The impact of opioid analgesic prescription uptake on the costs of recovery from injury: Evidence from compensable orthopaedic road trauma patients

Management of physical and psychological trauma resulting from motor vehicle crashes in Australian general practice: a mixed-methods approach

BACKGROUND

In Australia, motor vehicle crashes (MVC)-related health data are available from insurance claims and hospitals but not from primary care settings. This study aimed to identify the frequency of MVC-related consultations in Australian general practices, explore the pharmacological management of health conditions related to those crashes, and investigate general practitioners' (GPs) perceived barriers and enablers in managing these patients.

METHODS

Mixed-methods study. The quantitative component explored annual MVC-related consultation rates over seven years, the frequency of chronic pain, depression, anxiety or sleep issues after MVC, and management with opioids, antidepressants, anxiolytics or sedatives in a sample of 1,438,864 patients aged 16 + years attending 402 Australian general practices (MedicineInsight). Subsequently, we used content analysis of 81 GPs' qualitative responses to an online survey that included some of our quantitative findings to explore their experiences and attitudes to managing patients after MVC.

RESULTS

MVC-related consultation rates remained stable between 2012 and 2018 at around 9.0 per 10,000 consultations. In 2017/2018 compared to their peers, those experiencing a MVC had a higher frequency of chronic pain (48% vs. 26%), depression/anxiety (20% vs. 13%) and sleep issues (7% vs. 4%). In general, medications were prescribed more after MVC. Opioid prescribing was much higher among patients after MVC than their peers, whether they consulted for chronic pain (23.8% 95%CI 21.6;26.0 vs. 15.2%, 95%CI 14.5;15.8 in 2017/2018, respectively) or not (15.8%, 95%CI 13.9;17.6 vs. 6.7%, 95% CI 6.4;7.0 in 2017/2018). Qualitative analyses identified a lack of guidelines, local referral pathways and decision frameworks as critical barriers for GPs to manage patients after MVC. GPs also expressed interest in having better access to management tools for specific MVC-related consequences (e.g., whiplash/seatbelt injuries, acute/chronic pain management, mental health issues).

CONCLUSION

Chronic pain, mental health issues and the prescription of opioids were more frequent among patients experiencing MVC. This reinforces the relevance of appropriate management to limit the physical and psychological impact of MVC. GPs identified a lack of available resources (e.g. education, checklists and management support tools) for managing MVC-related consequences, and the need for local referral pathways and specific guidelines to escalate treatments.

Community Opioid Dispensing after Injury (CODI): Cohort characteristics and opioid dispensing patterns

BACKGROUND

Despite a focus of opioid-related research internationally, there is limited understanding of long-term opioid use in adults following injury. We analysed data from the 'Community Opioid Dispensing after Injury' data linkage study.

AIMS

This paper aims to describe the baseline characteristics of the injured cohort and report opioid dispensing patterns following injury-related hospitalisations.

METHODS

Retrospective cohort study of adults hospitalised after injury (ICD-10AM: S00-S99, T00-T75) in Queensland, Australia between 1 January 2014 and 31 December 2015, prior to implementation of opioid stewardship programs. Data were person-linked between hospitalisation, community opioid dispensing and mortality collections. Data were extracted for 90-days prior to the index hospital admission, to establish opiate naivety, to 720 days after discharge. Median daily oral morphine equivalents (i.e., dose) were averaged for each 30-day interval. Cumulative duration of dispensing and dose were compared by demographic and clinical characteristics, stratified by drug dependency status.

RESULTS

Of the 129,684 injured adults, 61.3 % had no opioids dispensed in the 2-year follow-up period. Adults having any opioids dispensed in the community (38.7 %) were more likely older, female, to have fracture injuries and injuries with a higher severity, compared to those with no opioids dispensed. Longer durations and higher doses of opioids were seen for those with pre-injury opioid use, more hospital readmissions and repeat surgeries, as well as those who died in the 2-year follow-up period. Median dispensing duration was 24-days with a median daily end dose of 13 oral morphine equivalents. If dispensing occurred prior to the injury, duration increased 10-fold and oral morphine equivalents doubled. Adults with a documented dependency prior to, or after, the injury had significantly longer durations of use and higher doses than the rest of the cohort receiving opioids. Approximately 7 % of the total cohort continued to be dispensed opioids at 2-years post injury.

CONCLUSION

This is a novel population-level profile of opioid dispensing patterns following injury-related hospitalisation, described for the time period prior to the implementation of opioid stewardship programs and regulatory changes in Queensland. Detailed understanding of this pre-implementation period is critical for evaluating the impact of these changes moving forward.

Pain Appraisals in Patients with Physical Injury: Assessing the Role of Distress Tolerance in the Relationship between Depression and Pain Catastrophizing

Pain is a complex construct contributing to significant impairment, particularly among physically injured patients seeking treatment in trauma and orthopedic surgery settings in which social workers are an integral component of care. The biopsychosocial theory, fear-avoidance, and cognitive mediation models of pain suggest that psychological factors (for example, depression) affect one's ability to tolerate distress, leading to negative pain appraisals, such as catastrophizing. This study examined whether distress tolerance serves as a mechanism by which depression is associated with pain catastrophizing. We administered a health survey to outpatient trauma and orthopedic surgery clinic patients who were using opioid medications; 84 patients were included in the final analysis; 39.3 percent screened positive for depression. A multilevel mediation model using structural equation modeling revealed a significant direct effect from depression to pain catastrophizing (ß = .31, z = 3.96, p < .001) and a significant indirect effect by distress tolerance (Δß = .27, z = 3.84, p < .001). These results, which suggest that distress tolerance partially mediated the path from depression to pain catastrophizing, can inform social workers and other members of the multidisciplinary team about both the critical role of psychosocial factors after injury and interventions to improve postinjury recovery.

An alternative closed-form crash severity model with the non-identical, heavy-tailed, and asymmetric properties

Crash severity model is a classical topic in road safety research. The multinomial logit (MNL) model, as a basic discrete outcome method, is widely applied to measure the association between crash severity and possible risk factors. However, the MNL model has several assumptions and properties that are possibly not consistent with the actual crash mechanism, and therefore with the association measure for crash severity. One significant attribute is the variation in drivers' safety perception. Risk-taking drivers tends to drive at a higher speed, which increases the likelihood of severe crashes. However, the variations in speed and other driving performance lead to the error in the utility function more profound. This violates the assumption of identical error distributions between different crash severity outcomes. In this paper, we propose a multinomial multiplicative (MNM) model, as an alternative for crash severity model. There are two possible formulations for the proposed MNM model: (1) Weibull and (2) Fréchet, according to the distributions of random propensities and subject to the signs of the systematic parts of the regression equation. The two heavy-tailed distributions can capture the effect of unobserved contributory factors on crash injury severity. Additionally, the MNM model can incorporate the effects of the non-identical, heavy-tailed, and asymmetric properties of the distribution, whereas the conventional MNL model cannot. Several operational considerations are also attempted in this study, including the specifications of the systematic parts and the interpretations of the parameters. The MNM model is further extended to the mixed MNM (MMNM) model by considering unobserved heterogeneities using random coefficients, while the mixed MNL (MMNL) model is used as the benchmark model. The proposed MMNM model is calibrated using the crash dataset obtained from the Guangdong Province, China. Results indicated that the proposed MMNM model outperformed the MMNL model in this case. Also, the results of parameter estimates are indicative to impact factors on crash severity as well as the design and implementation of policies. This justified the use of MMNM model as an alternative for crash severity model in practice. This is the first application of MMNM model in the traffic safety literature, it is worth exploring the application of other advanced multiplicative models for safety analysis in the future.

The road to recovery for vulnerable road users hospitalised for orthopaedic injury following an on-road crash

BACKGROUND

Pedestrians, cyclists and motorcyclists are vulnerable to serious injury due to limited external protective devices. Understanding the level of recovery, and differences between these road user groups, is an important step towards improved understanding of the burden of road trauma, and prioritisation of prevention efforts. This study aimed to characterise and describe patient-reported outcomes of vulnerable road users at 6 and 12 months following orthopaedic trauma.

METHODS

A registry-based cohort study was conducted using data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and included pedestrians, cyclists and motorcyclists who were hospitalised for an orthopaedic injury following an on-road collision that occurred between January 2009 and December 2016. Outcomes were measured using the 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3 L), Glasgow Outcome Scale - Extended (GOS-E) and return to work questions. Outcomes were collected at 6 and 12 months post-injury. Multivariable generalized estimating equations (GEE), adjusted for confounders, were used to compare outcomes between the road user groups over time.

RESULTS

6186 orthopaedic trauma patients met the inclusion criteria during the 8-year period. Most patients were motorcyclists (42.8%) followed by cyclists (32.6%) and pedestrians (24.6%). Problems were most prevalent on the usual activities item of the EQ-5D-3 L at 6-months post-injury, and the pain/discomfort item of the EQ-5D-3 L at 12 months. The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians. Moreover, an average cyclist had a greater odds of a good recovery on the GOS-E, (AOR 2.75, 95% CI 2.33, 3.25) and a greater odds of returning to work (AOR = 3.13, 95% CI 2.46, 3.99) compared to an average pedestrian.

CONCLUSION

Pedestrians and motorcyclists involved in on-road collisions experienced poorer patient-reported outcomes at 6 and 12 months post-injury when compared to cyclists. A focus on both primary injury prevention strategies, and investment in ongoing support and treatment to maximise recovery, is necessary to reduce the burden of road trauma for vulnerable road users.