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Baxter NB, Ho AZ, Byrd JN, Fernandez AC, Singh K, Chung KC. Predicting Persistent Opioid Use after Hand Surgery: A Machine Learning Approach. Plast Reconstr Surg 2024; 154:573-580. [PMID: 37772891 DOI: 10.1097/prs.0000000000011099] [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: 09/30/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the use of machine learning to predict persistent opioid use after hand surgery. METHODS The authors trained 2 algorithms to predict persistent opioid use, first using a general surgery data set and then using a hand surgery data set, resulting in 4 trained models. Next, the authors tested each model's performance using hand surgery data. Participants included adult surgery patients enrolled in a cohort study at an academic center from 2015 to 2018. The first algorithm (Michigan Genomics Initiative model) was designed to accommodate patient-reported data and patients with or without prior opioid use. The second algorithm (claims model) was designed for insurance claims data from patients who were opioid-naive only. The main outcome was model discrimination, measured by area under the receiver operating curve (AUC). RESULTS Of 889 hand surgery patients, 49% were opioid-naive and 21% developed persistent opioid use. Most patients underwent soft-tissue procedures (55%) or fracture repair (20%). The Michigan Genomics Initiative model had AUCs of 0.84 when trained only on hand surgery data, and 0.85 when trained on the full cohort of surgery patients. The claims model had AUCs of 0.69 when trained only on hand surgery data, and 0.52 when trained on the opioid-naive cohort of surgery patients. CONCLUSIONS Opioid use is common after hand surgery. Machine learning has the potential to facilitate identification of patients who are at risk for prolonged opioid use, which can promote early interventions to prevent addiction.
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Affiliation(s)
| | | | - Jacqueline N Byrd
- Section of Plastic Surgery, Department of Surgery
- Department of Surgery, University of Texas Southwestern Medical School
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Zhang J, Bradshaw F, Duchniewicz M, Fernandes FW, Geetala R, Krkovic M. Factors Affecting Upper Limb Fracture Opioid Requirements. Cureus 2024; 16:e56499. [PMID: 38638745 PMCID: PMC11026122 DOI: 10.7759/cureus.56499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction Understanding the different opioid pain relief requirements between patients with upper limb fractures can be useful in forming specific evidence-based guidelines and balancing patient-clinician prescribing discussions with opioid stewardship. We investigated the predictors for opioid requirements in upper limb fractures. Methods We retrospectively investigated all upper limb fractures from the shoulder to the wrist treated at a major trauma center from January 2015 to January 2022. The data collected consisted of fracture location, demographics, comorbidities, and management options. Post-injury opioid prescriptions in the first post-injury year were calculated every month up to six months and then grouped from the seventh to the 12th month and converted to morphine milligram equivalents (MMEs). We then calculated days requiring at least one medication (representing the "coverage") and relative "strength" in each time period. Results Six thousand four hundred thirteen patients sustaining a combined 9125 fractures were included in the study, with an MME mean of 436. Fracture locations of the scapula, proximal humerus, humeral shaft, distal humerus, and proximal ulna all had significantly higher MME requirements (p<0.05) at the one-year level. The radius shaft and distal radius had significantly lower MME requirements (p<0.05). The patients with depression, diabetes, drug abuse history, obesity, pulmonary circulatory disorder, and rheumatological conditions required higher strength of opioids at the one-year level (p<0.05). The patients with chronic kidney disease, depression, pulmonary circulation disorder, and rheumatological conditions required higher coverage of opioids at the one-year level (p<0.05). Conclusion Our study presents a high-resolution breakdown of the post-injury opioid requirements for patients with upper limb injuries. Fractures of the scapula, proximal humerus, and shaft of the humerus were associated with increases in both opioid strength and coverage. Depression, pulmonary disease, and rheumatological conditions were all associated with increased opioid strength and coverage. This provides a framework for which clinicians and patients can more accurately anticipate the course of the rehabilitation journey and risk stratify appropriately at the outset of injury.
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Affiliation(s)
- James Zhang
- Department of Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Florence Bradshaw
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Michal Duchniewicz
- Department of Trauma, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | | | - Rahul Geetala
- Department of Trauma and Orthopedics, University of Cambridge, Cambridge, GBR
| | - Matjia Krkovic
- Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
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Cunningham D, LaRose M, Patel P, Zhang G, Morriss N, Paniagua A, Gage M. Regional anesthesia improves inpatient but not outpatient opioid demand in tibial shaft fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2921-2931. [PMID: 36912951 DOI: 10.1007/s00590-023-03504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use. METHODS This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured. RESULTS RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05). CONCLUSIONS RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Preet Patel
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Nicholas Morriss
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA.
| | - Ariana Paniagua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Mark Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Newton W, Hoch C, Chen C, Scott DJ, Gross CE. Preoperative Opioid Use Predicts Poorer Outcomes of Total Ankle Arthroplasty and Hindfoot Fusions. Foot Ankle Spec 2023; 16:497-505. [PMID: 37119178 DOI: 10.1177/19386400231164677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND This study aimed to determine the impact of preoperative opioid use on outcomes of patients undergoing ankle or hindfoot arthrodesis, or total ankle arthroplasty (TAA). METHODS We conducted a retrospective review of 190 patients undergoing an ankle or hindfoot arthrodesis (n=122) or TAA (n=68) between December 2015 and September 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (PROMs) (eg, Foot and Ankle Outcome Score [FAOS]), and opioid use. RESULTS Patients with preoperative opioid use were more likely to continue usage at 90 (r = 0.931, P < .001) and 180 (r = 0.940, P < .001) days postoperatively. For the entire cohort, complication and reoperation rates were 48.9% and 13.2%, respectively. While preoperative opioid use groups did not differ in the overall complication rate, users had significantly more infections (user = 12.5%, nonuser = 3.3%; P = .036) and reoperations (user = 22.5%, nonuser = 10.7%; P = .049). When analyzing postoperative opioid prescriptions, there were many significant correlations with preoperative PROMs, mainly FAOS, such that increased postoperative opioid use was associated with worse subjective outcomes. CONCLUSION Preoperative opioid users are more likely to continue postoperative opioid use, experience infections, and undergo reoperations. LEVEL OF EVIDENCE Level III: Retrospective cohort study.
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Affiliation(s)
- William Newton
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Caroline Hoch
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Caroline Chen
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel J Scott
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher E Gross
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, South Carolina
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Castle JP, Jildeh TR, Abbas MJ, Hennekes ME, Buckley PJ, Shabet CL, Cotter DL, Moutzouros V. Patient factors influencing the choice of opioid versus non-opioid postoperative analgesia following common sports procedures: a prospective survey study. J Orthop 2023; 40:1-6. [PMID: 37124142 PMCID: PMC10130914 DOI: 10.1016/j.jor.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Purpose Despite established opioid-free protocols for postoperative analgesia after common orthopaedic sports procedures, many patients continue to request opioids postoperatively. The purpose of this study was to elucidate patient factors influencing preferences for opioid versus nonopioid postoperative analgesia. Methods Patients (age >/ = 15) without a history of a documented chronic pain disorder who were scheduled for one of ten sports procedure types from August 2020 to May 2021 were eligible for inclusion. Patients were excluded if undergoing revision surgery, had concomitant injuries, had opioids use >3 months preoperatively, or unable to read English. Recruitment ended after 100 patients enrolled. At the patients' preoperative visit, patients were administered a written survey assessing pain medication preferences. Participants completed the Opioid Risk Tool survey, as well as Visual Analog Scale and Patient-Reported Outcome Measurement Information System surveys. Results One hundred patients participated in the study. Forty-two patients preferred opioids versus 58 patients preferring nonopioid postoperative analgesia. Patients preferring opiates were more likely to have had previous surgery (90.2% vs. 69.6%, p = 0.023) with post-operative pain managed with opiates (87.5% vs 55.4%, p = 0.003), higher preoperative Visual Analog Scale score (6±3.5 vs. 3±2, p < 0.001), reported post-operative pain as a reason for opioids preference (88.1% vs 20.0%, p < 0.001), and were less concerned about addiction (4.8% vs. 45.5%, p < 0.001) and side effects (11.9% vs. 52.7%, p < 0.001). For every unit increase in Visual Analog Scale score, the odds of preferring opioid pain control increased 1.41 times. Conclusions Patients with a history of prior surgery utilizing opioid pain control, higher Visual Analog Scale scores preoperatively, and concern for inadequately managed postoperative pain were more likely to prefer opioid pain control following common orthopaedic sports procedures. Patients may benefit from increased preoperative education about opioid risks and the role of multimodal pain management regimens.
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Affiliation(s)
| | - Toufic R. Jildeh
- Michigan State University College of Human Medicine, 4660 Hagadorn Rd Suite 420, East Lansing, MI, 48823, USA
| | | | | | | | - Christina L. Shabet
- University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI, 40109, USA
| | - Daniel L. Cotter
- Ascension St. John Hospital, 22101 Moross Rd, Detroit, MI, 48236, USA
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Zhang SE, Anatone AJ, Figgie M, Long WJ, Della Valle AG, Lee GC. Spine or Hip First? Outcomes in Patients Undergoing Sequential Lumbar Spine or Hip surgery. J Arthroplasty 2023:S0883-5403(23)00386-8. [PMID: 37088220 DOI: 10.1016/j.arth.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/25/2023] Open
Abstract
INTRODUCTION Lumbar spine pathology frequently coexists in patients who have hip arthrosis. There is controversy on whether lumbar or hip pathology should be first addressed. The purpose of this study was to evaluate the outcomes of sequential lumbar spine (LSP) or hip arthroplasty (THA). METHODS Using a large national database from 2010 to 2020, we reviewed the records of 241,279 patients who had concurrent hip arthritis and lumbar spine disease defined as spinal stenosis, lumbar radiculopathy, or degenerative disc disease. During the study period, 6,458 (2.7%) patients with concurrent hip/spine disease underwent sequential operative treatment of either the hip joint or lumbar spine within 2 years. The rates of subsequent surgery in either the hip or spine, opioid requirements, and rates of hip dislocation were determined and analyzed using compared Chi-squared analyses. RESULTS Patients undergoing THA first had lower risk of subsequent spinal procedure compared to patients who had spinal procedures first (5.7 vs. 23.7 %, P < 0.001). This disparity was maintained up to 5 years (P<0.001). Opioid requirements at 1 year were highest in patients who underwent spinal procedures only (836 pills/patient) compared to any other group (THA only (566 pills/patient), LSP and then THA (564 pills/patient), THA and LSP (586 pills/patient). Also, THA following LSP was associated with significantly higher rates of dislocation compared to patients undergoing THA first (3.2 versus 1.9%, P<0.001). SUMMARY Total hip arthroplasty first in patients who have concurrent spine disease was associated with lower risk of subsequent surgery, opioid requirement, and risk of postoperative instability compared to patients having lumbar procedure first.
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Newton WN, Sossamon JA, Pire JR, Daley DN. Risks of Chronic Preoperative Opioid Use on Distal Radius Surgery Outcomes. Hand (N Y) 2023:15589447231160206. [PMID: 36946601 DOI: 10.1177/15589447231160206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The purpose of this study was to determine the influence of chronic preoperative opioid use on complications, reoperation rates, and postoperative opioid use among patients undergoing open reduction and internal fixation (ORIF) of distal radius fractures. METHODS A retrospective review of 111 patients who underwent ORIF of a distal radius fracture from 2019 to 2021 at an academic medical center by the same fellowship-trained orthopedic hand surgeon was conducted. Patient demographics, medical comorbidities, perioperative details, surgical complications, and patient-reported outcome measures were analyzed. The SCRIPTS database was used to obtain opioid prescription data. RESULTS A total of 10 patients (9.01%) were identified as preoperative chronic opioid users. This group was not associated with risk of increased complication. However, they were more likely to continue using narcotics at 90 and 180 days postoperatively. Patients with a history of substance use were at an increased risk of hardware complications and prolonged postoperative pain. In addition, these patients were more likely to receive narcotics at 90 and 180 days, and to have more refills postoperatively. CONCLUSION Patients with preoperative opioid use are not at an increased risk of surgical complication following ORIF of distal radius fractures. However, they are at an increased risk of prolonged postoperative opioid use. Patients with a known history of substance use were at an increased risk of hardware complications, prolonged pain, and increased postoperative opioid use. Surgeons should consider these associations to better manage individual patients in the postoperative period.
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Affiliation(s)
| | | | | | - Dane N Daley
- Medical University of South Carolina, Charleston, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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8
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Psychiatric Comorbidities Associated with Persistent Postoperative Opioid Use. Curr Pain Headache Rep 2022; 26:701-708. [PMID: 35960447 DOI: 10.1007/s11916-022-01073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review outlines the psychiatric comorbidities associated with persistent opioid use in the postoperative period. We finish our analysis with evidence-based, patient-centered interventions that can be rendered in the perioperative setting to decrease postoperative opioid requirements. RECENT FINDINGS Opioids are overprescribed in the USA, especially in the postoperative setting. Excess opioids can result in diversion and contribute to the ongoing opioid epidemic. Mental health and substance use disorders can contribute to persistent postoperative opioid use. Adequately managing these disorders preoperatively promises to reduce persistent postoperative opioid use. Due to the lack of homogenous, evidence-based recommendations on the appropriate quantity and duration of postoperative opioid therapy, there is wide variability in provider prescribing habits. Further research is needed to establish surgery-specific postoperative opioid therapy protocols. Opioids continue to be a mainstay in the treatment of postoperative pain. Unmonitored postoperative opioid use can lead to opioid use disorder. Mental health disorders increase susceptibility to persistent postoperative opioid use. By managing these psychiatric illnesses preoperatively, clinicians have the ability to decrease opioid consumption postoperatively. Lastly, given the healthcare burden of opioid misuse and abuse, it is important to establish concrete protocols to guide provider-prescribing habits.
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Cunningham DJ, Paniaugua AR, LaRose MA, DeLaura IF, Blatter MK, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery. Arch Orthop Trauma Surg 2022; 142:1873-1883. [PMID: 33938985 DOI: 10.1007/s00402-021-03892-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand. METHODS This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05). DISCUSSION In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - Ariana R Paniaugua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Isabel F DeLaura
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Michael K Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Zheng ZH, Yeh TT, Yeh CC, Lin PA, Wong CS, Lee PY, Lu CH. Multimodal Analgesia with Extended-Release Dinalbuphine Sebacate for Perioperative Pain Management in Upper Extremity Trauma Surgery: A Retrospective Comparative Study. Pain Ther 2022; 11:643-653. [PMID: 35426567 PMCID: PMC9098781 DOI: 10.1007/s40122-022-00383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Patients undergoing upper extremity fracture surgery (UEFS) commonly suffer from unbearable acute pain. Opioids remain the mainstay of moderate to severe pain alleviation, although there is a growing concern regarding the increasing trend in misuse and abuse. This study aimed to observe the safety and efficacy of dinalbuphine sebacate (DS), a novel extended-release analgesic, along with multimodal analgesia (MMA) for post-UEFS pain control. Methods We retrospectively reviewed the records of patients undergoing UEFS between August 2020 and January 2021. Eligible patients were included and divided into two groups, depending on the analgesic regimen. In the DS group, 150 mg DS was administered intramuscularly at least 12 h pre-operatively, while in the conventional analgesia (CA) group, 40 mg parecoxib was given within 3 h before surgery. Intraoperative fentanyl administration was guided by the Analgesia Nociception Index System in both groups. For breakthrough pain, fentanyl was used as rescue medicine in the postanaesthesia care unit while tramadol and parecoxib were administered in the ward. Results Forty-nine patients were allocated to the DS group and 60 patients were allocated to the CA group. In comparison with the CA group, the proportion of patients requiring opioids for breakthrough pain post-operatively was significantly lower in the DS group (fentanyl: 31% vs. 68%, p < 0.001; tramadol: 27% vs. 70%, p < 0.001). The DS group also consumed lower amounts of post-operative rescue opioids. Furthermore, both mean worst and least pain scores were significantly lower in the DS group from post-operative day (POD) 1 to POD 5. There was no significant difference in intraoperative consumption of fentanyl or incidence of adverse events. Conclusion This result suggests that extended-release DS is a suitable analgesic incorporated in MMA and a promising solution to the misuse and abuse of opioids.
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Rogers MJ, LaBelle MW, Kim J, Adeyemi TF, Sciarretta CE, Bokat CE, Maak TG. Effect of Perioperative Opioid Use on Patients Undergoing Hip Arthroscopy. Orthop J Sports Med 2022; 10:23259671221077933. [PMID: 35284588 PMCID: PMC8905069 DOI: 10.1177/23259671221077933] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022] Open
Abstract
Background Opioids are commonly used to treat postoperative pain; however, guidelines vary regarding safe opioid use after hip arthroscopy. Purpose/Hypothesis The purposes were to (1) identify risk factors for persistent opioid use, (2) assess the effect of opioid use on outcomes, and (3) describe common opioid prescribing patterns after hip arthroscopy. It was hypothesized that preoperative opioid use would affect complication rates and result in greater postoperative opioid use. Study Design Case-control study; Level of evidence 3. Methods The Utah State All Payer Claims Database was queried for patients who underwent hip arthroscopy between January 2013 and December 2017. Included were patients ≥14 years of age at index surgery with continuous insurance. Patients were separated into acute (<3 months) and chronic (≥3 months) postoperative opioid use groups. Primary outcomes included revision surgery, complications (infection, pulmonary embolism/deep venous thrombosis, death), emergency department (ED) visits, and hospital admissions. Multivariate logistic regression was utilized to identify factors associated with the outcomes. Results Included were 2835 patients (mean age, 47 years; range, 14-64 years), of whom 2544 were in the acute opioid use and 291 were in the chronic opioid use group. Notably, 91% of the patients in the chronic group took opioid medications preoperatively, and they were more than twice as likely to carry a mental health diagnosis (P < .01). Patients in the acute group had a significantly shorter initial prescription duration, took fewer opioid pills, and had fewer refills than those in the chronic group (P < .01 for all). Patients in the chronic group had a significantly higher risk of postoperative ED visits (odds ratio [OR], 2.76; P = .008), hospital admission (OR, 3.02; P = .002), and additional surgery (P = .003), as well as infection (OR, 2.55; P < .001) and hematoma (OR, 2.43; P = .030). Patients who had used opioids before hip arthroscopy were more likely to need more refills (P < .01). A formal opioid use disorder diagnosis correlated significantly with postoperative hospital admissions (OR, 3.83; P = .044) and revision hip arthroscopy (OR, 4.72; P = .003). Conclusion Mental health and substance use disorders were more common in patients with chronic postoperative opioid use, and chronic postoperative opioid use was associated with greater likelihood of postoperative complications. Preoperative opioid use was significantly correlated with chronic postoperative opioid use and with increased refill requests after index arthroscopy.
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Affiliation(s)
- Miranda J. Rogers
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Mark W. LaBelle
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Jaewhan Kim
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Temitope F. Adeyemi
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Christina E. Bokat
- Division of Pain Medicine, Department of Anesthesia, University of Utah, Salt Lake City, Utah, USA
| | - Travis G. Maak
- Department of Orthopaedic Surgery, University of Utah Orthopedic Center, University of Utah, Salt Lake City, Utah, USA
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Cunningham DJ, LaRose MA, Zhang GX, Au S, MacAlpine EM, Paniagua AR, Klifto CS, Gage MJ. Regional anesthesia reduces inpatient and outpatient perioperative opioid demand in periarticular elbow surgery. J Shoulder Elbow Surg 2022; 31:e48-e57. [PMID: 34481050 DOI: 10.1016/j.jse.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Regional anesthesia (RA) can be used to manage perioperative pain in the treatment of periarticular elbow fracture fixation. However, the opioid-sparing benefit is not well-characterized. The hypothesis of this study was that RA had reduced inpatient opioid consumption and outpatient opioid demand in patients who had undergone periarticular elbow fracture surgery. METHODS This study retrospectively reviews inpatient opioid consumption and outpatient opioid demand in all patients aged ≥18 years at a single Level I trauma center undergoing fixation of periarticular elbow (distal humerus and proximal forearm) fracture surgery (n=418 patients). In addition to RA vs. no RA, additional patient and operative characteristics were recorded. Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated decreases in inpatient opioid consumption postoperation in patients with RA (13.7 estimated oxycodone 5-mg equivalents or OEs without RA vs. 10.4 OEs with RA from 0 to 24 hours postoperation, P = .003; 12.3 vs. 9.2 OEs from 24 to 48 hours postoperation, P = .045). Estimated cumulative outpatient opioid demand differed significantly in patients with RA (166.1 vs. 132.1 OEs to 6 weeks, P = .002; and 181 vs. 138.6 OEs to 90 days, P < .001). DISCUSSION In proximal forearm and distal humerus fracture surgery, RA was associated with decreased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results encourage utilization of perioperative RA to reduce opioid use.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Gloria X Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sandra Au
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Elle M MacAlpine
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Stewart M, Mastrolonardo E, Ghias A, Butkus J, Hobelmann K, Zhan T, Dang S, Cognetti D, Rosen D, Boon M, Huntley C. Opioid Usage and Pain Control in Benign Oropharyngeal Surgery: An Observational Prospective Study. Ann Otol Rhinol Laryngol 2021; 131:1060-1067. [PMID: 34694150 DOI: 10.1177/00034894211053290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Little data is available on opioid usage in the adult population for benign oropharyngeal surgery. The objective here is to evaluate opioid prescribing patterns, opioid consumption, and patient pain patterns following benign oropharyngeal surgery, specifically tonsillectomy and adenoidectomy, tonsillectomy alone, and expansion sphincter pharyngoplasty. METHODS Patients aged ≥18 years old and received a tonsillectomy, tonsillectomy and adenoidectomy, or expansion sphincter pharyngoplasty between November 2019 and August 2020 were included. Patients were provided a survey which included a visual analog scale for recording their pain postoperatively and the amount of opioid they had remaining. RESULTS About 103 patients completed the post-operative questionnaire. Patients were prescribed 38 837 morphine milligram equivalents and used 28 644: approximately 26% went unused, which is the equivalent of 1346 5 mg oxycodone pills. Opioid consumption correlated with the initial dosage: patients consumed 12% more narcotic on average as the initial prescription went upwards by 50 morphine milligram equivalents. Obstructive sleep apnea, history of smoking, and being female predicted increased opioid usage in this cohort. Pain was reported the highest on postoperative day 1. A prescription of approximately 225 morphine milligram equivalents (150 mg oxycodone) was associated with decreased opioid use in this cohort. Larger initial prescriptions did not result in fewer requests for refills. CONCLUSION A significant amount of opioid medication went unused in this study. A prescription of 225 morphine milligram equivalents (or 150 mg oxycodone) provided appropriate analgesia for the majority of patients. Larger prescriptions may result in increased opioid consumption and may not reduce the amount of refills. More study is needed to confirm these findings.
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Affiliation(s)
- Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Eric Mastrolonardo
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Adeeba Ghias
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joann Butkus
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kealan Hobelmann
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sophia Dang
- Department of Otolaryngology Eye & Ear Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Cognetti
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David Rosen
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Cunningham DJ, Robinette JP, Paniagua AR, LaRose MA, Blatter M, Gage MJ. Regional anesthesia does not decrease opioid demand in pelvis and acetabulum fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1357-1370. [PMID: 34519897 DOI: 10.1007/s00590-021-03114-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/02/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Patients with pelvic and acetabular fractures often have considerable pain in the perioperative period. Regional anesthesia (RA) including peripheral nerve blocks and spinal analgesia may reduce pain. However, the real-world impact of these modalities on inpatient opioid consumption and outpatient opioid demand is largely unknown. The purpose of this study was to evaluate the impact of perioperative RA on inpatient opioid consumption and outpatient opioid demand. METHODS This is a retrospective, observational review of inpatient opioid consumption and outpatient opioid demand in all patients ages 18 and older undergoing operative fixation of pelvic and acetabular fractures at a single Level, I trauma center from 7/1/2013-7/1/2018 (n = 205). Unadjusted and adjusted analyses were constructed to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand while controlling for age, sex, race, body mass index (BMI), smoking, chronic opioid use, ASA score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. RESULTS Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (12.6 estimated OE's without RA vs 16.1 OE's with RA from 48 to 72 h post-op, p < 0.05) but no significant differences at other timepoints (17.5 estimated OE's without RA vs 16.8 OE's with RA from 0 to 24 h post-op, 15.3 vs 17.1 from 24 to 48 h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at discharge to 90 days post-op (and 156.8 vs 207.9 OE's to 90 days, p < 0.05) but did not differ significantly before that time (121.5 OE's without RA vs 123.9 with RA from discharge to two weeks, 145.2 vs 177.2 OE's to 6 weeks, p > 0.05). DISCUSSION In pelvis and acetabulum fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. Regional anesthesia may not be beneficial for these patients.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - J Patton Robinette
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Michael Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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