and consultants. Consecutive adult patients undergoing common elective and emergency general, orthopaedic, gynaecological and urological surgical procedures are eligible for inclusion, with follow-up 7 days after hospital discharge. The primary outcome will be the proportion of prescribed opioids consumed by patients at 7 days postdischarge. Secondary outcomes will include patient-reported quality of life and satisfaction scores, rate of non-opioid analgesic use, rate of continuing use of opioids at follow-up, rates of opioid prescription from other sources and hospital readmissions at 7 days postdischarge for opioid related side-effects or surgery-related pain. Descriptive and multivariate analyses will be conducted to investigate factors associated with opioid requirements and prescription-consumption discrepancies. ETHICS AND DISSEMINATION OPERAS has been approved in Australia by the Hunter New England Human Research Ethics Committee (Protocol 2021/ETH11508) and by the Southern Health and Disability Ethics Committee (2021 EXP 11199) in Aotearoa New Zealand. Results will be submitted for conference presentation and peer-reviewed publication. Centre-level data will be distributed to participating sites for internal audit. TRIAL REGISTRATION NUMBER ANZCTR (ID: ACTRN12621001451897p).
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Arwi GA, Tuffin PHR, Schug SA. Evaluating Adherence of Evidence-Based Post-Operative Discharge Opioid Prescribing Guidelines and Patient Outcomes Two Weeks Post-Discharge. J Pain Res 2022; 15:3115-3125. [PMID: 36247825 PMCID: PMC9562842 DOI: 10.2147/jpr.s345241] [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: 10/20/2021] [Accepted: 08/14/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction There is a growing public health concern regarding inappropriate prescribing practices of discharge analgesia. A tertiary Australian hospital first developed its Postoperative Inpatients Discharge Analgesia Guidelines after an initial audit in 2015. Adherence to the guidelines were evaluated in 2016 and 2017 which show reduced compliance from 93.5% in 2016 to 83.4% in 2017. Aim To assess ongoing compliance with the guidelines five years following its implementation and to evaluate patient outcome in terms of its clinical impact and minimization of harmful events. Methods Prescribing data were obtained for discharge analgesic medication for 200 surgical patients from August 2019 to April 2020. Records were assessed against the hospital's Postoperative Inpatients Discharge Analgesia Guidelines and compared with equivalent data from the previous 2015, 2016, and 2017 audits. Patients were interviewed by telephone two weeks after hospital discharge. Results Prescribing of analgesia was most compliant with overall guidelines for paracetamol (100% unchanged from 2017), followed by celecoxib (98%, up from 96% in 2017), tramadol IR (89% up from 74% in 2017), and pregabalin (89% up from 50% in 2017). Two weeks after discharge, 112 (56%) patients were surveyed and reported a mean pain-score of 2 (95% CI 1.5-2.5) out of 10 at that time. Thirty-two (29%) patients interviewed were still taking pain medication, with 17 (53%) taking medication supplied from the hospital. Seventy-eight (88%) patients stored their pain medication in an unlocked location. Among those no longer taking analgesia, 28 (43%) had unused pain medications, and only two (6%) had returned these to a community pharmacist. Conclusion This study found that compliance with hospital discharge analgesia prescribing guidelines has increased, although there is room for improvement. Follow-up of the participants reveals high rates of unused opioids, improper storage and disposal of their pain medication.
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Affiliation(s)
- Gerardo A Arwi
- Royal Perth Hospital, Perth, Western Australia, Australia,Anaesthesiology and Pain Medicine, University of Western Australia, Perth, Western Australia, Australia,Correspondence: Gerardo A Arwi, Email
| | | | - Stephan A Schug
- Anaesthesiology and Pain Medicine, University of Western Australia, Perth, Western Australia, Australia
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Dyson MP, Dong K, Sevcik W, Graham SZ, Saba S, Hartling L, Ali S. Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta‐analysis. J Am Coll Emerg Physicians Open 2022; 3:e12822. [PMID: 36203538 PMCID: PMC9523453 DOI: 10.1002/emp2.12822] [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: 04/29/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/08/2022] Open
Abstract
Objective To quantify unused opioids among adult and pediatric patients discharged from the emergency department (ED) or ambulatory care settings with a prescription for acute pain. Methods We searched MEDLINE, Embase, CINHAL, PsycINFO, the Cochrane Library, and the gray literature from inception to April 29, 2021. We included observational studies in which any patient with an acutely painful condition received a prescription for an opioid on discharge from an outpatient care setting, and unused opioids were quantified. Two reviewers screened records for eligibility, extracted data, and conducted the quality assessment. Where possible, we pooled data and otherwise described the results of studies narratively. Total unused prescriptions were synthesized using a weighted average. Random effects models were used, and heterogeneity was measured by the I2 statistic. Our primary outcome was the quantity of unused opioid medication available after receiving a prescription for acute pain. Secondary outcomes were the proportion of patients with unused opioids following a prescription, the proportion of patients using no opioids, morphine equivalents of unused opioids, and factors associated with leftover opioids. Results In this systematic review and meta‐analysis of 9 studies in emergency and ambulatory care settings, 59.6% of prescribed opioids remained unused; pediatric patients had 69.3% of their prescriptions remaining, compared to 54.6% among adult patients. The highest proportion of unused opioids was found following dental extractions (82.6%). Conclusions and Relevance More than 50% of opioids remain unused following prescriptions for acute pain. Responsible prescribing must be accompanied by education on safer use, storage, and disposal.
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Affiliation(s)
- Michele P. Dyson
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Kathryn Dong
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
- Inner City Health and Wellness Program Royal Alexandra Hospital Edmonton Alberta Canada
| | - William Sevcik
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Samir Z. Graham
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Sabrina Saba
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Lisa Hartling
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
| | - Samina Ali
- Department of Pediatrics University of Alberta Edmonton Alberta Canada
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
- Women and Children's Health Research Institute University of Alberta Edmonton Alberta Canada
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Murphy L, Leblanc K, Badr S, Ching E, Mao L, Steenhof N, Hamandi B, Rubin B, Seto A, Furlan AD. Opioid Utilization and Management in the Setting of Stewardship During Inpatient Rehab Care. Drug Healthc Patient Saf 2022; 14:161-170. [PMID: 36118374 PMCID: PMC9477087 DOI: 10.2147/dhps.s360832] [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: 02/04/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Opioid utilization and management in an inpatient rehabilitation setting have not been widely described, despite the unique opportunities that exist in this setting to support opioid stewardship across transitions in care. We aimed to characterize opioid utilization and management by interprofessional teams across a large, inpatient rehabilitation setting after incorporation of opioid stewardship principles by pharmacists as part of their daily practice. Patients and methods This was a retrospective chart review at Toronto Rehab, University Health Network, Toronto, Canada. Patients with admission orders for any opioid from November 2017 to February 2018 were included. Complex continuing care and palliative care patients were excluded. Descriptive statistics were primarily used to describe the data as well as univariate linear regression to compare associations with milligram morphine equivalent (MME) reduction. Results A total of 448 patients were included. A reduction in total daily MME was seen in 49% (n=219) of the patients during their inpatient stay, with 73% (n=159) of these patients having a reduction of ≥50%. Sixty-nine percent (n=311) of the patients received an opioid prescription at discharge, with most scheduled (90%, n=98) with a supply of less than 30 days. Rehabilitation length of stay was correlated with a MME decrease during rehab (p<0.01), suggesting that longer lengths of stay contributed to a greater reduction in MME. Patients with chronic opioid use prior to acute care admission (p=0.01), and those who started extended-release opioids during acute care (p=0.02) were significantly less likely to discontinue opioids during rehab stay. Conclusion Opioid utilization and management in the setting of opioid stewardship across inpatient rehab and transitions of care were characterized. Opportunities exist for further quality improvement initiatives within inpatient rehabilitation and acute care settings to identify and support patients with complex pain management needs.
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Affiliation(s)
- Laura Murphy
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Correspondence: Laura Murphy, Department of Pharmacy, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada, Tel +1 416-597-3422 x 3657, Fax +1 416-260-2658, Email
| | - Kori Leblanc
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Souzi Badr
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Emily Ching
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Lynda Mao
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Naomi Steenhof
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Bassem Hamandi
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Bonita Rubin
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Ada Seto
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Andrea D Furlan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Work & Health, Toronto, ON, Canada
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Woods A, Drovandi A, Konstantatos A, Bui T. Appropriateness of gabapentinoid prescription for surgical and trauma pain in gabapentinoid‐naïve patients: a retrospective review. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Aaron Woods
- Pharmacy Department Alfred Health Melbourne Australia
- College of Medicine and Dentistry James Cook University Townsville Australia
| | - Aaron Drovandi
- College of Medicine and Dentistry James Cook University Townsville Australia
| | - Alex Konstantatos
- Anaesthesia and Perioperative Medicine Department Alfred Health Melbourne Australia
- Medicine Nursing and Health Sciences Monash University Melbourne Australia
| | - Thuy Bui
- Pharmacy Department Alfred Health Melbourne Australia
- Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Australia
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Suckling B, Pattullo C, Liu S, James P, Donovan P, Patanwala A, Penm J. Persistent opioid use after hospital discharge in Australia: a systematic review. AUST HEALTH REV 2022; 46:367-380. [PMID: 35545810 DOI: 10.1071/ah21353] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/17/2022] [Indexed: 11/23/2022]
Abstract
ObjectiveThis systematic review identified studies that provided an estimate of persistent opioid use following patient discharge from hospital settings in Australia.MethodsA literature search was performed on 5 December 2020, with no date restrictions to identify studies that reported a rate of persistent opioid use following patient discharge from Australian Hospitals. The search strategy combined all terms relating to the themes 'hospital patients', 'prescribing', 'opioids' and 'Australia'. Studies that dealt solely with cancer, palliative care or addiction medicine were excluded. The databases searched in this review were Embase, PubMed, Scopus, CINAHL, and International Pharmaceutical Abstracts. Studies were assessed for bias using the Newcastle-Ottawa Scale and considered against international literature.ResultsIn total, 13 publications are included for final analysis in this review. Of these, 11 articles relate to post-surgical opioid use. With one exception, studies were of a 'good' quality. Methods of data collection in included studies were a mixture of those conducting follow up of patients directly over time and those utilising dispensing databases. Persistent opioid use among surgical patients generally ranged from 3.9 to 10.5% at between 2 and 4 months after discharge.ConclusionsHow rates of persistent opioid use following hospital encounters in Australia are established, and how long after discharge rates are reported, is heterogeneous. Literature primarily relates to post-surgical patients, with very few studies investigating other settings such as encounters with the emergency department.
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Affiliation(s)
- Benita Suckling
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; and Caboolture Hospital Pharmacy Department, Metro North Health, Queensland Health, Caboolture, Qld, Australia
| | - Champika Pattullo
- Clinical Pharmacology Department, Royal Brisbane and Women's Hospital, Queensland Health, Herston, Qld, Australia
| | - Shania Liu
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; and Department of Pharmacy, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Prudence James
- Redcliffe Hospital Pharmacy Department, Queensland Health, Redcliffe, Qld, Australia
| | - Peter Donovan
- Clinical Pharmacology Department, Royal Brisbane and Women's Hospital, Queensland Health, Herston, Qld, Australia
| | - Asad Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; and Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; and Department of Pharmacy, Prince of Wales Hospital, Randwick, NSW, Australia
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Chitwood C, Haug KL, Wenthur C, Gillis C, Maloney JD, Johnson D. Evaluation of Prescribing Patterns Following Surgical Procedures in Opioid Naïve Patients at a Veterans Affairs Teaching Hospital. Mil Med 2022; 188:usac106. [PMID: 35451478 DOI: 10.1093/milmed/usac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/11/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates. METHODS This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations. RESULTS Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation. CONCLUSION Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.
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Affiliation(s)
- Caleb Chitwood
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
| | - Karlie L Haug
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
| | - Cody Wenthur
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI 53705, USA
| | - Carly Gillis
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI 53705, USA
| | - James D Maloney
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
| | - Diane Johnson
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
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Characteristics of Opioid Prescribing in Non-surgical Medicine Patients with Acute Pain at Hospital Discharge. J Gen Intern Med 2022; 37:565-572. [PMID: 34382139 PMCID: PMC8858354 DOI: 10.1007/s11606-021-07092-x] [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: 11/24/2020] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The opioid epidemic and new Joint Commission standards around opioid stewardship have made the appropriate prescribing of opioids a priority. A knowledge gap exists pertaining to the short-term prescription of opioids at hospital discharge for acute pain in non-surgical patients. OBJECTIVE To characterize the quantity, type, and indication of opioids prescribed for non-surgical patients on hospital discharge and subsequent patient utilization. DESIGN This multicenter, single-health system retrospective cohort study was conducted for quality improvement purposes from December 2019 to May 2020 with patient follow-up 15 to 29 days after hospital discharge. PARTICIPANTS Patients discharged from a medicine service with new opioid prescriptions, defined as no opioid prescription documented within the past 90 days, were identified as eligible through the electronic health record. Surveys were attempted until a total of 200 were completed, with 374 surveys attempted and a 53% response rate. INTERVENTION Patients were contacted via phone and surveyed post-discharge. Surveys consisted of 28 questions and assessed opioid consumption, duration of use, refills, patient satisfaction, and opioid disposal. MAIN MEASURES Prescribing indications and morphine milligram equivalents (MME) quantities were collected for patients at discharge. Subsequently, the quantity of prescribed opioids utilized, remaining, and disposed of post-discharge were collected via patient self-reported survey responses. KEY RESULTS Indications for opioid prescribing for 200 surveyed patients were grouped into eight broad prescribing categories. A median of 112.5 total MME was prescribed to patients at hospital discharge. Median MME consumed for surveyed patients was 45. The median total MME remaining at time of survey was 35 MME. Only 5.9% of patients who had leftover opioids reported disposal of the medication. CONCLUSIONS Given the observed variation in opioid prescribing and utilization data, standardized indication-based opioid prescribing guidance in the non-surgical medical population would help curb the amount of opioids that remain unused post-discharge.
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Leader PW, Oyler DR, Carter TM, Damron DS, Lee CY, Sloan DA, Inabnet WB, Randle RW. Opioid-Free Thyroid and Parathyroid Operations: Are Patients Satisfied With Pain Control? Am Surg 2021:31348211048846. [PMID: 34732084 DOI: 10.1177/00031348211048846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of this study was to evaluate pain control and patient satisfaction using an opioid-free analgesic regimen following thyroid and parathyroid operations. METHODS Surveys were distributed to all postoperative patients following total thyroidectomy, thyroid lobectomy, and parathyroidectomy between January and April 2020. After surgery, patients were discharged without opioids except in rare cases based on patient needs and surgeon judgment. We measured patient-reported Numeric Rating Scale (NRS) pain scores and satisfaction categorically as either satisfied or dissatisfied. RESULTS We received 90 of 198 surveys distributed, for a 45.5% response rate. After excluding neck dissections (n = 6) and preoperative opioid use (n = 4), the final cohort included 80 patients after total thyroidectomy (26.3%), thyroid lobectomy (41.3%), and parathyroidectomy (32.5%).The majority reported satisfaction with pain control (87.5%) and the entire surgical experience (95%). A similar proportion of patients reported satisfaction with pain control after total thyroidectomy (90.9%), thyroid lobectomy (90.5%), and parathyroidectomy (80.8%), indicating the procedure did not significantly impact satisfaction with pain control (P = .47). Patients who reported dissatisfaction with pain control were more likely to receive opioid prescriptions (30% vs 2.9%, P < .01), but the majority still reported satisfaction with their entire operative experience (70%). DISCUSSION Even with an opioid-free postoperative pain regimen, most patients report satisfaction with pain control after thyroid and parathyroid operations, and those who were dissatisfied with their pain control generally reported satisfaction with their overall surgical experience. Therefore, an opioid-free postoperative pain control regimen is well tolerated and unlikely to decrease overall patient satisfaction.
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Affiliation(s)
- Preston W Leader
- Department of Otolaryngology, 4530University of Kentucky College of Medicine, Lexington, KY, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, 12252University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Tonya M Carter
- Department of Surgery, 12252University of Kentucky College of Medicine, Lexington, KY, USA
| | - Donna S Damron
- Department of Surgery, 12252University of Kentucky College of Medicine, Lexington, KY, USA
| | - Cortney Y Lee
- Department of Surgery, 12252University of Kentucky College of Medicine, Lexington, KY, USA
| | - David A Sloan
- Department of Surgery, 12252University of Kentucky College of Medicine, Lexington, KY, USA
| | - William B Inabnet
- Department of Surgery, 12252University of Kentucky College of Medicine, Lexington, KY, USA
| | - Reese W Randle
- Department of General Surgery, 528756Wake Forest Baptist Health, Winston-Salem, NC, USA
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Butler C, Kornberg Z, Copp HL. Practitioner counseling associated with improved opioid disposal among families of postoperative pediatric patients. J Pediatr Urol 2021; 17:634.e1-634.e7. [PMID: 34479805 DOI: 10.1016/j.jpurol.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 06/22/2021] [Accepted: 08/04/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Death from opioid-related overdose has doubled in recent years. Interestingly, there has been a similar increase in the number of opioid prescriptions. Medical providers, unfortunately, have contributed towards this rise in prescriptions. To combat the opioid epidemic, numerous efforts have been made to focus on the medical field and its role in the opioid epidemic. Proposed solutions for reduction of circulating opioids have included such measures as education, monitoring programs, alternative pain management strategies, and improved opioid disposal. OBJECTIVES We aimed to assess if counseling is associated with proper opioid disposal among families of post-operative pediatric patients. STUDY DESIGN We conducted a cross-sectional, convenience sample study of families of post-surgical, pediatric patients at a single academic institution. Participants completed a survey during their postoperative visit assessing opioid requirements, storage and disposal during and after the postoperative period, and if they were counseled by any medical professional on proper disposal methods. We used multivariable logistic regression to evaluate the association between the independent variables and the primary outcome. RESULTS We enrolled 180 participants, mean age of 8 years. Thirty-four percent reported having no opioid medication remaining at follow up because the medication was either consumed or the prescription was not filled. Sixty-six percent had leftover medication at the time of follow up. Sixty-six percent of participants knew the proper opioid disposal methods. However, only 22% of patients with leftover medication properly disposed of the medication. Patients who were counseled about proper opioid disposal were 3 times more likely to practice proper disposal practices than those who were not (p < 0.01). DISCUSSION Our study uniquely look at opioid consumption, disposal rates, and the effect of counseling in a diverse post-surgical pediatric population. Our findings confirm similar observations in the literature with regards to low opioid consumption, but in a larger, more surgically diverse cohort with a 100% response rate. Limitations included a lack of demographic diversity and lack of data measuring the impact of timing or frequency of counseling on opioid disposal practices. Further research goals would be to evaluate the effectiveness of counseling on proper opioid disposal, and the influence of timing and various counseling methods. CONCLUSIONS Most patients do not use all of their opioid medication prescription. Proper opioid disposal counseling by a medical professional may play an important role in adherence to recommended opioid disposal practices.
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Affiliation(s)
- Christi Butler
- University of California San Francisco, 1825 Fourth Street, San Francisco, CA, 94143, USA
| | - Zachary Kornberg
- University of California San Francisco, 1825 Fourth Street, San Francisco, CA, 94143, USA; Stanford University, 300 Pastuer Drive, Stanford, CA, 94305, USA
| | - Hillary L Copp
- University of California San Francisco, 1825 Fourth Street, San Francisco, CA, 94143, USA.
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Krancevich NM, Belfer JJ, Draper HM, Schmidt KJ. Impact of Opioid Administration in the Intensive Care Unit and Subsequent Use in Opioid-Naïve Patients. Ann Pharmacother 2021; 56:52-59. [PMID: 33998324 DOI: 10.1177/10600280211016856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Opioids are a mainstay of therapy for patients in the intensive care unit (ICU) as part of the analgesia-first approach to sedation. Despite knowledge of acute consequences of opioid based analgosedation, less is known about the potential long-term consequences, including the effect of opioid administration in the ICU on subsequent opioid use in opioid-naïve patients. OBJECTIVE To evaluate the relationship between ICU opioid administration to opioid-naïve patients and subsequent opioid use following discharge. METHODS A query of the electronic medical record was performed to identify opioid-naïve adult patients admitted directly to an ICU. Patients who received continuous intravenous infusion of fentanyl, hydromorphone, or morphine were screened for inclusion into the analysis. RESULTS Of the 342 patients included for analysis, 164 (47.1%) received an opioid at hospital discharge. In total, 17 of the 342 patients (5.0%) became long-term users, noted to be more common in patients who received an opioid prescription at discharge (8.7% vs 1.6%; P = 0.006). Neither total ICU morphine milligram equivalent (MME) nor average daily ICU MME administration were found to correlate with daily MME prescription quantity at discharge (R2 = 0.008 and R2 = 0.03, respectively). Following control for potentially confounding variables, total ICU MME administration remained an insignificant predictor of subsequent receipt of an opioid prescription at discharge and long-term opioid use. CONCLUSION AND RELEVANCE This study failed to find a significant relationship between ICU opioid use in opioid-naïve patients and subsequent opioid use. These findings highlight the need to focus on transitions points between the ICU and discharge as potential opportunities to reduce inappropriate opioid continuation.
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Affiliation(s)
| | | | | | - Kyle J Schmidt
- Mercy Health Saint Mary's, Grand Rapids, MI, USA.,Ferris State University, Big Rapids, MI, USA
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Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, Cox FJ, de Boer HD, Dowdy SC, Hattingh K, Knaggs RD, Mariano ER, Pelosi P, Scott MJ, Lobo DN, Macintyre PE. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76:520-536. [PMID: 33027841 DOI: 10.1111/anae.15262] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 01/01/2023]
Abstract
This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.
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Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - J Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - W J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - V Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - F J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - H D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K Hattingh
- Bendigo Health, Bendigo, Victoria, Australia
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - M J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - P E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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Liu SM, Flink-Bochacki R. A single-blinded randomized controlled trial evaluating pain and opioid use after dilator placement for second-trimester abortion. Contraception 2021; 103:171-177. [PMID: 33285100 DOI: 10.1016/j.contraception.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/19/2020] [Accepted: 11/25/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To compare pain levels and medication needs after placement of laminaria vs Dilapan-S, and after dilation and evacuation (D&E). STUDY DESIGN We conducted a single-blinded randomized control trial of patients undergoing D&E at 15 0/7 to 23 6/7 weeks gestation, randomizing to cervical preparation with laminaria or Dilapan-S. We compared pain levels and medication usage following dilator placement (5 minutes; 2, 4, and 8 hours; the following morning) and D&E (1, 4, 24, and 48 hours). Our primary outcome was median change from baseline pain, and secondary outcomes included maximum pain timing and overall narcotic use. We compared baseline characteristics, median pain increases and quantities of narcotics used. RESULTS We analyzed 67 participants with laminaria (n = 34) and Dilapan-S (n = 33). More Dilapan-S users had a prior vaginal delivery (n = 20, 60.6%) than laminaria users (n = 11, 32.4%), p = 0.02. Maximum median pain was not statistically different (Laminaria: +3.5 (interquartile range [IQR] +0.5, +6.5); Dilapan-S: +3 (IQR +1, +5); p = 0.42. Thirty-seven (63.8%) participants reported higher levels of pain following dilator placement than D&E. Overall, 26 (42.6%) participants used narcotics during their abortion episode, with no difference in median number of tablets between laminaria (2, range 1-8) and Dilapan-S (4.5, range 1-15) participants (p = 0.34). CONCLUSIONS Median pain increase did not differ in participants receiving laminaria or Dilapan-S for cervical preparation prior to D&E. The majority of patients will use a small amount of narcotics if available. IMPLICATIONS The lack of difference in pain between laminaria and Dilapan-S enhances the applicability of pain intervention research across dilator types. With over half of participants using a small amount of narcotics during their D&E episode, pain management should be individualized to patient needs.
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Affiliation(s)
- Serena M Liu
- Albany Medical Center, Department of Obstetrics & Gynecology, 391 Myrtle Ave. MC-74, Albany, NY 12208, United States
| | - Rachel Flink-Bochacki
- Albany Medical Center, Department of Obstetrics & Gynecology, 391 Myrtle Ave. MC-74, Albany, NY 12208, United States.
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