Institutional reductions in opioid prescribing do not change patient satisfaction on Press Ganey surveys after total shoulder arthroplasty

Preoperative opioid use is associated with worse two-year patient-reported outcomes after hand surgery: A retrospective cohort study

Introduction

Opioid overprescribing has caused a substantial increase in opioid related deaths and billions of dollars in additional healthcare costs. Orthopaedic surgeons commonly prescribe opioids in the perioperative period; however, research has shown preoperative opioid use may be associated with worse postoperative outcomes. Despite this body of evidence, there are few studies investigating the association between preoperative opioid use and two-year outcomes after hand surgery.

Materials and methods

This study evaluated two-year postoperative patient-reported outcomes in patients who used opioids prior to hand surgery, and those who did not. Patients completed pre and postoperative questionnaires including Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Brief Michigan Hand Questionnaire (BMHQ), and other questionnaires related to pain, function, and satisfaction. 342 patients undergoing upper-extremity surgery were enrolled into a prospective orthopaedic surgery outcome registry, and 69.9% completed the follow-up surveys. Preoperative opioid use and its association to patient outcome scores was analyzed through bivariate analysis. Significant associations were further tested by multivariable analysis to determine independent predictors.

Results

Preoperative opioid use was associated with worse two-year PROMIS Fatigue (p ​< ​.01), PROMIS Anxiety (p ​< ​.01), PROMIS Depression (p ​< ​.01), SSQ-8 (p ​= ​.01), BMHQ (p ​= ​.01), NPS Hand (p ​< ​.01) and MODEMS met expectations (p ​= ​.03). No significant differences were observed in patient-reported outcome change scores. Multivariable analysis demonstrated that preoperative opioid use was predictive of worse two-year PROMIS Fatigue (p ​< ​.01), PROMIS Anxiety (p ​< ​.01), PROMIS Depression (p ​= ​.02), BMHQ (p ​= ​.01), SSQ-8 (p ​< ​.01), NPS Hand (p ​= ​.02) and MODEMS met expectations (p ​< ​.01).

Conclusion

Preoperative opioid use was associated with worse patient-reported outcomes two years after elective hand surgery. There was no significant difference in the improvement from baseline between the two groups. Clinically significant differences were observed in follow-up PROMIS Anxiety, BMHQ and NPS - Hand scores. Clinically significant change scores were noted in both groups for PROMIS PF, PROMIS PI, PROMIS SS, BMHQ, and NPS - Hand.

Pain Control and Satisfaction With Peripheral Nerve Blocks for Upper Extremity Surgery

BACKGROUND

Regional anesthesia ("block") is an important component of upper extremity (UE) surgery pain control. However, little is known about patient experience related to perioperative opioid use. This study assessed patient-reported pain control and satisfaction with UE blocks and evaluated how opioid consumption impacted these outcomes before the block "wore off."

METHODS

A postoperative phone survey was administered to patients who underwent outpatient UE surgery at a surgery center for more than 16 months. It assessed pain scores (scale 1-10), satisfaction with block duration (scale 1-5), duration until return of UE function, and opioid consumption. Analyses used Mann-Whitney U tests, Fisher exact tests, and bivariate and multivariable linear and ordered logistic regressions to understand relationships between opioid use and outcomes.

RESULTS

A total of 509 patients (61%) completed the survey, and 441 (88%) were satisfied with block duration. Initial and final pain scores were significantly higher in patients who took opioids prior to the block wearing off (6 and 4.5, P = .04 and 3.5 and 2, P = .002, respectively). Although satisfaction with block duration was not different in group comparisons (ie, patients who premedicated vs those who did not), in a multivariable analysis, patients who premedicated with opioids had 78% increased odds of reporting the highest level of satisfaction compared with the lower 4 levels (P = .03).

CONCLUSIONS

Upper extremity blocks are associated with high overall patient satisfaction and postsurgical pain control. Premedicating before the block wears off may increase patient satisfaction with block duration even if pain is not notably impacted.

How low can we go? A randomized controlled trial of low-quantity initial opioid prescriptions for shoulder surgery

BACKGROUND

Orthopedic surgeons are the third most frequent prescribers of opioid medications. Given the current opioid addiction crisis, it is critical to limit opioid prescriptions to the lowest effective dose. In this study, we investigated how the initial opioid prescription after shoulder surgery affects maximum possible opioid consumption. We hypothesized that fewer pills in the initial opioid prescription would lead to less opioid consumption, a lower refill request rate, and fewer post-surgery office contacts for pain.

METHODS

In this single-center, prospective, randomized controlled clinical trial, 74 adults who underwent shoulder arthroplasty, rotator cuff repair, or other arthroscopic shoulder procedures were enrolled from December 2020 to July 2022. Follow-up was completed by February 2023. Participants were randomly assigned to receive postoperative prescriptions of seven 5-mg oxycodone pills (n = 20), 15 pills (n = 29), or 23 pills (n = 25). The primary outcome was maximum possible opioid consumption within 2 weeks after surgery, calculated by assuming consumption of all pills in the initial prescription, as well as any refills. Secondary outcomes were the opioid prescription refill request rates, post-surgery pain-related telephone calls or messages to the provider's office ("office contacts") within 2 weeks after surgery, and American Shoulder and Elbow Surgeons pain scores 2 weeks after surgery. Baseline characteristics did not differ among groups except for mean age, which was younger in the 7-pill group (P = .047).

RESULTS

Maximum possible opioid consumption increased with the number of pills initially prescribed, with means of 78 morphine milligram equivalents (MME) for the 7-pill group, 118 MME for the 15-pill group, and 199 MME for the 23-pill group (P < .001). None of the secondary outcome measures differed among groups. Refill request rates were 20% for the 7-pill group, 3.4% for the 15-pill group, and 12% for the 23-pill group (P = .20). The proportions of patients with at least 1 office contact were 35% in the 7-pill group, 45% in the 15-pill group, and 28% in the 23-pill group (P = .43). Mean American Shoulder and Elbow Surgeons pain scores were 49 in the 7-pill group, 44 in the 15-pill group, and 40 in the 23-pill group (P = .20).

CONCLUSION

After shoulder surgery, an initial prescription of fewer opioid pills was associated with less maximum possible opioid consumption without an increase in the percentage of patients requesting opioid refills or contacting the provider's office for pain-related concerns. An initial postoperative prescription of fewer 5-mg oxycodone pills may be equally or more effective compared with larger quantities for most patients.

State-level variation in distribution of oxycodone and opioid-related deaths from 2000 to 2021: an ecological study of ARCOS and CDC WONDER data in the USA

OBJECTIVES

This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021.

DESIGN

This is an observational study.

SETTING

More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them.

METHODS

The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics.

RESULTS

There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics.

CONCLUSIONS

Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.

Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting

OBJECTIVE

The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns.

DESIGN

A prospective observational study.

SETTING

One large healthcare system.

PATIENTS AND PARTICIPANTS

Adult patients presenting with shoulder osteoarthritis.

INTERVENTIONS

A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder.

MAIN OUTCOME MEASURE

The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures.

RESULTS

A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription.

CONCLUSION

Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Rapid Adoption of Telemedicine Increases Opioid Prescribing in Orthopedic Surgery

Background: The COVID-19 pandemic led to health care practitioners utilizing new technologies to deliver health care, including telemedicine. The purpose of this study was to examine the effect of rapidly proliferative use of video visits on opioid prescribing to orthopedic patients at a large academic health system that had existing procedure-specific opioid prescribing guidelines. Methods: This IRB-exempt study examined 651 opioid prescriptions written to patients who had video (visual and audio), telephone (audio only), or in-person encounters at our institution from March 1 to June 1, 2020 and compared them with 963 prescriptions written during the same months in 2019. Prescriptions were converted into daily milligram morphine equivalents (MMEs) to facilitate direct comparison. Chi-square testing was used to compare categorical data, whereas analysis of variance and Mann-Whitney tests were used to compare numerical data between groups. Statistical significance was set at <0.05. Results: Six hundred fifty-one of 1,614 prescriptions analyzed (40.3%) occurred during the pandemic. Patients prescribed opioids during video visits were prescribed 53.3 ± 37 MME, significantly higher than in-person (p = 0.002) or audio visits (p < 0.001) before or during the pandemic. Prepandemic, significantly higher MME were prescribed for in-person versus audio only visits (41.6 ± 89 vs. 30.2 ± 28 MME; p = 0.026); during the pandemic, there was no difference between these groups (p = 0.91). Significantly higher MME were prescribed by Nurse Practitioners and Physician Associates versus MD or DO prescribers for both time periods (51.3 ± 109 vs. 27.9 ± 42 MME; p < 0.001; 42.9 ± 70 vs. 28.2 ± 42 MME; p < 0.001). Conclusion: During crisis and with new technology, we should be vigilant about prescribing of opioid analgesics. Despite well-established protocols, patients received significantly higher MME through video than for other encounter types, including in-person encounters. In addition, significantly higher MME were prescribed by mid-level prescribers compared with DOs or MDs. Institutions should ensure these prescribers are involved during creation of opioid prescribing protocols after orthopedic surgery.

Opioid-sparing pain management protocol after shoulder arthroplasty results in less opioid consumption and higher satisfaction: a prospective, randomized controlled trial

BACKGROUND

The opioid epidemic has become a central focus in health care. In an effort to reduce opioid use, orthopedic surgeons use multimodal strategies to control postoperative pain. However, no clear consensus exists on ideal pain management strategies after shoulder arthroplasty, and most protocols are opioid-driven. This study sought to determine if patients undergoing shoulder arthroplasty using a postoperative opioid-sparing pain-control regimen would have equivalent pain scores and satisfaction as patients using a traditional opioid-based regimen.

METHODS

Patients undergoing primary anatomic or reverse total shoulder arthroplasty were prospectively enrolled and randomized into an opioid-sparing (OS) or a traditional opioid-based (OB) postoperative pain protocol. Both groups received opioid education, periarticular injection with liposomal bupivacaine, and preoperative and postoperative multimodal management (acetaminophen, celecoxib, and gabapentin). The OB group was discharged with 40 oxycodone tablets and standard icing, whereas the OS group received ketorolac during admission, continuous cryotherapy, and discharged with 10 oxycodone tablets for rescue. Patients were queried regarding levels of pain and opioid consumption at days 1-7 and at 2, 6, and 12 weeks postoperatively. Patient satisfaction was recorded at 1, 2, 6, and 12 weeks. Range of motion (ROM), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) scores were assessed preoperatively and at 12 weeks postoperatively. Complications, readmissions, and reoperations were recorded.

RESULTS

In 78 patients, no difference in VAS pain scores were seen at any time between groups. The OS group consumed less oral morphine equivalents (OME) from inpatient hospitalization to 12 weeks postoperatively (P < .05). Total OME consumption was reduced by 213% for the OS vs. the OB group (112 vs. 239; P < .0001). The OS group consumed fewer opioid pills at all time points (P < .05). A 395% reduction in number of opioid pills consumed in the first 12 weeks postoperatively was seen in the OS vs. the OB group (4.3 vs. 17.0; P < .0001). Significantly more patients in the OS group discontinued opioids by 2 weeks postoperatively (86.1% vs. 58.5%; P = .011), and 94.4% in the OS group discontinued opioids by 6 weeks postoperatively. The OS group was more satisfied with pain management at 1 and 6 weeks (P = .05). No difference in ROM, ASES or SANE scores, complications, readmissions, or reoperations were seen between groups.

CONCLUSIONS

This study demonstrated a nearly 4-fold reduction in opioid pain pill consumption and earlier cessation of opioids with an OS pain management protocol. Patients also reported higher satisfaction with this pain management strategy.

Analysis of Patient’s Willingness and Concerns for Discharge Following Shoulder Arthroplasty

Background

Patient's willingness and barriers for discharge after shoulder arthroplasty (SA) has not been studied. The aim of this study was to prospectively analyze patient's willingness for discharge and barriers to discharge beyond postoperative day #1 (POD#1) after SA.

Methods

In this prospective study, patients undergoing primary or revision SA (anatomic, reverse, or hemiarthroplasty) at our institution were enrolled to determine their willingness and concerns for discharge after SA. Patient's willingness for discharge was inquired daily until discharge. Demographic information, patient's medical history, intraoperative details (duration of surgery, estimated blood loss, intraoperative complication), discharge disposition, length of stay (LOS), and reasons for extension of LOS beyond POD#1 were analyzed.

Results

A total of 184 patients who underwent SA were included. Eight patients were discharged on POD#0, 114 patients on POD#1, 37 patients on POD#2, and 25 patients after POD#2. One hundred nineteen (119) patients were discharged to home, 40 were discharged to home with services, 15 were discharged to nursing facilities, and 10 were discharged to rehabilitation centers. Reasons for extension of LOS past POD#1 included patients failing to clear home safety evaluation (n = 4), inadequate pain control (n = 6), worsening of preexisting medical conditions (n = 8), delay in patient disposition (awaiting placement in a rehabilitation facility [n = 6] and awaiting culture results [n = 9]). Social reasons (n = 29) were the most common reasons for extension of LOS. These included patients requesting an extra day of stay (n = 20), patients requesting rehabilitation facility placement (n = 5), lack of a timely ride home (n = 2), and family-related reasons (death in the family [n = 1], lack of home help [n = 1]).

Conclusions

This prospective study demonstrates modifiable factors associated with LOS beyond POD#1 (inadequate pain control, logistic delays in disposition, and patient-related social concerns) after SA. With increasing interest in same-day discharge and rising concerns to control cost and use bundled payment initiatives with SA, improving patient's willingness to discharge by addressing their concerns can improve early discharge after SA.

Prescription opioids are commonly unused after ambulatory head and neck surgeries: Opioids prescription presence and size has no effect on patient satisfaction with pain control

PURPOSE

To explore the opioid prescribing practices after common ambulatory head and neck surgeries in a large academic institution; and to examine the association between opioid prescription and the patient's satisfaction with pain control.

METHODS

This retrospective cohort study conducted in a tertiary academic medical center. Phone interviews of patients who underwent ambulatory head and neck surgeries one month after their procedures were conducted. The interview included, among several questions, the amount of opioid prescribed and consumed, the use of non-opioid pain medications, and the patient's satisfaction with pain control. Logistic regression models were used to investigate the significant factors affecting the patient's satisfaction with pain control.

RESULTS

Most patients were prescribed opioids at discharge (84%). Of those, 17% did not use their prescriptions. The median of leftover opioid was 76.50 morphine milligram equivalents (MMEs) with IQR (45-130.95). Patient satisfaction with pain control is not associated with opioid prescription at discharge (OR 0.195 [95% CL, 0.036-1.036], p = 0.059) or the amount of the prescribed opioid (OR 1.001 [95% CL, 0.997-1.004], p = 0.717) after controlling for other patient and procedural factors.

CONCLUSION

A significant portion of ambulatory head and neck surgery patients were discharged with opioid prescriptions they may not use. Patient satisfaction with pain control is not associated with the presence or the amount of opioid prescribed.

Perioperative opioid use and Press Ganey patient satisfaction scores after anterior cruciate ligament reconstruction

Background

Satisfaction measures such as Press Ganey (PG) scores are increasingly used to determine reimbursement.

Purpose

To investigate the relationship between PG satisfaction scores and perioperative opioid use in patients undergoing anterior cruciate ligament reconstruction (ACLR).

Methods

Patients undergoing ACLR were retrospectively identified. Perioperative opioid prescription data were collected using the electronic medical record.

Results

Positive correlations existed between immediate preoperative total morphine equivalents (TMEs) and PG scores. There was a negative correlation between "Pain Control" and preoperative TMEs.

Conclusion

PG scores were correlated with preoperative and intraoperative opioid administration but not postoperative opioid administration.

Institutional Reductions in Opioid Prescribing Following Hip Arthroscopy Do Not Change Patient Satisfaction Scores

Purpose

To investigate what effect decreased opioid prescribing following hip arthroscopy had on Press-Ganey satisfaction survey scores.

Methods

A retrospective review of prospectively collected data was conducted on patients who underwent primary hip arthroscopy for femoroacetabular impingement between October 2014 and October 2019. Inclusion criteria consisted of complete Press-Ganey survey information, no history of trauma, fracture, connective tissue disease, developmental hip dysplasia, autoimmune disease, or previous hip arthroscopy. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy that occurred in October 2018. Prescriptions were converted to milligram morphine equivalents (MME) for direct comparison between different opioids.

Results

A total of 113 patients met inclusion criteria, 88 preprotocol and 25 postprotocol. There were no statistically significant differences between groups with respect to patient demographics or intraoperative pathologies (P > .05). Average opioid prescription dropped from 249.6 ± 152 MME (equivalent to 33.3 tablets of oxycodone 5 mg) preprotocol to 108.6 ± 84.7 MME (equivalent to 14.5 tablets of oxycodone 5 mg) postprotocol; P = .0002. There were no statistically significant differences in Press-Ganey survey scores between pre- and postprotocol groups (P > .05).

Conclusions

A reduction in opioids prescribed after a hip arthroscopy is not associated with any statistically significant difference in patient satisfaction with pain management, as measured by the Press-Ganey survey.

Level of Evidence

Level III, retrospective comparative study.