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von Oelreich E, Campoccia Jalde F, Rysz S, Eriksson J. Opioid use following cardio-thoracic intensive care: risk factors and outcomes: a cohort study. Sci Rep 2024; 14:20. [PMID: 38168129 PMCID: PMC10762227 DOI: 10.1038/s41598-023-50508-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
Opioid misuse has become a serious public health problem. Patients admitted to cardio-thoracic critical care are usually exposed to opioids, but the incidence and effects of chronic opioid use are not known. The primary objective was to describe opioid use after admission to a cardio-thoracic intensive care unit. Secondary objectives were to identify factors associated with chronic opioid usage and analyze risk of death. This cohort study included all cardio-thoracic ICU care episodes in Sweden between 2010 and 2018. Among the 34,200 patients included in the final study cohort, 4050 developed persistent opioid use after ICU care. Younger age, preadmission opioid use, female sex, presence of comorbidities and earlier year of ICU admission were all found to be associated with persistent opioid use. The adjusted hazard ratio for mortality between 6 and 18 months after admission among individuals with persistent opioid use was 2.2 (95% CI 1.8-2.6; P < 0.001). For opioid-naïve patients before ICU admission, new onset of chronic opioid usage was significant during the follow-up period of 24 months. Despite the absence of conclusive evidence supporting extended opioid treatment, the average opioid consumption remains notably elevated twelve months subsequent to cardio-thoracic ICU care.
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Affiliation(s)
- Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 171 65, Solna, Stockholm, Sweden.
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 171 65, Solna, Stockholm, Sweden
| | - Susanne Rysz
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 171 65, Solna, Stockholm, Sweden
| | - Jesper Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 171 65, Solna, Stockholm, Sweden
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Gross DJ, Alnajar A, Villamizar NR, Nguyen DM. Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience. JTCVS OPEN 2023; 15:508-519. [PMID: 37808010 PMCID: PMC10556950 DOI: 10.1016/j.xjon.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 10/10/2023]
Abstract
Objectives Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid-free discharge. Methods We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent), and opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid-free discharge; our secondary objective was to determine the incidence of new persistent opioid users. Results In total, 466 patients from our optimized ERATS protocol were included; 309 (66%) were discharged without opioids. However, 34 (11%) of patients discharged without opioids required a prescription postdischarge. Conversely, 7 of 157 patients (11%), never filled their opioid prescriptions given at discharge. Factors associated with opioid-free discharges were nonanatomic resections, mediastinal procedures, minimal pain, and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges (P = .0013). Finally, only 2.3% of opioid-naive patients of the entire cohort became chronic opioid users; there was no difference in the incidence of chronic use by opioid discharge status. Conclusions Optimized opioid-sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic.
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Affiliation(s)
- Daniel J. Gross
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Ahmed Alnajar
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Nestor R. Villamizar
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Dao M. Nguyen
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
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Mondoñedo JR, Brescia AA, Clark MJ, Chang ML, Jiang S, He C, Welsh RJ, Popoff AM, Kulkarni MG, Lall SC, Pratt JW, Adams KN, Alnajjar RM, Martin JR, Gandhi DB, Brummett CM, Chang AC, Lagisetty KH. Evidence-based opioid prescribing guidelines after lung resection: a prospective, multicenter analysis. J Thorac Dis 2023; 15:3285-3294. [PMID: 37426143 PMCID: PMC10323572 DOI: 10.21037/jtd-22-1621] [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: 11/13/2022] [Accepted: 03/24/2023] [Indexed: 07/11/2023]
Abstract
Background Opioid prescribing guidelines have significantly decreased overprescribing and post-discharge use after cardiac surgery; however, limited recommendations exist for general thoracic surgery patients, a similarly high-risk population. We examined opioid prescribing and patient-reported use to develop evidence-based, opioid prescribing guidelines after lung cancer resection. Methods This prospective, statewide, quality improvement study was conducted between January 2020 to March 2021 and included patients undergoing surgical resection of a primary lung cancer across 11 institutions. Patient-reported outcomes at 1-month follow-up were linked with clinical data and Society of Thoracic Surgery (STS) database records to characterize prescribing patterns and post-discharge use. The primary outcome was quantity of opioid used after discharge; secondary outcomes included quantity of opioid prescribed at discharge and patient-reported pain scores. Opioid quantities are reported in number of 5-mg oxycodone tablets (mean ± standard deviation). Results Of the 602 patients identified, 429 met inclusion criteria. Questionnaire response rate was 65.0%. At discharge, 83.4% of patients were provided a prescription for opioids of mean size 20.5±13.1 pills, while patients reported using 8.2±13.0 pills after discharge (P<0.001), including 43.7% who used none. Those not taking opioids on the calendar day prior to discharge (32.4%) used fewer pills (4.4±8.1 vs. 11.7±14.9, P<0.001). Refill rate was 21.5% for patients provided a prescription at discharge, while 12.5% of patients not prescribed opioids at discharge required a new prescription before follow-up. Pain scores were 2.4±2.5 for incision site and 3.0±2.8 for overall pain (scale 0-10). Conclusions Patient-reported post-discharge opioid use, surgical approach, and in-hospital opioid use before discharge should be used to inform prescribing recommendations after lung resection.
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Affiliation(s)
| | | | - Melissa J. Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Matthew L. Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shannon Jiang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Robert J. Welsh
- Beaumont Hospital, Royal Oak, MI, USA
- Beaumont Hospital, Troy, MI, USA
| | | | | | | | | | | | | | | | | | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew C. Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Turner KM, Delman AM, Griffith A, Wima K, Wallen TE, Starnes SL, Budde BM, Van Haren RM. The Impact of Enhanced Recovery After Surgery on Persistent Opioid Use Following Pulmonary Resection. Ann Thorac Surg 2023; 115:249-255. [PMID: 35779597 DOI: 10.1016/j.athoracsur.2022.05.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/15/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been associated with improved perioperative outcomes after thoracic surgery; however, the impact on long-term opioid use remains unknown. The aim of our study was to evaluate the effects of ERAS on long-term opioid use. METHODS Patients who underwent pulmonary resection were identified from a prospectively maintained database and linked to the regional prescription drug monitoring program. Outcomes were compared between pre-ERAS (February 2016 to November 2018) and ERAS (December 2018 to June 2020) cohorts. Our ERAS protocol included regional anesthetic, multimodal pain control, and protocolized rehabilitation. RESULTS We analyzed 240 pulmonary resections, 64.6% (n = 155) in the pre-ERAS era and 35.4% (n = 85) in the ERAS era. Baseline characteristics were similar; however, more patients in the ERAS cohort underwent minimally invasive surgery (67.7% vs 87.9%; P = .002). Median length of stay was reduced (5 days vs 4 days; P = .03) upon implementation of ERAS, with no change in perioperative complications or readmission rate. On multivariate analysis, ERAS was associated with decreased total inpatient morphine milligram equivalent and discharge morphine milligram equivalent. However, both long-term opioid use up to 1 year postoperatively and new persistent opioid use remained similar despite implementation of ERAS. On multivariate analysis, implementation of ERAS was not associated with a reduction in opioid use 14 to 90 days postoperatively or persistent opioid use 90 to 180 days postoperatively. CONCLUSIONS Despite short-term opioid reduction, long-term opioid use persisted after implementation of ERAS. Additional strategies to monitor for and avoid opioid dependence are urgently needed to prevent chronic opioid use after pulmonary resection.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Azante Griffith
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sandra L Starnes
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bradley M Budde
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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