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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.
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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)
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Cronin WA, Nealeigh MD, Zeien JL, Goc JM, Amoako MY, Velosky AG, Williman MC, Cyr KL, Highland KB. Opioid Prescribing Variation After Laparoscopic Cholecystectomy in the US Military Health System. J Surg Res 2024; 297:149-158. [PMID: 37604706 DOI: 10.1016/j.jss.2023.06.056] [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: 04/07/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION After laparoscopic cholecystectomy (LC), there is a wide variation in opioid prescription miligram morphine equivalent dose (MED) and refills across US medical institutions. Given wide variation and opioid prescription guidelines, it is essential to conduct thorough health services research across medical, surgical, and patient-level factors that can be implemented to improve system-wide prescribing practices. Therefore, this study describes discharge MED variation and opioid refill probability after emergent and nonemergent LC. MATERIALS AND METHODS This retrospective cohort study included medical record data of adult patients (N = 20,025) undergoing LC from January 2016 to June 2021 in the US Military Health System. Data visualizations and bivariate analyses examined prescription patterns across hospitals and evaluated the relationship between patient-level, care-level, and system-level factors and each outcome: discharge MED and opioid refill probability. Two generalized additive mixed models evaluated the relationship between predictors and each outcome. RESULTS There was a significant variation in opioid and nonopioid pain medication prescribing practices across hospitals. While several factors were associated with discharge MED and opioid refill probability, the strongest effects were related to time period (before versus after a June 2018 Defense Health Agency policy release) and receipt of an opioid/nonopioid combination medication. Despite decreases in MED, the MED remained almost twice the recommended dose per prior research. CONCLUSIONS Variation by hospital suggests the need for system-level changes that target genuine practice change and opioid stewardship. Inclusion of patient-reported outcomes, electronic health record decision support tools, and academic detailing programs may support system-level improvements.
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Affiliation(s)
- William A Cronin
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Justin L Zeien
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jonathan M Goc
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Maxwell Y Amoako
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland; Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, Texas
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland; Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, Texas
| | - Melina C Williman
- School of Medicine, Uniformed Services University, Bethesda, Maryland; Department of Anesthesiology, Brooke Army Medical Center, San Antonio, Texas
| | - Kyle L Cyr
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland.
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Pak A, Smith H, Okada H, Butt AL. Sex-Based Differences in Opioid Administration: A Puzzle Yet to Be Solved. J Cardiothorac Vasc Anesth 2024; 38:1275-1276. [PMID: 38458825 DOI: 10.1053/j.jvca.2024.02.024] [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] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Aimee Pak
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Hannah Smith
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Hisako Okada
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Gaitanidis A, Dorken Gallastegi A, Van Erp I, Gebran A, Velmahos GC, Kaafarani HM. Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter. J Am Coll Surg 2024; 238:280-288. [PMID: 38357977 DOI: 10.1097/xcs.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. STUDY DESIGN Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. RESULTS Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. CONCLUSIONS Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.
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Affiliation(s)
- Apostolos Gaitanidis
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - Ander Dorken Gallastegi
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - Inge Van Erp
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands (Van Erp)
| | - Anthony Gebran
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - George C Velmahos
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
| | - Haytham Ma Kaafarani
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA (Gaitanidis, Dorken Gallastegi, Van Erp, Gebran, Velmahos, Kaafarani)
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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.
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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
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Biesboer EA, Al Tannir AH, Karam BS, Tyson K, Peppard WJ, Morris R, Murphy P, Elegbede A, de Moya MA, Trevino C. A Prescribing Guideline Decreases Postoperative Opioid Prescribing in Emergency General Surgery. J Surg Res 2024; 293:607-612. [PMID: 37837815 DOI: 10.1016/j.jss.2023.09.012] [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: 05/05/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Patients prescribed higher opioid dosages have a higher risk of persistent opioid use, overdose, and death. There is a lack of standardization for opioid prescribing for acute surgical pain in emergency general surgery (EGS) patients. We hypothesized that implementing a guideline to standardize opioid prescribing would be associated with a decrease in prescribing at hospital discharge for EGS patients without increasing additional postdischarge refills. METHODS This was a quasi-experimental study evaluating opioid prescribing by EGS providers before and after the implementation of a prescribing guideline. Patients were assigned to preguideline and postguideline groups based on admission date surrounding the implementation of the guideline. The primary outcome was the proportion of patients receiving an opioid prescription for ≥50 Morphine Milligram Equivalents (MME) per day on hospital discharge. RESULTS There were 227 patients in the preguideline group and 226 patients in the postguideline group. After guideline implementation, median total MME prescribed decreased from 113 (interquartile range = 75) to 75 (interquartile range = 75, P = 0.03). The proportion of patients receiving a prescription for daily MME ≥50 also decreased from 75% to 25% (P ≤0.01). There were no increases in requested refills (17% versus 16%, P = 0.72) or received refills (14% versus 14%, P = 0.98). Guideline compliance ranged from 75% in ventral hernia repair patients to 94% in laparoscopic cholecystectomy patients. CONCLUSIONS A departmental guideline to standardize postoperative opioid prescriptions was associated with a decrease in the amount of MMEs prescribed to EGS patients without an increase in requested or received refills.
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Affiliation(s)
- Elise A Biesboer
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Abdul Hafiz Al Tannir
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Basil S Karam
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katherine Tyson
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William J Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin
| | - Rachel Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Patrick Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anuoluwapo Elegbede
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marc A de Moya
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Colleen Trevino
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Beauchamp G, Deol P, Sipko J, Yazdanyar A, Rosentel J, Kuehler D, Sandhu RS, McCambridge M. Modifying Post-operative Opioid Stewardship Through a System of Educational Feedback. Am Surg 2023; 89:5175-5182. [PMID: 36418926 DOI: 10.1177/00031348221129511] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Background: The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns.Methods: An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered.Results: A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase.Discussion: An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED.
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Affiliation(s)
- Gillian Beauchamp
- Department of Emergency and Hospital Medicine, USF Morsani College of Medicine, Allentown, PA, USA
| | - Pavit Deol
- University of South Florida (USF) Morsani College of Medicine, Allentown, PA, USA
| | - Joseph Sipko
- University of South Florida (USF) Morsani College of Medicine, Allentown, PA, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, USF Morsani College of Medicine, Allentown, PA, USA
| | - Joshua Rosentel
- Department of Quality Assessment, Lehigh Valley Health Network, Allentown, PA, USA
| | - Daniel Kuehler
- Department of Surgery, Lehigh Valley Health Network, Allentown, PA, USA
| | - Rovinder S Sandhu
- Department of Surgery, Lehigh Valley Health Network, Allentown, PA, USA
| | - Matthew McCambridge
- Department of Quality Assessment, Lehigh Valley Health Network, Allentown, PA, USA
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Fiscella K, Awad AN, Shihadeh H, Patel A. Variability in Opioid Prescribing Among Plastic Surgery Residents After Bilateral Breast Reduction. Ann Plast Surg 2023; 91:702-708. [PMID: 37651681 DOI: 10.1097/sap.0000000000003675] [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: 09/02/2023]
Abstract
BACKGROUND Prescription opioid misuse in the United States accounts for significant avoidable morbidity and mortality. Over one third of all prescriptions written by surgeons are for opioids. Although opioids continue to provide needed analgesia for surgical patients, there are few guidelines in the plastic surgery literature for their safe and appropriate use after surgery. The consequence is wide variability and excessive opioid prescriptions. Understanding patterns of prescribing among plastic surgery residents is a crucial step toward developing safer practice models for managing postoperative pain. METHODS The authors performed a retrospective analysis of discharge opioid prescriptions after bilateral breast reduction at a single academic medical center from 2018 to 2021. Single factor 1-way analysis of variance was used to evaluate prescribing patterns by resident, postgraduate year, attending of record, and patient characteristics for 126 patients. A multivariate analysis was performed to determine the degree to which these factors predicted opioid prescriptions. RESULTS This analysis revealed significant variability among residents prescribing opioids after bilateral breast reductions ( P < 0.001) irrespective of patient comorbidities and demographics. Residents were found to be the main predictor of opioid prescriptions after surgery ( P < 0.001) with a greater number of morphine milligram equivalents prescribed by the more junior residents ( P < 0.001). CONCLUSIONS Excessive and variable opioid prescriptions among plastic surgery residents highlight the need for opioid prescribing education early in surgical training and improved oversight and communication with attending surgeons. Furthermore, implementation of evidence-based opioid-conscious analgesic protocols after common surgical procedures may improve patient safety by standardizing postoperative analgesic prescriptions.
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Affiliation(s)
- Kimberly Fiscella
- From the Division of Plastic Surgery, Albany Medical Center, Albany, NY
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Lewis PR, Pelzl C, Benzer E, Szad S, Judge C, Wang A, Van Gent M. Bringing Opiates Off the Streets and Undertaking Excess Scripts: A novel opiate reclamation and prescription reduction program. Surgery 2023; 174:574-580. [PMID: 37414590 DOI: 10.1016/j.surg.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Opioid diversion and misuse continue to present problems in modern medicine. The "opioid epidemic" has claimed more than 250,000 lives since 1999, with studies pointing to prescription opioids as the culprit for future opiate misuse. Currently, there are no well-described, data-driven processes to educate surgeons on reducing opiate prescribing, informed by personal practice patterns. We designed and implemented a novel opiate reclamation and prescription reduction program for surgeons to reclaim unused medications and decrease prescribing using individual provider data. METHODS We performed a prospective collection of all unused opiate pain medications for general surgery postoperative patients from July 15, 2020 to January 15, 2021. Patients brought their unused opiates to their routine postoperative follow-up appointment, where they were counted and disposed of in a secure drug take-back bin. Reclaimed opiates were totaled, analyzed, and reported to the providers, who used their individual reclamation rates to refine prescribing habits. RESULTS During the reclamation period, 168 operations were performed, with a total of 12,970 morphine milligram equivalents of opiate prescribed by 5 physicians. A total of 6,077.5 morphine milligram equivalents (46.9%) were reclaimed, which is the equivalent of 800 5-mg tablets of oxycodone. A review of these data led to a 30.9% decrease in opiate prescriptions by participating surgeons in addition to the reclamation of an additional 3,150 morphine milligram equivalents over the next 6 months. CONCLUSION Continuous monitoring of the medications returned by patients now continues to inform our providers' prescribing practices, decreases the amount of opiates in the community, and improves patient safety.
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Affiliation(s)
- Paul R Lewis
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan.
| | - Casey Pelzl
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Emily Benzer
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Sean Szad
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Carolyn Judge
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Andrew Wang
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
| | - Michael Van Gent
- Naval Medical Readiness and Training Center Okinawa, Ginowan, Japan
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Tyson K, Karam BS, Peppard WJ, Morris R, Murphy P, Elegbede A, Schroeder M, Somberg L, Trevino CM. Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study. Surgery 2023; 173:794-798. [PMID: 36371358 DOI: 10.1016/j.surg.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. METHODS This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. RESULTS We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. CONCLUSION A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.
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Affiliation(s)
- Katherine Tyson
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Basil S Karam
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - William J Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Anuoluwapo Elegbede
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Schroeder
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lewis Somberg
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen M Trevino
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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11
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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.
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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
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12
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Hamilton GM, Ladha K, Wheeler K, Nguyen F, McCartney CJL, McIsaac DI. Incidence of persistent postoperative opioid use in patients undergoing ambulatory surgery: a retrospective cohort study. Anaesthesia 2023; 78:170-179. [PMID: 36314355 DOI: 10.1111/anae.15900] [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: 10/10/2022] [Indexed: 01/11/2023]
Abstract
The opioid crisis remains a major public health concern. In ambulatory surgery, persistent postoperative opioid use is poorly described and temporal trends are unknown. A population-based retrospective cohort study was undertaken in Ontario, Canada using routinely collected administrative data for adults undergoing ambulatory surgery between 1 January 2013 and 31 December 2017. The primary outcome was persistent postoperative opioid use, defined using best-practice methods. Multivariable generalised linear models were used to estimate the association of persistent postoperative opioid use with prognostic factors. Temporal trends in opioid use were examined using monthly time series, adjusting for patient-, surgical- and hospital-level variables. Of 340,013 patients, 44,224 (13.0%, 95%CI 12.9-13.1%) developed persistent postoperative opioid use after surgery. Following multivariable adjustment, the strongest predictors of persistent postoperative opioid use were pre-operative: utilisation of opioids (OR 9.51, 95%CI 8.69-10.39); opioid tolerance (OR 88.22, 95%CI 77.21-100.79); and utilisation of benzodiazepines (OR 13.75, 95%CI 12.89-14.86). The time series model demonstrated a small but significant trend towards decreasing persistent postoperative opioid use over time (adjusted percentage change per year -0.51%, 95%CI -0.83 to -0.19%, p = 0.003). More than 10% of patients who underwent ambulatory surgery experienced persistent postoperative opioid use; however, there was a temporal trend towards a reduction in persistent opioid use after surgery. Future studies are needed that focus on interventions which reduce persistent postoperative opioid use.
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Affiliation(s)
- G M Hamilton
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, ON, Canada
| | - K Ladha
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto and Institute of Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
| | - K Wheeler
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - F Nguyen
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, ON, Canada
| | - D I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, ON, Canada
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13
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Melucci AD, Dave YA, Lynch OF, Hsu S, Erlick MR, Linehan DC, Moalem J. Predictors of opioid-free discharge after laparoscopic cholecystectomy. Am J Surg 2023; 225:206-211. [PMID: 35948514 DOI: 10.1016/j.amjsurg.2022.07.027] [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: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA. https://twitter.com/AlexaMelucci
| | - Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Olivia F Lynch
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - Shawn Hsu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mariah R Erlick
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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14
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Lorentzen WJ, Perez N, Galet C, Allan LD. The butterfly effect: How an outpatient quality improvement project affected inpatient opioid‘s prescribing habits. SURGERY IN PRACTICE AND SCIENCE 2022; 11. [DOI: 10.1016/j.sipas.2022.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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15
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The variation of opioid prescription after injury and its association with long-term chronic pain: A multicenter cohort study. Surgery 2022; 172:1844-1850. [PMID: 36123179 DOI: 10.1016/j.surg.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Opioid overprescription in trauma contributes to the opioid epidemic through diversion of unused pills. Through our study, we sought to do the following: (1) understand the variation in opioid prescription after injury and its relationship to patient and/or clinical variables, and (2) study the relationship between opioid prescribing and long-term pain and analgesic use. METHOD Trauma patients with an injury severity score ≥9 admitted to 3 level 1 trauma centers were screened for chronic pain and analgesic use 6 to 12 months postinjury. First, multivariable linear regression models were constructed with "oral morphine equivalents" and "number of opioid pills prescribed" at discharge as dependent variables. The coefficients of determination were calculated to determine how much of the variation in opioid prescription was explained by patient and clinical variables. Second, a multivariable logistic regression analysis was created to study the association between opioid prescription at discharge and chronic pain/analgesic use at 6 to 12 months. Analyses were adjusted for patient demographics, socioeconomics, comorbidities, injury parameters, and hospital course. RESULTS Of the 2,702 patients included (mean [standard deviation] age: 61.0 [21.5]; 55% males), 74% were prescribed opioids at discharge (mean number of pills [standard deviation]: 24.0 [26.5]; mean oral morphine equivalent [standard deviation]: 204.8 [348.1]). The adjusted coefficients of determination for oral morphine equivalents and number of pills was 0.12 and 0.21, respectively, suggesting that the measured patient and clinical factors explain <21% of the variation in opioid prescribing in trauma. Patients prescribed opioids were more likely to have chronic pain (odds ratio [95%] confidence interval: 1.34 [1.05-1.71]) and use analgesics daily (odds ratio [95%] confidence interval: 1.86 [1.25-2.77]) 6 to 12 months postinjury. CONCLUSION The variation in opioid prescription after traumatic injury is more affected by system and provider level rather than clinical or patient-related factors, and opioid prescribing correlates independently with long-term chronic pain and continued analgesic use postinjury. Efforts to decrease opioid use should prioritize standardizing prescription practices after traumatic injury.
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16
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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]
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17
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Effects of opioid addiction risk information on Americans’ agreement with postoperative opioid minimization and perceptions of quality. Healthcare (Basel) 2022; 10:100629. [DOI: 10.1016/j.hjdsi.2022.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/19/2022] Open
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18
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Goodman EM, Wells A, Jensen HK, Kalkwarf KJ. Opioid Prescribing Behaviors Among Surgical Intensive Care Unit Attending Physicians. Am Surg 2022; 88:1479-1483. [PMID: 35337200 DOI: 10.1177/00031348221082280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND More than 5 million Americans misuse opioids. Six percent of patients who receive opioids for acute pain progress to chronic use; this increases with higher doses and longer prescriptions. Prescribing variation exists within trauma centers and after emergency surgery but has not been demonstrated among intensivists. METHODS Milligram morphine equivalents (MME) per patient-ICU-day provided by eleven surgical intensivists were analyzed. The patients were separated into 2 groups based on their percentage of time intubated in the surgical ICU. Both study groups were compared using demographics and comorbidity scores. The attendings were divided into high- and low-prescribing groups based on their MME/pt-ICU-day for intubated patients, and bivariate statistical analyses were performed. A similar analysis compared surgery vs anesthesia intensivists. RESULTS The analysis included 257 patients in the "long-vent group" (LVG) and 668 patients in the "short-vent group" (SVG). The average MME/pt-ICU-day for the LVG was 222. Despite no significant differences in age, sex, or Elixhauser Comorbidity Index, there was a 45% difference between the high- and low-prescribing physicians in the LVG (253.7 vs 175.4 MME/pt-ICU-day; P = .008). This difference was not observed for patients in the SVG (74.3 vs 93.1 MME/pt-ICU-day; P = .141) nor based on intensivist specialty (LVG: 217.9 vs 209.5 MME/pt-ICU-day; P = .8) (SVG: 79.0 vs 93.3 MME/pt-ICU-day; P = .288).
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Affiliation(s)
- Emily M Goodman
- College of Medicine, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Allison Wells
- Department of Surgery, College of Medicine, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hanna K Jensen
- Department of Surgery, College of Medicine, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, College of Medicine, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
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19
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Schaffer S, Bayat D, Biffl WL, Smith J, Schaffer KB, Dandan TH, Wang J, Snyder D, Nalick C, Dandan IS, Tominaga GT, Castelo MR. Pain management on a trauma service: a crisis reveals opportunities. Trauma Surg Acute Care Open 2022; 7:e000862. [PMID: 35402732 PMCID: PMC8948384 DOI: 10.1136/tsaco-2021-000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/08/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). Methods Retrospective analysis of pain management at a level II trauma center for January-November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. Results 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. Conclusions Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. Level of evidence IV.
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Affiliation(s)
- Sabina Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Dunya Bayat
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jeffrey Smith
- Orthopedic Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Tala H Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jiayan Wang
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Deb Snyder
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Chris Nalick
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Imad S Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Gail T Tominaga
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Matthew R Castelo
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
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20
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Witt RG, Cope B, Chiang YJ, Newhook T, Lillemoe H, Tzeng CWD, Chen IB, Fisher SB, Lucci A, Wargo JA, Lee JE, Ross MI, Gershenwald JE, Robinson J, Keung EZ. Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy. J Surg Oncol 2022; 125:719-729. [PMID: 34904258 PMCID: PMC9108995 DOI: 10.1002/jso.26768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy. METHODS A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed. RESULTS Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001). CONCLUSIONS Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.
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Affiliation(s)
- Russell G. Witt
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Brandon Cope
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Timothy Newhook
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Heather Lillemoe
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Iris B. Chen
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Sarah B. Fisher
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Anthony Lucci
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jennifer A. Wargo
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Merrick I. Ross
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Gershenwald
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Justine Robinson
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Emily Z. Keung
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
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Slater BJ, Corvin CG, Heiss K, Vandewalle R, Shah SR, Cunningham M, Huang E, Lipskar AM, Denning NL, Dassinger M, Cina RA, Rothstein DH, Kauffman J, Gonzalez R, Ingram MC, Raval MV. Provider education leads to sustained reduction in pediatric opioid prescribing after surgery. J Pediatr Surg 2022; 57:474-478. [PMID: 34456039 PMCID: PMC8996746 DOI: 10.1016/j.jpedsurg.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers. METHODS Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers. RESULTS In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p<0.001, Fig. (1). Five centers showed statistically significant improvement and the other four demonstrated decreased prescribing, though not statistically significant. CONCLUSIONS Our multicenter study demonstrates sustained reduction in opioid prescribing after pediatric umbilical hernia repair after a provider-based educational intervention. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of pediatric surgical procedures. LEVELS OF EVIDENCE (treatment study)-level 3.
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Affiliation(s)
- Bethany J. Slater
- Comer Children’s Hospital, Pediatric Surgery, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA,Corresponding author. Best, Bethany J. Slater, University of Chicago, Comer Children's Hospital, 5841 S. Maryland Avenue, Chicago, IL, USA 60,637, Phone: 773–702–6175, ,
| | - Chase G. Corvin
- Comer Children’s Hospital, Pediatric Surgery, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Kurt Heiss
- Pediatric Surgery, Emory University School Of Medicine, Atlanta, GA, USA
| | - Robert Vandewalle
- Pediatric Surgery, Emory University School Of Medicine, Atlanta, GA, USA
| | - Sohail R. Shah
- Baylor College Of Medicine, Texas Children’s Hospital, Pediatric Surgery, Houston, TX, USA
| | - Megan Cunningham
- Baylor College Of Medicine, Texas Children’s Hospital, Pediatric Surgery, Houston, TX, USA
| | - EuniceY. Huang
- Vanderbilt University Medical Center, Pediatric Surgery, Nashville, TN, USA
| | - Aaron M. Lipskar
- Cohen Children’s Medical Center, Pediatric Surgery, New Hyde Park, NY, USA
| | - Naomi-Liza Denning
- Cohen Children’s Medical Center, Pediatric Surgery, New Hyde Park, NY, USA
| | | | - Robert A. Cina
- Pediatric Surgery, The Medical University Of South Carolina, Charleston, SC, USA
| | | | - Jeremy Kauffman
- John’s Hopkins All Children’s Hospital, Pediatric Surgery, St. Petersburg, FL, USA
| | - Raquel Gonzalez
- John’s Hopkins All Children’s Hospital, Pediatric Surgery, St. Petersburg, FL, USA
| | - Martha-Conley Ingram
- Lurie Children’s Hospital of Chicago, Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Mehul V. Raval
- Lurie Children’s Hospital of Chicago, Pediatric Surgery, Northwestern University, Chicago, IL, USA
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22
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Hayes D, Tan M, Wang M, Weinsheimer R. A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy. Surg Endosc 2022; 36:6250-6254. [PMID: 35169880 PMCID: PMC8853128 DOI: 10.1007/s00464-022-09107-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022]
Abstract
Background Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy. Methods A quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019–3/31/2020. We utilized the preceding year’s data (October 1, 2018–September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results. Results A total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p < 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005). Conclusion A multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09107-y.
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Affiliation(s)
- Danielle Hayes
- Department of General Surgery, Swedish Medical Center First Hill, Seattle, WA, USA. .,Department of General Surgery, Swedish Medical Center First Hill, 747 Broadway, Heath Tenth Floor, Seattle, WA, 98122-4307, USA.
| | - Mimi Tan
- Department of General Surgery, Swedish Medical Center First Hill, Seattle, WA, USA
| | - Mansen Wang
- Medical Data Research Center, Providence Health & Services, Portland, OR, USA
| | - Robert Weinsheimer
- Department of Pediatric Surgery, Swedish Medical Center First Hill, Seattle, WA, USA
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Kharasch ED, Clark JD, Adams JM. Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology 2022; 136:10-30. [PMID: 34874401 PMCID: PMC10715730 DOI: 10.1097/aln.0000000000004065] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.
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Affiliation(s)
- Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - J David Clark
- the Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Jones K, Engler L, Fonte E, Farid I, Bigham MT. Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery. Pediatrics 2021; 148:183388. [PMID: 34851410 DOI: 10.1542/peds.2020-001487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. METHODS Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. RESULTS Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). CONCLUSIONS The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.
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Opioid Prescribing after Carpal Tunnel Release: Analysis from the Michigan Collaborative Hand Initiative for Quality in Surgery. Plast Reconstr Surg 2021; 148:1064-1072. [PMID: 34705779 DOI: 10.1097/prs.0000000000008421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known regarding the national practice patterns for postoperative opioid prescribing after carpal tunnel release, which is one of the most common surgical procedures performed. The authors sought to assess the rate of opioid prescribing after carpal tunnel release and patient-, surgeon-, and practice-level predictors of opioid prescriptions after surgery. METHODS The authors conducted a cohort study from the Michigan Collaborative Hand Initiative for Quality in Surgery, a national consortium of nine practices with 33 surgeons who prospectively collect data for the purpose of quality improvement. Patients were included who underwent carpal tunnel release between July 1, 2019, and December 31, 2019. Multilevel logistic regression was used to determine practice and surgeon variation in postoperative opioid prescribing related to patient characteristics. RESULTS Of the 648 patients with 792 operative hands, 52.9 percent were prescribed a postoperative opioid. After controlling for patient, surgeon, and practice characteristics, endoscopic carpal tunnel releases were associated with a decreased odds of receiving a postoperative opioid prescription compared to open carpal tunnel releases (OR, 0.19; 95 percent CI, 0.07 to 0.52). However, 57.4 percent of the variation in opioid prescribing was explained at the practice level, and 4.1 percent of the variation was explained at the surgeon level. CONCLUSIONS Practice-level prescribing patterns play a substantial role in opioid prescribing. National efforts should consider development of evidence-based opioid prescribing recommendations for carpal tunnel release that target all prescribers, including trainees and advanced practice providers. In addition, endoscopic carpal tunnel release may offer an opportunity to minimize opioid prescribing. The authors recommend that providers encourage the use of nonopioid analgesia and limit opioid prescriptions after carpal tunnel release. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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26
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Winkelman RD, Kavanagh MD, Tanenbaum JE, Pelle DW, Benzel EC, Mroz TE, Steinmetz MP. The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform. J Neurosurg Spine 2021; 35:275-283. [PMID: 34243163 DOI: 10.3171/2020.11.spine201046] [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] [Received: 06/09/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. METHODS This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. RESULTS A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. CONCLUSIONS Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.
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Affiliation(s)
- Robert D Winkelman
- 1Center for Spine Health, Neurological Institute, and
- 2Case Western Reserve University School of Medicine; and
- Departments of3Neurosurgery and
| | - Michael D Kavanagh
- 1Center for Spine Health, Neurological Institute, and
- 2Case Western Reserve University School of Medicine; and
| | - Joseph E Tanenbaum
- 1Center for Spine Health, Neurological Institute, and
- 2Case Western Reserve University School of Medicine; and
- 4Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Dominic W Pelle
- 1Center for Spine Health, Neurological Institute, and
- 5Orthopaedic Surgery, Cleveland Clinic
| | - Edward C Benzel
- 1Center for Spine Health, Neurological Institute, and
- Departments of3Neurosurgery and
| | - Thomas E Mroz
- 1Center for Spine Health, Neurological Institute, and
- 5Orthopaedic Surgery, Cleveland Clinic
| | - Michael P Steinmetz
- 1Center for Spine Health, Neurological Institute, and
- Departments of3Neurosurgery and
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Development of a Practice Guideline for Discharge Opioid Prescribing After Major Colorectal Surgery. Dis Colon Rectum 2021; 64:1120-1128. [PMID: 34397560 DOI: 10.1097/dcr.0000000000002024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Better alignment of opioid prescription quantities with patient need could help reduce excessive prescribing. OBJECTIVE The study sought to develop an institutional prescribing guideline based on defined opioid consumption patterns after inpatient colorectal operations. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a single tertiary care center. PATIENTS Patients who underwent elective major colorectal procedures between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS Patients were categorized into 3 groups based on consumption in the 24-hour period before discharge: tier 1 consumed 0 equianalgesic oxycodone 5-mg pills (n = 53), tier 2 consumed 0.1 to 3.0 equianalgesic oxycodone 5-mg pills (n = 25), and tier 3 consumed >3.0 equianalgesic oxycodone 5-mg pills (n = 22). Average prescription quantity was 17.5 ± 10.5 equianalgesic oxycodone 5-mg pills (range, 0-78). Patients consumed a mean of 6.7 ± 10.9 equianalgesic oxycodone 5-mg pills after discharge and had 10.8 ± 10.2 equianalgesic oxycodone 5-mg pill excess, whereas 51% of patients consumed no pills. Opioid consumption was significantly different between each tier (p < 0.001). A prescribing guideline was developed to satisfy the majority of patients: 0 equianalgesic oxycodone 5-mg pills if tier 1, 12 pills if tier 2, and 30 pills if tier 3. Tiered guideline adoption could reduce prescribed pills by 45% and excess pills per prescription by 73%. Patient history of IBD was independently associated with increased odds of exceeding the guideline (adjusted OR = 7.2 (95% CI, 1.6-32.6)). LIMITATIONS The study was limited by its single-center, retrospective design and that outpatient opioid consumption was self-reported. CONCLUSIONS Following hospital discharge after major colorectal surgery, more than half of patients consumed no opioid pills, and 62% of prescribed opioids were in excess. Outpatient opioid consumption was highly associated with inpatient opioid use in the 24 hours before discharge. Prospective validation of this prescribing guideline is needed, but adoption could reduce excessive prescribing. See Video Abstract at http://links.lww.com/DCR/B575. DESARROLLO DE UNA GUA PRCTICA PARA LA PRESCRIPCIN DE OPIOIDES AL EGRESO DESPUS DE UNA CIRUGA COLORRECTAL MAYOR ANTECEDENTES:Una mejor alineación de las cantidades de prescripción de opioides con las necesidades del paciente podría ayudar a reducir la prescripción excesiva.OBJETIVO:El estudio buscó desarrollar una guía institucional de prescripción basada en patrones definidos de consumo de opioides luego de cirugías colorrectales hospitalarias.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:El estudio se llevó a cabo en un solo centro de atención terciaria.PACIENTES:Pacientes que se sometieron a procedimientos colorrectales mayores electivos entre julio de 2018 y enero de 2019.PRINCIPALES MEDIDAS DE RESULTADO:El estudio midió las cantidades de prescripción y consumo medidas como píldoras de 5 mg de oxicodona equianalgésica (EOP).RESULTADOS:Los pacientes se clasificaron en tres grupos según el consumo en el período de 24 horas antes del egreso: el nivel 1 consumió 0 EOP (n = 53), el nivel 2 consumió 0,1-3 EOP (n = 25) y el nivel 3 consumió más de 3 EOP (n = 22). La cantidad promedio de prescripción fue 17,5 (± 10,5) EOP (rango: 0-78). Los pacientes consumieron una media de 6,7 (± 10,9) EOP posterior al egreso y tuvieron un exceso de 10,8 (± 10,2) EOP, mientras que el 51% de los pacientes no consumieron píldoras. El consumo de opioides fue significativamente diferente entre cada nivel (p <0,001). Se desarrolló una guía de prescripción para satisfacer a la mayoría de los pacientes: 0 EOP del nivel 1, 12 EOP del nivel 2 y 30 EOP del nivel 3. La adquisición de una guía escalonada podría reducir las píldoras recetadas en un 45% y el exceso de píldoras por receta en un 73%. El historial del paciente de enfermedad inflamatoria intestinal se asoció de forma independiente con un aumento de las probabilidades de superar la guía (ORa 7,2; IC del 95%: 1,6-32,6).LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro y por el consumo de opioides del paciente ambulatorio el cual fue autoinformado.CONCLUSIONES:Tras el egreso hospitalario de una cirugía colorrectal mayor, más de la mitad de los pacientes no consumieron pastillas opioides y el 62% de los opioides prescritos estaban en exceso. El consumo de opioides como paciente ambulatorio estuvo altamente asociado con el uso de opioides como paciente hospitalizado en las 24 horas previas al egreso. Se necesita una validación prospectiva de esta guía de prescripción, pero la adopción podría reducir la prescripción excesiva. Consulte Video Resumen en http://links.lww.com/DCR/B575.
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Mokhtari TE, Miller LE, Chen JX, Hartnick CJ, Varvares MA. Opioid prescribing practices in academic otolaryngology: A single institutional survey. Am J Otolaryngol 2021; 42:103038. [PMID: 33878642 DOI: 10.1016/j.amjoto.2021.103038] [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: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing. METHODS This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents. RESULTS A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively). CONCLUSION There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
| | - Lauren E Miller
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Jenny X Chen
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
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Wackerbarth JJ, Ham SA, Aizen J, Richgels J, Faris SF. Persistent Opioid Usage After Urologic Intervention and the Impact of Tramadol. Urology 2021; 157:114-119. [PMID: 34333038 DOI: 10.1016/j.urology.2021.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine if patients who receive tramadol are as likely to develop persistent usage compared to other opioids after urologic surgery and procedures. METHODS We identified adults 18 to 64 years old who underwent a urologic procedure in the years 2014 to 2017 using the Truven MarketScan database and subsequently filled an opioid prescription within two weeks of discharge. Patients were excluded if they had any previous opioid prescriptions in the year before surgery. A multivariate logistic regression model was constructed to estimate influence of type of opioid on discharge and various comorbidities on persistent use to determine if persistent use was related to the choice of discharge opioid. We also compared these rates to a 1:3 comorbidities matched, non-surgical cohort of patients from the general population. RESULTS Overall, 115,687 patients were included. After 1 year, 14.8% of the urologic surgery cohort had persistent opioid usage compared to 10.8% in the opioid naïve matched non-surgical cohort (OR = 1.37; 95% CI 1.35-1.39). Discharge with tramadol was associated with a higher odd of persistent usage compared to class II opioids controlling for type of urologic surgery, age, gender, and pain related comorbidities (OR = 1.23 95% CI 1.13-1.35). The odds of persistent usage varied slightly by type of urologic procedure, but all were higher than matched non-surgical cohort. CONCLUSION Patients developed persistent opiate usage after urologic surgery compared to a comorbidity matched non-surgical cohort. In this model, tramadol specifically was associated with higher odds of novel persistent opioid usage compared to other opioids. Urologists should not consider tramadol to be a safer choice with regard to developing persistent usage and consider prospective validation of these results.
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Affiliation(s)
| | - Sandra A Ham
- Center for Health and the Social Services, University of Chicago, Chicago, IL
| | - Joshua Aizen
- Section of Urology, University of Chicago Medical Center, Chicago, IL
| | - John Richgels
- Section of Urology, University of Chicago Medical Center, Chicago, IL
| | - Sarah F Faris
- Section of Urology, University of Chicago Medical Center, Chicago, IL.
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Huynh V, Colborn K, Christian N, Rojas K, Nehler M, Bronsert M, Cumbler E, Ahrendt G, Tevis S. Resident Opioid Prescribing Habits Do Not Reflect Best Practices in Post-Operative Pain Management: An Assessment of the Knowledge and Education Gap. JOURNAL OF SURGICAL EDUCATION 2021; 78:1286-1294. [PMID: 33386285 DOI: 10.1016/j.jsurg.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/13/2020] [Accepted: 12/15/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate deficiencies in knowledge and education in opioid prescribing and to compare surgical resident opioid-prescribing practices to Opioid Prescribing Engagement Network (OPEN) procedure-specific guidelines. DESIGN Anonymous web-based survey distributed to all general surgery residents to evaluate prior education received and confidence in knowledge in opioid prescribing. The number of 5 milligram oxycodone tablets prescribed for common procedures was assessed and compared with OPEN for significance using Wilcoxon signed rank tests. SETTING General surgery residency program within large university-based tertiary medical center. PARTICIPANTS Categorical general surgery residents of all postgraduate years. RESULTS Fifty-six of 72 (78%) categorical residents completed the survey. Few reported receiving formal education in opioid prescribing in medical school (32%) or residency (16%). While 82% of residents felt confident in opioid side effects, fewer felt the same with regards to opioid pharmacokinetics (36%) or proper opioid disposal (29%). Opioids prescribed varied widely with residents prescribing significantly more than recommended by OPEN in 9 of 14 procedures. CONCLUSIONS Tackling the evolving opioid epidemic requires a multidisciplinary approach that addresses prescribing at all steps of the process, starting with trainee education.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Nicole Christian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kristin Rojas
- Dewitt-Daughtry Department of Surgery, Division of Surgical Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Mark Nehler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michael Bronsert
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gretchen Ahrendt
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah Tevis
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Huepenbecker S, Hillman RT, Iniesta MD, Chen T, Cain K, Mena G, Lasala J, Wang XS, Williams L, Taylor JS, Lu KH, Ramirez PT, Meyer LA. Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery. Int J Gynecol Cancer 2021; 31:1052-1060. [PMID: 34135073 DOI: 10.1136/ijgc-2021-002674] [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: 04/02/2021] [Accepted: 05/17/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program. METHODS We compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan-Meier curves for symptom recovery. RESULTS Among 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts. CONCLUSIONS After implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.
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Affiliation(s)
- Sarah Huepenbecker
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tsun Chen
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Shelley Wang
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Loretta Williams
- Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karen H Lu
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Huynh V, Colborn K, Rojas KE, Christian N, Ahrendt G, Cumbler E, Schulick R, Tevis S. Evaluation of opioid prescribing preferences among surgical residents and faculty. Surgery 2021; 170:1066-1073. [PMID: 33858683 DOI: 10.1016/j.surg.2021.02.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. METHODS Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. RESULTS Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. CONCLUSION There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/THuynhMD
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/ColbornKathryn
| | - Kristin E Rojas
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, FL. https://twitter.com/kristinrojasMD
| | - Nicole Christian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Gretchen Ahrendt
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/@ahrendt50
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Richard Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Tevis
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery. J Pediatr Urol 2021; 17:259.e1-259.e6. [PMID: 33514499 DOI: 10.1016/j.jpurol.2021.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/01/2021] [Accepted: 01/07/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain. OBJECTIVES As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures. METHODS We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure). RESULTS Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries. CONCLUSIONS Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.
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Porter ED, Bessen SY, Molloy IB, Kelly JL, Ramkumar N, Phillips JD, Loehrer AP, Wilson MZ, Hasson RM, Ivatury SJ, Henkin JR, Barth RJ. Guidelines for Patient-CenteredOpioid Prescribing and Optimal FDA-Compliant Disposal of Excess Pills after Inpatient Operation: Prospective Clinical Trial. J Am Coll Surg 2021; 232:823-835.e2. [PMID: 33640521 DOI: 10.1016/j.jamcollsurg.2020.12.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/28/2020] [Accepted: 12/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND To optimize responsible opioid prescribing after inpatient operation, we implemented a clinical trial with the following objectives: prospectively validate patient-centered opioid prescription guidelines and increase the FDA-compliant disposal rate of leftover opioid pills to higher than currently reported rates of 20% to 30%. STUDY DESIGN We prospectively enrolled 229 patients admitted for 48 hours or longer after elective general, colorectal, urologic, gynecologic, or thoracic operation. At discharge, patients received a prescription for both nonopioid analgesics and opioids based on their opioid usage the day before discharge: if 0 oral morphine milligram equivalents (MME) were used, then five 5-mg oxycodone pill-equivalents were prescribed; if 1 to 29 MME were used, then fifteen 5-mg oxycodone pill-equivalents were prescribed; if 30 or more MME were used, then thirty 5-mg oxycodone pill-equivalents were prescribed. We considered patients' opioid pain medication needs to be satisfied if no opioid refills were obtained. To improve FDA-compliant disposal of leftover pills, we implemented patient education, convenient drop-box, reminder phone call, and questionnaire. RESULTS Our opioid guideline satisfied 93% (213 of 229) of patients. Satisfaction was significantly higher in lower opioid usage groups (p = 0.001): 99% (99 of 100) in the 0 MME group, 90% (91 of 101) in the 1 to 29 MME group, and 82% (23 of 28) in the 30 or more MME group. Overall, 95% (217 of 229) of patients used nonopioid analgesics. Sixty percent (138 of 229) had leftover pills; 83% (114 of 138) disposed of them using an FDA-compliant method and 51% (58 of 114) used the convenient drop-box. Of 2,604 prescribed pills, only 187 (7%) were kept by patients. CONCLUSIONS This clinical trial prospectively validated a patient-centered opioid discharge prescription guideline that satisfied 93% of patients. FDA-compliant disposal of excess pills was achieved in 83% of patients with easily actionable interventions.
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Affiliation(s)
- Eleah D Porter
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Ilda B Molloy
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Julia L Kelly
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Niveditta Ramkumar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | - Joseph D Phillips
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andrew P Loehrer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Z Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Rian M Hasson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Jessica R Henkin
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard J Barth
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Titan A, Doyle A, Pfaff K, Baiu I, Lee A, Graham L, Shelton A, Hawn M. Impact of policy-based and institutional interventions on postoperative opioid prescribing practices. Am J Surg 2021; 222:766-772. [PMID: 33593614 DOI: 10.1016/j.amjsurg.2021.02.004] [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: 11/25/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We assessed the impact of policy-based and institutional interventions to limit postoperative opioid prescribing. METHODS Retrospective cohort study of patients who underwent laparoscopic/open appendectomies, laparoscopic/open cholecystectomies, and laparoscopic/open inguinal hernia repair during a 6-month interval in 2018 (control), 2019 (post-policy intervention), and 2020 (post-institutional intervention) to assess changes in postoperative opioid prescribing patterns. A survey was collected for the 2020 cohort. RESULTS Comparing the 762 patients identified in 2018, 2019, and 2020 cohorts there was a significant decrease in mean opioid tabs prescribed (23.5 ± 8.9 vs. 16.2 ± 7.0 vs. 12.8 ± 4.9, p < 0.01) and mean OME dosage (148.0 ± 68.0 vs. 108.6 ± 51.8 vs. 95.4 ± 38.0, p < 0.01), without a difference in refill requests. Patient survey (response rate 63%) indicated 91.4% of patients reported sufficient pain control. CONCLUSION Formalized opioid-prescribing guidelines and statewide regulations can significantly decrease postoperative opioid prescribing with good patient satisfaction. Surgeon education may facilitate efforts to minimize narcotic over-prescription without compromising pain management.
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Affiliation(s)
- Ashley Titan
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Alexis Doyle
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Kayla Pfaff
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Ioana Baiu
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Angela Lee
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Laura Graham
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Andrew Shelton
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Mary Hawn
- Department of Surgery, Stanford University Hospital, Stanford, CA, USA.
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Paredes AZ, Hyer JM, Tsilimigras DI, Dillhoff ME, Ejaz A, Cloyd JM, Tsung A, Pawlik TM. Wide variation in inpatient opioid utilization following hepatopancreatic surgery. HPB (Oxford) 2021; 23:212-219. [PMID: 32561176 DOI: 10.1016/j.hpb.2020.05.011] [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: 04/06/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inpatient opioid utilization following major surgery remains relatively unknown. We sought to characterize inpatient opioid consumption following hepatopancreatic surgery and determine factors associated with the variability in opioid utilization. METHODS Adult patients who underwent hepatopancreatic surgery at a single institution were identified. Multimodal pain management strategies assessed included opioids (oral morphine equivalents, OME), acetaminophen, ibuprofen and ketorolac. RESULTS Among 2,054 patients, the median total OME utilized was 465 (129-815) during a patient's hospitalization following hepatopancreatic surgery. The interquartile range for total OMEs administered following hepatopancreatic surgery was as high as 940 OMEs (125 oxycodone-5mg pills) following a pancreaticoduodenectomy versus 520 OMEs (69 oxycodone-5mg pills) following a hemi-hepatectomy. Despite relatively high use of acetaminophen post-operatively (n = 1,588, 77.0%), multimodal pain control with acetaminophen and ibuprofen was infrequent (n = 175, 8.5%). Furthermore, individuals with high opioid utilization used on average 147 OMEs (20 oxycodone-5mg pills) the day before discharge versus 44 OME (6 oxycodone-5mg pills) among patients with expected opioid utilization. CONCLUSIONS Marked variability in inpatient opioid consumption following hepatopancreatic surgery was noted. Future work is necessary to decrease the variability in inpatient opioid prescribing practices to promote the safe and effective management of pain.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Meyer DC, Hill SS, McDade JA, Harnsberger CR, Davids JS, Sturrock PR, Maykel JA, Alavi K. Opioid Consumption Patterns After Anorectal Operations: Development of an Institutional Prescribing Guideline. Dis Colon Rectum 2021; 64:103-111. [PMID: 33306536 DOI: 10.1097/dcr.0000000000001680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Closer scrutiny of prescription patterns following surgery could contribute to the national effort to combat the opioid epidemic. OBJECTIVE This study aimed to define opioid consumption patterns following anorectal operations for development of an institutional prescribing guideline. DESIGN This was a retrospective cohort study. SETTING The study was conducted at a single tertiary care center. PATIENTS Patients undergoing outpatient anorectal surgery between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS There were 174 operations categorized into 4 operation categories: 72 hemorrhoid excisions, 55 fistulas-in-ano operations, 8 anal condyloma fulgurations, and 39 miscellaneous operations (14 sphincterotomies, 16 anal biopsies/skin tag excisions, and 9 transanal rectal lesion excisions). Prescription quantity was varied (range, 3-80 equianalgesic oxycodone 5-mg pills). Overall, 39% of patients consumed no pills, 18% consumed all, and 5% required refills. Of total pills prescribed, 63% of were unconsumed. Consumption was significantly different by operation category (average 13.6 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 6.3 after fistula-in-ano operations, 5.8 after condyloma fulguration, and 2.9 after miscellaneous operations; p < 0.001). Home opioid requirements would be met for 80% of patients using the following guideline: 27 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 13 after fistula-in-ano operations, 20 after anal condyloma fulguration, and 4 after miscellaneous operations. Guideline adoption would result in a 41% reduction in excess pills per prescription. LIMITATIONS The study was limited by its retrospective, single-center design and because opioid consumption was self-reported. CONCLUSIONS Opioid prescribing patterns and consumption are widely variable after anorectal operations and appear to be highly dependent on the operation category. It is noteworthy that 63% of opioids prescribed after anorectal operations were unused by the patient and may pose a significant public health risk. Based on the usage patterns observed in this study, prospective studies should be performed to optimize opioid prescribing. See Video Abstract at http://links.lww.com/DCR/B374. PATRONES DE CONSUMO DE OPIOIDES DESPUÉS DE OPERACIONES ANORRECTALES: DESARROLLO DE UNA GUÍA PARA PRESCRIPCIÓN INSTITUCIONAL: Una revisión enfocada de los patrones de prescripción después de la cirugía podría contribuir al esfuerzo nacional para combatir la epidemia de opioides.Este estudio tuvo como objetivo definir los patrones de consumo de opioides después de las operaciones anorrectales para el desarrollo de una guía para prescripción institucional.Estudio de cohorte retrospectivo.El estudio se realizó en un solo centro de atención de tercer nivel.pacientes de cirugía anorrectal ambulatoria entre julio de 2018 y enero de 2019.El estudio valoro el numero de recetas medicas y consumo de píldoras equianalgésicas de oxicodona de 5 mg.174 operaciones se clasificaron en cuatro categorías: 72 extirpaciones de hemorroides, 55 operaciones de fistula anal, 8 fulguraciones de condilomas anales y 39 operaciones misceláneas (14 esfinterotomías, 16 biopsias anales / extirpaciones de lesiones de piel y 9 escisiones de lesiones rectales por vía transanal). La cantidad de medicamentos recetados fue variada (rango: 3-80 pastillas de oxicodona equianalgésica de 5 mg). En general, el 39% de los pacientes no consumió píldoras, el 18% consumió todo y el 5% requirió equianalgesica adicional. Del total de píldoras recetadas, el 63% no se consumió. El consumo fue significativamente diferente según la categoría de la operación (promedio de 13,6 píldoras de oxicodona equianalgésica de 5 mg después de las hemorroidectomías, 6,3 después de las operaciones de fístula en el ano, 5,8 después de la fulguración del condiloma y 2,9 después de las operaciones misceláneas, p <0,001). Los requisitos de opioides en el hogar se cumplirían para el 80% de los pacientes con las siguientes pautas: 27 píldoras de oxicodona equianalgésicas de 5 mg después de las hemorroidectomías, 13 después de las operaciones de fístula anal, 20 después de la fulguración del condiloma anal y 4 después de operaciones misceláneas. La adopción de la guía daría como resultado una reducción del 41% en el exceso de píldoras por receta.El estudio estuvo limitado por su diseño retrospectivo de un solo centro y el consumo de opioides fue autoinformado.Los patrones de prescripción de opioides y el consumo son variables después de las operaciones anorrectales y parecen ser altamente dependientes de la categoría de la operación. En particular, el 63% de los opioides recetados después de las operaciones anorrectales no fueron utilizados por el paciente y pueden representar un riesgo significativo para la salud pública. Según los patrones de uso observados en este estudio, se deben realizar estudios prospectivos para optimizar la prescripción de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B374.
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Affiliation(s)
- David C Meyer
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Susanna S Hill
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Janet A McDade
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Cristina R Harnsberger
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jennifer S Davids
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Paul R Sturrock
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Justin A Maykel
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
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Ayakta N, Sceats LA, Merrell SB, Kin C. "It's Like Learning by the Seat of Your Pants": Surgeons Lack Formal Training in Opioid Prescribing. JOURNAL OF SURGICAL EDUCATION 2021; 78:160-167. [PMID: 32917541 DOI: 10.1016/j.jsurg.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/07/2020] [Accepted: 07/03/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To determine the training surgical residents and faculty receive on opioid prescribing, and to identify opportunities for curricula development to fill training gaps. DESIGN We conducted qualitative semi-structured interviews and surveys. After applying an overarching organizational framework, we used an iterative, team-based process to develop relevant inductive codes. We then performed thematic analyses to identify and catalogue critical domains related to surgeons' education about opioid prescribing. SETTING Tertiary care academic medical center. PARTICIPANTS Maximum variation purposive sampling was used to recruit general surgery residents and surgical faculty members. RESULTS We interviewed 21 attending surgeons and 20 surgical residents. Surgeons reported minimal formal training on pain management and prescribing opioids. A minority of individuals described receiving opioid training in the form of continuing medical education, intern boot camp sessions, and medical school classes. Participants compensated for the lack of formal training during residency by informally learning from senior residents, consulting pain specialists, and seeking external learning resources. Increased surgical experience was correlated with increased comfort with pain management. A majority of surgeons desired formal training. The most commonly requested educational resources were opioid prescribing guidelines for common operations and recommendations for treating chronic pain patients. Residents requested that training occur early in residency to maximize the benefits received. Based on these findings, we developed a conceptual framework to explain how surgeons learn to prescribe opioids and to highlight opportunities for improvement. CONCLUSIONS Although surgeons routinely prescribe opioids and desire education on opioids, a majority of them do not receive any training. Instituting formal educational programs is critical for improving opioid prescribing practices among surgeons.These programs should include standard prescribing guidelines and address management of acute postoperative pain in patients with chronic pain.
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Affiliation(s)
- Nagehan Ayakta
- School of Medicine, Stanford University, Stanford, California
| | - Lindsay A Sceats
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery (S-SPIRE), Stanford University, Stanford, California
| | - Sylvia Bereknyei Merrell
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery (S-SPIRE), Stanford University, Stanford, California
| | - Cindy Kin
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery (S-SPIRE), Stanford University, Stanford, California.
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Kemp Bohan PM, Chick RC, Wall ME, Hale DF, Tzeng CWD, Peoples GE, Vreeland TJ, Clifton GT. An Educational Intervention Reduces Opioids Prescribed Following General Surgery Procedures. J Surg Res 2021; 257:399-405. [DOI: 10.1016/j.jss.2020.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/05/2020] [Accepted: 08/02/2020] [Indexed: 12/19/2022]
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Ivanics T, Nasser H, Kandagatla P, Leonard-Murali S, Jones A, Abouljoud M, Gupta AH, Woodward A. Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines. Am Surg 2020; 87:1039-1047. [PMID: 33295200 DOI: 10.1177/0003134820956332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. METHODS This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). RESULTS Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). CONCLUSIONS Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.
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Affiliation(s)
- Tommy Ivanics
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Nasser
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | | | | | - Adam Jones
- Department of Strategic and Operation Analytics, Henry Ford Hospital, Detroit MI, USA
| | - Marwan Abouljoud
- Department of Transplantation Surgery, Henry Ford Hospital, Detroit MI, USA
| | | | - Ann Woodward
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
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Pain or No Pain, We Will Give You Opioids: Relationship Between Number of Opioid Pills Prescribed and Severity of Pain after Operation in US vs Non-US Patients. J Am Coll Surg 2020; 231:639-648. [DOI: 10.1016/j.jamcollsurg.2020.08.771] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 11/20/2022]
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Serrell EC, Greenberg CC, Borza T. Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic. Cancer 2020; 127:184-187. [PMID: 33002194 DOI: 10.1002/cncr.33199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Emily C Serrell
- Department of Urology, University of Wisconsin, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
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Rodriguez-Monguio R, Naveed M, Croci R, Gross K, Langnas E, Chen CL, Seoane-Vazquez E. Perioperative Prescribing Practices of Extended-Release Opioids in Noncancer Surgical Patients, 2015-2018. Anesth Analg 2020; 131:1249-1259. [PMID: 32925346 DOI: 10.1213/ane.0000000000004952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Extended-release (ER) opioids are indicated for the management of persistent moderate to severe pain in patients requiring around-the-clock opioid analgesics for an extended period of time. Concerns have been raised regarding safety of ER opioids due to its potential for abuse and dependence. However, little is known about perioperative prescribing practices of ER opioids. This study assessed perioperative prescribing practices of ER opioids in noncancer surgical patients stratified by type of opioid exposure prior to admission and examined predictors of postoperative opioid administration in oral morphine equivalents (OME). METHODS This was a retrospective cohort study using the University of California San Francisco Medical Center electronic health record data. This study included 25,396 adult noncancer patients undergoing elective surgery under general anesthesia in the period 2015-2018. The primary study outcome was predictors of postoperative administration of opioids in hospitalized surgical patients. Secondary outcomes included patients discontinued and initiated on ER opioids during their hospital stay. RESULTS substance use disorder diagnosis and use of opioids, surgery type, and postoperative administration of nonopioid analgesics were associated with postoperative administration of opioids (P < .0001). The estimated adjusted mean (95% confidence interval [CI]) of postoperative administration of OME prior to admission in ER opioid users (170.08 mg; 147.08-196.67) was twice the amount for opioid-naïve patients (81.36 mg; 70.7-93.63; P < .0001). One in 5 prior to admission ER opioid users were weaned off ER opioids while hospitalized without adversely affecting their postoperative pain or hospital length of stay (LOS). Four of 5 patients who used ER opioids prior to admission also received ER opioids after surgery, whereas, 1 in 100 opioid-naïve patients received ER opioids during their hospital stay. CONCLUSIONS We found significant variability in the perioperative prescribing practices of ER opioids in hospitalized noncancer surgical patients by use of opioids prior to admission and surgery type. Pain medicine practitioners and surgeons may play a significant role tackling the surgery-related risk of exposure to ER opioids and decreasing opioid-related complications.
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Affiliation(s)
- Rosa Rodriguez-Monguio
- From the Department of Clinical Pharmacy
- Medication Outcomes Center
- Philip R. Lee Institute for Health Policy Studies
| | | | | | - Kendall Gross
- Medication Outcomes Center
- Department of Pharmaceutical Services, UCSF Health
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California
| | - Catherine L Chen
- Philip R. Lee Institute for Health Policy Studies
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California
| | - Enrique Seoane-Vazquez
- Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy, Chapman University, Irvine, California
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Kushner BS, Tan WH, Sehnert M, Jordan K, Aft R, Silviera M, Brunt LM. Assessment of postoperative opioid stewardship using a novel electronic-based automated text and phone messaging platform. Surgery 2020; 169:660-665. [PMID: 32928572 DOI: 10.1016/j.surg.2020.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/17/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Practices of opioid prescribing vary widely across general surgery providers. The goal of this study was to use a text-based platform to assess postdischarge opioid utilization. METHODS A prospective, cohort study enrolled adult patients undergoing operations across the following 3 general surgery sections: minimally invasive surgery, colorectal, and surgical oncology. Using Epharmix, an electronic text-based platform, short message service text messages were sent to enrolled patients on postdischarge days 1 to 7, 14, 2, and 28 inquiring about the number of opioid pills taken since discharge and pain medication refills. RESULTS A total of 253 patients enrolled and completed the intervention. Patient participation was robust, with 80% of patients responded to >50% of all text-based questions, and 64% responded to >80% of all questions. Patients undergoing bariatric surgery were prescribed the most narcotic pain medications (average milligram of morphine equivalents: 250.8), and those undergoing endocrine neck surgery the least (average milligram of morphine equivalent: 53.5). All surgical categories studied consumed ≤25% of their total prescribed milligram of morphine equivalents. Only 8 patients (3.2%) requested an opioid refill by postdischarge days 28. CONCLUSION A text-based platform can track reliably patients' opioid usage postdischarge. Such platforms may facilitate the development of data-driven, standardized practices of opioid prescribing matched to patients' anticipated opioid usage postdischarge.
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Affiliation(s)
- Bradley S Kushner
- Department of Surgery, Washington University School of Medicine, St. Louis, MO.
| | - Wen Hui Tan
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Margaret Sehnert
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Katherine Jordan
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rebecca Aft
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Matthew Silviera
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - L Michael Brunt
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Abstract
Increases in opioid prescribing over the last several decades is correlated with an alarming increase in opioid-related morbidity and mortality owing to both prescription opioid misuse and abuse as well as heroin abuse. Prescribing after surgery is commonly in excess, and leftover pills are an important driver of opioid use disorders owing to diversion and misuse. Creating evidence-based prescribing guidelines based on patient-centered outcomes and encouraging safe opioid storage and disposal is critical to curbing opioid-related morbidity and mortality going forward and to ensure safe and appropriate postoperative pain management.
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Affiliation(s)
- Lily A Upp
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA
| | - Jennifer F Waljee
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA; Department of Plastic Surgery, University of Michigan Medical School, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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46
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Moo TA, Pawloski KR, Sevilimedu V, Charyn J, Simon BA, Sclafani LM, Plitas G, Barrio AV, Kirstein LJ, Van Zee KJ, Morrow M. Changing the Default: A Prospective Study of Reducing Discharge Opioid Prescription after Lumpectomy and Sentinel Node Biopsy. Ann Surg Oncol 2020; 27:4637-4642. [PMID: 32734370 DOI: 10.1245/s10434-020-08886-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Whether routinely prescribed opioids are necessary for pain control after discharge among lumpectomy/sentinel node biopsy (Lump/SLNB) patients is unclear. We hypothesize that Lump/SLNB patients could be discharged without opioids, with a failure rate < 10%. This study prospectively examines outcomes after changing standard discharge prescription from an opioid/non-steroidal anti-inflammatory drug (NSAID) to NSAID/acetaminophen. PATIENTS AND METHODS Standard discharge pain medication orders included opioids in the first 3-month study period and were changed to NSAID/acetaminophen in the second 3-month period. Patient-reported medication consumption and pain scores were collected by post-discharge survey. Frequency of discharge with opioid, NSAID/acetaminophen failure rate, opioid use, and pain scores were examined. RESULTS From May to October 2019, 663 patients had Lump/SLNB: 371 in the opioid study period and 292 in the NSAID period. In the opioid period, 92% (342/371) of patients were prescribed an opioid at discharge; of 142 patients who documented opioid use on the survey, 86 (61%) used zero tablets. Among 56 (39%) patients who used opioids, the median number taken by POD 5 was 4. After the change to NSAID/acetaminophen, rates of opioid prescription decreased to 14% (41/292). The NSAID/acetaminophen failure rate was 2% (5/251). Among survey respondents, there was no significant difference in the maximum reported pain scores (POD 1-5) between the opioid period and the NSAID period (p = 0.7). CONCLUSIONS In Lump/SLNB patients, a change to default discharge with NSAID/acetaminophen resulted in a 78% absolute reduction in opioid prescription, with a failure rate of 2% and no difference in patient-reported pain scores. Most Lump/SLNB patients can be discharged with NSAID/acetaminophen.
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Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jillian Charyn
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brett A Simon
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lisa M Sclafani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - George Plitas
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Does Surgical Intensity Correlate With Opioid Prescribing?: Classifying Common Surgical Procedures. Ann Surg 2020; 275:897-903. [PMID: 32740234 DOI: 10.1097/sla.0000000000004299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the relationship between aspects of surgical intensity and postoperative opioid prescribing. SUMMARY OF BACKGROUND DATA Despite the emergence of postoperative prescribing guidelines, recommendations are lacking for many procedures. Identifying a framework based on surgical intensity to guide prescribing for those procedures in which guidelines may not exist could inform postoperative prescribing. METHODS We used clustering analysis with 4 factors of surgical intensity (intrinsic cardiac risk, pain score, median operative time, and work relative value units) to devise a classification system for common surgical procedures. We used IBM MarketScan Research Database (2010-2017) to examine the correlation between this framework with initial opioid prescribing and rates of refill for each cluster of procedures. RESULTS We examined 2,407,210 patients who underwent 128 commonly performed surgeries. Cluster analysis revealed 5 ordinal clusters by intensity: low, mid-low, mid, mid-high, and high. We found that as the cluster-order increased, the median amount of opioid prescribed increased: 150 oral morphine equivalents (OME) for low-intensity, 225 OME for mid-intensity, and 300 OME for high-intensity surgeries. Rates of refill increased as surgical intensity also increased, from 17.4% for low, 26.4% for mid, and 48.9% for high-intensity procedures. The odds of refill also increased as cluster-order increased; relative to low-intensity procedures, high-intensity procedures were associated with 4.37 times greater odds of refill. CONCLUSION Surgical intensity is correlated with initial opioid prescribing and rates of refill. Aspects of surgical intensity could serve as a guide for procedures in which guidelines based on patient-reported outcomes are not available.
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Sarin A, Lancaster E, Chen LL, Porten S, Chen LM, Lager J, Wick E. Using provider-focused education toolkits can aid enhanced recovery programs to further reduce patient exposure to opioids. Perioper Med (Lond) 2020; 9:21. [PMID: 32670568 PMCID: PMC7346381 DOI: 10.1186/s13741-020-00153-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background Evidence-based perioperative analgesia is an important tactic for reducing patient exposure to opioids in the perioperative period and potentially preventing new persistent opioid use. Study design We assessed the impact of a multifaceted optimal analgesia program implemented in the setting of a mature surgical pathway program at an academic medical center. Using existing multidisciplinary workgroups established for continuous process improvement in three surgical pathway areas ((colorectal, gynecology, and urologic oncology (cystectomy)), we developed an educational toolkit focused on implementation strategies for multimodal analgesia and non-pharmacologic approaches for managing pain with the goal of reducing opioid exposure in hospitalized patients. We analyzed prospectively collected data from pathway patients before dissemination of the toolkit (July 2016–June 2017; n = 869) and after (July 2017–June 2018; n = 838). We evaluated the association between program implementation and use of oral morphine equivalents (OME), average pain scores, time to first ambulation after surgery, urinary catheter duration, time to solid food after surgery, length of stay, discharge opioid prescriptions, and readmission. Results Multivariate regression demonstrated that the program was associated with significant decreases in intraoperative OME (14.5 ± 2.4 mEQ (milliequivalents) reduction; p < 0.0001), day before discharge OME (18 ± 6.5 mEQ reduction; p < 0.005), day of discharge OME (9.6 ± 3.28 mEQ reduction; p < 0.003), and discharge prescription OME (156 ± 22 mEq reduction; p < 0.001). Reduction in OME was associated with earlier resumption of solid food (0.58 ± 0.15 days reduction; p < 0.0002). Conclusion Our multifaceted optimal analgesia program to manage perioperative pain in the hospital was effective and further improved analgesia in the setting of a mature enhanced recovery program.
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Affiliation(s)
- Ankit Sarin
- Department of Surgery, University of California San Francisco, 550 16th Street, 6th Floor, San Francisco, CA 94158 USA
| | - Elizabeth Lancaster
- Department of Surgery, University of California San Francisco, 550 16th Street, 6th Floor, San Francisco, CA 94158 USA
| | - Lee-Lynn Chen
- Department of Anesthesia & Perioperative Medicine, University of California San Francisco, 505 Parnassus Ave. M917, San Francisco, CA 94143-0624 USA
| | - Sima Porten
- Department of Urology, University of California San Francisco, 1825 4th Street, Fourth Floor, San Francisco, CA 94158 USA
| | - Lee-May Chen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 550 16th Street, 7th Floor, San Francisco, CA 94158 USA
| | - Jeanette Lager
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 550 16th Street, 7th Floor, San Francisco, CA 94158 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 550 16th Street, 6th Floor, San Francisco, CA 94158 USA
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49
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Leinicke JA, Carbajal V, Senders ZJ, Patil N, Wogsland A, Stein SL, Steinhagen E. Opioid Prescribing Patterns After Anorectal Surgery. J Surg Res 2020; 255:632-640. [PMID: 32663700 DOI: 10.1016/j.jss.2020.05.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anorectal procedures are frequently performed and have the potential to be particularly painful. There are no evidence-based guidelines regarding opioid prescribing after anorectal surgery and limited data on how surgeons determine opioid prescriptions after anorectal procedures. We hypothesize significant variations in prescribing practices. The aim of this study is to determine current opioid prescribing patterns after anorectal surgery. METHODS A survey was sent to members of the American Society of Colon and Rectal Surgeons. It included demographics, opioid prescribing habits after anorectal procedures, and factors influencing prescribing. Median morphine equivalents were calculated. Respondents prescribing higher than the median for >4 procedures were considered high prescribers. RESULTS 519 surveys were completed (3160 sent). 38.6% of respondents were high prescribers, and 61.4% were low prescribers. There were significant differences by years in practice (P = 0.049), hospital type (P = 0.037), region (P < 0.001), and procedures performed per month (P < 0.001). 73% prescribed a standard quantity of opioids for each procedure. The mean milligrams of ME prescribed overall was 129 (SD 82); by procedure the quantities were as follows: hemorrhoidectomy 188 (111), condyloma treatment 149 (105), fistulotomy 146 (98), advancement flap 144 (97), LIFT 140 (93), abscess drainage 107 (91), sphincterotomy 105 (85), chemodenervation 64 (34). Nearly, all (98%) surgeons used local anesthesia. 91% typically prescribed adjunctive medications. In multivariable analysis, performing <10 anorectal procedures per month or practicing in the Northeast or outside the US was associated with low prescribers. High prescribers were more likely to be in practice for >10 y, report >25% of patients request refills, or significantly consider patient satisfaction or phone calls when prescribing. CONCLUSIONS Opioid prescribing patterns are highly variable after anorectal procedures. Creating opioid prescribing guidelines for anorectal surgery is important to improve patient safety and quality of care.
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Affiliation(s)
| | - Valerie Carbajal
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Zachary J Senders
- University Hospitals Cleveland Medical Center/UH-RISES: Research in Surgical Outcomes & Effectiveness Center), Cleveland, OH
| | - Nirav Patil
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center/UH-RISES: Research in Surgical Outcomes & Effectiveness Center), Cleveland, OH
| | - Aric Wogsland
- University Hospitals Cleveland Medical Center/UH-RISES: Research in Surgical Outcomes & Effectiveness Center), Cleveland, OH
| | - Sharon L Stein
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center/UH-RISES: Research in Surgical Outcomes & Effectiveness Center), Cleveland, OH
| | - Emily Steinhagen
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center/UH-RISES: Research in Surgical Outcomes & Effectiveness Center), Cleveland, OH.
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50
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Lancaster E, Inglis-Arkell C, Hirose K, Seib CD, Wick E, Sosa JA, Duh QY. Variability in Opioid-Prescribing Patterns in Endocrine Surgery and Discordance With Patient Use. JAMA Surg 2020; 154:1069-1070. [PMID: 31411647 DOI: 10.1001/jamasurg.2019.2518] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Christina Inglis-Arkell
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco
| | - Kenzo Hirose
- Department of Surgery, University of California, San Francisco
| | - Carolyn D Seib
- Department of Surgery, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
| | - Julie A Sosa
- Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
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