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Lee YJ, Bettick D, Rosenberg C. Improving Pain Self-Efficacy in Orthopedic Surgery Patients Through Video-Based Education: A Quality Improvement Project. Pain Manag Nurs 2024; 25:451-458. [PMID: 38719657 DOI: 10.1016/j.pmn.2024.04.008] [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: 01/07/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND Effective pain management following discharge is critical for postoperative recovery, with pain self-efficacy serving as a crucial component in this process. Patient education plays a key role in enhancing self-efficacy. Among various educational modalities, a growing body of evidence supports the efficacy of video-based methods. LOCAL PROBLEM A lack of evidence-based pain education programs for patients undergoing elective orthopedic surgery was identified at an urban academic hospital on the East Coast of the United States. This quality improvement project aimed to develop and assess a video-based pain education program, focusing on pain self-efficacy and self-reported preparedness among adult patients prescribed opioids for postsurgical pain. METHODS This project adopted a pretest-posttest design, utilizing the knowledge-to-action framework. Data collection spanned 3 months. Among the 69 patients screened for eligibility, 13 participants were included in the analysis. The primary intervention consisted of a 15-minute educational video covering essential pain management aspects. Following the intervention, pain self-efficacy and self-reported preparedness were evaluated using the Pain Self-Efficacy Questionnaire and a five-point Likert scale, respectively. RESULTS Median (IQR) scores on the Pain Self-Efficacy Questionnaire increased significantly from 20 (16) to 32 (14) (p < .01). Mean (SD) scores for patients' self-reported preparedness also increased from 21.92 (6.53) to 31.85 (2.41) (p < .01). All participants reported being satisfied or very satisfied with the educational intervention. CONCLUSION Video-based education is a time-efficient and cost-effective approach. Healthcare providers can consider integrating video education to enhance pain self-efficacy in the postoperative phase, thus enhancing postsurgical pain outcomes and overall recovery experience.
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Affiliation(s)
- Yoon-Jae Lee
- School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Dianne Bettick
- Department of Quality, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, 21224, USA
| | - Carol Rosenberg
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, 21205, USA
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Patterns of opioid use after surgical discharge: a multicentre, prospective cohort study in 25 countries. Anaesthesia 2024; 79:924-936. [PMID: 38721718 DOI: 10.1111/anae.16297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Excessive opioid prescribing following surgery contributes to the growing opioid crisis. Prescribing practices are modifiable, yet data to guide appropriate prescription of opioids at surgical discharge remain sparse. This study aimed to evaluate factors associated with opioid consumption following discharge from surgery. METHODS An international prospective multicentre cohort study was performed recruiting adult patients undergoing common general, orthopaedic, gynaecological and urological surgery, with follow-up 7 days after discharge. The primary outcome measures were the quantities of prescribed and consumed opioids in oral morphine milligram equivalents. Descriptive and multivariable analyses were performed to investigate factors associated with the primary outcome measures. RESULTS This analysis included 4273 patients from 144 hospitals in 25 countries. Overall, 1311 (30.7%) patients were prescribed opioids at discharge. For those patients prescribed opioids, mean (SD) 179 (240) oral morphine milligram equivalents were prescribed, yet only 81 (145) oral morphine milligram equivalents were consumed within the first 7 days after discharge. An increased dose of opioids prescribed at discharge was associated with an increased dose of opioids consumed during the follow-up period (β = 0.33 (95%CI 0.31-0.34), p < 0.001). The risk of prescribing more opioids than patients consumed increased as quantities of opioids prescribed at discharge exceeded 100 oral morphine milligram equivalents, independent of patient comorbidity, procedure and pain. Patients were prescribed more than twice the quantity of opioids they consumed in the first 7 days following discharge from surgery. CONCLUSIONS Our data suggest that the current quantities of opioids provided at discharge exceed patient needs and may contribute to increasing community opioid use and circulation.
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Kay AH, Levy R, Hills N, Jang A, Mcgough-Maduena A, Dematteo N, Mark M, Ueda S, Chen LM, Chapman JS. Evidence-based prescribing of opioids after laparotomy: A quality-improvement initiative in gynecologic oncology. Gynecol Oncol Rep 2024; 53:101396. [PMID: 38725997 PMCID: PMC11078636 DOI: 10.1016/j.gore.2024.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Across specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy. Methods In 2021, open surgical gynecologic oncology patients were called 2-4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2-4 weeks after surgery to again assess their opioid use at home. Results Data from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p < 0.01) and self-reported use of opioids at home decreased from 22.5 to 7.5 OME (p = 0.05). The refill rate did not differ (12.6 % pre- and 11.6 % post-intervention, p = 0.82). The surplus of opioids our patients reported having at home decreased from 1264 doses of 5 mg oxycodone tabs in the pre-intervention cohort, to 490 doses in the post-intervention cohort, a 61 % reduction. Conclusions An evidence-based approach for prescribing opioids to patients after laparotomy decreased the surplus of opioids we introduced into our patients' communities without impacting refill rates.
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Affiliation(s)
- Allison H. Kay
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Rachel Levy
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Nancy Hills
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16 Street, 2nd Floor, San Francisco, CA 94158, USA
| | - Allyson Jang
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Alison Mcgough-Maduena
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Natalia Dematteo
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Melissa Mark
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Stefanie Ueda
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Lee-may Chen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
| | - Jocelyn S. Chapman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 490 Illinois Street, 10th Floor, Box 0132, San Francisco, CA 94143, USA
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Gaitanidis A, Dorken Gallastegi A, Van Erp I, Gebran A, Velmahos GC, Kaafarani HM. Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter. J Am Coll Surg 2024; 238:280-288. [PMID: 38357977 DOI: 10.1097/xcs.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. STUDY DESIGN Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. RESULTS Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. CONCLUSIONS Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.
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Affiliation(s)
- Apostolos Gaitanidis
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - Ander Dorken Gallastegi
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - Inge Van Erp
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands (Van Erp)
| | - Anthony Gebran
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - George C Velmahos
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - Haytham Ma Kaafarani
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
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Kuechly H, Kurkowski S, Bonamer J, Newyear B, Johnson B, Grawe B. Opioid use and disposal at 2 weeks post-surgery: Brief communication regarding excess opioids and disposal habits. J Opioid Manag 2024; 20:103-107. [PMID: 38700391 DOI: 10.5055/jom.0854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To measure the number of unused prescription opioids and disposal habits of patients following orthopedic shoulder surgery. DESIGN A prospective observational study. SETTING Academic orthopedic sports medicine department. PATIENTS Sixty-seven patients undergoing shoulder surgery. INTERVENTIONS Nine-question opioid use questionnaire. MAIN OUTCOME MEASURES Responses to an opioid use questionnaire were collected at 2 weeks post-surgery. Outcomes of interest included the amount of initial opioid prescription used and the disposal of excess opioids. RESULTS Sixty-seven patients completed the opioid use questionnaire. Forty-six (68.7 percent) patients reported having excess opioids at 2 weeks. Of the 46 patients with excess opioids, 57 percent disposed of the excess, and 43 percent planned to keep their opioids. CONCLUSION Two-thirds of the patients reported having excess opioids, highlighting the issue of an overabundance of unused prescription opioids in America. Utilization of opioid-free pain management strategies and drug disposal kits should be explored to reduce the number of unused and improperly disposed opioids.
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Affiliation(s)
- Henry Kuechly
- Department of Orthopaedic Surgery and Sports Medicine, University of Cincinnati, Cincinnati, Ohio. ORCID: https://orcid.org/0000-0002-7290-1081
| | - Sarah Kurkowski
- Department of Orthopaedic Surgery and Sports Medicine, University of Cincinnati, Cincinnati, Ohio
| | - John Bonamer
- Department of Orthopaedic Surgery and Sports Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Brian Johnson
- Department of Orthopaedic Surgery and Sports Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brian Grawe
- Department of Orthopaedic Surgery and Sports Medicine, University of Cincinnati, Cincinnati, Ohio
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Egan KL, McCallum L, Matthews JC, Eldridge LA. Elucidating determinants of medication disposal programs at retail pharmacies in North Carolina. J Am Pharm Assoc (2003) 2024; 64:111-119. [PMID: 37940096 DOI: 10.1016/j.japh.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Pharmacy-based medication disposal programs is one approach to prevent diversion of unused prescription opioids. OBJECTIVE(S) The objective of this study was to assess the extent to which disposal programs have been implemented by retail pharmacies and identify determinants of implementation using the Consolidated Framework for Implementation Research. METHODS A sequential mixed-method design was used to examine implementation of medication disposal programs at pharmacies in Pitt County, NC. We conducted environmental scans of all retail pharmacies that served community members (N = 31) to assess the extent to which disposal programs had been implemented. Then, we conducted interviews with pharmacists (n = 15; 48.4%) to identify determinants of implementation. The following pharmacy types were represented in the completed interviews: corporate chain (n = 10), small chain (n = 1), independently owned and operated (n = 1), medical (n = 2), and government (n = 1). RESULTS We found that 32.3% of pharmacies (n = 10) had a medication disposal box and 12.9% (n = 4) had posted a flyer on medication disposal. Pharmacists perceived that patients benefit from disposal boxes and medication disposal is in their purview. Determinants of implementation included the cost of sustaining the intervention, polices of corporate and regional management, variable local control in the decision-making process to implement a disposal box, and experience with having a medication disposal box. CONCLUSION Our findings highlight one way in which pharmacists can have a vital role in preventing diversion of opioid analgesics and associated consequences. There is a need to expand disposal boxes at pharmacies to increase community member accessibility and use. Future research is needed to determine the cost-effectiveness of expanding the scale of disposal box implementation in community pharmacies.
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Reiter AJ, Huang R, Iroz CB, Slocum JD, D'Orazio BM, Johnson JK, Stulberg JJ. Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative. J Surg Res 2024; 293:274-280. [PMID: 37804797 DOI: 10.1016/j.jss.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/28/2023] [Accepted: 09/12/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION The opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative. METHODS From July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery. RESULTS One thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%. CONCLUSIONS On-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.
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Affiliation(s)
- Audra J Reiter
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Reiping Huang
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Cassandra B Iroz
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John D Slocum
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brianna M D'Orazio
- Surgical Outcomes and Quality Improvement Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julie K Johnson
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonah J Stulberg
- Department of Surgery, University of Texas Health Sciences Center of Houston, McGovern Medical School, Houston, Texas.
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Huang LC, Bleicher J, Torre M, Johnson JE, Presson A, Millar MM, Gordon AJ, Brooke BS, Kaphingst KA, Harris AHS. Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags. Health Serv Res 2023; 58:1256-1265. [PMID: 37700549 PMCID: PMC10622267 DOI: 10.1111/1475-6773.14227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVE To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids. DATA SOURCES AND STUDY SETTING We collected patient surveys and electronic medical record data at an academic health system. STUDY DESIGN We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias. DATA COLLECTION/EXTRACTION METHODS From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy. PRINCIPAL FINDINGS We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up. CONCLUSIONS A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.
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Affiliation(s)
- Lyen C. Huang
- Department of SurgeryUniversity of UtahSalt Lake CityUtahUSA
- Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
| | - Josh Bleicher
- Department of SurgeryUniversity of UtahSalt Lake CityUtahUSA
| | - Michael Torre
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | | | - Angela Presson
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Morgan M. Millar
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
- Informatics, Decision‐Enhancement, and Analytic Sciences (IDEAS) CenterVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | | | - Kimberly A. Kaphingst
- Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
- Department of CommunicationUniversity of UtahSalt Lake CityUtahUSA
| | - Alex H. S. Harris
- Department of SurgeryStanford UniversityStanfordCaliforniaUSA
- VA HSR&D Center for Innovation to ImplementationPalo Alto VA Health Care SystemPalo AltoCaliforniaUSA
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Krebsbach MN, Alexander KM, Miller JJ, Doll EL, Lee YL, Simmons JD. Implementing a Discharge Opioid Bundle in Adult Trauma Patients Decreases the Amount of Opioids Prescribed at Discharge. Am Surg 2023; 89:4281-4287. [PMID: 35622969 DOI: 10.1177/00031348221101483] [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: 11/17/2022]
Abstract
BACKGROUND Opioids remain the mainstay treatment of acute pain caused by trauma. The lack of evidence driven prescribing creates a challenging situation for providers. We hypothesized that the implementation of a trauma discharge opioid bundle (TDOB) would decrease the total morphine milligram equivalents (MME) prescribed at discharge while maintaining pain control. METHODS This was a pre-post study of adult trauma patients before and after implementation of a TDOB to guide the prescription of opioids and discharge prescription education in patients discharged from a level one trauma center. The pre-group and post-group, included consecutively discharged patients from September through November in 2018 and 2019. The primary outcome was the total MME prescribed at discharge. RESULTS A total of 377 patients met inclusion criteria. One hundred and fifty-one patients were included in the pre-group and 226 in the post-group. The total MME prescribed at discharge (225 ± [150-300] pre vs 200 ± [100-225] post, P = < .001) and maximum MME/day (45 ± [30-45] vs 30 ± [20-45], P = .004) were significantly less in the post-group. Incidence of outpatient refills within fourteen days were similar. More non-opioid pain adjuncts were prescribed post-intervention and discharge pain education was provided more frequently. CONCLUSION The implementation of a TDOB significantly reduced the MME prescribed at discharge without increasing the number of opioid refills.
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Affiliation(s)
- Mackenzie N Krebsbach
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | | | - Jennifer J Miller
- College of Nursing, Department of Adult Health Nursing, University of South Alabama, Mobile, AL, USA
| | - Elizabeth L Doll
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | - Yann-Leei Lee
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | - Jon D Simmons
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
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Lewis PR, Pelzl C, Benzer E, Szad S, Judge C, Wang A, Van Gent M. Bringing Opiates Off the Streets and Undertaking Excess Scripts: A novel opiate reclamation and prescription reduction program. Surgery 2023; 174:574-580. [PMID: 37414590 DOI: 10.1016/j.surg.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Opioid diversion and misuse continue to present problems in modern medicine. The "opioid epidemic" has claimed more than 250,000 lives since 1999, with studies pointing to prescription opioids as the culprit for future opiate misuse. Currently, there are no well-described, data-driven processes to educate surgeons on reducing opiate prescribing, informed by personal practice patterns. We designed and implemented a novel opiate reclamation and prescription reduction program for surgeons to reclaim unused medications and decrease prescribing using individual provider data. METHODS We performed a prospective collection of all unused opiate pain medications for general surgery postoperative patients from July 15, 2020 to January 15, 2021. Patients brought their unused opiates to their routine postoperative follow-up appointment, where they were counted and disposed of in a secure drug take-back bin. Reclaimed opiates were totaled, analyzed, and reported to the providers, who used their individual reclamation rates to refine prescribing habits. RESULTS During the reclamation period, 168 operations were performed, with a total of 12,970 morphine milligram equivalents of opiate prescribed by 5 physicians. A total of 6,077.5 morphine milligram equivalents (46.9%) were reclaimed, which is the equivalent of 800 5-mg tablets of oxycodone. A review of these data led to a 30.9% decrease in opiate prescriptions by participating surgeons in addition to the reclamation of an additional 3,150 morphine milligram equivalents over the next 6 months. CONCLUSION Continuous monitoring of the medications returned by patients now continues to inform our providers' prescribing practices, decreases the amount of opiates in the community, and improves patient safety.
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Affiliation(s)
- Paul R Lewis
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan.
| | - Casey Pelzl
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Emily Benzer
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Sean Szad
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Carolyn Judge
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Andrew Wang
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Michael Van Gent
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
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Millard JL, Hahn EA, Schumann E, Register L, Blackhurst D, Carbonell AM, Cobb WS, Warren JA. A Standardized Protocol for Opioid Prescribing After Surgery Decreases Total Morphine Equivalents Prescribed. Am Surg 2023; 89:3771-3777. [PMID: 37195287 DOI: 10.1177/00031348231175494] [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: 05/18/2023]
Abstract
INTRODUCTION Perioperative opioid analgesia has been extensively reexamined during the opioid epidemic. Multiple studies have demonstrated over prescription of opioids, demonstrating the need for change in prescribing practices. A standard opioid prescribing protocol was implemented to evaluate opioid prescribing trends and practices. OBJECTIVES To evaluate opioid use after primary ventral, inguinal, and incisional hernia repair and to assess clinical factors that may impact opioid prescribing and consumption. Secondary outcomes include the number of refills, patients without opioid requirement, difference in opioid use based on patient characteristics and adherence to prescribing protocol. METHODS This is a prospective observational study examining patients undergoing inguinal, primary ventral and incisional hernias between February and November 2019. A standardized prescribing protocol was implemented and utilized for postoperative prescribing. All data was captured in the abdominal core health quality collaborative (ACHQC) and opioid use was standardized via morphine milligram equivalents (MME). RESULTS 389 patients underwent primary ventral, incisional, and inguinal hernia repair, with a total of 285 included in the final analysis. 170 (59.6%) of patients reported zero opioid use postoperatively. Total opioid MME prescribed and high MME consumption were significantly higher after incisional hernia repair with a greater number of refills were required. Compliance with prescribing protocol resulted in lower MME prescription, but not actual lower MME consumption. CONCLUSIONS Implementation of a standardized protocol for opioid prescribing after surgery decreases the total MME prescribed. Compliance with our protocol significantly reduced this disparity, which has the potential for decreasing abuse, misuse, and diversion of opioids by better estimating actual postoperative analgesic requirements.
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Affiliation(s)
- Jessica L Millard
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
| | - Elizabeth A Hahn
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Emily Schumann
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Lindsey Register
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Dawn Blackhurst
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
| | - Alfredo M Carbonell
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - William S Cobb
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Jeremy A Warren
- Prisma Health- Upstate, Department of General Surgery, Greenville Memorial, Greenville, SC, USA
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
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12
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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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13
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Varady NH, Chen AF, Niu R, Chung M, Freccero DM, Smith EL. Association Between Surgical Opioid Prescriptions and Opioid Initiation by Opioid-naïve Spouses. Ann Surg 2023; 277:e1218-e1224. [PMID: 34954759 DOI: 10.1097/sla.0000000000005350] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses. SUMMARY OF BACKGROUND DATA Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown. METHODS This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from January 1, 2011 to June 30, 2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months after surgery was assessed. Secondary analyses assessed how this association varied with postoperative time. RESULTS There were 318,022 patients (mean ± standard deviation age 48.8 ±9.3 years; 49.5% women). Among the 50,833 (16.0%) patients that did not fill a surgical opioid prescription, 2152 (4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189 (84.0%) patients who filled a surgical opioid prescription, 15,026 (5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery [unadjusted P < 0.001; adjusted odds ratio (aOR) 1.37, 95% confidence interval (CI) 1.31-1.43, P < 0.001]. Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95% CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57,95% CI 1.391.76, P < 0.001). CONCLUSIONS Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Hospital of Special Surgery, New York, NY
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Ruijia Niu
- Department of Orthopaedic Surgery, Boston Medical center, Boston, MA
| | - Mei Chung
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA; and
| | - David M Freccero
- Department of Orthopaedic Surgery, Boston Medical center, Boston, MA
| | - Eric L Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA
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Bleicher J, Johnson JE, Cain BT, Shaw RD, Acher AA, Gleason L, Barth RJ, Chu DI, Jung S, Melnick D, Kaphingst KA, Smith BK, Huang LC. Surgical Trainee Perspectives on the Opioid Crisis: The Influence of Explicit and Hidden Curricula. JOURNAL OF SURGICAL EDUCATION 2023; 80:786-796. [PMID: 36890045 PMCID: PMC10200738 DOI: 10.1016/j.jsurg.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/16/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE In order to effectively create and implement an educational program to improve opioid prescribing practices, it is important to first consider the unique perspectives of residents on the frontlines of the opioid epidemic. We sought to better understand resident perspectives on opioid prescribing, current practices in pain management, and opioid education as a needs assessment for designing future educational interventions. DESIGN This is a qualitative study using focus groups of surgical residents at 4 different institutions. SETTING We conducted focus groups using a semistructured interview guide in person or over video conferencing. The residency programs selected for participation represent a broad geographic range and varying residency sizes. PARTICIPANTS We used purposeful sampling to recruit general surgery residents from the University of Utah, University of Wisconsin, Dartmouth-Hitchcock Medical Center, and the University of Alabama at Birmingham. All general surgery residents at these locations were eligible for inclusion. Participants were assigned to focus groups by residency site and their status as junior (PGY-2, PGY-3) or senior resident (PGY-4, PGY-5). RESULTS We completed 8 focus groups with a total of 35 residents included. We identified 4 main themes. First, residents relied on clinical and nonclinical factors when making decisions about opioid prescribing. However, hidden curricula based on unique institutional cultures and attending preferences heavily influenced residents' prescribing practices. Second, residents acknowledged that stigma and biases towards certain patient groups influenced opioid prescribing practices. Third, residents encountered barriers within their health systems to evidence-based opioid prescribing. Fourth, residents did not routinely receive formal education on pain management or opioid prescribing. Residents recommended several interventions to improve the current state of opioid prescribing, including standardized prescribing guidelines, improved patient education, and formal training during the first year of residency. CONCLUSIONS Our study highlighted several areas of opioid prescribing that can be improved upon through educational interventions. These findings can be used to develop programs aimed at improving residents' opioid prescribing practices, both during and after training, and ultimately the safe care of surgical patients. ETHICS STATEMENT This project was approved by the University of Utah Institutional Review Board, ID # 00118491. All participants provided written informed consent.
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Affiliation(s)
- Josh Bleicher
- Department of Surgery, University of Utah, Salt Lake City, Utah.
| | | | - Brian T Cain
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Robert D Shaw
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexandra A Acher
- Department of Surgery, University of Utah, Salt Lake City, Utah; Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Lauren Gleason
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard J Barth
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel I Chu
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Sarah Jung
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - David Melnick
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Kimberly A Kaphingst
- Department of Communication, Unversity of Utah and Huntsman Cancer Institute, Salt Lake City, Utah
| | | | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
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15
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Huang LC, Johnson JE, Bleicher J, Blumling AN, Savarise M, Wetter DW, Cohan JN, Harris AA, Kaphingst KA. Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study. HEALTH EDUCATION & BEHAVIOR 2023; 50:281-289. [PMID: 34963358 PMCID: PMC10473843 DOI: 10.1177/10901981211057540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids. AIMS Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region. METHODS We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM). RESULTS We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient-provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden. CONCLUSIONS We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.
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Affiliation(s)
| | | | | | | | | | | | | | - Alex A.S. Harris
- Stanford University, CA, USA
- VA Palo Alto Healthcare System, CA, USA
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16
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Kay AH, Othieno A, Boscardin J, Chen LL, Alvarez EA, Swanson M, Ueda S, Chen LM, Chapman JS. The past, present, and future of opioid prescribing: perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021. Gynecol Oncol Rep 2023; 46:101172. [PMID: 37065538 PMCID: PMC10090236 DOI: 10.1016/j.gore.2023.101172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
Objective To describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates. Methods Part one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge. Results 1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients. Conclusion Inpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients' actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.
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17
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Owens SM, Voigt P, Ponzini MD, Wilson MD, Chen HA. Perioperative Education and Postoperative Discharge Medications in Gynecologic Oncology Patients: Prescribing Practices, Clinical Encounters, and Patient Satisfaction. J Gynecol Surg 2023. [DOI: 10.1089/gyn.2022.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Steffanie M. Owens
- University of California Davis Medical Center, Sacramento, California, USA
| | - Petra Voigt
- University of California Davis Medical Center, Sacramento, California, USA
| | - Matthew D. Ponzini
- University of California Davis Medical Center, Sacramento, California, USA
| | - Machelle D. Wilson
- University of California Davis Medical Center, Sacramento, California, USA
| | - H. Amy Chen
- University of California Davis Medical Center, Sacramento, California, USA
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18
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Patient Willingness to Dispose of Leftover Opioids After Surgery: A Mixed Methods Study. ANNALS OF SURGERY OPEN 2022; 3:e223. [PMID: 36590888 PMCID: PMC9780041 DOI: 10.1097/as9.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/28/2022] [Indexed: 12/12/2022] Open
Abstract
We examined how convenience and financial incentives influence patient willingness to dispose of leftover prescription opioids after surgery. We also identified additional barriers and facilitators to disposal. Background In the United States, up to 70% of surgical patients are prescribed opioids and up to 92% will have leftover tablets. Most do not dispose of leftover opioids, increasing the risk for opioid-related harm. Current interventions promoting opioid disposal have shown mixed success. Methods We conducted a mixed methods study using a standard gamble survey and semi-structured interviews. Participants estimated willingness to dispose in 16 scenarios with varying convenience (time requirements of <5, 15, 30, and 60 minutes) and financial incentives ($0, $5, $25, $50). We estimated the likelihood of disposal using a multivariable mixed effects modified Poisson regression model. Semi-structured interviews explored how convenience, financial incentives, and other barriers and facilitators influenced decisions to dispose. Results Fifty-five participants were surveyed and 42 were interviewed. Most were willing to dispose when the time required was <15 minutes. Few were willing to dispose if the process required 60 minutes, although a $50 financial incentive increased rates from 9% to 36%. Anxiety about future pain, opioid scarcity, recreational use, family safety, moral beliefs, addiction, theft, and environmental harm also influenced decision-making. Conclusions Interventions promoting opioid disposal should focus on convenience, but the selective use of financial incentives can be effective. Tailoring interventions to individual barriers and facilitators could also increase disposal rates.
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19
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Zito A, Briskin I, Bena JF, Albert NM. Effect of a Medication Disposal Pouch versus Usual Care on Post Discharge Disposal of Unused Opioids: A Randomized Controlled Trial. J Perianesth Nurs 2022; 37:842-847. [PMID: 35382960 DOI: 10.1016/j.jopan.2022.01.005] [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: 06/02/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine frequency of disposal of unused opioids after surgical procedures based on medication disposal pouch use or usual care, and patient factors associated with disposal. DESIGN Two-group experimental design and convenience sample. METHODS Same-day surgery adults who received opioid orders were randomized to usual care or usual care plus a medication disposal pouch for opioid disposal. Opioid disposal and pain characteristics were collected by telephone at 30±10 days post discharge. Other data were abstracted from a hospital database. Data were compared using Kruskal-Wallis, Pearson's Chi-Square and Fisher's exact tests. Logistic regression models were built to identify predictors of disposal of unused opioids. FINDINGS Of 221 adults, mean age was 58.5 years and 50.2% were female. Overall, 121 received medication disposal pouches and 100 received usual care. Among those with a filled prescription, there was no between-group difference in the number of patients who used all of their opioid medication (disposal pouch group, 29.5%; usual care group, 21.7%). Of 74 disposal pouch and 65 usual care patients who did not use all opioid medications, 23.0% and 13.8%, respectively, disposed of opioids, and of the 23.0% of patients who disposed of medications in the disposal pouch group, 94.1% used the medication disposal pouch. After controlling for 7 factors, the odds of disposal of unused opioids increased among patients who received the intervention, had lower pain scores on the worst day of postoperative pain, and had a history of renal diagnoses (versus those with gastrointestinal diagnoses). CONCLUSIONS Although opioid medication disposal rates were higher in the medication disposal pouch group; overall rates of disposal of unused opioid medications were low. More research is needed to learn important factors and methods associated with opioid disposal.
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Affiliation(s)
- Antoinette Zito
- Cleveland Clinic Hillcrest Hospital, Nursing Institute, Mayfield Heights, OH.
| | - Isaac Briskin
- Cleveland Clinic, Quantitative Health Sciences, Cleveland, OH
| | - James F Bena
- Cleveland Clinic, Quantitative Health Sciences, Cleveland, OH
| | - Nancy M Albert
- Cleveland Clinic, Nursing Research and Innovation, Cleveland, OH
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20
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An Education Intervention to Raise Awareness Reduces Self-reported Opioid Overprescribing by Plastic Surgery Residents. Ann Plast Surg 2022; 89:600-609. [DOI: 10.1097/sap.0000000000003247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Ghaddaf AA, Alsharef JF, Alhindi AK, Bahathiq DM, Khaldi SE, Alowaydhi HM, Alshehri MS. Influence of perioperative opioid-related patient education: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2022; 105:2824-2840. [PMID: 35537899 DOI: 10.1016/j.pec.2022.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/01/2022] [Accepted: 04/27/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To determine the role of perioperative protocolized opioid-specific patient education on opioid consumption for individuals undergoing surgical procedures. METHODS We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) that compared protocolized perioperative opioid-specific patient education to the usual care for adult individuals undergoing surgical interventions. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes. RESULTS In total, 15 RCTs that enrolled 2546 participants were deemed eligible. Protocolized opioid-specific patient education showed a significant reduction in postoperative opioid consumption and postoperative pain score compared to usual care (SMD= -0.15, 95% confidence interval [CI]: -0.28 to -0.03 and SMD= -0.17, 95% CI: -0.28 to -0.06, respectively). No significant difference was found between the protocolized opioid-specific patient education and the usual care in terms of the number of refill requests (RR=0.82, 95% CI: 0.50-1.34), patients with opioid leftovers (RR=0.92, 95% CI: 0.78-1.08), and patients taking opioids after hospital discharge. CONCLUSIONS This meta-analysis demonstrated that protocolized opioid-specific patient education significantly reduces postoperative opioid consumption and pain score but has no influence on the number of opioid refill requests, opioid leftovers, and opioid use after hospital discharge. PRACTICE IMPLICATIONS Healthcare professionals may offer opioid-related educational sessions for the surgical patients during the perioperative period through a video-based material that emphasizes the role of alternative analgesics to opioids, patients' expectations about the post-operative pain, and the potential side effects of opioid consumptions.
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Affiliation(s)
- Abdullah A Ghaddaf
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Jawaher F Alsharef
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Abeer K Alhindi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Dena M Bahathiq
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Shahad E Khaldi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Hanin M Alowaydhi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Mohammed S Alshehri
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Surgery/Orthopedic section, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
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22
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Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study. Can J Anaesth 2022; 69:974-985. [DOI: 10.1007/s12630-022-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/15/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
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23
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Cogan JC, Accordino MK, Beauchemin MP, Spivack JH, Ulene SR, Elkin EB, Melamed A, Taback B, Wright JD, Hershman DL. Efficacy of a password-protected, pill-dispensing device with mail return capacity to enhance disposal of unused opioids after cancer surgery. Cancer 2022; 128:3392-3399. [PMID: 35819926 DOI: 10.1002/cncr.34384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/22/2022] [Accepted: 06/15/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery. METHODS A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction. RESULTS Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved. CONCLUSIONS Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.
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Affiliation(s)
- Jacob C Cogan
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Melissa K Accordino
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Melissa P Beauchemin
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Columbia University School of Nursing, New York, New York, USA
| | - John H Spivack
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Sophie R Ulene
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Elena B Elkin
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Bret Taback
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, New York, USA
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Jeffery MM, Ahadpour M, Allen S, Araojo R, Bellolio F, Chang N, Ciaccio L, Emanuel L, Fillmore J, Gilbert GH, Koussis P, Lee C, Lipkind H, Mallama C, Meyer T, Moncur M, Nuckols T, Pacanowski MA, Page DB, Papadopoulos E, Ritchie JD, Ross JS, Shah ND, Soukup M, St Clair CO, Tamang S, Torbati S, Wallace DW, Zhao Y, Heckmann R. Acute pain pathways: protocol for a prospective cohort study. BMJ Open 2022; 12:e058782. [PMID: 35790333 PMCID: PMC9258513 DOI: 10.1136/bmjopen-2021-058782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/31/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses. METHODS AND ANALYSIS This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients' patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids. ETHICS AND DISSEMINATION This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public. TRIAL REGISTRATION NUMBER NCT04509115.
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Affiliation(s)
- Molly Moore Jeffery
- Emergency Medicine and Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mitra Ahadpour
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Summer Allen
- Knowledge and Evaluation Research Unit; Department of Family Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Richardae Araojo
- Office of the Commissioner, Office of Minority Health and Health Equity, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Fernanda Bellolio
- Emergency Medicine and Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy Chang
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Laura Ciaccio
- Division of Population Health and Genomics, University of Dundee School of Medicine, Dundee, UK
| | - Lindsay Emanuel
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jonathan Fillmore
- Department of Surgery, Mayo Clinic Division of Oral and Maxillofacial Surgery, Rochester, Minnesota, USA
| | - Gregg H Gilbert
- Department of Clinical and Community Sciences, School of Dentistry, The University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama, USA
| | - Patricia Koussis
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Lee
- Office of the Commissioner, Office of Minority Health and Health Equity, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Heather Lipkind
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Celeste Mallama
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Tamra Meyer
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Megan Moncur
- Center for Drug Evaluation and Research, Office of New Drugs, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Teryl Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael A Pacanowski
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - David B Page
- Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, The University of Alabama, Birmingham, Alabama, USA
| | - Elektra Papadopoulos
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jessica D Ritchie
- Center for Outcomes Research and Evaluation, Yale University Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
| | - Joseph S Ross
- Internal Medicine, Yale University Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
| | - Nilay D Shah
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mat Soukup
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christopher O St Clair
- Center for Drug Evaluation and Research, Office of New Drugs, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stephen Tamang
- Department of Family Medicine, Monument Health, Rapid City, South Dakota, USA
| | - Sam Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Douglas W Wallace
- Department of Emergency Medicine, Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, The University of Alabama, Birmingham, Alabama, USA
| | - Yueqin Zhao
- Center for Drug Evaluation and Research, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rebekah Heckmann
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
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Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane-Blocks in Abdominally-Based Microvascular Breast Reconstruction. Plast Reconstr Surg 2022; 150:506e-515e. [PMID: 35749219 DOI: 10.1097/prs.0000000000009398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transversus Abdominis Plane (TAP) blocks can improve pain control and decrease opioid usage within an ERAS protocol, in patients undergoing abdominally-based autologous breast reconstruction. The author has transitioned to using a local analgesic cocktail in place of liposomal bupivacaine for TAP blocks. The purpose of this study is to compare post-operative opioid use in patients who received the different TAP blocks. METHODS A retrospective review of patients undergoing abdominally-based autologous breast reconstruction between November 2015 and December 2019 was performed. The study group received Bupivacaine, Ketorolac, Dexmedetomidine, and Dexamethasone, and the control group received Liposomal Bupivacaine +/- Bupivacaine, Ketorolac, or Dexmedetomidine, as a TAP block. The primary outcome of interest was post-operative opioid use and pain scores. RESULTS A total of 104 women met inclusion criteria: 36 in Group A (pre-ERAS, pre-TAP), 38 in Group B (ERAS, TAP with liposomal bupivacaine), and 30 in Group C (ERAS, TAP with local anesthetic cocktail). Total and average daily OME consumption were significantly less for Group C in the inpatient phase (Group A: 633, B: 240, C: 135; p<0.0001) (Group A: 137, B: 56, C: 29; p<0.0001). Patients in Group C were prescribed significantly less outpatient OMEs (Group A: 79, B: 74, C: 52; p=0.01). CONCLUSION TAP blocks are a significant component of an ERAS protocol for abdominally-based breast reconstruction. Liposomal bupivacaine is a popular option for TAP blocks. Our results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease post-operative opioid use.
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Keane AM, Larson EL, Payne RM, Cooke S, Zubovic E, Patel KB, Mackinnon SE, Snyder-Warwick AK. Dispose with dish soap: a simple and convenient method to increase proper opioid disposal in postoperative pediatric patients. J Plast Reconstr Aesthet Surg 2022; 75:3845-3852. [DOI: 10.1016/j.bjps.2022.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 03/09/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
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Sharples HM, Rieck HA, Hagood K, Brummett CM, Nalliah RP. Dean reported opioid and pain management curriculum in US dental schools. J Dent Educ 2022; 86:1271-1278. [PMID: 35533070 DOI: 10.1002/jdd.12947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/31/2022] [Accepted: 04/09/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Dental students learn to prescribe pain management medications in dental school, including opioids. Given the current state of opioid-related morbidity and mortality in the US, dental schools should evaluate the context and implementation of opioid prescribing in their dental school clinics (DSCs). METHODS A nationwide survey of deans of clinical operations at all US dental schools was conducted in 2020 related to pain management in their DSC. The Michigan Medicine Institutional Review Board deemed this study unregulated (HUM00151607). RESULTS Of the 68 accredited dental schools in the United States, 26 deans of DSCs responded to the survey, yielding a 40% response rate. The survey results showed differences in the levels of education for dental students on opioid prescribing and patient education requirements. A comprehensive curriculum regarding safe opioid prescribing and patient education training was reported by 12 schools. Four dental programs did not have a single guideline or policy in relation to opioids for their dental students. CONCLUSION The implementation of opioid prescribing guidelines and the surrounding context are different among DSCs, which could result in knowledge gaps and confusion for novice providers. Although many dental programs provide extensive opioid safety training, there is room for improvement and standardization to further advance patient care.
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Affiliation(s)
| | - Heidi A Rieck
- Michigan Medicine, Michigan OPEN, Ann Arbor, Michigan, USA
| | - Katelyn Hagood
- University of Michigan School of Dentistry, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Division of Pain Research, Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Romesh P Nalliah
- Patient Services, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA
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Davey MG, Joyce WP. Reducing Opioid Consumption Levels Post-Operatively following Gastrointestinal Surgery – A Systematic Review of Randomized Trials. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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29
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Egan KL, Johnston CA, Jackson JT, Foster SE, Lee JG. Rates and correlates of medicine disposal program implementation at pharmacies in North Carolina: A longitudinal study, 2016 to 2021. J Am Pharm Assoc (2003) 2022; 62:1329-1337. [DOI: 10.1016/j.japh.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
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Zubovic E, Skolnick GB, AuBuchon JD, Waters EA, Snyder-Warwick AK, Patel KB. Variability and Excess in Opioid Prescribing Patterns After Cleft and Craniosynostosis Repairs. Cleft Palate Craniofac J 2022:10556656221083082. [PMID: 35226537 DOI: 10.1177/10556656221083082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To critically analyze pediatric opioid prescription patterns after cleft and craniosynostosis repairs. DESIGN Observational study 1) retrospectively reviewing pediatric opioid prescriptions from July 2018 to June 2019 and 2) prospectively surveying patients about actual opioid use from August 2019 to February 2020. SETTING Academic tertiary care pediatric hospital. PATIENTS 133 pediatric patients undergoing cleft lip and/or palate or craniosynostosis repairs. Prospective surveys were offered at postoperative visits; 45 of 69 eligible patients were enrolled. INTERVENTION None. MAIN OUTCOME MEASURES Opioid doses prescribed at discharge and actual home opioid use. RESULTS 90 patients with cleft lip and/or palate and 43 patients with craniosynostosis were included. Median prescribed opioid doses were 10.3 for cleft lip and/or palate procedures (range 0-75), and 14.3 for craniosynostosis repairs (range 0-50). In patients with cleft lip and/or palate, there was a negative correlation between age at surgery and prescribed opioid doses (rs = -0.228, p = 0.031). 45 patients completed surveys of home opioid use. No patients used more than 10 doses. Forty percent used no opioids at home, 33% used 1 to 2 doses, 18% used 3 to 5 doses, and 9% used 6 to 10 doses. CONCLUSIONS Opioid prescriptions vary widely after common craniofacial procedures. Younger patients with cleft lip and/or palate may be more likely to be prescribed more doses. Actual home opioid use is less than prescribed amounts, with most patients using five or fewer doses. A prescribing guideline is proposed.
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Affiliation(s)
- Ema Zubovic
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Gary B Skolnick
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Jacob D AuBuchon
- Department of Anesthesiology, 12275Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Erika A Waters
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Alison K Snyder-Warwick
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kamlesh B Patel
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Macintyre PE, Quinlan J, Levy N, Lobo DN. Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review. JAMA Surg 2022; 157:158-166. [PMID: 34878527 DOI: 10.1001/jamasurg.2021.6210] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Uncontrolled and indiscriminate prescribing of opioids has led to an opioid crisis that started in North America and spread throughout high-income countries. The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, focusing on drivers that led to escalation of use, patient harms, the move away from using self-reported pain scores alone to assess adequacy of analgesia, concerns about the routine use of controlled-release opioids for the management of acute pain, opioid-free anesthesia and analgesia, and prescription of opioids on discharge from hospital. Observations The origins of the opioid crisis are multifactorial and may include good intentions to keep patients pain free in the postoperative period. Assessment of patient function may be better than unidimensional numerical pain scores to help guide postoperative analgesia. Immediate-release opioids can be titrated more easily to match analgesic requirements. There is currently no good evidence to show that opioid-free anesthesia and analgesia affects opioid prescribing practices or the risk of persistent postoperative opioid use. Attention should be paid to discharge opioid prescribing as repeat and refill prescriptions are risk-factors for persistent postoperative opioid use. Opioid stewardship is paramount, and many governments are passing legislation, while statutory bodies and professional societies are providing advice and guidance to help mitigate the harm caused by opioids. Conclusions and Relevance Opioids remain a crucial part of many patients' journey from surgery to full recovery. The last few decades have shown that unfettered opioid use puts patients and societies at risk, so caution is needed to mitigate those dangers. Opioid stewardship provides a multilayered structure to allow continued safe use of opioids as part of broad pain management strategies for those patients who benefit from them most.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, United Kingdom
| | - Dileep 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, United Kingdom
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
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Kharasch ED, Clark JD, Adams JM. Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology 2022; 136:10-30. [PMID: 34874401 PMCID: PMC10715730 DOI: 10.1097/aln.0000000000004065] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.
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Affiliation(s)
- Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - J David Clark
- the Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Edwards JM, Evans H, Dollar SD, Odom-Forren J, Johnson B. Surgical Patient Compliance With Healthcare Facility-Provided In-home Opioid Disposal Products: A Systematic Review. J Nurs Adm 2022; 52:35-41. [PMID: 34910707 DOI: 10.1097/nna.0000000000001100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to review the literature regarding the use of an in-home opioid disposal product on unused opioids after surgery. BACKGROUND The opioid epidemic in the United States is a major cause of concern for healthcare facilities. The misuse and diversion of retained opioids after a surgical procedure continues to contribute to this problem. METHODS A comprehensive search of the Cumulative Index of Nursing and Allied Health Literature, OVID, and PubMed databases with keywords including opioid, analgesics, narcotics, medical waste disposal, medical disposal, refuse disposal, and opioid disposal resulted in 286 articles. Articles were screened based on strict inclusion and exclusion criteria. RESULTS Eight studies determined that an in-home opioid disposal product provided by a healthcare facility produced rates of opioid disposal between 19% and 71%. CONCLUSIONS The provision of an in-home opioid disposal product by a healthcare facility is likely to increase the disposal of unused opioid medications in the postoperative surgical patient population.
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Affiliation(s)
- John M Edwards
- Author Affiliations : Acute Pain Service Codirector (Drs Edwards and Dollar), Baptist Health Lexington, Kentucky, Course Instructor (Dr Evans), Middle Tennessee School of Anesthesia, Madison, Tennessee; Associate Professor (Dr Odom-Forren), University of Kentucky College of Nursing, Lexington, and Coeditor, Journal of PeriAnesthesia Nursing, Philadelphia; and Director (Dr Johnson), Acute Surgical Pain Management Fellowship and the Doctor of Nurse Anesthesia Practice Completion Program, Middle Tennessee School of Anesthesia, Madison
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Bettlach CLR, Hasak JM, Santosa KB, Larson EL, Tung TH, Fox IK, Moore AM, Mackinnon SE. A Simple Brochure Improves Disposal of Unused Opioids: An Observational Cross-Sectional Study. Hand (N Y) 2022; 17:170-176. [PMID: 33025827 PMCID: PMC8721787 DOI: 10.1177/1558944720959898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND We evaluated the effectiveness of a simple, low-cost educational brochure in improving disposal rates of unused opioids after outpatient upper extremity surgery. METHODS This cross-sectional study enrolled eligible adult patients from a peripheral nerve clinic between November 2017 and September 2018. Patients either received or did not receive the educational brochure, which outlined a simple method to dispose of unused opioids and completed a survey at 2 weeks after surgery. We compared the proportion of patients who disposed of unused opioids after surgery between the group that had received the brochure and the group that had not. Categorical data were analyzed with χ2 test, proportions data with binomial tests, and numerical data with Mann-Whitney U test, all with a significance level of P < .05. RESULTS There were 339 survey respondents. Nineteen patients who did not meet inclusion criteria were excluded. Of the 320 remaining patients, 139 received the brochure and 181 did not. An additional 55 patients were excluded due to preoperative opioid use. Overall, 35.3% of recipients and 38.3% of those who did not receive the brochure used all of their prescribed opioid medication (P = .625; confidence interval = -14.6%-8.8%). Among patients with unused opioid medication, a significantly higher proportion of brochure recipients disposed of the medicine compared with those who did not receive the brochure (46.7% vs 19.6%, P < .001). CONCLUSIONS Distribution of an educational brochure significantly improved disposal of unused opioids after surgery. This easily implemented intervention can improve disposal of unused opioids and ultimately decrease excess opioids available for diverted use in the community.
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Affiliation(s)
| | | | | | - Ellen L. Larson
- Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas H. Tung
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ida K. Fox
- Washington University School of Medicine, St. Louis, MO, USA
| | - Amy M. Moore
- Washington University School of Medicine, St. Louis, MO, USA
| | - Susan E. Mackinnon
- Washington University School of Medicine, St. Louis, MO, USA,Susan E. Mackinnon, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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35
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Using an Environmentally Friendly Disposal Bag to Discard Leftover Opioids After Gynecologic Surgery. Obstet Gynecol 2022; 139:91-96. [PMID: 34856576 PMCID: PMC8717636 DOI: 10.1097/aog.0000000000004593] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/26/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the effects of an environmentally friendly drug deactivation bag on opioid disposal among patients undergoing gynecologic surgery. METHODS This prospective cohort study included patients undergoing gynecologic procedures requiring an opioid prescription from March 2020 to December 2020. Patients were managed on a restrictive opioid prescribing algorithm and given an opioid disposal bag. The carbon drug deactivation bag neutralizes the opioid medication and can be discarded safely in the trash. Patients were educated about pain management goals and the disposal bag. Patients were surveyed at their postoperative visit to evaluate satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics 26. RESULTS Two hundred patients were asked to complete the survey, with a response rate of 78%. The most common procedures were exploratory laparotomy (50%) and minimally invasive hysterectomy (41%). Most patients (91%, 95% CI 91-97) filled their opioid prescription and 64 (41%, 95% CI 34-48) had leftover opioid pills. Most patients with leftover opioid pills (73%, 95% CI 67-79) discarded them; 78%, 95% CI 69-80 used the disposal bag. Patients undergoing an exploratory laparotomy most commonly used the disposal bag. All patients who used the disposal bag stated they would use it again. CONCLUSION Despite a restrictive opioid prescribing algorithm, 41% of gynecologic surgical patients had leftover opioid pills. This study demonstrated that leftover opioid pills were safely discarded 73% of the time when patients were provided an opioid disposal bag and preoperative education.
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Coughlin JM, Terranella SL, Ritz EM, Xu TQ, Tierney JF, Velasco JM, Myers JA. Understanding Opioid Prescribing Practices of Resident Physicians. Am Surg 2021:31348211060412. [PMID: 34971336 DOI: 10.1177/00031348211060412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. METHODS An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher's exact test assessed differences in prescribing practices between specialties. RESULTS Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient's history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills (P < .001). DISCUSSION The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.
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Affiliation(s)
- Julia M Coughlin
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | | | - Ethan M Ritz
- Bioinformatics and Biostatistics Core, 2468Rush University Medical Center, Chicago, IL, USA
| | - Thomas Q Xu
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - John F Tierney
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Jose M Velasco
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Jonathan A Myers
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
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Abstract
BACKGROUND Despite increased public awareness to dispose of unused narcotics, opioids prescribed postoperatively are retained, which may lead to drug diversion and abuse. This study assessed retention of unused opioids among hand surgery patients and describes disposal methods and barriers. METHODS Participants undergoing hand surgery were given an opioid disposal information sheet preoperatively (N = 222) and surveyed postoperatively to assess disposal or retention of unused opioids, disposal methods, and barriers to disposal. A binomial logistic regression was conducted to assess whether age, sex, pain intensity, and/or the type of procedure were predictors of opioid disposal. RESULTS There were 171 patients included in the analysis (n = 51 excluded; finished prescription or continued opioid use for pain control). Unused opioids were retained by 134 patients (78%) and disposal was reported by 37 patients (22%). Common disposal methods included returning opioids to a pharmacy (49%) or mixing them with an unwanted substance (24%). Reasons for retention included potential future use (54%), inconvenient disposal methods (21%), or keeping an unfilled prescription (9%). None of the patient factors analyzed (age, sex, type of procedure performed, or pain score) were predictors of disposal of unused narcotics (P > .05). CONCLUSIONS Most patients undergoing hand surgery retained prescribed opioids for future use or due to impractical disposal methods. The most common disposal methods included returning narcotics to a pharmacy or mixing opioids with unwanted substances. Identifying predictors of disposal may provide important information when developing strategies to increase opioid disposal.
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Bleicher J, Fender Z, Johnson JE, Cain BT, Phan K, Powers D, Wei G, Presson AP, Kwok A, Pickron TB, Scaife CL, Huang LC. Use of post-discharge opioid consumption patterns as a tool for evaluating opioid prescribing guidelines. Am J Surg 2021; 224:58-63. [DOI: 10.1016/j.amjsurg.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/08/2021] [Accepted: 12/18/2021] [Indexed: 12/15/2022]
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Bleicher J, Esplin J, Blumling AN, Cohan JN, Savarise Md M, Wetter DW, Harris AHS, Kaphingst KA, Huang LC. Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study. J Opioid Manag 2021; 17:455-464. [PMID: 34904694 PMCID: PMC10473844 DOI: 10.5055/jom.2021.0680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients' perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal. DESIGN We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method. SETTING All participants underwent surgery at a single, academic tertiary-care center. PARTICIPANTS Adult patients who had a general surgery operation in the prior 60 days. OUTCOME MEASURE Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education. RESULTS Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication. CONCLUSIONS Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.
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Affiliation(s)
- Josh Bleicher
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Jordan Esplin
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | | | - Jessica N Cohan
- Department of Surgery, University of Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | | | - David W Wetter
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Alex H S Harris
- Department of Surgery, Stanford University, Stanford; Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
| | - Kimberly A Kaphingst
- Department of Communication, University of Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Lyen C Huang
- Department of Surgery, University of Utah; Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
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40
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Hacker EC, Pere MM, Yu M, Gul ZG, Jacobs BL, Davies BJ. Large Variation in International Prescribing Rates of Opioids After Robotic Prostatectomy. Urology 2021; 159:93-99. [PMID: 34678308 DOI: 10.1016/j.urology.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/13/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare international opioid prescribing patterns for patients undergoing robotic assisted laparoscopic prostatectomy. To our knowledge, this is the first study to assess international opioid prescribing trends among urologists. METHODS An anonymous Web-based survey assessing the frequency and quantity of opioid prescriptions for robotic assisted laparoscopic prostatectomy was designed using Qualtrics software. The survey was distributed to urologists internationally via Twitter and email in early 2021. Prescribing patterns were analyzed based on country of practice in three groups: United States, Canada, and all other countries. RESULTS 160 participants from 26 countries completed the survey including the United States (51%), Greece (19%), Canada (9%), Israel (3.1%). The percentage of providers prescribing post-discharge opioids significantly differed between Canada, the United States, and other countries (86%, 63%, and 11%, respectively, P <.0001). There was a significant difference between years of experience in those who provide opioids compared to those who do not (8 years vs 5 years, P = .0004). The average morphine milligram equivalents (MME) provided in those who did prescribe opioids was greatest in the United States but was not significantly different between groups (mean MME: United States 58 mg, Canada 46 mg, all others 54 mg; P = .63). Attending physicians prescribed more MME than trainees (residents, fellows) on average (attending mean MME = 75 mg, trainee mean MME = 40 mg, P = .017). CONCLUSION Opioid prescriptions after robotic assisted prostatectomy are common in North America and used sparingly in the rest of the world.
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Affiliation(s)
- Emily C Hacker
- University of Pittsburgh, School of Medicine, Pittsburgh, PA.
| | - Maria M Pere
- University of Pittsburgh Medical Center, Department of Urology, Pittsburgh, PA
| | - Michelle Yu
- University of Pittsburgh Medical Center, Department of Urology, Pittsburgh, PA
| | - Zeynep G Gul
- University of Pittsburgh Medical Center, Department of Urology, Pittsburgh, PA
| | - Bruce L Jacobs
- University of Pittsburgh Medical Center, Department of Urology, Pittsburgh, PA
| | - Benjamin J Davies
- University of Pittsburgh Medical Center, Department of Urology, Pittsburgh, PA
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Opioid Overprescribing and Procedure-Specific Opioid Consumption Patterns for Plastic and Reconstructive Surgery Patients. Plast Reconstr Surg 2021; 147:669e-679e. [PMID: 33761520 DOI: 10.1097/prs.0000000000007782] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioid prescribing practices contribute to opioid misuse, dependency, and diversion. There are currently no comprehensive and quantitative evidence-based guidelines that give procedure-specific recommendations regarding opioid prescribing in plastic surgery. METHODS A retrospective review of 479 plastic surgery patients encompassing 23 different plastic surgery procedure categories was performed. Opioid prescribing patterns and patient-reported opioid use at 1 and 3 months postoperatively are reported. RESULTS Opioid overprescribing was common, averaging an excess of 13 pills per patient across all procedure categories (prescribed versus consumed, 25.4 ± 23.1 versus 12.1 ± 19.7; p = 3.0 × 10-19), with a total excess of 5895 pills (30,967 oral morphine equivalents) for the study's sample. Fifty-two percent of all opioid pills prescribed went unused. Opioid consumption ranged between four and 37 pills across procedure categories. A greater proportion of patients who reported a history of preoperative opioid use were still using opioids at the time of their 1-month and 3-month follow-up appointments (62 percent versus 9 percent at 1 month, and 31 percent versus 1 percent at 3 months). Most patients (83 percent) did not store opioids in a locked location, and 64 percent did not dispose of opioids at 1 month. CONCLUSIONS Opioids are commonly overprescribed by plastic surgery providers. This study determined procedure-specific opioid consumption patterns, which can help providers reduce opioid waste. In addition, patients do not properly store or dispose of opioids, demonstrating the need for better patient education.
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Yeung C, Kiss A, Rehou S, Shahrokhi S. Identifying risk factors that increase analgesic requirements at discharge among patients with burn injuries. J Burn Care Res 2021; 43:710-715. [PMID: 34525191 DOI: 10.1093/jbcr/irab179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Patients with burn injuries require large doses of opioids and gabapentinoids to achieve pain control and are often discharged from hospital with similar amounts. This study aimed to identify patient risk factors that increase analgesic requirements among patients with burn injuries and to determine the relationship between opioid and gabapentinoid use. Patient charts from July 1, 2015 - 2018 were reviewed retrospectively to determine analgesic requirements 24 hours before discharge. Linear mixed regression models were performed to determine patient risk factors (age, gender, history of substance misuse, total body surface area of burn, length of stay in hospital, history of psychiatric illness, or surgical treatment) that may increase analgesic requirements. This study found that patients with a history of substance misuse (p = 0.01) or who were managed surgically (p = 0.01) required higher doses of opioids at discharge. Similarly, patients who had undergone surgical debridement required more gabapentinoids (p < 0.001). For every percent increase in TBSA, patients also required 14 mg more gabapentinoids (p = 0.01). In contrast, older patients (p = 0.006) and those with a longer hospital stay (p = 0.009) required fewer amounts of gabapentinoids before discharge. By characterizing factors that increase analgesic requirements at discharge, burn care providers may have a stronger understanding of which patients are at greater risk of developing chronic opioid or gabapentinoid misuse. The quantity and duration of analgesics prescribed at discharge may then be tailored according to these patient specific risk factors.
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Affiliation(s)
- Celine Yeung
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shahriar Shahrokhi
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada.,Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Sundararajan K, Ajrawat P, Canizares M, Power JD, Perruccio AV, Sarro A, Montoya L, Rampersaud YR. The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey. PLoS One 2021; 16:e0256741. [PMID: 34437639 PMCID: PMC8389484 DOI: 10.1371/journal.pone.0256741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/15/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP). METHODS Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids. RESULTS 569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP. CONCLUSION While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.
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Affiliation(s)
- Kala Sundararajan
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Prabjit Ajrawat
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Mayilee Canizares
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - J Denise Power
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Anthony V Perruccio
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Angela Sarro
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Luis Montoya
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Y Raja Rampersaud
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
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Rao IJ, Humphreys K, Brandeau ML. Effectiveness of Policies for Addressing the US Opioid Epidemic: A Model-Based Analysis from the Stanford-Lancet Commission on the North American Opioid Crisis. LANCET REGIONAL HEALTH. AMERICAS 2021; 3:100031. [PMID: 34790907 PMCID: PMC8592267 DOI: 10.1016/j.lana.2021.100031] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The U.S. opioid crisis has been exacerbated by COVID-19 and the spread of synthetic opioids (e.g., fentanyl). METHODS We model the effectiveness of reduced prescribing, drug rescheduling, prescription monitoring programs (PMPs), tamper-resistant drug reformulation, excess opioid disposal, naloxone availability, syringe exchange, pharmacotherapy, and psychosocial treatment. We measure life years, quality-adjusted life years (QALYs), and opioid-related deaths over five and ten years. FINDINGS Under the status quo, our model predicts that approximately 547,000 opioid-related deaths will occur from 2020 to 2024 (range 441,000 - 613,000), rising to 1,220,000 (range 996,000 - 1,383,000) by 2029. Expanding naloxone availability by 30% had the largest effect, averting 25% of opioid deaths. Pharmacotherapy, syringe exchange, psychosocial treatment, and PMPs are uniformly beneficial, reducing opioid-related deaths while leading to gains in life years and QALYs. Reduced prescribing and increasing excess opioid disposal programs would reduce total deaths, but would lead to more heroin deaths in the short term. Drug rescheduling would increase total deaths over five years as some opioid users escalate to heroin, but decrease deaths over ten years. Combined interventions would lead to greater increases in life years, QALYs, and deaths averted, although in many cases the results are subadditive. INTERPRETATION Expanded health services for individuals with opioid use disorder combined with PMPs and reduced opioid prescribing would moderately lessen the severity of the opioid crisis over the next decade. Tragically, even with improved public policies, significant morbidity and mortality is inevitable.
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Affiliation(s)
- Isabelle J. Rao
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Keith Humphreys
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,Corresponding author. 401 N. Quarry Road, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94305-5717
| | - Margaret L. Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
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45
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Schäfer WLA, Johnson JK, Wafford QE, Plummer SG, Stulberg JJ. Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:548-558. [PMID: 34292095 DOI: 10.1080/00952990.2021.1937635] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: In the U.S., 50-75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic.Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes.Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools.Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03).Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.
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Affiliation(s)
- Willemijn L A Schäfer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Julie K Johnson
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Q Eileen Wafford
- Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sarah G Plummer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jonah J Stulberg
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Lamplot JD, Premkumar A, James EW, Lawton CD, Pearle AD. Postoperative Disposal of Unused Opioids: A Systematic Review. HSS J 2021; 17:235-243. [PMID: 34421437 PMCID: PMC8361585 DOI: 10.1177/15563316211001366] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 11/15/2022]
Abstract
Introduction: Opioid misuse and overprescription have contributed to a national public health crisis in the United States. Postoperatively, patients are often left with unused opioids, which pose a risk for diversion if not appropriately disposed of. Patients are infrequently provided instructions on safe disposal methods of surplus opioids. Purpose: We sought to determine the current rates of disposal of unused opioids and the reported disposal mechanisms for unused opioids that were prescribed for acute postoperative pain control. Methods: A systematic review was performed of the PubMed, Cochrane, and Embase databases for relevant articles from their earliest entries through October 2, 2019. We used the search terms "opioid" or "narcotic" and "disposal" and "surgery." Studies were considered for inclusion if they reported the rate of disposal of unused opioids following surgery. A screening strategy was used to identify relevant articles using Covidence. For studies meeting inclusion criteria, relevant information was extracted. Results: Sixteen studies met inclusion criteria. We found that surplus opioid disposal rates varied widely, from 4.9% to 87.0%. Among studies with no intervention (opioid disposal education or drug disposal kit/bag), rates of opioid disposal ranged from 4.9% to 46.5%. While 7 studies used opioid disposal education as an intervention, only 3 showed a significant increase in surplus opioid disposal compared with standard care. All 3 studies that used an opioid disposal kit or bag as an intervention demonstrated significant increases in opioid disposal. Conclusions: Baseline rates of surplus opioid disposal are relatively low in the postoperative setting. Our findings suggest that opioid disposal kits significantly increase rates of surplus opioid disposal postoperatively. Further research, including a large-scale cost-benefit analysis, will be necessary prior to recommending widespread implementation of drug disposal kits or bags.
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Affiliation(s)
- Joseph D. Lamplot
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA,Joseph D. Lamplot, MD, Department of Orthopaedics, Emory University, 59 Executive Park S., Atlanta, GA 30324, USA.
| | - Ajay Premkumar
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Evan W. James
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | | | - Andrew D. Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
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Rahman R, Wallam S, Zhang B, Sachdev R, McNeely EL, Kebaish KM, Riley LH, Cohen DB, Jain A, Lee SH, Sciubba DM, Skolasky RL, Neuman BJ. Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge. World Neurosurg 2021; 150:e600-e612. [PMID: 33753317 PMCID: PMC8187334 DOI: 10.1016/j.wneu.2021.03.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors. METHODS We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05). RESULTS Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95). CONCLUSIONS Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.
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Affiliation(s)
- Rafa Rahman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara Wallam
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rahul Sachdev
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emmanuel L McNeely
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lee H Riley
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David B Cohen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sang H Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Nadarajah V, Meredith SJ, Jauregui JJ, Smuda MP, Medina S, Gilotra MN, Hasan SA, Henn RF. Preoperative opioid use in patients undergoing shoulder surgery. Shoulder Elbow 2021; 13:248-259. [PMID: 34659464 PMCID: PMC8512997 DOI: 10.1177/1758573219879689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Opioids are commonly used to manage pain from acute injury or chronic degenerative diseases. The objective of this study was to assess the prevalence of preoperative opioid use in patients undergoing shoulder surgery and the clinical factors associated with preoperative opioid use. METHODS This was an analytical cross-sectional study of 175 patients undergoing shoulder surgery at an urban hospital from June 2015 to June 2017. Multivariable regression models were used to determine independent associations. RESULTS Fifty-three patients reported preoperative opioid use, which was significantly associated with primary procedure performed (Current Procedural Terminology [CPT]), higher body mass index (BMI), unemployment, lower income, smoking, higher American Society of Anesthesiologists score, greater number of previous surgeries, higher comorbidity burden, and decreased expectations to exercise and do recreational activities (p < 0.05). Preoperative opioid use was independently associated with worse scores on the: Numeric Pain Scale, ASES, IPAQ, and PROMIS domains of Physical Function, Pain Interference, and Social Satisfaction (p < 0.05). CONCLUSION More than one in four patients reported preoperative opioid use. Several health measures, including worse pain, function, and social satisfaction were independently associated with preoperative opioid use. These findings suggest that orthopaedic surgeons need to identify patients using opioids preoperatively in order to effectively establish and execute a plan for pain management, which may include weaning off opioids prior to surgery, managing psychological distress, and optimizing coping strategies.Level of Evidence: III.
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Affiliation(s)
- Vidushan Nadarajah
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
- Department of Orthopaedic Surgery and
Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Sean J Meredith
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Julio J Jauregui
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Michael P Smuda
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Shaun Medina
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of
Medicine, Baltimore, MD, USA
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49
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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: 101] [Impact Index Per Article: 33.7] [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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50
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Srivastava D, Wilkinson P. Surgery and opioids: some cracks in an enduring romance. Br J Anaesth 2021; 126:1088-1092. [PMID: 33707092 DOI: 10.1016/j.bja.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
| | - Paul Wilkinson
- Department of Anaesthesia, Newcastle Pain Management Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK.
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