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Liu O, Leon D, Gough E, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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Zubieta CS, Shabet C, Lin J, Muzaurieta A, Arora A, Maghsoodi N, Brummett CM, Edelman A. Financial model for a transitional pain service at a large tertiary academic center in the USA. Reg Anesth Pain Med 2023:rapm-2023-104992. [PMID: 38124160 DOI: 10.1136/rapm-2023-104992] [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: 09/09/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023]
Abstract
Approximately 1 in 10 patients undergoing surgery is considered at high risk for poor pain and opioid-related outcomes due to chronic pain or persistent opioid use prior to surgery, leading to increased hospital lengths of stay, emergency department visits, hospital readmissions, and worse long-term outcomes. Multidisciplinary transitional pain services (TPSs) have been shown to effectively identify and optimize high-risk patients before surgery, leading to a reduction in healthcare utilization. We conducted a series of semistructured interviews, a literature search, and a financial analysis to develop a reproducible business case for establishing a TPS. These interviews involved discussions with clinicians and administrators at Michigan Medicine, as well as leaders of TPS initiatives at peer institutions across the USA and Canada. The aim was to understand possible operational structures and potential sources of revenue and cost savings that needed inclusion in our model. Subsequently, the authors developed a modifiable financial modeling tool, which is freely available for download and adaptable to any healthcare institution. The model suggests that the primary source of cost savings can be attributed to a reduction in length of stay. Furthermore, several operational options exist for incorporating a TPS that performs at breakeven or positive net profit. This tool and these findings are important for informing health systems of operational and financial considerations when implementing a TPS program. Future research should evaluate this financial tool's reproducibility in community health system contexts.
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Affiliation(s)
- Caroline S Zubieta
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Christina Shabet
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - James Lin
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Aurelio Muzaurieta
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Akul Arora
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Nazanin Maghsoodi
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Research Institute, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony Edelman
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Brooke BS, Bayless K, Anderson Z, Holeman TA, Zhang C, Hales J, Buys MJ. Opioid tapering after surgery and its association with patient-reported outcomes and behavioral changes: a mixed-methods analysis. Reg Anesth Pain Med 2023:rapm-2023-104807. [PMID: 37865394 DOI: 10.1136/rapm-2023-104807] [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: 06/30/2023] [Accepted: 10/02/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION Opioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was to evaluate how opioid tapering following surgery was associated with patient-reported outcome measures related to pain control and behavioral changes that affect quality of life. METHODS We conducted an explanatory sequential mixed-methods study at a VA Medical Center among patients with chronic opioid use who underwent a spectrum of orthopedic, vascular, thoracic, urology, otolaryngology, and general surgery procedures between 2018 and 2020. Patients were stratified based on the extent that opioid tapering was successful (complete, partial, and no-taper) by 90 days after surgery, followed by qualitative interviews of 10 patients in each taper group. Longitudinal patient-reported outcome measures related to pain intensity, interference, and catastrophizing were compared using Kruskal Wallis tests over the 90-day period after surgery. Qualitative interviews were conducted among patients in each taper group to identify themes associated with the impact of opioid tapering after surgery on quality of life. RESULTS We identified 211 patients with chronic opioid use (92% male, median age 66 years) who underwent surgery during the time period, including 42 (20%) individuals with complete tapering, 48 (23%) patients with partial tapering, and 121 (57%) patients with no taper of opioids following surgery. Patients who did not taper were more likely to have a history of opioid use disorder (10%-partial, 2%-complete vs 17%-no taper, p<0.05) and be discharged on a higher median morphine equivalent daily dose (52-partial, 30-complete vs 60-no taper; p<0.05) than patients in the partial and complete taper groups. Pain interference (-7.2-partial taper and -9.8-complete taper vs -3.5-no taper) and pain catastrophizing (-21.4-partial taper and -16.5-complete taper vs -1.7-no taper) scores for partial and complete taper groups were significantly improved at 90 days relative to baseline when compared with patients in the no-taper group (p<0.05 for both comparisons), while pain intensity was similar between groups. Finally, patients achieving complete and partial opioid tapering were more likely to report improvements in activity, mood, thinking, and sleep following surgery as compared with patients who failed to taper. CONCLUSIONS Partial and complete opioid tapering within 90 days after surgery among patients with chronic opioid use was associated with improved patient-reported measures of pain control as well as behaviors that impact a patient's quality of life.
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Affiliation(s)
- Benjamin Sands Brooke
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Teryn A Holeman
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Julie Hales
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Michael J Buys
- Anesthesiology, Salt Lake City VA Medical Center, Salt Lake City, Utah, USA
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van Deventer L, Bronstone A, Leonardi C, Bennett M, Yager P, Dasa V. A modern multimodal pain protocol eliminates the need for opioids for most patients following total knee arthroplasty: results from a retrospective comparative cohort study. J Exp Orthop 2023; 10:20. [PMID: 36806032 PMCID: PMC9940069 DOI: 10.1186/s40634-023-00585-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/04/2023] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Modern multimodal analgesia has been shown to significantly reduce opioid use following total knee arthroplasty (TKA). This study was conducted to determine if changing TKA discharge opioid prescriptions from automatic to upon request resulted in more opioid free recoveries without compromising pain control. METHODS Between December 2019 and August 2021, an orthopedic surgeon performed 144 primary unilateral TKAs; patients received the same multimodal analgesia protocol except for postoperative opioid prescribing. The first consecutively-treated cohort automatically received an opioid prescription following discharge (automatic group) and the second cohort received opioid prescriptions only upon request (upon request group). Opioid prescription data were derived from a prescription monitoring program and patient-reported outcomes (PROs) were collected preoperatively and at 2 and 12 weeks postoperatively. RESULTS A higher percentage of the upon request group was opioid free 3 months after TKA compared with the automatic group (55.6% vs 4.3%, p < 0.0001) without compromising pain or function. Among opioid-naïve patients, 72% in the upon request group were opioid free after TKA compared with 5.4% in the automatic group. Opioid prescribing was not significantly reduced among opioid-experienced patients regardless of the pain protocol. CONCLUSION Requiring patients to request opioid prescriptions following TKA resulted in a higher rate of opioid free TKA, especially among opioid-naïve patients, without increasing pain compared with offering all patients an initial opioid prescription. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Leland van Deventer
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Amy Bronstone
- grid.279863.10000 0000 8954 1233Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112 USA
| | - Claudia Leonardi
- grid.279863.10000 0000 8954 1233School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Matthew Bennett
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Peter Yager
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA ,grid.279863.10000 0000 8954 1233Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112 USA
| | - Vinod Dasa
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA. .,Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA, 70112, USA.
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