1
|
Chen SY, Ourshalimian S, Hijaz D, Odegard MN, Kim E, Andras L, Kelley-Quon LI. Opioid consumption before discharge predicts outpatient opioid use in adolescents undergoing surgery. Surgery 2024; 176:462-468. [PMID: 38763792 PMCID: PMC11246811 DOI: 10.1016/j.surg.2024.03.041] [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: 11/01/2023] [Revised: 02/10/2024] [Accepted: 03/25/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND The majority of adolescents undergoing surgery report unused prescription opioids after surgery, increasing the risk of diversion, misuse, and addiction. Adult studies have demonstrated that opioid use 24 hours before discharge corresponds with opioid use at home. We hypothesized that inpatient opioid consumption is associated with outpatient opioid use in adolescents. METHODS Adolescents aged 13-20 years undergoing elective surgery associated with an opioid prescription were prospectively recruited. Parent-adolescent dyads were surveyed preoperatively to assess sociodemographics, health literacy, and baseline substance use, and opioid use was measured at 30- and 90-days postoperatively. Medical records were reviewed to calculate cumulative opioid use during hospitalization. Inpatient and postoperative opioid use was converted to oral morphine equivalents. Adjusting for age, sex, race, health literacy, alcohol use, pain score, and surgery, multivariable linear regression identified factors associated with outpatient oral morphine equivalent use 90 days postoperatively. RESULTS Overall, 103 adolescents were enrolled. Median oral morphine equivalents used from 24 and 48 hours before discharge and throughout the hospitalization were 30.8 (interquartile range:11.7-45.0), 67.5 (interquartile range:37.5-94.3), and 97.5 (interquartile range:18.0-152.7), respectively. Regression analysis demonstrated that adolescent-reported pain at discharge (P = .028) and cumulative oral morphine equivalents used 24 hours (P < .001) and 48 hours (P = .003) before discharge were significantly associated with postoperative oral morphine equivalents use at home. Oral morphine equivalents consumption 24 hours before discharge estimated cumulative oral morphine equivalents use 90 days postoperatively at a 1-to-5 ratio in 94.1% of patients. CONCLUSION For adolescents undergoing surgery, patient-reported pain at discharge and oral morphine equivalents administered 24 hours before discharge are associated with cumulative outpatient opioid use. Tailoring outpatient prescriptions to total oral morphine equivalent consumption 24 hours before discharge could reduce excess opioid prescribing.
Collapse
Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA. https://twitter.com/steph_y_chen
| | | | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjorie N Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA. https://twitter.com/MarjorieOdegard
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lindsay Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery & Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| |
Collapse
|
2
|
Barth RJ. Invited Commentary. J Am Coll Surg 2024; 238:1010-1012. [PMID: 38567835 DOI: 10.1097/xcs.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
|
3
|
Beaulieu-Jones BR, Berrigan MT, Marwaha JS, Robinson KA, Nathanson LA, Fleishman A, Brat GA. Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use. J Am Coll Surg 2024; 238:1001-1010. [PMID: 38525970 DOI: 10.1097/xcs.0000000000001084] [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: 03/26/2024]
Abstract
BACKGROUND Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline. STUDY DESIGN We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed. RESULTS A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively. CONCLUSIONS Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.
Collapse
Affiliation(s)
- Brendin R Beaulieu-Jones
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Brat)
| | - Margaret T Berrigan
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Jayson S Marwaha
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Brat)
| | - Kortney A Robinson
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Larry A Nathanson
- Emergency Medicine (Nathanson), Beth Israel Deaconess Medical Center, Boston, MA
| | - Aaron Fleishman
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Gabriel A Brat
- From the Departments of Surgery (Beaulieu-Jones, Berrigan, Marwaha, Robinson, Fleishman, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Brat)
| |
Collapse
|
4
|
Beaulieu-Jones BR, Berrigan MT, Robinson KA, Marwaha JS, Kent TS, Brat GA. An Institutional Curriculum for Opioid Prescribing Education: Outcomes From 2017 to 2022. J Surg Res 2024; 295:1-8. [PMID: 37951062 PMCID: PMC10922287 DOI: 10.1016/j.jss.2023.09.058] [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: 05/26/2023] [Revised: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 11/13/2023]
Abstract
INTRODUCTION Prescription opioids, including those prescribed after surgery, have greatly contributed to the US opioid epidemic. Educating opioid prescribers is a crucial component of ensuring the safe use of opioids among surgical patients. METHODS An annual opioid prescribing education curriculum was implemented among new surgical prescribers at our institution between 2017 and 2022. The curriculum includes a single 75-min session which is comprised of several components: pain medications (dosing, indications, and contraindications); patients at high risk for uncontrolled pain and/or opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations. Participants were asked to complete an opioid knowledge assessment before and after the didactic session. RESULTS Presession and postsession assessments were completed by 197 (89.6%) prescribers. Across the five studied years, the median presession score was 54.5%. This increased to 63.6% after completion of the curriculum, representing a median relative knowledge increase of 18.2%. The median relative improvement was greatest for preinterns and interns (18.2% for both groups); smaller improvements were observed for postgraduate year 2-5 residents (9.1%) and advanced practice providers (9.1%). On a scale of 1 to 10 (with 5 being comfortable), median (interquartile range) self-reported comfort in prescribing opioids increased from 3 (2-5) before education to 5 (4-6) after education (P < 0.001). CONCLUSIONS Each year, the curriculum substantially improved provider knowledge of and comfort in opioid prescribing. Despite increased national awareness of the opioid epidemic and increasing institutional initiatives to improve opioid prescribing practices, there was a sustained knowledge and comfort gap among new surgical prescribers. The observed effects of our opioid education curriculum highlight the value of a simple and efficient educational initiative.
Collapse
Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Margaret T Berrigan
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts
| | - Kortney A Robinson
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts
| | - Jayson S Marwaha
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts
| | - Gabriel A Brat
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
5
|
Basabe MS, Suki TS, Munsell MF, Iniesta MD, Garcia Lopez JE, Hillman RT, Cain K, Huepenbecker S, Mena G, Taylor JS, Ramirez PT, Meyer LA. Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement. Int J Gynecol Cancer 2024; 34:251-259. [PMID: 38123191 PMCID: PMC11186977 DOI: 10.1136/ijgc-2023-004948] [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: 12/23/2023] Open
Abstract
BACKGROUND Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription. OBJECTIVE To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education. METHODS We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis. RESULTS The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99). CONCLUSION Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.
Collapse
Affiliation(s)
- M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina S Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Department of Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
6
|
Song J, Li Y, Waljee JF, Gunaseelan V, Brummett CM, Englesbe MJ, Bicket MC. What evidence is needed to inform postoperative opioid consumption guidelines? A cohort study of the Michigan Surgical Quality Collaborative. Reg Anesth Pain Med 2024; 49:23-29. [PMID: 37247946 PMCID: PMC10684823 DOI: 10.1136/rapm-2023-104581] [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: 04/10/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION To balance adequate pain management while minimizing opioid-related harms after surgery, opioid prescribing guidelines rely on patient-reported use after surgery. However, it is unclear how many patients are required to develop precise guidelines. We aimed to compare patterns of use, required sample size, and the precision for patient-reported opioid consumption after common surgical procedures. METHODS We analyzed procedure-specific 30-day opioid consumption data reported after discharge from 15 common surgical procedures between January 2018 and May 2019 across 65 hospitals in the Michigan Surgical Quality Collaborative. We calculated proportions of patients using no pills and the estimated number of pills meeting most patients' needs, defined as the 75th percentile of consumption. We compared several methods to model consumption patterns. Using the best method (Tweedie), we calculated sample sizes required to identify opioid consumption within a 5-pill interval and estimates of pills to meet most patients' needs by calculating the width of 95% CIs. RESULTS In a cohort of 10,688 patients, many patients did not consume any opioids after all types of procedures (range 20%-40%). Most patients' needs were met with 4 pills (thyroidectomy) to 13 pills (abdominal hysterectomy). Sample sizes required to estimate opioid consumption within a 5-pill wide 95% CI ranged from 48 for laparoscopic appendectomy to 188 for open colectomy. The 95% CI width for estimates ranged from 0.7 pills for laparoscopic cholecystectomy to 7.0 pills for ileostomy/colostomy. CONCLUSIONS This study demonstrates that profiles of opioid consumption share more similarities than differences for certain surgical procedures. Future investigations on patient-reported consumption are required for procedures not currently included in prescribing guidelines to ensure surgeons and perioperative providers can appropriately tailor recommendations to the postoperative needs of patients.
Collapse
Affiliation(s)
- Jiyeon Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Yi Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
| | - Vidhya Gunaseelan
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
| | - Mark C Bicket
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Agarwal AK, Xiong R, Ebert J, Shofer F, Spencer E, Lee D, Ali Z, Delgado MK. Identifying Patient Characteristics Associated With Opioid Use to Inform Surgical Pain Management. ANNALS OF SURGERY OPEN 2023; 4:e355. [PMID: 38144506 PMCID: PMC10735081 DOI: 10.1097/as9.0000000000000355] [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: 07/12/2023] [Accepted: 09/28/2023] [Indexed: 12/26/2023] Open
Abstract
Objective Balancing surgical pain management and opioid stewardship is complex. Identifying patient-level variables associated with low or no use can inform tailored prescribing. Methods A prospective, observational study investigating surgical procedures, prescription data, and patient-reported outcomes at an academic health system in Pennsylvania. Surgical patients were consented following surgery, and prospective data were captured using automated text messaging (May 1, 2021-February 29, 2022). The primary outcome was opioid use. Results Three thousand six hundred three (30.2%) patients consented. Variation in patient reported used included 28.1% of men reported zero use versus 24.3% of women, 20.5% of Black patients reported zero use versus 27.2% of white patients. Opioid-naïve patients reported more zero use as compared with chronic use (29.7% vs 9.8%). Patients reporting higher use had more telephone calls and office visits within 30 days but no change in emergency department utilization or admissions. Higher discharge pain score was associated with higher use. In the adjusted analysis, opioid use relative to the guideline, higher use was associated with age, male sex, obesity, discharge pain score, and history of mental health disorder. In the adjusted model, younger age and being opioid-naïve to be associated with low to zero use across procedures. Conclusions Younger age, being opioid-naïve, and lower discharge pain score are associated with low or no postoperative opioid use. These characteristics can be used by clinicians to help tailor opioid prescribing to specific patients to reduce the risk of prolonged exposure and unused `ts in the community.
Collapse
Affiliation(s)
- Anish K. Agarwal
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Ruiying Xiong
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey Ebert
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Fran Shofer
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Evan Spencer
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Daniel Lee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Division of Urology, University of Pennsylvania, Philadelphia, PA
| | - Zarina Ali
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA
| | - M. Kit Delgado
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
9
|
Boyev A, Jain AJ, Newhook TE, Prakash LR, Chiang YJ, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm. JAMA Surg 2023; 158:e234154. [PMID: 37672236 PMCID: PMC10483385 DOI: 10.1001/jamasurg.2023.4154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/16/2023] [Indexed: 09/07/2023]
Abstract
Importance Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.
Collapse
Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
10
|
Lapointe-Gagner M, Jain S, Alali N, Elhaj H, Poirier AS, Kaneva P, Alhashemi M, Lee L, Agnihotram RV, Feldman LS, Gagner M, Andalib A, Fiore JF. Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study. Surg Endosc 2023; 37:8611-8622. [PMID: 37491658 DOI: 10.1007/s00464-023-10307-3] [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: 05/07/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery. METHODS This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors. RESULTS Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (β + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]). CONCLUSION Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.
Collapse
Affiliation(s)
- Maxime Lapointe-Gagner
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Shrieda Jain
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Naser Alali
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Anne-Sophie Poirier
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ramanakumar V Agnihotram
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Michel Gagner
- Clinique Michel Gagner MD Inc., Montreal, QC, Canada
| | - Amin Andalib
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Department of Surgery, Center for Bariatric Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| |
Collapse
|
11
|
Seo CH, Howe KL, McAllister KB, McDaniel BL, Sharp HD, Lucktong TA, Bower KL, Collier BR, Gillen JR. Standardizing Opioids Prescribed at Discharge in Trauma Surgery. J Surg Res 2023; 290:52-60. [PMID: 37196608 DOI: 10.1016/j.jss.2023.03.049] [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: 10/24/2022] [Revised: 03/18/2023] [Accepted: 03/26/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Excessive opioid use after sustaining trauma has contributed to the opioid epidemic. Standardizing the quantity of opioids prescribed at discharge can improve prescribing behavior. We hypothesized that adopting new electronic medical record order sets would be associated with decreased morphine milligram equivalents (MME) prescribed at discharge for trauma patients. METHODS This was a quasi-experimental study examining opioid prescribing practices at a Level 1 Trauma Center. All patients ages 18-89 admitted to the Trauma Service from January 2017 through March 2021 and hospitalized for at least 2 d were included. In November 2020, new trauma admission and discharge order sets were implemented with recommended discharge opioid quantity based on inpatient opioid usage the day prior to discharge multiplied by five. Postintervention prescribing practices were compared to historical controls. The primary outcome was MME at discharge. RESULTS Baseline characteristics between preintervention and postintervention cohorts were comparable. There was a significant reduction in median MME prescribed at discharge postintervention (112.5 versus 75.0, P < 0.0001). Median inpatient MME usage also significantly reduced postintervention (184.1 versus 160.5; P < 0.0001). There were trends toward increased ideal prescribing per order set recommendation and a reduction in overprescribing. Patients receiving the recommended opioid quantity at discharge had the lowest opioid refill prescription rate (under: 29.6%, ideal: 7.3%, over: 19.7%, P < 0.0001). CONCLUSIONS For trauma patients requiring inpatient opioid therapy, a pragmatic and individualized intervention was associated with a reduced quantity of discharge opioids without negative outcomes. Reduction in inpatient opioid use was also associated with standardizing prescribing practices of surgeons with electronic medical record order sets.
Collapse
Affiliation(s)
- Claire H Seo
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| | - Katherine L Howe
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Kelly B McAllister
- Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Bradford L McDaniel
- Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Hunter D Sharp
- Carilion Clinic Health Analytics Research, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Tananchai A Lucktong
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Katie L Bower
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Brian R Collier
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Jacob R Gillen
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| |
Collapse
|
12
|
Bauer PS, Damle A, Abelson JS, Otegbeye EE, Smith RK, Glasgow SC, Wise PE, Hunt SR, Mutch MG, Silviera ML. Discharge Prescribing Protocol Decreases Opioids in Circulation and Does Not Increase Refills After Colorectal Surgery. Dis Colon Rectum 2023; 66:840-847. [PMID: 36729859 PMCID: PMC10205649 DOI: 10.1097/dcr.0000000000002483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Up to 10% of patients develop new, persistent opioid use after surgery. We aimed to assess our prescribing practices and patient utilization of opioids after colorectal surgery. OBJECTIVE This study aimed to implement an opioid-prescribing protocol that will minimize the number of postoperative opioids to decrease community circulation and persistent use by patients. DESIGN This was a single-institution, prospective study based on questionnaires of postoperative patients in 2019 and 2020 to determine opioid prescribing and usage patterns. Based on these preliminary results, a protocol was implemented in which patients were discharged with 5 or 15 oxycodone 5 mg equivalents based on opioid usage in the 24 hours before discharge. Patients were surveyed after protocol implementation. SETTINGS Our institution is a large referral center for surgical treatment of colorectal disease. PATIENTS Adults who underwent inpatient abdominal colorectal procedures. MAIN OUTCOME MEASURES End points included the number of opioids prescribed, number of prescribed opioids taken, and refill rate. Nonparametric testing was used. RESULTS Of 77 eligible patients, 61 were opioid naive. Preprotocol, opioid-naive patients (n = 29) were prescribed a median of 30 (interquartile range [IQR], 30-45) tablets but took only 10 (IQR, 0-10; p < 0.0001). Eighty-three percent took 20 or fewer tablets. After protocol implementation, opioid-naive patients (n = 32) were prescribed fewer tablets (median 15; IQR, 7-15; p < 0.0001) but took a similar number of tablets as the preprotocol group (median 10; IQR, 0-10; p = 0.21). The refill rate remained similar (13.8% vs 18.8%; p = 0.60). Protocol adherence was 90.6%. LIMITATIONS This study is limited by sample size, cohort heterogeneity, and generalizability. CONCLUSIONS Patients took significantly fewer opioids than were prescribed. Our protocol limited overprescribing and resulted in fewer opioids in the community without opportunity costs such as increased refills. Long-term studies are needed to assess the effects of persistent opioid use after surgery. See Video Abstract at http://links.lww.com/DCR/C93 .
Collapse
Affiliation(s)
- Philip S Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Alex A.S. Harris
- Stanford University, CA, USA
- VA Palo Alto Healthcare System, CA, USA
| | | |
Collapse
|
14
|
Lamm R, Cannaday S, Ponzini F, Moskal D, Lundgren M, Williamson JE, Wummer B, Huang R, Sun G, Song SG, Im B, Kowal LL, Wu I, Bowne WB, Nevler A, Cowan SW, Yeo T, Yeo CJ, Lavu H. Implementation of an opioid reduction toolkit in pancreatectomy patients significantly increases patient awareness of safe practice and decreases amount prescribed and consumed. HPB (Oxford) 2023:S1365-182X(23)00098-9. [PMID: 37019725 DOI: 10.1016/j.hpb.2023.03.012] [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: 10/27/2022] [Revised: 02/07/2023] [Accepted: 03/19/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Postoperative opioid abuse following surgery is a major concern. This study sought to create an opioid reduction toolkit to reduce the number of narcotics prescribed and consumed while increasing awareness of safe disposal in pancreatectomy patients. METHODS Prescription, consumption, and refill request data for postoperative opioids were collected from patients receiving an open pancreatectomy before and after the implementation of an opioid reduction toolkit. Outcomes included safe disposal practice awareness for unused medication. RESULTS 159 patients were included in the study: 24 in the pre-intervention and 135 in the post-intervention group. No significant demographic or clinical differences existed between groups. Median morphine milliequivalents (MMEs) prescribed were significantly reduced from 225 (225-310) to 75 (75-113) in the post-intervention group (p < 0.0001). Median MMEs consumed were significantly reduced from 109 (111-207) to 15 (0-75), p < 0.0001), as well. Refill request rates remained equivalent during the study (Pre: 17% v Post: 13%, p = 0.9) while patient awareness of safe disposal increased (Pre: 25% v Post: 62%, p < 0.0001). DISCUSSION An opioid reduction toolkit significantly reduced the number of postoperative opioids prescribed and consumed after open pancreatectomy, while refill request rates remained the same and patients' awareness of safe disposal increased.
Collapse
Affiliation(s)
- Ryan Lamm
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA.
| | - Shawnna Cannaday
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| | - Francesca Ponzini
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - David Moskal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Megan Lundgren
- Penn Highlands Hospital, Department of Surgery, Dubois, PA, 15801, USA
| | - John E Williamson
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Brandon Wummer
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Rachel Huang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - George Sun
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Steven G Song
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Brian Im
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Luke L Kowal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Inga Wu
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Wilbur B Bowne
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| | - Avinoam Nevler
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| | - Scott W Cowan
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| | - Theresa Yeo
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| | - Charles J Yeo
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| | - Harish Lavu
- Thomas Jefferson University Hospital, Department of General Surgery, Philadelphia, PA, 19107, USA
| |
Collapse
|
15
|
Leung T, Simpson S, Zhong W, Burton BN, Mehdipour S, Said ET. A Neural Network Model Using Pain Score Patterns to Predict the Need for Outpatient Opioid Refills Following Ambulatory Surgery: Algorithm Development and Validation. JMIR Perioper Med 2023; 6:e40455. [PMID: 36753316 PMCID: PMC9947767 DOI: 10.2196/40455] [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: 06/21/2022] [Revised: 12/06/2022] [Accepted: 01/24/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Expansion of clinical guidance tools is crucial to identify patients at risk of requiring an opioid refill after outpatient surgery. OBJECTIVE The objective of this study was to develop machine learning algorithms incorporating pain and opioid features to predict the need for outpatient opioid refills following ambulatory surgery. METHODS Neural networks, regression, random forest, and a support vector machine were used to evaluate the data set. For each model, oversampling and undersampling techniques were implemented to balance the data set. Hyperparameter tuning based on k-fold cross-validation was performed, and feature importance was ranked based on a Shapley Additive Explanations (SHAP) explainer model. To assess performance, we calculated the average area under the receiver operating characteristics curve (AUC), F1-score, sensitivity, and specificity for each model. RESULTS There were 1333 patients, of whom 144 (10.8%) refilled their opioid prescription within 2 weeks after outpatient surgery. The average AUC calculated from k-fold cross-validation was 0.71 for the neural network model. When the model was validated on the test set, the AUC was 0.75. The features with the highest impact on model output were performance of a regional nerve block, postanesthesia care unit maximum pain score, postanesthesia care unit median pain score, active smoking history, and total perioperative opioid consumption. CONCLUSIONS Applying machine learning algorithms allows providers to better predict outcomes that require specialized health care resources such as transitional pain clinics. This model can aid as a clinical decision support for early identification of at-risk patients who may benefit from transitional pain clinic care perioperatively in ambulatory surgery.
Collapse
Affiliation(s)
| | - Sierra Simpson
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, United States
| | - William Zhong
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, United States
| | - Brittany Nicole Burton
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Soraya Mehdipour
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, United States
| | - Engy Tadros Said
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, United States
| |
Collapse
|
16
|
Reasons for Long-term Opioid Prescriptions After Guideline-directed Opioid Prescribing and Excess Opioid Pill Disposal. Ann Surg 2023; 277:173-178. [PMID: 36827492 DOI: 10.1097/sla.0000000000004967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal. BACKGROUND Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed. METHODS We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply. RESULTS 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess. CONCLUSIONS In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.
Collapse
|
17
|
Chan KY, Keogh S, Aucharaz N, Merrigan A, Tormey S. Opioid prescribing after breast surgery: A systematic review of guidelines. Surgeon 2022:S1479-666X(22)00139-1. [PMID: 36593160 DOI: 10.1016/j.surge.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite advances in opioid-sparing analgesia, opioid prescribing in breast surgery remains suboptimal. Besides delayed rehabilitation, excess post-operative opioids may contribute significantly to opioid dependence. This systematic review of guidelines evaluates current opioid-prescribing recommendations after breast surgery to identify trends in prescribing. Additionally, it compares recommendations on different non-opioid and non-pharmacological adjuncts. METHODS Electronic databases were searched systematically using terms "breast surgery", "analgesia", "opioid" and "guidelines". The grey literature was used to supplement the search. All articles that provided guidance on opioid prescribing in breast surgery were included. Quality of the guidelines were assessed using the AGREE II tool. Recommendations pertaining to opioid prescribing, analgesic adjuncts and non-pharmacological interventions were summarised and reported with descriptive statistics. RESULT Eight guidelines pertaining to mastectomies, breast conserving surgery and breast reconstructions were included in this review. Although an opioid-sparing approach was unanimous, there were conflicting recommendations on opioid doses. Opioid requirements were stratified by procedure in 3 guidelines, and by patient risk factors in 2 guidelines. There was significant variability in the recommended multimodal adjuncts. Notably, non-pharmacological interventions such as patient education were infrequently included in guidelines. CONCLUSION There is a lack of high-quality guidance on opioid prescribing after breast surgery. The optimum approach for personalised opioid prescribing remains unknown. Significant variability between guidelines provide little actionable interventions for prescribers. This could be driven by the paucity in evidence supporting a single efficacious analgesic regimen for patients undergoing breast surgery. Future guidelines should also regularly incorporate non-pharmacological adjuncts to reduce opioid prescribing.
Collapse
Affiliation(s)
- Kin Yik Chan
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland.
| | - Shane Keogh
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Nitin Aucharaz
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Anne Merrigan
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Shona Tormey
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| |
Collapse
|
18
|
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.
Collapse
|
19
|
VanIderstine C, Johnston E. Risk Factors for Prolonged Opioid Use Following Total Hip Arthroplasty and Total Knee Arthroplasty: A Narrative Review of Recent Literature. Ann Pharmacother 2022:10600280221133078. [DOI: 10.1177/10600280221133078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Objective: To provide pharmacists and other health care professionals with the knowledge required to minimize the risk of prolonged opioid use following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Data Sources: A literature search of PubMed and Embase was performed, and included the search terms: (opioid OR opiate OR opium) AND (risk factor OR predict*) AND (arthroplasty OR replacement) NOT shoulder. Study Selection and Data Extraction: Randomized control trials, cohort studies (both prospective and retrospective), systematic reviews, and meta-analyses were included if risk ratios (RRs) or odds ratios (ORs) were reported and published within the last 5 years. Data Synthesis: ]Twenty studies met inclusion criteria, including 2 meta-analyses and 2 prospective studies. There were several risk factors that overlapped between studies and presented clinically significant risks for prolonged opioid use following THA and TKA surgery. Of these, age < 65 (RRs: 1.15-9.36), preoperative opioid use (RRs: 1.09-7.81), larger quantities of opioids prescribed at discharge (RRs: 1.26-8.81), and TKA surgery (RRs: 1.73-6.07) were the most significant. Several risk factors were recently described, including migraines (RRs: 1.14-5.11) and fibromyalgia (RRs: 1.1-2.3) that may be of interest for further research. Relevance to Patient Care and Clinical Practice: This review presents a discussion of the factors associated with prolonged opioid use following THA and TKA surgeries, which are among the most common orthopedic surgeries. Conclusions: Prescribers should carefully consider patient-specific factors when prescribing opioids as there are several factors, including age, surgery type, and medical conditions that can predispose patients to prolonged opioid use.
Collapse
Affiliation(s)
- Carter VanIderstine
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Pharmacy Department Halifax Infirmary, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Emily Johnston
- Pharmacy Department Halifax Infirmary, Nova Scotia Health, Halifax, Nova Scotia, Canada
| |
Collapse
|
20
|
Toward Zero Prescribed Opioids for Outpatient General Surgery Procedures: A Prospective Cohort Trial. J Surg Res 2022; 278:293-302. [DOI: 10.1016/j.jss.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Association of Patient Controlled Analgesia and Total Inpatient Opioid Use After Pancreatectomy. J Surg Res 2022; 275:244-251. [DOI: 10.1016/j.jss.2022.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 12/31/2022]
|
23
|
DiPeri TP, Newhook TE, Arvide EM, Dewhurst WL, Bruno ML, Chun YS, Tran Cao HS, Lee JE, Vauthey JN, Tzeng CWD. Prospective Implementation of Standardized Post-Hepatectomy Care Pathways to Reduce Opioid Prescription Volume after Inpatient Surgery. J Am Coll Surg 2022; 235:41-48. [PMID: 35703961 PMCID: PMC9205619 DOI: 10.1097/xcs.0000000000000231] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Among the goals of prospectively implemented post-hepatectomy care pathways was a focus on patient-centric opioid reduction. We sought to evaluate the impact of pathway implementation on opioid volumes in the last 24-hour period and discharge prescriptions. STUDY DESIGN This is a retrospective cohort study comparing a prospective cohort ("POST," September 2019 through February 2020) treated after pathway implementation to a historical cohort of hepatectomy patients ("PRE," March 2016 through December 2017) before our 2018 departmental opioid reduction efforts. Opioid volumes in the last 24 hours and prescribed at discharge were converted to oral morphine equivalents (OME) and compared between cohorts. RESULTS There were 276 PRE and 100 POST patients. There was a similar proportion of major (PRE-34.1% vs POST-40%) and minimally invasive hepatectomies (PRE-19.9% vs POST-11%, p = 0.122). Implementation was associated with a shorter length of stay (median 5 d PRE vs 4 d POST, p < 0.001). Standardized opioid weaning was associated with a lower median last 24-hour OME (20 mg PRE vs 10 mg POST, p = 0.001). Using a standardized discharge calculation, median discharge OME were lower (200 mg PRE vs 50 mg POST, p < 0.001). More POST patients were discharged opioid-free (6.9% PRE vs 21% POST, p < 0.001). CONCLUSIONS Implementation of post-hepatectomy care pathways was associated with a 50% reduction in last 24-hour OME, which, combined with a standardized discharge calculation, was associated with an overall 75% reduction in discharge opioid volumes and tripled opioid-free discharges. These data suggest that no-cost, reproducible pathways can be considered in abdominal operations with similar incisions/length of stay to decrease variation in opioid dosing while prioritizing patient-centric opioid needs.
Collapse
Affiliation(s)
- Timothy P DiPeri
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Porter ED, Sacks OA, Ramkumar N, Barth RJ. Surgery Prescription Opioid Misuse and Diversion in US Adults and Associated Risk Factors. J Surg Res 2022; 275:208-217. [DOI: 10.1016/j.jss.2022.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/24/2021] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
|
25
|
DiPeri TP, Newhook TE, Day RW, Chiang YJ, Dewhurst WL, Arvide EM, Bruno ML, Scally CP, Roland CL, Katz MH, Vauthey JN, Chang GJ, Badgwell BD, Perrier ND, Grubbs EG, Lee JE, Tzeng CWD. A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients. Surg Open Sci 2022; 9:51-57. [PMID: 35663797 PMCID: PMC9161107 DOI: 10.1016/j.sopen.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care. Methods Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates. Results Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742). Conclusion The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.
Collapse
Affiliation(s)
- Timothy P. DiPeri
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy E. Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ryan W. Day
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney L. Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elsa M. Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Morgan L. Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher P. Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christina L. Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H.G. Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J. Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy D. Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G. Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
26
|
Delgado MK. Patient-Centered Default Opioid Orders-A Path Forward for Postoperative Opioid Stewardship. JAMA Netw Open 2022; 5:e2219712. [PMID: 35771581 DOI: 10.1001/jamanetworkopen.2022.19712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Kit Delgado
- Perelman School of Medicine, Penn Medicine Nudge Unit and the Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| |
Collapse
|
27
|
DiPeri TP, Newhook TE, Tran Cao HS, Ikoma N, Dewhurst WL, Arvide EM, Bruno ML, Katz MHG, Vauthey JN, Lee JE, Tzeng CWD. Opioid Discharge Prescriptions After Inpatient Surgery: Risks of Rebound Refills by Length of Stay. J Surg Res 2022; 278:111-118. [PMID: 35597025 DOI: 10.1016/j.jss.2022.04.057] [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: 12/29/2021] [Revised: 03/02/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION As inpatient stays become shorter, one concern with standardizing discharge opioid prescriptions is the potential risk of "rebound refills." We sought to compare opioid prescription refill rates and volumes for surgical patients discharged on postoperative day (POD) 2-3, 4-7, and 8+. METHODS In a prospective quality improvement protocol, faculty volunteered to use either a 5x-multiplier (5x) or usual care (UC) for discharge prescriptions after inpatient (≥48 h stay) surgery from Sep-Dec 2019. The 5x-multiplier is 5-times the patient's last 24-h opioid use (by oral morphine equivalents, OME). Cohorts were compared by POD of discharge: POD 2-3 ("SHORT"), POD 4-7 ("INTERMEDIATE"), and POD 8+ ("LONG"). The primary endpoint was 30-d refill rates. Secondary endpoints included 30-d refill OME and inpatient opioid weaning/discharge metrics. RESULTS From 22 faculty, 409 patients were included. When stratified by POD, 154 (37.7%) were discharged SHORT, 176 (43.0%) INTERMEDIATE, and 79 (19.3%) LONG. SHORT stay patients had a median last 24-h OME of 10 mg (versus 5 mg INTERMEDIATE, 5 mg LONG; P = 0.268), and a median discharge OME of 55 mg (versus 75 mg INTERMEDIATE, 100 mg LONG; P = 0.221). Patients with SHORT stays did not have higher refill rates (11.7% versus 18.2% INTERMEDIATE, 19.0% LONG; P = 0.193) or higher median refill OME (150 mg versus 300 mg INTERMEDAITE, 339 mg LONG; P = 0.154). CONCLUSIONS Despite concerns of increased refills, patients discharged by POD 2-3 were not associated with "rebound refills." A patient-centered 5x-multiplier standardization of discharge opioid prescriptions is feasible in all inpatient surgery patients, even those discharged following a short inpatient stay.
Collapse
Affiliation(s)
- Timothy P DiPeri
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| |
Collapse
|
28
|
Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention's 2016 opioid prescribing guideline. BMC Anesthesiol 2022; 22:141. [PMID: 35546657 PMCID: PMC9097447 DOI: 10.1186/s12871-022-01678-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention's (CDC) March 2016 opioid prescribing guideline did not include prescribing recommendations for surgical pain. Although opioid over-prescription for surgical patients has been well-documented, the potential effects of the CDC guideline on providers' opioid prescribing practices for surgical patients in the United States remains unclear. METHODS We conducted an interrupted time series analysis (ITSA) of 37,009 opioid-naïve adult patients undergoing inpatient surgery from 2013-2019 at an academic medical center. We assessed quarterly changes in the discharge opioid prescription days' supply, daily and total doses in oral morphine milligram equivalents (OME), and the proportion of patients requiring opioid refills within 30 days of discharge. RESULTS The discharge opioid prescription declined by -0.021 (95% CI, -0.045 to 0.003) days per quarter pre-guideline versus -0.201 (95% CI, -0.223 to -0.179) days per quarter post-guideline (p < 0.0001). Likewise, the mean daily and total doses of the discharge opioid prescription declined by -0.387 (95% CI, -0.661 to -0.112) and -7.124 (95% CI, -9.287 to -4.962) OME per quarter pre-guideline versus -2.307 (95% CI, -2.560 to -2.055) and -20.68 (95% CI, -22.66 to -18.69) OME per quarter post-guideline, respectively (p < 0.0001). Opioid refill prescription rates remained unchanged from baseline. CONCLUSIONS The release of the CDC opioid guideline was associated with a significant reduction in discharge opioid prescriptions without a concomitant increase in the proportion of surgical patients requiring refills within 30 days. The mean prescription for opioid-naïve surgical patients decreased to less than 3 days' supply and less than 50 OME per day by 2019.
Collapse
|
29
|
Robinson KA, Marwaha JS, Kennedy CJ, Beaulieu-Jones BR, Fleishman A, Yu JK, Nathanson LA, Brat GA. Evaluation of U.S. state opioid prescribing restrictions using patient opioid consumption patterns from a single, urban, academic institution. Subst Abus 2022; 43:932-936. [DOI: 10.1080/08897077.2022.2056934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Kortney A. Robinson
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Jayson S. Marwaha
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Chris J. Kennedy
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Brendin R. Beaulieu-Jones
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Justin K. Yu
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Computer Science Artificial Intelligence Laboratory (CSAIL), Massachusetts Institute of Technology (MIT), Cambridge, MA, USA
| | | | - Gabriel A. Brat
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
30
|
Marwaha JS, Kennedy CJ, Brat GA. Surgical Residency Programs Should Leverage Recent Advances in National Policy, Real-World Data, and Public Opinion to Improve Post-Surgery Opioid Prescribing. J Grad Med Educ 2022; 14:25-29. [PMID: 35222816 PMCID: PMC8848891 DOI: 10.4300/jgme-d-21-00617.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Jayson S. Marwaha
- Jayson S. Marwaha, MD, is a General Surgery Resident and Postdoctoral Fellow in Biomedical Informatics, Department of Surgery, Beth Israel Deaconess Medical Center, and Department of Biomedical Informatics, Harvard Medical School
| | - Chris J. Kennedy
- Chris J. Kennedy, PhD, is Postdoctoral Fellow in Biomedical Informatics, Department of Surgery, Beth Israel Deaconess Medical Center, and Department of Biomedical Informatics, Harvard Medical School
| | - Gabriel A. Brat
- Gabriel A. Brat, MD, MPH, is Assistant Professor of Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, and Instructor in Biomedical Informatics, Department of Biomedical Informatics, Harvard Medical School
| |
Collapse
|
31
|
Optimization of postoperative opioid prescriptions in gynecologic oncology: Striking a balance between opioid reduction and pain control. Gynecol Oncol 2021; 162:756-762. [PMID: 34226021 DOI: 10.1016/j.ygyno.2021.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To implement a quality-improvement initiative to assess the impact various patient and procedural factors have on postoperative opioid use. To develop a tailored opioid prescribing algorithm for gynecologic oncology patients. METHODS A retrospective cohort study was performed of patients who underwent a laparoscopy or laparotomy procedure for a suspected or known gynecologic malignancy between 3/2019-9/2020. Patients were assessed preoperatively for the presence of suspected risk factors for opioid misuse (depression, anxiety, chronic pain, current opioid use, or substance abuse). Patients completed a 30-day postoperative questionnaire assessing for total opioid pill use and refills requests. Multivariate models were developed to estimate the independent effect of sociodemographic characteristics, risk factors for opioid misuse and procedural factors on patient reported postoperative opioid use. RESULTS A total of 390 patients were analyzed. Thirty-nine percent (N = 151/390) of patients reported not using opioids after discharge and 5% (N = 20/390) received an opioid refill. For both minimally invasive procedures and laparotomy procedures, body mass index, comorbidities, intraoperative or postoperative complications and final diagnosis of malignancy were not associated with the amount of opioid consumption. However, younger age and history of risk factors for opioid misuse significantly impacted postoperative opioid use. In multivariate analysis, age (p = 0.038) and risk factors (p < 0.001) remained significant after controlling for other factors. CONCLUSIONS Two out of every five patients did not use opioids after surgery. Younger patients and those with risk factors for opioid misuse need a tailored approach to prescribing opioids to balance the need for adequate pain control with the risk of misuse.
Collapse
|
32
|
Invited Commentary. J Am Coll Surg 2021; 232:835-836. [PMID: 34030845 DOI: 10.1016/j.jamcollsurg.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
|
33
|
Hur J, Tang S, Gunaseelan V, Vu J, Brummett CM, Englesbe M, Waljee J, Wiens J. Predicting postoperative opioid use with machine learning and insurance claims in opioid-naïve patients. Am J Surg 2021; 222:659-665. [PMID: 33820654 DOI: 10.1016/j.amjsurg.2021.03.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The clinical impact of postoperative opioid use requires accurate prediction strategies to identify at-risk patients. We utilize preoperative claims data to predict postoperative opioid refill and new persistent use in opioid-naïve patients. METHODS A retrospective study was conducted on 112,898 opioid-naïve adult postoperative patients from Optum's de-identified Clinformatics® Data Mart database. Potential predictors included sociodemographic data, comorbidities, and prescriptions within one year prior to surgery. RESULTS Compared to linear models, non-linear models led to modest improvements in predicting refills - area under the receiver operating characteristics curve (AUROC) 0.68 vs. 0.67 (p < 0.05) - and performed identically in predicting new persistent use - AUROC = 0.66. Undergoing major surgery, opioid prescriptions within 30 days prior to surgery, and abdominal pain were useful in predicting refills; back/joint/head pain were the most important features in predicting new persistent use. CONCLUSIONS Preoperative patient attributes from insurance claims could potentially be useful in guiding prescription practices for opioid-naïve patients.
Collapse
Affiliation(s)
- Jaewon Hur
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA
| | - Shengpu Tang
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Joceline Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Jenna Wiens
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|