Opioids in hip fracture patients: an analysis of mortality and post hospital opioid use

Use of electronic health record data to examine administrations of pro re nata analgesics during hip fracture post-acute care

PURPOSE

Medications prescribed to older adults in US skilled nursing facilities (SNF) and administrations of pro re nata (PRN) "as needed" medications are unobservable in Medicare insurance claims. There is an ongoing deficit in our understanding of medication use during post-acute care. Using SNF electronic health record (EHR) datasets, including medication orders and barcode medication administration records, we described patterns of PRN analgesic prescribing and administrations among SNF residents with hip fracture.

METHODS

Eligible participants resided in SNFs owned by 11 chains, had a diagnosis of hip fracture between January 1, 2018 to August 2, 2021, and received at least one administration of an analgesic medication in the 100 days after the hip fracture. We described the scheduling of analgesics, the proportion of available PRN doses administered, and the proportion of days with at least one PRN analgesic administration.

RESULTS

Among 24 038 residents, 57.3% had orders for PRN acetaminophen, 67.4% PRN opioids, 4.2% PRN non-steroidal anti-inflammatory drugs, and 18.6% PRN combination products. The median proportion of available PRN doses administered per drug was 3%-50% and the median proportion of days where one or more doses of an ordered PRN analgesic was administered was 25%-75%. Results differed by analgesic class and the number of administrations ordered per day.

CONCLUSIONS

EHRs can be leveraged to ascertain precise analgesic exposures during SNF stays. Future pharmacoepidemiology studies should consider linking SNF EHRs to insurance claims to construct a longitudinal history of medication use and healthcare utilization prior to and during episodes of SNF care.

Time trends in opioid use for patients undergoing hip fracture surgery in 1997-2018: A Danish population-based cohort study

BACKGROUND

Although opioids are a mainstay for perioperative pain management in hip fracture patients, no studies have described changes in opioid use over the last two decades. The aim of this study was to describe time trends in opioid use in a population-based cohort of patients undergoing a first-time hip fracture surgery during 1997-2018.

METHODS

Opioid-naïve hip fracture patients >55 years old were identified in Danish medical databases (n = 115,962). By 2-year calendar periods, we calculated prevalence rates (PR) of opioid use in the four quarters after surgery (Q1-Q4). Corresponding prevalence rate ratios (PRR) with 1997-1998 as a reference were estimated with 95% confidence intervals. Further, we calculated the median morphine milligram equivalents (MME) for each quarter.

RESULTS

For Q1, the PR of opioid use increased from 29% in 1997-1998 to 78% in 2017-2018 corresponding to a PRR of 2.7 (2.6-2.8). For Q4, the PR was 15% in 1997-1998, peaked in 2003-2004 and then decreased, but stayed high at 13% in 2017-2018. The median MME did not increase when comparing 2017-2018 with 1997-1998, irrespective of the quarter. Tramadol was most frequently used in 1997-1998 shifting to oxycodone in 2017-2018.

CONCLUSION

The PRs of opioid use in Q1 after surgery increased substantially from 1997 to 2018, but this did not translate into increased opioid use up to 1 year after hip fracture surgery or higher dosage. Our findings underline the importance of sustained focus on opioid tapering, dosage and use of opioids with the lowest potential for addiction and other adverse events.

SIGNIFICANCE STATEMENT

Overall, opioid use in Q1 after hip fracture surgery increased 2.7 times from 1997 to 2018, but the doses and opioid use up to 1 year after surgery remained stable. Compared to elderly, younger patients were more likely to use opioid in Q1, while the tendency was opposite in Q2-Q4. The most used opioid type changed from tramadol to oxycodone. Our findings underline the importance of personalized opioid tapering and doses, and use of opioids with the lowest potential for addiction and other adverse events.

Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis

INTRODUCTION

 Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma.

MATERIALS AND METHODS

A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery.

RESULTS

Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study.

CONCLUSIONS

 Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study

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.

A Retrospective Cohort Study on Chronic Opioid Use After Geriatric Hip Fracture Surgery-Risk Factors, Trends, and Outcomes

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.

Prolonged Opioid Usage Following Hip Fracture Surgery in Opioid-Naïve Older Patients

BACKGROUND

While the risk of long-term dependence following the opioid treatment of musculoskeletal injury is often studied in younger populations, studies in older patients have centered on short-term risks such as oversedation and delirium. This study investigated prolonged opioid usage after hip fracture in older individuals, focusing on prevalence, risk factors, and changes over time.

METHODS

In this retrospective cohort study of 47,309 opioid-naïve patients aged ≥ 60 years who underwent hip fracture surgery (2009 to 2020), outpatient opioid use was evaluated in 3 postoperative time periods: P1 (day 0 to 30 postsurgery); P2 (day 31 to 90); and P3 (day 91 to 180). The primary outcome was prolonged outpatient opioid use, defined as having one or more opioid prescriptions dispensed in all 3 time periods.

RESULTS

The incidence of prolonged opioid usage among patients surviving to P3 was 6.3% (2,834 of 44,850). Initial prescription quantities decreased over time, as did the risk of prolonged opioid usage (from 8.0% in 2009 to 3.9% in 2019). In the multivariable analyses, risk factors for prolonged opioid usage included younger age, women, current/former smoking, fracture fixation (as compared to hemiarthroplasty), and anxiety. Prolonged opioid usage was less common among patients who were Asian or had a history of dementia.

CONCLUSIONS

While prior research on the hazards of opioids in the elderly has focused on short-term risks such as oversedation and delirium, these findings suggest that prolonged opioid usage may be a risk for this older population as well. As initial prescription amounts have decreased, declines in prolonged opioid medication usage have also been observed.

Prevalence of Chronic Opioid Use in the Elderly After Hip Fracture Surgery

BACKGROUND

While interest has focused on opioid use after total hip arthroplasty, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients go on to chronic opioid use after hip fracture surgery.

METHODS

We reviewed a consecutive series of 219 patients 65 years and older who underwent surgical fixation between January 1, 2016 and February 28, 2019 for a native hip fracture. Patients were excluded for polytrauma, periprosthetic or pathologic fractures, recent major surgery, or death within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use.

RESULTS

Overall, 58 patients (26%) were postoperative chronic opioid users. Of the initial 188 opioid-naïve patients, 43 (23%) became chronic users. Of the 31 preoperative opioid users, 15 (48%) continued as chronic users. Chronic postoperative users were more likely to be White (76% vs 91%, P = .04), younger (78 vs 82 years, P = .003), and preoperative opioid users (odds ratio 3.3, P = .007). Arthroplasty vs fixation did not affect the rate of chronic opioid use (P = .22).

CONCLUSION

Chronic opioid use is surprisingly common after hip fracture repair in the elderly. Twenty-three percent of opioid-naïve hip fracture patients became chronic users after surgery. Continued vigilance is needed by orthopedic surgeons to limit the amount and duration of postoperative narcotic prescriptions and to monitor for continued use.

Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use

Introduction

Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures.

Materials and Methods

This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups.

Results

Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging.

Discussion

Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ.

Conclusion

Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.

Effect of Opioids on All-cause Mortality and Sustained Opioid Use in Elderly Patients with Hip Fracture: a Korea Nationwide Cohort Study

BACKGROUND

The purpose of our study was to assess the use of opioids before and after hip fracture in elderly patients in order to determine the effect of opioid use on all-cause mortality, and to analyze how the history of opioid use before fracture increases the risk of sustained use following hip fracture using a Korea nationwide cohort.

METHODS

Our study identified hip fracture patients from the Korean National Health Insurance Service-Senior cohort. The index date was defined as 90-days after admission to the acute care hospital that fulfilled the eligibility criteria of elderly hip fracture. Patients were classified into past user, current user, and sustained user according to the use of opioid at each period based on the time of admission and index date. The opioids were classified into strong opioids and tramadol. A generalized estimating equation model with a Poisson distribution and logarithmic link function was performed to estimate the adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) to assess the association between past use and sustained use. A multivariable-adjusted Cox proportional hazard model was used to investigate the effects of strong opioid and tramadol use on all-cause mortality.

RESULTS

A total of 12,927 patients were included in our study. There were 7,384 (57.12%) opioid past-users, 11,467 (88.71%) opioid current-users, and 7,172 (55.48%) sustained users. In comparison of the death risk according to current use or the defined daily dose of the opioids or past opioid use, there were no significant differences in the adjusted hazard ratio for death in all groups, compared to the current non-users (P > 0.05). Among survivors 1 year after hip fracture, opioid past-use increased the risk of opioid sustained use by 1.52-fold (aRR; 95% CI, 1.45-1.8; P < 0.001).

CONCLUSION

Current use and past use of opioid did not increase all-cause mortality after hip fracture in elderly patients over 65 years of age. Past use of opioid before hip fracture increased risk of sustained use of opioid compared to the current opioid used without past use.

Persistent postoperative opioid use in Europe: A systematic review

BACKGROUND

In the United States, postoperative opioid prescriptions have been implicated in the so-called 'opioid epidemic'. In Europe, the extent of overprescribing or misuse of opioids is not known.

OBJECTIVES

To describe the proportion of persistent postoperative opioid use in adults (>18 years) in European countries.

DESIGN

Systematic review of the published data.

DATA SOURCES

We searched the electronic literature databases MEDLINE (Ovid), Embase (Ovid), PubMed/MEDLINE and Scopus.

ELIGIBILITY CRITERIA

Studies describing opioid use in adult patients (>18 years) at least 3 months after surgery.

RESULTS

One thousand three hundred and seven studies were found, and 12 studies were included in this review. The rate of opioid use after 3 to 6 months was extracted from the studies and categorised by the type of surgery. Nine studies investigated opioid use after total hip or total knee arthroplasties (THA and TKA) and reported opioid user rates between 7.9 and 41% after 3 months. In all the included studies, a proportion between 2 and 41% of patients were opioid users 3 months after surgery. The level of evidence varied from high to very low.

CONCLUSION

To describe persistent opioid use in relation to specific countries or types of surgery is not possible. Because of the wide ranges observed, we can neither confirm nor rule out a possible public health problem linked to the persistent use of opioids in Europe.

STUDY REGISTRATION

PROSPERO: CRD42019154292.

Risk factors for new chronic opioid use after hip fracture surgery: a Danish nationwide cohort study from 2005 to 2016 using the Danish multidisciplinary hip fracture registry

OBJECTIVE

To examine the risk factors for new chronic opioid use in elderly patients who underwent hip fracture surgery.

DESIGN

Prospective population-based cohort study.

SETTING AND PARTICIPANTS

Using Danish nationwide health registries, we identified all opioid non-user patients aged ≥65 years who had undergone hip fracture surgery from 2005 to 2016 and were alive within the first year following surgery.

MAIN OUTCOME MEASURES

New chronic opioid use defined by the dispensing of at least two prescription opioids within two of the last three quarters during the first year following surgery.

RESULTS

We identified 37 202 opioid non-user patients who underwent hip fracture surgery. Of these, 5497 (15%) developed new chronic opioid user within 1 year of surgery. Risk factors for new chronic opioid use were Body Mass Index (BMI) of <18.5 (adjusted OR (aOR) 1.22, 95% CI 1.09 to 1.36), BMI of 25.0-29.9 (aOR 1.12, 95% CI 1.04 to 1.21) and BMI of ≥30 (aOR 1.57, 95% CI 1.40 to 1.76) with BMI 18.6-24.9 as reference, a pertrochanteric/subtrochanteric fracture (aOR 1.27, 95% CI 1.20 to 1.34) with femoral neck fracture as reference, preoperative use (vs no-use) of non-steroidal anti-inflammatory drug (aOR 1.68, 95% CI 1.55 to 1.83), selective serotonin reuptake inhibitor (aOR 1.42, 95% CI 1.32 to 1.53), antidepressants (aOR 1.36, 95% CI 1.24 to 1.49), antipsychotics (aOR 1.21, 95% CI 1.07 to 1.35), corticosteroids (aOR 1.54, 95% CI 1.35 to 1.76), statins (aOR 1.09, 95% CI 1.02 to 1.18), antibiotics (aOR 1.32, 95% CI 1.22 to 1.42), antiosteoporosis drugs (aOR 1.33, 95% CI 1.19 to 1.49) and anticoagulatives (aOR 1.24, 95% CI 1.17 to 1.32). Presence of cardiovascular comorbidities, diabetes, gastrointestinal diseases, dementia, chronic obstructive pulmonary disease or renal diseases was further identified as a risk factor.

CONCLUSION

In this large nationwide cohort study, we identified several risk factors associated with new chronic opioid use after hip fracture surgery among patients who were alive within the first year following surgery. Although not all factors are modifiable preoperative, this will allow clinicians to appropriately counsel patients preoperatively and tailor postoperative treatment.

The association between initial opioid type and long-term opioid use after hip fracture surgery in elderly opioid-naïve patients

Objectives Long-term opioid use after hip fracture surgery has been demonstrated in previously opioid-naïve elderly patients. It is unknown if the opioid type redeemed after hip surgery is associated with long-term opioid use. The aim of this study was to examine the association between the opioid type redeemed within the first three months after hip fracture surgery and opioid use 3-12 months after the surgery. Methods A nationwide population-based cohort study was conducted using data from Danish health registries (2005-2015). Previously opioid-naïve patients registered in the Danish Multidisciplinary Hip Fracture Registry, aged ≥65 years, who redeemed ≥1 opioid prescription within three months after the surgery, were included. Long-term opioid use was defined as ≥1 redeemed prescription within each of three three-month periods within the year after hip fracture surgery. The proportion with long-term opioid use after surgery, conditioned on nine-month survival, was calculated according to opioid types within three months after surgery. Adjusted odds ratios (aOR) for different opioid types were computed by logistic regression analyses with 95% confidence intervals (CI) using morphine as reference. Subgroup analyses were performed according to age, comorbidity and calendar time before and after 2010. Results The study included 26,790 elderly, opioid-naïve patients with opioid use within three months after hip fracture surgery. Of these patients, 21% died within nine months after the surgery. Among the 21,255 patients alive nine months after surgery, 15% became long-term opioid users. Certain opioid types used within the first three months after surgery were associated with long-term opioid use compared to morphine (9%), including oxycodone (14%, aOR; 1.76, 95% CI 1.52-2.03), fentanyl (29%, aOR; 4.37, 95% CI 3.12-6.12), codeine (13%, aOR; 1.55, 95% CI 1.14-2.09), tramadol (13%, aOR; 1.56, 95% CI 1.35-1.80), buprenorphine (33%, aOR; 5.37, 95% CI 4.14-6.94), and >1 opioid type (27%, aOR; 3.83, 95% CI 3.31-4.44). The proportion of long-term opioid users decreased from 18% before 2010 to 13% after 2010. Conclusions The findings suggest that use of certain opioid types after hip fracture surgery is more associated with long-term opioid use than morphine and the proportion initiating long-term opioid use decreased after 2010. The findings suggest that some elderly, opioid-naïve patients appear to be presented with untreated pain conditions when seen in the hospital for a hip fracture surgery. Decisions regarding the opioid type prescribed after hospitalization for hip fracture surgery may be linked to different indication for pain treatment, emphasizing the likelihood of careful and conscientious opioid prescribing behavior.

Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions

The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.

Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis

IMPORTANCE

Prolonged opioid use after surgery may be associated with opioid dependency and increased health care use. However, published studies have reported varying estimates of the magnitude of prolonged opioid use and risk factors associated with the transition of patients to long-term opioid use.

OBJECTIVES

To evaluate the rate and characteristics of patient-level risk factors associated with increased risk of prolonged use of opioids after surgery.

DATA SOURCES

For this systematic review and meta-analysis, a search of MEDLINE, Embase, and Google Scholar from inception to August 30, 2017, was performed, with an updated search performed on June 30, 2019. Key words may include opioid analgesics, general surgery, surgical procedures, persistent opioid use, and postoperative pain.

STUDY SELECTION

Of 7534 articles reviewed, 33 studies were included. Studies were included if they involved participants 18 years or older, evaluated opioid use 3 or more months after surgery, and reported the rate and adjusted risk factors associated with prolonged opioid use after surgery.

DATA EXTRACTION AND SYNTHESIS

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Two reviewers independently assessed and extracted the relevant data.

MAIN OUTCOMES AND MEASURES

The weighted pooled rate and odds ratios (ORs) of risk factors were calculated using the random-effects model.

RESULTS

The 33 studies included 1 922 743 individuals, with 1 854 006 (96.4%) from the US. In studies with available sex and age information, participants were mostly female (1 031 399; 82.7%) and had a mean (SD) age of 59.3 (12.8) years. The pooled rate of prolonged opioid use after surgery was 6.7% (95% CI, 4.5%-9.8%) but decreased to 1.2% (95% CI, 0.4%-3.9%) in restricted analyses involving only opioid-naive participants at baseline. The risk factors with the strongest associations with prolonged opioid use included preoperative use of opioids (OR, 5.32; 95% CI, 2.94-9.64) or illicit cocaine (OR, 4.34; 95% CI, 1.50-12.58) and a preoperative diagnosis of back pain (OR, 2.05; 95% CI, 1.63-2.58). No significant differences were observed with various study-level factors, including a comparison of major vs minor surgical procedures (pooled rate: 7.0%; 95% CI, 4.9%-9.9% vs 11.1%; 95% CI, 6.0%-19.4%; P = .20). Across all of our analyses, there was substantial variability because of heterogeneity instead of sampling error.

CONCLUSIONS AND RELEVANCE

The findings suggest that prolonged opioid use after surgery may be a substantial burden to public health. It appears that strategies, such as proactively screening for at-risk individuals, should be prioritized.

Persistent Postoperative Opioid Use: A Systematic Literature Search of Definitions and Population-based Cohort Study

BACKGROUND

While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events.

METHODS

The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery.

RESULTS

Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00.

CONCLUSIONS

The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.

A descriptive study of pain treatment and its follow-up in primary care of elderly patients after orthopaedic care

Background

Pain treatment post orthopaedic care in the elderly is complicated and requires careful follow-up. Current guidelines state all patients prescribed opioids should have a plan for gradual reduction, with the treatment progressively reduced and ended if any pain remains after more than three months. How this works in primary care remains to be explored.

The aim was to describe pain treatment and its follow-up in primary care of elderly patients after orthopaedic care.

Methods

In this descriptive study, medical case histories were collected for patients ≥ 75 years, which were enrolled at two rural primary care units in southern Sweden, and were discharged from orthopaedic care. Pain medication follow-up plans were noted, as well as current pain medication at discharge as well as two, six and twelve weeks later.

Results

We included a total of 49 community-dwelling patients with medication aid from nurses in municipality care and nursing home residents, ≥ 75 years, discharged from orthopaedic care. The proportion of patients prescribed paracetamol increased from 28/49 (57%) prior to admission, to 38/44 (82%) after 12 weeks. The proportion of patients prescribed opioids increased from 5/49 (10%) to 18/44 (41%). Primary care pain medication follow-up plans were noted for 16/49 patients (33%).

Conclusions

Many patients still used pain medication 12 weeks after discharge, and follow-up plans were quite uncommon, which may reflect upon lacking follow-up of these patients in primary care.

An updated analysis of opioids increasing the risk of fractures

Objective

To assess the relationship between opioid therapy for chronic noncancer pain and fracture risk by a meta-analysis of cohort studies and case-control studies.

Methods

The included cohort studies and case-control studies were identified by searching the PubMed and EMBASE databases from their inception until May 24, 2019. The outcome of interest was a fracture. This information was independently screened by two authors. When the heterogeneity among studies was significant, a random effects model was used to determine the overall combined risk estimate.

Results

In total, 12 cohort studies and 6 case-control studies were included. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of the included literature, and 14 of the studies were considered high-quality studies. The overall relative risk of opioid therapy and fractures was 1.78 (95% confidence interval (CI) 1.53–2.07). Subgroup analyses revealed sources of heterogeneity, sensitivity analysis was stable, and no publication bias was observed.

Conclusions

The meta-analysis showed that the use of opioids significantly increased the risk of fracture.

Factors associated with discharge opioid prescription after hip fracture fixation

OBJECTIVE

Opioid prescribing after hip fracture fixation is variable, but the factors that drive this prescribing variation are not well-described. The purpose of this study was to determine independent factors associated with increased opioid prescription upon discharge after hip fracture fixation.

METHODS

A retrospective cohort study of 296 adult patients who underwent hip fracture fixation between January 2016 and December 2017 at two Level I trauma centers were included in our study. The primary outcome measurement was opioid prescription at discharge in morphine milligram equivalents (MME). Bivariate analysis was used to screen for factors, and multivariable regression analysis was used to identify independent factors associated with opioid prescription upon discharge from the hospital.

RESULTS

Discharge opioid prescription amounts were available for 280 out of 296 patients (95%). The mean (±standard deviation) discharge opioid prescription was 212 (±319) MME. Multivariable regression analysis showed that younger age (p = 0.004), diabetes mellitus (p = 0.02), smoking (p < 0.001), treatment at hospital #2 (p < 0.001), and weekend discharge (p = 0.03) were associated with increased opioid prescription at discharge.

CONCLUSIONS

Increased opioid prescribing after hip fracture fixation is associated with patient- and system-related factors. Prescriber education programs, prescription guidelines, and safe handoff practices that focus on these factors may help to decrease prescription variability and opioid overprescription across institutions.

Risk of Opioid Use Disorder from Exposure to Opioids in the Perioperative Period: A Systematic Review

Opioid use disorder, a major source of morbidity and mortality globally, is regularly linked to opioids given around the time of surgery. Perioperative period, however, is markedly heterogeneous, with the diverse providers using opioids distinctively, and the various drivers of opioid misuse at-play dissimilarly, throughout the perioperative period. The risk of opioid use disorder may, therefore, be different from opioids given at the various phases of perioperative care, and the ensuing recommendations for their use may also be dissimilar. Systematic search and analysis of the pertinent literature, following the accepted standards, showed an overall increased risk of misuse from the perioperative opioids. However, the analyzed studies had significant methodological limitations, and were constrained mainly to the out-patient phase of the perioperative period. Lacking any data, this risk, therefore, is unknown for intraoperative and postoperative recovery periods. Consequently, no firm recommendations can be extended to anesthesia providers generally managing these perioperative stages. Furthermore, with significant methodological limitations, the current recommendations for opioid use after surgery are also arbitrary. Thus, though proposals for perioperative opioid use are formulated in this article, substantive recommendations would require clear delineation of these risks, while avoiding the limitations noted in this review.

Post-acute Use of Opioids and Psychotropics in Patients after Hip Fracture: Unintended Consequences of Implementing Diagnosis-Related Grouping Payment

OBJECTIVE

How implementing diagnostic-related grouping (DRG) payment affected the use of opioids and psychotropics by hip fracture patients following hospitalization remained unknown.

DESIGN

A retrospective, pre-post design, cohort study of data excerpted from Taiwan's National Health Insurance Research database (NHIRD).

SETTING AND PARTICIPANTS

Adults aged ≥ 65 years first admitted for hip fracture surgery from 2007 to 2012 were identified and divided into two 1:1 propensity-score matched groups: pre-DRG (2007-2009); DRG (2010-2012).

MEASUREMENTS

The outcome measures were use of opioid and/or psychotropic drugs within 30 days, 90 days, 180 days, and 365 days after discharge.

RESULTS

Data of 16,522 subjects were excerpted, and 8,261 propensity-score matched subjects each classified into the pre-DRG and DRG groups. After adjustment, the DRG group was significantly more likely than the pre-DRG group to have used antipsychotics after discharge from hip fracture surgery (≤30 days, ≤90 days, ≤180 days and ≤365 days). The DRG group also had significantly higher prescription rates of benzodiazepines and antipsychotics during the observation period. Moreover, the DRG group was less likely to use non-steroidal anti-inflammatory drugs (≤30 days, ≤90 days, ≤180 days and ≤365 days) and more likely to use acetaminophen (≤30 days, ≤180 days, and ≤365 days).

CONCLUSIONS

In conclusion, DRG implementation in Taiwan substantially increased post-acute prescription of antipsychotic and psychotropic agents for hip fracture patients, and changed use of analgesics, which may result in suboptimal quality and safety for these patients. Further research is needed to evaluate the long-term outcomes of DRG implementation, and the potential benefits of appropriate post-acute care bundled with DRG payment.

Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study

OBJECTIVE

To determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study using administrative health claims database from the Australian Government Department of Veterans' Affairs (DVA). DVA gold card holders aged between 18 and 100 years who were admitted to hospital for a surgical admission between 1 January 2014 and 30 December 2015 and naïve to opioid therapy prior to admission were included in the study. Gold card holders are eligible for all health services that DVA funds.

MAIN OUTCOME MEASURES

The outcome of interest was time to cessation of opioids, with follow-up occurring over 12 months. Cessation was defined as a period without an opioid prescription that was equivalent to three times the estimated supply duration. The proportion who became chronic opioid users was defined as those who continued taking opioids for greater than 90 days post discharge. Cumulative incidence function with death as a competing event was used to determine time to cessation of opioids post discharge.

RESULTS

In 2014-2015, 24 854 persons were admitted for a surgical admission. In total 3907 (15.7%) were discharged on opioids. In total 3.9% of those discharged on opioids became chronic users of opioids. The opioid that the patients were most frequently discharged with was oxycodone; oxycodone alone accounted for 43%, while oxycodone with naloxone accounted for 8%.

CONCLUSIONS

Opioid initiation post-surgical hospital admission leads to chronic use of opioids in a small percentage of the population. However, given the frequency at which surgical procedures occur, this means that a large number of people in the population may be affected. Post-discharge assessment and follow-up of at-risk patients is important, particularly where psychosocial elements such as anxiety and catastrophising are identified.

Opioid use after hip fracture surgery: A Danish nationwide cohort study from 2005 to 2015

BACKGROUND

There is currently a knowledge gap regarding persistent opioid use after hip fracture surgery. Thus, opioid use within a year after hip fracture surgery in patients with/without opioid use before surgery was examined.

METHODS

This population-based cohort study included all patients (aged ≥ 65) undergoing primary hip fracture surgery in Denmark (2005-2015) identified from the Danish Multidisciplinary Hip Fracture Database. Opioid use was assessed from The Danish National Health Service Prescription Database as redeemed prescriptions. The proportion of patients with ≥1 opioid prescription was computed within 6 months before surgery and each of four 3-month periods (quarters) after surgery, among patients alive first day in each period. Proportion differences (95% CI) were calculated for each quarter compared to before surgery. Proportions were calculated for users and nonusers before surgery, including initiators after first quarter.

RESULTS

This study included 69,456 patients. Proportion differences of opioid users were 35.0 (95% CI 34.5-35.5), 7.0 (95% CI 6.5-7.5), 2.9 (95% CI 2.4-3.4) and 1.4 percentage-points (95% CI 0.9-1.9) the four quarters after surgery compared to before. Among opioid nonusers before surgery, 54.7% (95% CI 54.3-55.1), 21.8% (95% CI 21.4-22.2), 17.8% (95% CI 17.4-18.2) and 16.8% (95% CI 16.4-17.2) were opioid users in 1st-4th quarter after surgery. However, 8.5% (95% CI 8.2-8.7) of the nonusers before surgery in 4th quarter initiated opioid use more than a quarter after surgery.

CONCLUSIONS

The proportion of opioid users increased after hip fracture surgery and was 1.4 percentage-points increased in fourth quarter compared to before. Of opioid nonusers before surgery, 16.8% were opioid users fourth quarter after surgery.

SIGNIFICANCE

Opioid use 1 year after hip fracture surgery is common, both in patients who were opioid users and nonusers before the surgery. These significant findings point out the need for indication of benefits and risks of opioid use in the acute and long-term management of patients undergoing hip fracture surgery.

The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis

Purpose

Fascia iliaca compartment block (FICB) provides an analgesic option for total hip arthroplasty (THA) patients. The evidence supporting FICB is still not well established. The purpose of this meta-analysis was to assess FICB for pain control in THA patients.

Methods

PubMed, Embase, Cochrane Library, and Chinese Wanfang database were interrogated from their inceptions to December 15, 2018. We included randomized controlled studies reported as full text, those published as abstracts only, and unpublished data, if available. Data were independently extracted by two reviewers and synthesized using a random-effects model or fixed-effects model according to the heterogeneity.

Results

A total of eight RCTs were finally included for meta-analysis. Compared with placebo, FICB could significantly reduce VAS pain scores at 1–8 h (WMD = − 0.78, 95% CI [− 1.01, − 0.56], P = 0.000), 12 h (WMD = − 0.69, 95% CI [− 1.22, − 0.16], P = 0.011), and 24 h (WMD = − 0.46, 95% CI [− 0.89, − 0.02], P = 0.039). Compared with the control group, FICB could significantly decrease the occurrence of nausea and length of hospital stay (P < 0.05). There was no significant difference between the VAS pain score at 48 h and risk of fall between the FICB and the control groups (P > 0.05).

Conclusions

FICB could be used to effectively reduce pain intensity up to 24 h, total morphine consumption, and length of hospital stay in THA patients. Optimal strategies of FICB need to be studied in the future.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1053-1) contains supplementary material, which is available to authorized users.

Risk Factors and Pooled Rate of Prolonged Opioid Use Following Trauma or Surgery: A Systematic Review and Meta-(Regression) Analysis

BACKGROUND

Prolonged use of opioids initiated for surgical or trauma-related pain management has become a global problem. While several factors have been reported to increase the risk of prolonged opioid use, there is considerable inconsistency regarding their significance or effect size. Therefore, we aimed to pool the effects of risk factors for prolonged opioid use following trauma or surgery and to assess the rate and temporal trend of prolonged opioid use in different settings.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched Embase, PubMed, Web of Science, EBM (Evidence-Based Medicine) Reviews - Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from inception to August 28, 2017, without language restriction. Observational studies reporting risk factors for, or the rate of, prolonged opioid use among adult patients following surgery or trauma with a minimum of 1 month of follow-up were included. Study and patient characteristics, risk factors, and the rate of prolonged opioid use were synthesized.

RESULTS

Thirty-seven studies with 1,969,953 patients were included; 4.3% (95% confidence interval [CI] = 2.3% to 8.2%) of patients continued opioid use after trauma or surgery. Prior opioid use (number needed to harm [NNH] = 3, odds ratio [OR] = 11.04 [95% CI = 9.39 to 12.97]), history of back pain (NNH = 23, OR = 2.10 [95% CI = 2.00 to 2.20]), longer hospital stay (NNH = 25, OR = 2.03 [95% CI = 1.03 to 4.02]), and depression (NNH = 40, OR = 1.62 [95% CI = 1.49 to 1.77]) showed some of the largest effects on prolonged opioid use (p < 0.001 for all but hospital stay [p = 0.042]). The rate of prolonged opioid use was higher in trauma (16.3% [95% CI = 13.6% to 22.5%]; p < 0.001) and in the Workers' Compensation setting (24.6% [95% CI = 2.0% to 84.5%]; p = 0.003) than in other subject enrollment settings. The temporal trend was not significant for studies performed in the U.S. (p = 0.07) while a significant temporal trend was observed for studies performed outside of the U.S. (p = 0.014).

CONCLUSIONS

To our knowledge, this is the first meta-analysis reporting the pooled effect of risk factors that place patients at an increased chance for prolonged opioid use. Understanding the pooled effect of risk factors and their respective NNH values can aid patients and physicians in developing effective and individualized pain-management strategies with a lower risk of prolonged opioid use.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Infiltration Techniques for Local Infiltration Analgesia With Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion

BACKGROUND

Liposomal bupivacaine (LB) has demonstrated efficacy in improving pain scores and reducing opioid consumption across a variety of surgical settings, including orthopaedic surgery. However, meticulous infiltration techniques combined with a multimodal approach are important to optimizing outcomes.

METHODS

A panel of 4 orthopaedic surgeons and 3 anesthesiologists convened on April 1, 2017, to discuss current practices and develop a consensus statement regarding local infiltration analgesia with LB for extracapsular and intracapsular hip fracture surgery, including LB infiltration techniques.

RESULTS

Optimizing surgical outcomes with LB in hip fracture surgery requires an understanding of the neuroanatomy of the surgical site and the pharmacology of the drug. Meticulous infiltration technique is critical to achieve optimal results with LB given its viscosity and reduced diffusion compared with bupivacaine HCl. For extracapsular procedures, a total injection volume of 120 mL is recommended, whereas intracapsular procedures typically require a lower volume (∼80 mL). In both cases, infiltration is best achieved using a 22-gauge needle and applying a tracking and/or fanning technique. To ensure optimal placement, LB should be infiltrated using multiple, small-volume (1- to 5-mL) injections spaced at 1.0-cm intervals.

CONCLUSIONS

These consensus recommendations regarding LB infiltration techniques can serve as a resource for designing clinical studies to evaluate outcomes using periarticular infiltration of LB in extracapsular and intracapsular hip fracture surgery as part of a multimodal pain management approach.

LEVEL OF EVIDENCE

Level V.

Opioid intake prior to admission is not increased in elderly patients with low-energy fractures: A case-control study in a German hospital population

BACKGROUND

Recent studies revealed an increased prescription rate of opioids for elderly patients suffering bone fractures. To gain further insight, we conducted face-to-face interviews in the present study to compare the opioid intake between patients with low-energy fractures and patients suffering from internal diseases.

METHODS

In this case-control study, 992 patients, aged 60 years and older, were enrolled between March 2014 and February 2015. The interview comprised a fall and medication history, comorbidities, mobility and other risk factors for fractures. Odds ratios (OR) and a multiple logistic regression model were calculated.

RESULTS

The number of patients with pre-admission opioid intake in the last 12 months was comparable in the fracture (n = 399, 13.3%) and the control group (n = 593, 14.7% OR: 0.89, CI: 0.62-1.29). The number of patients with current opioid intake of short duration (<3 months) was similar in both groups (14% vs. 20%; OR: 0.66, CI: 0.23-1.93). Patients with opioid intake in the fracture group reported more frequently fatigue as an adverse event of opioid medication (58% vs. 30%; OR: 3.32, CI: 1.48-7.45). Patients with opioid intake showed more severe comorbidities and significantly decreased mobility compared to those without opioids.

CONCLUSION

Elderly patients internalized due to low-energy fractures did not take opioids more frequently than patients with internal admission, for both short (<3 months) and longer duration intake. Patients with opioid intake were generally in poorer physical condition. The risk of fracture might increase in patients suffering from fatigue as a side effect of opioid medication.

SIGNIFICANCE

This study is based on face-to-face interviews with patients, including details about side effects and fracture history, providing a more pronounced picture of the relation of opioid intake and risk of fracture.

A systematic review of opioid use after extremity trauma in orthopedic surgery

BACKGROUND

The United States is in a prescription opioid crisis. Orthopedic surgeons prescribe more opioid narcotics than any other surgical specialty. The purpose of this study was to evaluate the state of opioid use after extremity trauma in orthopedic surgery.

METHODS

A computerized literature search of PubMed/MEDLINE was conducted to evaluate the status of opioids after extremity fractures. Six articles were identified and included in the review.

RESULTS

Patients who consume more opioids communicate greater pain intensity and less satisfaction with pain control. Intraoperative multimodal drug injection and nerve blockade are viable alternatives for postoperative pain control and can help decrease systemic opioid use. Orthopedic surgeons are overprescribing opioids. Compared to other countries, the United States consumes more opioids with no better satisfaction with pain control.

CONCLUSION

Orthopedic trauma surgeons should tailor their postoperative opioid prescriptions to the individual patient and utilize alternative options in order to control postoperative pain. Patients should be counseled regarding narcotic addiction and dependence. Patients unable to manage pain postoperatively should be followed closely and receive the proper chronic pain management, mental and social health services referrals.

Opioid Prescription and Usage in Adolescents Undergoing Orthopaedic Surgery in the United States: A Systematic Review

BACKGROUND

The proper use of opioid analgesia for postoperative pain management is controversial. While opioids are considered the standard of care for multimodal postoperative pain modulation in the United States, there is a lack of established protocols for prescribing opioids in adolescents undergoing outpatient orthopaedic surgery. The objective of this review was to identify and report on current literature on opioid prescription for pain management in adolescents undergoing all procedures, as well as in adults undergoing outpatient orthopaedic surgery.

METHODS

A comprehensive literature search using PRISMA guidelines was performed to identify all articles relevant to opioid use in adolescents for postoperative pain and in adults following outpatient orthopaedic procedures.

RESULTS

A total of 4,446 results were identified from databases and relevant journal web sites. Of these, 9 articles were selected that fit the criteria for review. Five studies discussed the dosage and type of opioids prescribed in adolescent populations, and 4 quantified patient self-administration in adult populations.

CONCLUSIONS

Adolescent opioid pain management following outpatient orthopaedic surgery is not documented. Current recommendations for opioid prescription in adolescents lack support and are primarily based on adult dosages. Adult studies suggest that opioid medications may be overprescribed following outpatient orthopaedic surgery. These results clearly indicate that there is a pressing need for quantitative research on pain management following outpatient orthopaedic surgery in the adolescent population in the United States.

CLINICAL RELEVANCE

There appear to be no studies on self-administered opioid pain medication following orthopaedic surgery in an adolescent population, suggesting that there is no objective basis for the current prescription recommendations.

Communication with Orthopedic Trauma Patients via an Automated Mobile Phone Messaging Robot

BACKGROUND

Communication with orthopedic trauma patients is traditionally problematic with low response rates (RRs). The purpose of this investigation was to (1) evaluate the feasibility of communicating with orthopedic trauma patients postoperatively, utilizing an automated mobile phone messaging platform; and (2) assess the first 2 weeks of postoperative patient-reported pain and opioid use after lower extremity orthopedic trauma procedures.

MATERIALS AND METHODS

This was a prospective investigation at a Level 1 trauma center in the United States. Adult patients who were capable of mobile phone messaging and were undergoing common, lower extremity orthopedic trauma procedures were enrolled in the study. Patients received a daily mobile phone message protocol inquiring about their current pain level and amount of opioid medication they had taken in the past 24 h starting on postoperative day (POD) 3 and continuing through POD 17. Our analysis considered (1) Patient completion rate of mobile phone questions, (2) Patient-reported pain level (0-10 scale), and (3) Number and percentage of daily prescribed opioid medication patients reported taking.

RESULTS

Twenty-five patients were enrolled in this investigation. Patients responded to 87.5% of the pain and opioid medication inquiries they received over the 2-week study period. There were no differences in RRs by patient age, sex, or educational attainment. Patient-reported pain decreased over the initial 2-week study period from an average of 4.9 ± 1.7 on POD 3 to 3 ± 2.2 on POD 16-17. Patients took an average of 68% of their maximum daily narcotic prescription on POD 3 compared with 35% of their prescribed pain medication on POD 16-17.

CONCLUSIONS

We found that in orthopedic trauma patients, an automated mobile phone messaging platform elicited a high patient RR that improved upon prior methods in the literature. This method may be used to reliably obtain pain and medication utilization data after trauma procedures.

Opioids increase hip fracture risk: a meta-analysis

The relationship between hip fracture risk and opioid use remains controversial. Thus, we performed a meta-analysis to assess the risk of hip fracture among opioid users. PubMed and EMBASE were searched for studies published from the inception of the databases until June 2015. The information was extracted independently by two teams of authors. When the heterogeneity was significant, the random-effects model was used to calculate the overall pooled risk estimates. Ten studies with 697,011 patients were included in the final meta-analysis. The overall combined relative risk for the use of opioids and hip fracture was 1.54 [95 % confidence interval (CI) 1.34-1.77]. Subgroup analyses revealed sources of heterogeneity, and sensitivity analysis indicated stable results, and no publication bias was observed. This meta-analysis demonstrates that opioids significantly increase the risk of hip fracture.

Post-operative serious adverse events in a mixed surgical population - a retrospective register study

BACKGROUND

The number of surgical procedures is increasing, and knowledge of surgical risk factors, post-operative mortality and serious adverse events (SAE) is essential. The aim with our study was to determine the risk of a composite outcome of post-operative: death; myocardial infarction; pulmonary embolism; stroke; gastrointestinal bleeding; dialysis or reoperation.

METHODS

Data of surgical procedures in the period from January 1, 2012 to June 30, 2012 were retrieved from the Danish Anaesthesia Database (DAD). Follow-up of all patients undergoing hip or knee replacement, abdominal or gynaecological surgery was conducted retrieving data from The Danish Civil Registration System and the National Patient Register. Total observation time was from January 1, 2012 to June 6, 2013.

RESULTS

A total7449 adult patients were included in the final analysis. The risk of the composite outcome during a follow-up until 342 days after inclusion of the last patient was estimated to 8.3%, 95% Confidence Intervals (CI) (7.8-9.0), with a median observation time of 437 days (IQR 387-485, range 0-522). The risk of the composite outcome within 90- and 180-day follow-up of each patient was 4.8% (4.4-5.3) and 5.9% (5.4-6.5), respectively. Mortality within longest follow-up as well as 90 and 180 days post-operatively was 3.6% (3.1-4.0), 1.7% (1.4-2.0), and 2.2% (1.9-2.6), respectively.

CONCLUSION

We found a risk of one or more events in the composite outcome within 342 days after inclusion of the last patients of 8.3% (7.8-9.0). The results are applicable in estimations of adequate sample sizes in future clinical trials investigating effects of interventions on SAEs.