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Staton M, Levi M, Winston E, B Oser C, Fallin-Bennett A, Dickson M, Matthew Webster J, Leukefeld C, Tillson M. Examining use of telehealth in jails: linking women to community OUD services. BMC Womens Health 2024; 24:549. [PMID: 39367439 PMCID: PMC11451235 DOI: 10.1186/s12905-024-03394-4] [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: 08/29/2024] [Accepted: 09/27/2024] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND Opioid use disorder (OUD) remains a significant health care need for women, particularly those involved in the criminal legal system (CLS). There are no studies to date that focus on the utilization of telehealth as a platform for assessment and linkage to medications to treat opioid use disorder (MOUD) at community re-entry for women, despite the fact that women have unique risk factors that may contribute to opioid relapse in the community. The purpose of this mixed-methods study is to provide an overview of the innovative use of telehealth for linking incarcerated women to community MOUD treatment in the Kentucky-hub of the Justice Community Opioid Innovation Network (JCOIN). METHODS This study incorporates qualitative and quantitative data collection with MOUD providers, recovery staff involved in peer navigation services, and women who are incarcerated to understand perceptions of the use of telehealth prior to jail release as a linkage to community services. RESULTS Findings from this study suggest overall support for the use of telehealth between community MOUD treatment providers and women who are incarcerated using videoconferencing technology. On average, there was very little variation in provider favorable feedback related to clinical engagement or in face-to-face comparability, as well as how telehealth allowed the participant to discuss personal and sensitive issues during the clinical assessment. CONCLUSIONS Study findings suggest benefits associated with the use of telehealth in increasing access to treatment for women with OUD. Jails are critical venues for telehealth interventions because they provide the opportunity to reach women who have been actively using illicit substances, often have advanced-stage substance use disorders which have compromised their health and mental health, and often have not been previously identified as needing treatment. TRIAL REGISTRATION This study was originally registered on 8/23/19, ClinicalTrials.gov, #NCT04069624.
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Affiliation(s)
- Michele Staton
- College of Medicine, Department of Behavioral Science, University of Kentucky, 1100 Veterans Drive, Lexington, KY, 40536, USA.
| | - Mary Levi
- College of Arts & Sciences, Department of Psychology, University of Kentucky, 106 Kastle Hall, Lexington, KY, 40506, USA
| | - Erin Winston
- Center on Drug and Alcohol Research, University of Kentucky, 643 Maxwelton Court, Lexington, KY, 40506, USA
| | - Carrie B Oser
- College of Arts & Sciences, Department of Sociology, University of Kentucky, 1531 Patterson Office Tower, 40506, Lexington, KY, USA
| | - Amanda Fallin-Bennett
- College of Nursing, University of Kentucky, 751 Rose Street, 40536, Lexington, KY, USA
| | - Megan Dickson
- College of Medicine, Department of Behavioral Science, University of Kentucky, 1100 Veterans Drive, Lexington, KY, 40536, USA
| | - J Matthew Webster
- College of Medicine, Department of Behavioral Science, University of Kentucky, 1100 Veterans Drive, Lexington, KY, 40536, USA
| | - Carl Leukefeld
- College of Medicine, Department of Behavioral Science, University of Kentucky, 1100 Veterans Drive, Lexington, KY, 40536, USA
| | - Martha Tillson
- Center on Drug and Alcohol Research, University of Kentucky, 643 Maxwelton Court, Lexington, KY, 40506, USA
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Coe JL, Morgan MH, Rehberg K, Kranzler EC, Ingersoll R, Namrow N, Huber-Krum S. Evaluating the implementation of family-centered substance use treatment for pregnant and postpartum people: A mixed-methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 164:209409. [PMID: 38768816 PMCID: PMC11300141 DOI: 10.1016/j.josat.2024.209409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/02/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Family-centered substance use treatment (FCSUT) approaches for pregnant and postpartum people have the potential to prevent intergenerational transmission of adverse childhood experiences (ACEs). Guided by two theoretical frameworks drawn from implementation science (the Consolidated Framework for Implementation Research [CFIR] and the Reach, Effectiveness, Adoption, Implementation and Maintenance [RE-AIM] framework), this study used a mixed methods approach to answer: (1) What is the extent to which FCSUT approaches are offered for pregnant and postpartum people seeking substance use disorder (SUD) treatment? and (2) How are FCSUT approaches for pregnant and postpartum people implemented? METHODS This study utilized a sequential mixed methods design that began with quantitative data collection followed by qualitative data collection. The quantitative component consisted of service provision surveys of facilities that provided FCSUT to pregnant and postpartum people (n = 118). The qualitative component consisted of semi-structured in-depth interviews with administrators and providers working at FCSUT facilities (n = 26) and pregnant and postpartum people who were currently receiving or had previously received services in the last two years from FCSUT facilities (n = 27). The qualitative findings were used to deepen understanding of the quantitative findings. RESULTS Findings from the quantitative survey of treatment facilities' FCSUT provision revealed that while most facilities offered services related to substance use treatment, behavioral health, and parenting skills development or parent training, a smaller proportion offered services related to prenatal and postpartum health, sexual and reproductive health, and family-related services. Qualitative in-depth interviews with program administrators and providers and pregnant and postpartum people who had participated in FCSUT programs revealed major themes around expanding reach of facilities by maintaining participants' familial connections, resources for implementation and maintenance of FCSUT, the importance of program adaptation, and gaps in service delivery. CONCLUSIONS Results indicated there is a wide range of FCSUT services offered at treatment facilities across the United States. Furthermore, while many pregnant and postpartum people expressed positive experiences with FCSUT, there are some areas that should be considered for future progress to be made.
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Affiliation(s)
- Jesse L Coe
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary Harbert Morgan
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | | | | | | | - Sarah Huber-Krum
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Guevara N, Chapiolkina V, Pesantez J, Rakovica L, Ibrahim J. A Case Report of Challenging Diagnosis of Persistent Hypoglycemia Secondary to Methadone Dose-Dependence in a Patient With End-Stage Renal Disease (ESRD) and Liver Cirrhosis (LC). Cureus 2024; 16:e62903. [PMID: 39040763 PMCID: PMC11261997 DOI: 10.7759/cureus.62903] [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: 04/22/2024] [Accepted: 06/22/2024] [Indexed: 07/24/2024] Open
Abstract
Methadone is a widely used opioid used for the management of chronic pain, treatment for opioid use disorders (heroin addiction), as well as for acute opioid withdrawal syndrome. Even though methadone is considered a safe drug, it is not exempt from unwanted side effects, some of them can be rare and may be overlooked due to patients' comorbidities, delaying proper identification of the actual etiology. This article highlights one of those side effects, hypoglycemia, in a 64-year-old woman with a medical history of end-stage renal disease (ESRD) on hemodialysis, Acquired immune deficiency syndrome, liver cirrhosis, and a history of intravenous (IV) drug abuse disorder on a methadone maintenance program, and the importance of prompt identification and management, such as dose splitting or alternate medication to manage opioid withdrawal. The case underscores the importance of a proper approach and the high clinical suspicion that must be present when multiple variables are in place.
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Affiliation(s)
| | | | - Juan Pesantez
- Medicine, St. Barnabas Hospital Health System, New York, USA
| | - Loran Rakovica
- Medicine, St. Barnabas Hospital Health System, New York, USA
| | - Jamil Ibrahim
- Critical Care Medicine, St. Barnabas Hospital Health System, New York, USA
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Sutton KF, Cabell GH, Ashley LW, Lentz TA, Lewis BD, Olson SA, Mather RC. Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study. BMC Musculoskelet Disord 2024; 25:304. [PMID: 38643071 PMCID: PMC11031887 DOI: 10.1186/s12891-024-07418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/05/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.
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Affiliation(s)
- Kent F Sutton
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Grant H Cabell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lucas W Ashley
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian D Lewis
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven A Olson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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List EB, Boers N, Martin E, Krijgh DD, Henk Coert J. Patient-reported outcomes after free muscle flap coverage for therapy-resistant neuropathic pain from the ulnar nerve. J Hand Surg Eur Vol 2024; 49:250-256. [PMID: 37747704 PMCID: PMC10845818 DOI: 10.1177/17531934231201930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/15/2023] [Accepted: 08/27/2023] [Indexed: 09/26/2023]
Abstract
Extensive microsurgical neurolysis followed by free gracilis muscle flap coverage can be performed as a last resort for patients with persistent neuropathic pain of the ulnar nerve. All patients who had this surgery between 2015 and 2021 were identified. Data were collected from the medical records of 21 patients and patient-reported outcomes were collected from 18 patients, with a minimum follow-up of 12 months. The median visual analogue pain score decreased significantly 8 months postoperatively from 8.0 to 6.0 and stabilized to 5.4 at the 3-year follow-up. Health-related quality-of-life scores remained diminished compared to normative data. In the treatment of therapy-resistant neuropathic pain of the ulnar nerve, extensive neurolysis with a subsequent free gracilis muscle flap coverage shows a promising reduction of pain that persists at long-term follow-up.Level of evidence: IV.
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Affiliation(s)
- Emile B. List
- Emile B. List, Department of Plastic and Reconstructive Surgery G04.126, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | | | - Enrico Martin
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David D. Krijgh
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J. Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Liang Y, Sharma D, Wang B, Wang H, Feng X, Ma R, Berkman T, Char S, Bekker A, Tao YX. Transcription factor EBF1 mitigates neuropathic pain by rescuing Kv1.2 expression in primary sensory neurons. Transl Res 2024; 263:15-27. [PMID: 37607607 PMCID: PMC10840933 DOI: 10.1016/j.trsl.2023.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/31/2023] [Accepted: 08/15/2023] [Indexed: 08/24/2023]
Abstract
Nerve injury-induced alternations of gene expression in primary sensory neurons of the dorsal root ganglion (DRG) are molecular basis of neuropathic pain genesis. Transcription factors regulate gene expression. In this study, we examined whether early B cell factor 1 (EBF1), a transcription factor, in the DRG, participated in neuropathic pain caused by chronic constriction injury (CCI) of the sciatic nerve. EBF1 was distributed exclusively in the neuronal nucleus and coexpressed with cytoplasmic/membrane Kv1.2 in individual DRG neurons. The expression of Ebf1 mRNA and protein was time-dependently downregulated in the ipsilateral lumbar (L) 3/4 DRGs after unilateral CCI. Rescuing this downregulation through microinjection of the adeno-associated virus 5 expressing full-length Ebf1 mRNA into the ipsilateral L3/4 DRGs reversed the CCI-induced decrease of DRG Kv1.2 expression and alleviated the development and maintenance of mechanical, heat and cold hypersensitivities. Conversely, mimicking the downregulation of DRG EBF1 through microinjection of AAV5-expressing Ebf1 shRNA into unilateral L3/4 DRGs produced a reduction of Kv1.2 expression in the ipsilateral L3/4 DRGs, spontaneous pain, and the enhanced responses to mechanical, heat and cold stimuli in naive mice. Mechanistically, EBF1 not only bound to the Kcna2 gene (encoding Kv1.2) promoter but also directly activated its activity. CCI decreased the EBF1 binding to the Kcna2 promoter in the ipsilateral L3/4 DRGs. Our findings suggest that DRG EBF1 downregulation contributes to neuropathic pain likely by losing its binding to Kcna2 promoter and subsequently silencing Kv1.2 expression in primary sensory neurons. Exogenous EBF1 administration may mitigate neuropathic pain by rescuing DRG Kv1.2 expression.
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Affiliation(s)
- Yingping Liang
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Dilip Sharma
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Bing Wang
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Huixing Wang
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Xiaozhou Feng
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Ruining Ma
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Tolga Berkman
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Steven Char
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Alex Bekker
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Yuan-Xiang Tao
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey; Department of Physiology, Pharmacology & Neuroscience, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey; Departments of Cell Biology & Molecular Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey.
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7
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Jevtovic-Todorovic V, Todorovic SM. The Role of Neuroactive Steroids in Analgesia and Anesthesia: An Interesting Comeback? Biomolecules 2023; 13:1654. [PMID: 38002336 PMCID: PMC10669813 DOI: 10.3390/biom13111654] [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: 10/16/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Published evidence over the past few decades suggests that general anesthetics could be neurotoxins especially when administered at the extremes of age. The reported pathology is not only at the morphological level when examined in very young and aged brains, given that, importantly, newly developing evidence suggests a variety of behavioral impairments. Since anesthesia is unavoidable in certain clinical settings, we should consider the development of new anesthetics. A promising and safe solution could be a new family of anesthetics referred to as neuroactive steroids. In this review, we summarize the currently available evidence regarding their anesthetic and analgesic properties.
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Affiliation(s)
- Vesna Jevtovic-Todorovic
- Department of Anesthesiology, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA;
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Wang B, Ma L, Guo X, Du S, Feng X, Liang Y, Govindarajalu G, Wu S, Liu T, Li H, Patel S, Bekker A, Hu H, Tao YX. A sensory neuron-specific long non-coding RNA reduces neuropathic pain by rescuing KCNN1 expression. Brain 2023; 146:3866-3884. [PMID: 37012681 PMCID: PMC10473565 DOI: 10.1093/brain/awad110] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 04/05/2023] Open
Abstract
Nerve injury to peripheral somatosensory system causes refractory neuropathic pain. Maladaptive changes of gene expression in primary sensory neurons are considered molecular basis of this disorder. Long non-coding RNAs (lncRNAs) are key regulators of gene transcription; however, their significance in neuropathic pain remains largely elusive.Here, we reported a novel lncRNA, named sensory neuron-specific lncRNA (SS-lncRNA), for its expression exclusively in dorsal root ganglion (DRG) and trigeminal ganglion. SS-lncRNA was predominantly expressed in small DRG neurons and significantly downregulated due to a reduction of early B cell transcription factor 1 in injured DRG after nerve injury. Rescuing this downregulation reversed a decrease of the calcium-activated potassium channel subfamily N member 1 (KCNN1) in injured DRG and alleviated nerve injury-induced nociceptive hypersensitivity. Conversely, DRG downregulation of SS-lncRNA reduced the expression of KCNN1, decreased total potassium currents and afterhyperpolarization currents and increased excitability in DRG neurons and produced neuropathic pain symptoms.Mechanistically, downregulated SS-lncRNA resulted in the reductions of its binding to Kcnn1 promoter and heterogeneous nuclear ribonucleoprotein M (hnRNPM), consequent recruitment of less hnRNPM to the Kcnn1 promoter and silence of Kcnn1 gene transcription in injured DRG.These findings indicate that SS-lncRNA may relieve neuropathic pain through hnRNPM-mediated KCNN1 rescue in injured DRG and offer a novel therapeutic strategy specific for this disorder.
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Affiliation(s)
- Bing Wang
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Longfei Ma
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Xinying Guo
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Shibin Du
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Xiaozhou Feng
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Yingping Liang
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Gokulapriya Govindarajalu
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Shaogen Wu
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Tong Liu
- Center for Advanced Proteomics Research, Departments of Biochemistry, Microbiology and Molecular Genetics, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Hong Li
- Center for Advanced Proteomics Research, Departments of Biochemistry, Microbiology and Molecular Genetics, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Shivam Patel
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Alex Bekker
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Huijuan Hu
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
- Department of Physiology, Pharmacology and Neuroscience, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Yuan-Xiang Tao
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
- Department of Physiology, Pharmacology and Neuroscience, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
- Department of Cell Biology and Molecular Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
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Hussain M, Norgeot B, Zaafran A, Stark J, Caridi J, Fenoy A, Pivalizza E. Virtual transitional pain service delivered via telehealth is effective in preventing new and persistent opioid use amongst post-surgical spine patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.18.23294272. [PMID: 37645940 PMCID: PMC10462235 DOI: 10.1101/2023.08.18.23294272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Opioid dependence is a national crisis, with 30 million patients annually at risk of becoming persistent opioid users after receiving opioids for post-surgical pain management. Translational Pain Services (TPS) demonstrate effectiveness for behavioral health improvements but its effectiveness in preventing persistent opioid use is less established, especially amongst opioid exposed patients. Prohibitive costs and accessibility challenges have hindered TPS program adoption. To address these limitations, we designed and implemented a remote telehealth TPS protocol focusing on preventing continued opioid use while improving behavioral health. Licensed therapists trained in the opioid-tapering CBT protocol delivered sessions reimbursed through standard payer reimbursement. Our prospective study evaluated the protocol's effectiveness on preventing persistent opioid use and behavioral health outcomes amongst both opioid naïve and exposed patients. In an opioid-naive patient cohort (n=67), 100% completely tapered off opioids, while in an opioid-exposed cohort (n =19) 52% completely tapered off opioids, demonstrating promising results. In both cohorts, we observed significant improvements in behavioral health scores, including pain. This opioid-tapering digital TPS is effective, adoptable, and incurs no out-of-pocket cost for healthcare systems. We provide the opioid-tapering CBT protocol in the supplement to facilitate adoption. Trial Registration Impact of Daily, Digital and Behavioral Tele-health Tapering Program for Perioperative Surgical Patients Exposed to Opioids and Benzodiazepines registered at clinicaltrials.gov, NCT04787692. https://clinicaltrials.gov/ct2/show/NCT04787692?term=NCT04787692&draw=2&rank=1.
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Affiliation(s)
| | | | | | - Jessica Stark
- University of Texas Health Sciences Center, McGovern Medical School
| | - John Caridi
- University of Texas Health Sciences Center, McGovern Medical School
| | - Albert Fenoy
- Northwell Health Feinstein Institutes for Medical Research, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | - Evan Pivalizza
- University of Texas Health Sciences Center, McGovern Medical School
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Mo KC, Gupta A, Movsik J, Covarrubius O, Greenberg M, Riley LH, Kebaish KM, Neuman BJ, Skolasky RL. Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery. Spine J 2023; 23:723-730. [PMID: 37100496 PMCID: PMC10154031 DOI: 10.1016/j.spinee.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 11/14/2022] [Accepted: 12/15/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND CONTEXT Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse. PURPOSE The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores. PATIENT SAMPLE Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. OUTCOME MEASURES PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience. METHODS Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores. RESULTS Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all). CONCLUSIONS In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.
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Affiliation(s)
- Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Arjun Gupta
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Movsik
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Oscar Covarrubius
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Marc Greenberg
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Lee H Riley
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
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11
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Buckner JD, Scherzer CR, Crapanzano KA, Morris PE. Group Cognitive Behavioral Therapy for Substance Use Disorders Among Psychiatric Inpatients in a Medically Underserved Area: An Intervention for Opioid Misuse. Public Health Rep 2023; 138:90S-95S. [PMID: 37226947 PMCID: PMC10226069 DOI: 10.1177/00333549231170219] [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: 05/26/2023] Open
Abstract
OBJECTIVES Opioid misuse is a serious public health concern, yet few people seek treatment for this condition. Hospitals may be one opportunity to identify those with opioid misuse and to teach them skills to help manage their opioid misuse upon discharge. We tested the relationship between opioid misuse status and motivation to change substance use among patients admitted with substance misuse to an inpatient psychiatric unit in a medically underserved area in Baton Rouge, Louisiana, who attended at least 1 group session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) from January 29, 2020, through March 10, 2022. METHODS Of the 419 patients in our sample, 86 (20.5%) appeared to misuse opioids (62.5% male; mean age, 35.0 y; 57.7% non-Hispanic/Latin White). At the beginning of each session, patients completed 2 measures of motivation-importance and confidence to change substance use-from 0 (not at all) to 10 (most). At the end of each session, patients rated perceived session helpfulness from 1 (extremely hindering) to 9 (extremely helpful). RESULTS Opioid misuse was associated with greater importance (Cohen d = 0.12) and confidence (Cohen d = 0.13) to change substance use and with attending more MET-CBT sessions (Cohen d = 0.13). Patients with opioid misuse rated sessions as highly helpful (score of 8.3 of 9), and these ratings did not differ from patients who used other substances. CONCLUSIONS Inpatient psychiatry hospitalizations may provide an opportunity to identify patients with opioid misuse and introduce these patients to MET-CBT to learn skills to manage opioid misuse upon discharge.
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Affiliation(s)
- Julia D Buckner
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
- Department of Psychiatry, Louisiana State University School of Medicine, Baton Rouge, LA, USA
- Division of Mental and Behavioral Health, Department of Psychiatry, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | | | - Kathleen A Crapanzano
- Department of Psychiatry, Louisiana State University School of Medicine, Baton Rouge, LA, USA
| | - Paige E Morris
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
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12
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Lam T, Xia T, Biggs N, Treloar M, Cheng O, Kabu K, Stevens JA, Evans JD, da Gama ME, Lubman DI, Nielsen S. Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone. Anaesthesia 2023; 78:420-431. [PMID: 36535726 DOI: 10.1111/anae.15933] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use ('persistence'). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience ('opioid-naive' having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed-effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid-naive and 27.24% opioid-experienced patients met the criteria for persistence. For opioid-naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69-0.94) for opioid-naive patients and 0.81 (0.71-0.93) for opioid-experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.
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Affiliation(s)
- T Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - T Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - N Biggs
- NostraData, Kew, VIC, Australia
| | | | - O Cheng
- IQVIA, St Leonards, NSW, Australia
| | - K Kabu
- IQVIA, St Leonards, NSW, Australia
| | - J A Stevens
- St Vincent's Clinical School, UNSW Medicine, Darlinghurst, NSW, Australia
| | - J D Evans
- Slade Pharmacy, Mount Waverley, VIC, Australia
| | | | - D I Lubman
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
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13
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Mansoor K, De Souza Goncalves B, Lakhani HV, Tashani M, Jones SE, Sodhi K, Thompson E, Dougherty T. Prevalence of Substance Abuse Among Trauma Patients in Rural West Virginia. Cureus 2023; 15:e36468. [PMID: 37090413 PMCID: PMC10117230 DOI: 10.7759/cureus.36468] [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] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Substance abuse poses considerable clinical, economic, and social challenges. West Virginia is hailed as the epicenter of the substance abuse in the United States, the prevalence and pattern of different trauma mechanisms in a rural context or in patients with different forms of substance abuse remain unclear. OBJECTIVE We performed the following analysis to understand the prevalence of substance abuse in patients with different trauma mechanisms in the rural setting with high substance abuse in the West Virginia. METHODS We performed a cross-sectional retrospective analysis of adult trauma patients (motor vehicle, fall, assault, firearm suicide, brawl/rape and machinery) hospitalized in two tertiary care hospitals in West Virginia between 2006 and 2016. We identified all patients who had a urine drug screen (UDS) test and extracted the data related to the substance and trauma. RESULTS Among 8734 patients screened using UDS, 5940 (68.1%) patients were tested positive for the substance. Opiates, alcohol, benzodiazepines, and cannabis were the four most common substances identified in trauma victims. In all instances, the prescribed drug was less than 20%. Fatal outcome was observed in 366 patients in the sample, with 44% (n=162) testing positive for UDS, 12% (n=45) testing positive for only alcohol, and 15% (n=56) testing positive for both alcohol and UDS. Regarding the trauma mechanism, the motor vehicle accident (MVA) was the most prominent with a clear association of substance abuse with fatal outcome. CONCLUSION The most prevalent trauma mechanism was a MVA, with a strong link between drug usage and mortality. Due to the high incidence of positive substance abuse screens, UDS tests may need to be more widely implemented in trauma in the West Virginia region. The findings of this study might help in establishing regional or national policies to reduce acute substance abuse.
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Affiliation(s)
- Kanaan Mansoor
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Bruno De Souza Goncalves
- Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
- Biomedical Sciences, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Hari Vishal Lakhani
- Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
- Biomedical Sciences, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Mohammad Tashani
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Sharon E Jones
- Pharmacology, St. Mary's Medical Center, Huntington, USA
| | - Komal Sodhi
- Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
- Biomedical Sciences, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Ellen Thompson
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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14
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DeJesus J, Shah NR, Franco-Mesa C, Walters ET, Palackic A, Wolf SE. Risk factors for opioid use disorder after severe burns in adults. Am J Surg 2023; 225:400-407. [PMID: 36184330 DOI: 10.1016/j.amjsurg.2022.09.023] [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: 07/27/2022] [Revised: 09/09/2022] [Accepted: 09/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Risk factors for opioid dependence amongst burn patients have not been well-explored compared to other surgical fields. METHODS The TrinetX database was queried for patients diagnosed with opioid use disorder (OUD) after thermal or chemical burn. Propensity score matching was performed. Opioid and non-opioid analgesia use, ICU care, surgery, and comparative risks among common opiates were examined using descriptive and univariate regression models, including odds ratios. Subgroup analysis evaluated the impact of multimodal analgesia. RESULTS Odds of receiving IV opioids for acute analgesia (p = <0.0001, OR = 1.80, CI = 1.45-2.25), undergoing surgery (p = <0.0001, OR = 1.58, CI = 1.26-1.98), and ICU care (p = <0.0001, OR = 3.60, CI = 2.00-3.83) after burn injury were higher in patients who developed OUD. Patients receiving multimodal therapy within 24 hours of admission had lower odds of developing OUD (OR = 0.74, CI = 2.76-4.68, p = 0.0001) and chronic pain (OR = 0.89, CI = 0.78-1.00, p = 0.05) regardless of TBSA. CONCLUSION Patients who developed opioid use disorder following burn injury had higher odds of receiving opioid exclusive pain management, more frequent surgery, ICU care.
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Affiliation(s)
- Jana DeJesus
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Nikhil R Shah
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Camila Franco-Mesa
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Elliot T Walters
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Alen Palackic
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, 8036, Austria.
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
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Liu YS, Kiyang L, Hayward J, Zhang Y, Metes D, Wang M, Svenson LW, Talarico F, Chue P, Li XM, Greiner R, Greenshaw AJ, Cao B. Individualized Prospective Prediction of Opioid Use Disorder. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2023; 68:54-63. [PMID: 35892186 PMCID: PMC9720482 DOI: 10.1177/07067437221114094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD) is a chronic relapsing disorder with a problematic pattern of opioid use, affecting nearly 27 million people worldwide. Machine learning (ML)-based prediction of OUD may lead to early detection and intervention. However, most ML prediction studies were not based on representative data sources and prospective validations, limiting their potential to predict future new cases. In the current study, we aimed to develop and prospectively validate an ML model that could predict individual OUD cases based on representative large-scale health data. METHOD We present an ensemble machine-learning model trained on a cross-linked Canadian administrative health data set from 2014 to 2018 (n = 699,164), with validation of model-predicted OUD cases on a hold-out sample from 2014 to 2018 (n = 174,791) and prospective prediction of OUD cases on a non-overlapping sample from 2019 (n = 316,039). We used administrative records of OUD diagnosis for each subject based on International Classification of Diseases (ICD) codes. RESULTS With 6409 OUD cases in 2019 (mean [SD], 45.34 [14.28], 3400 males), our model prospectively predicted OUD cases at a high accuracy (balanced accuracy, 86%, sensitivity, 93%; specificity 79%). In accord with prior findings, the top risk factors for OUD in this model were opioid use indicators and a history of other substance use disorders. CONCLUSION Our study presents an individualized prospective prediction of OUD cases by applying ML to large administrative health datasets. Such prospective predictions based on ML would be essential for potential future clinical applications in the early detection of OUD.
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Affiliation(s)
- Yang S Liu
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada.,Analytics and Performance Reporting Branch, Ministry of Health, 151965Government of Alberta, Edmonton, Alberta, Canada
| | - Lawrence Kiyang
- Analytics and Performance Reporting Branch, Ministry of Health, 151965Government of Alberta, Edmonton, Alberta, Canada
| | - Jake Hayward
- Department of Emergency Medicine, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Yanbo Zhang
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Dan Metes
- Analytics and Performance Reporting Branch, Ministry of Health, 151965Government of Alberta, Edmonton, Alberta, Canada
| | - Mengzhe Wang
- Analytics and Performance Reporting Branch, Ministry of Health, 151965Government of Alberta, Edmonton, Alberta, Canada
| | - Lawrence W Svenson
- Analytics and Performance Reporting Branch, Ministry of Health, 151965Government of Alberta, Edmonton, Alberta, Canada.,School of Public Health, 3158University of Alberta, Edmonton, Alberta, Canada.,Division of Preventive Medicine, 3158University of Alberta, Edmonton, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Fernanda Talarico
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Pierre Chue
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Xin-Min Li
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Russell Greiner
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada.,Department of Computing Science, 3158University of Alberta, Edmonton, Alberta, Canada.,Alberta Machine Intelligence Institute (Amii), Edmonton, Alberta, Canada
| | - Andrew J Greenshaw
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Bo Cao
- Department of Psychiatry, 3158University of Alberta, Edmonton, Alberta, Canada.,Analytics and Performance Reporting Branch, Ministry of Health, 151965Government of Alberta, Edmonton, Alberta, Canada
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16
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Auty SG, Barr KD, Frakt AB, Garrido MM, Strombotne KL. Effect of a Veterans Health Administration mandate to case review patients with opioid prescriptions on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial. Addiction 2022; 118:870-879. [PMID: 36495477 DOI: 10.1111/add.16110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
AIMS The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high risk by STORM. The aim of this study was to measure the effect of this mandate on all-cause mortality and SAEs among VHA patients newly diagnosed with opioid use disorder (OUD). DESIGN Secondary analysis of a stepped-wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018 to 2020. SETTING AND PARTICIPANTS United States VHA facilities were randomized to case review the top 1 or 5% of high-risk patients prescribed opioid analgesics identified by STORM. A total of 28 251 patients were diagnosed with OUD during the trial and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post-hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation. MEASUREMENTS All-cause mortality and opioid-related, drug-related, suicide-related and other SAEs within 90 days of OUD diagnosis. FINDINGS Mandated case review increased the odds of 90-day mortality [odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.06, 2.87], but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all-cause mortality within 90 days was 5.87 (95% CI = 1.85, 18.58) relative to control patients. CONCLUSIONS Veterans Health Administration patients newly diagnosed with opioid use disorder experienced increased all-cause mortality following expansion of a case review mandate for high-risk patients prescribed opioids.
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Affiliation(s)
- Samantha G Auty
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Kyle D Barr
- Partnered Evidence-Based Policy Resource Center, Veterans Administration Boston Healthcare System, Boston, MA, USA
| | - Austin B Frakt
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.,Partnered Evidence-Based Policy Resource Center, Veterans Administration Boston Healthcare System, Boston, MA, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.,Partnered Evidence-Based Policy Resource Center, Veterans Administration Boston Healthcare System, Boston, MA, USA
| | - Kiersten L Strombotne
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.,Partnered Evidence-Based Policy Resource Center, Veterans Administration Boston Healthcare System, Boston, MA, USA
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17
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Kim M, Kim S, Suh HS. Economic burden of opioid misuse focused on direct medical costs. Front Pharmacol 2022; 13:928890. [PMID: 36324692 PMCID: PMC9620516 DOI: 10.3389/fphar.2022.928890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Since their development, synthetic opioids have been used to control pain. With increased opioid use, problematic opioid prescription has also increased, resulting in a growing economic burden. However, there is a paucity of research studies on the economic burden of prescription opioid misuse in Asia, especially South Korea. Objectives: To estimate the incremental economic burden of prescription opioid misuse for the South Korean population. Methods: The National Health Insurance Service-National Sample Cohort database, covering 2% of the South Korean population between 2010 and 2015, was analyzed. Outpatients aged 18 or older who took one or more prescription opioids were selected. Based on their opioid prescription patterns, patients were classified into opioid misuse and non-misuse groups. The direct medical costs per person per year (PPPY) and the incremental economic burden of the opioid misuse group were explored using an exponential conditional model with a suitable distribution and log link function. All analyses were performed using SAS® Enterprise Guide version 9.4, and p < 0.05 was considered statistically significant. Results: The number of patients who had ≥1 opioid prescription was 345,020 including 84,648 (24.53%) in the opioid misuse group and 260,372 (75.47%) in the non-misuse group. The adjusted mean direct medical costs PPPY were estimated to be USD 401 for the opioid misuse group, which is 1.49 times significantly higher than that for the non-misuse group (p < 0.0001). The incremental economic burden of the opioid misuse group in the South Korean population was estimated to be approximately USD 0.52 billion for the period 2010–2015. Conclusion: Prescription opioid misuse was significantly associated with the increased economic burden. Along with proper policies for using opioids, it is necessary to monitor opioid prescription patterns to prevent opioid misuse and reduce the related economic burden.
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Affiliation(s)
- Miryoung Kim
- College of Pharmacy, Pusan National University, Busan, South Korea
| | - Siin Kim
- College of Pharmacy, Kyung Hee University, Seoul, South Korea
| | - Hae Sun Suh
- College of Pharmacy, Kyung Hee University, Seoul, South Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, South Korea
- *Correspondence: Hae Sun Suh,
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18
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Kay A, Shmuts R, Beck M. Understanding and co-managing medication treatment options for opioid use disorder. Intern Emerg Med 2022; 17:2159-2165. [PMID: 35138549 DOI: 10.1007/s11739-022-02936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
The number of patients with opioid use disorder (OUD) has increased dramatically. Substance use disorders in general are thought to occur in one in five patients in primary care. However, despite this prevalence, there is a dearth of training in undergraduate and continuing medical education to manage OUDs, and internal medicine doctors need to have an understanding of the basic physiology and treatment options for this illness. Expanding knowledge of OUD treatments will allow internists to use their skills and strong patient-doctor relationships to ensure the trust of their patients with OUD, leading to better outcomes and increased chances of recovery. It will also allow clinicians to appropriately refer their patients for lifesaving specialized care and help them prevent dangerous medical complications often seen as a result of addiction. There are three FDA-approved medications to treat OUD disorder, known collectively as medication-assisted treatment (MAT). In this paper, the three medications-methadone, naltrexone, and buprenorphine-are presented, compared, contrasted, and clinically reviewed.
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Affiliation(s)
- Abigail Kay
- Department of Psychiatry and Human Behavior-Division of Substance Abuse, The Sidney Kimmel Medical College at Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rachel Shmuts
- Department of Psychiatry, Rowan University School of Osteopathic Medicine, Mount Laurel, NJ, USA.
| | - Melanie Beck
- Cooper Medical School of Rowan University at AtlantiCare Regional Medical Center, Atlantic City, NJ, USA
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19
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Hoke AT, Malfitano M, Zanation AM, Ebert CS, Senior BA, Kimple AJ, Thorp BD. Postoperative Pain Management and Perceived Patient Outcomes following Endoscopic Pituitary Surgery. J Neurol Surg B Skull Base 2022; 83:397-404. [PMID: 35903651 PMCID: PMC9324296 DOI: 10.1055/a-1692-9879] [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: 07/07/2020] [Accepted: 11/06/2021] [Indexed: 10/19/2022] Open
Abstract
Objectives Pain management remains a point of emphasis given the ongoing opioid crisis. There are no studies in the literature interrogating opioid prescribing and use following endoscopic pituitary surgery. This study investigates provider prescribing tendency, patient utilization of analgesics, and patient outcomes regarding pain management after endoscopic pituitary surgery. Methods We identified 100 patients undergoing endoscopic pituitary surgery at one institution from 2016 to 2018 in the electronic medical record (EMR) and state narcotic database to determine postoperative analgesic regimens. A telephone survey was used to characterize postoperative analgesic use and satisfaction with prescribed regimen. Results Fifty-two different pain control regimens were prescribed to the study patients. Also, 93% of study patients were prescribed an opioid postoperatively. The average quantity of opioids prescribed per patient in morphine milligram equivalents (MMEs) was 625 (equivalent 83 oxycodone 5-mg tablets) with an average MME/day of 59 (equivalent 8 oxycodone 5-mg tablets). A total of 71% survey respondents who used opioids reported using <25% of their prescription. The majority of prescription narcotic users consumed >50% of their postoperative opioid intake in the first 24 to 48 hours after discharge. There were no significant differences in pain outcome between opioid users and nonopioid users. Conclusion Vast heterogeneity exists in narcotic prescribing by providers at our institution following endoscopic pituitary surgery. Narcotic prescribing patterns exceeded most patients' analgesic needs. Opioid analgesics were not superior to nonopioids regimens in patient-reported pain outcomes in this study population.
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Affiliation(s)
- Austin T.K. Hoke
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Madison Malfitano
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Adam M. Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Charles S. Ebert
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Brent A. Senior
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Adam J. Kimple
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
| | - Brian D. Thorp
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel, North Carolina, United States
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20
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Swiggett SJ, Ciminero ML, Weisberg MD, Vakharia RM, Sadeghpour R, Choueka J. Implant-related complications in patients with opioid use disorder undergoing primary shoulder arthroplasties: a matched-controlled analysis. Shoulder Elbow 2022; 14:395-401. [PMID: 35846397 PMCID: PMC9284306 DOI: 10.1177/1758573221994790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether patients undergoing primary shoulder arthroplasty with opioid use disorder have higher rates of (1) implant-related complications; (2) in-hospital lengths of stay; (3) readmission rates; and (4) costs of care. METHODS Opioid use disorder patients undergoing primary shoulder arthroplasty were queried and matched in a 1:5 ratio to controls by age, sex, and medical comorbidities within the Medicare database. The query yielded 25,489 patients with (n = 4253) and without (n = 21,236) opioid use disorder. Primary outcomes analyzed included: 2-year implant related complications, in-hospital lengths of stay, 90-day readmission rates, and 90-day costs of care. A p value less than 0.01 was considered statistically significant. RESULTS Opioid use disorder patients had significantly longer in-hospital lengths of stay (3 days vs. 2 days; p < 0.0001) compared to matched controls. Opioid use disorder patients were also found to have higher incidence and odds (OR) of readmission rates (12.84 vs. 7.45%; OR: 1.16, p < 0.0001) and implant-related complications (20.03 vs. 7.95%; OR: 1.82, p < 0.0001). Study group patients also incurred significantly higher 90-day costs of care ($16,918.85 vs. $15,195.37, p < 0.0001). DISCUSSION This study can be used to help further augment efforts to reduce opioid prescriptions from healthcare providers in shoulder arthroplasty settings.
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Affiliation(s)
| | | | | | - Rushabh M Vakharia
- Rushabh M Vakharia, Maimonides Medical Center, 4802
10th Avenue, Brooklyn, NY 11219, USA.
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21
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Vowles KE, Schmidt ZS, Ford CG. Opioid and Alcohol Misuse in Veterans with Chronic Pain: A Risk Screening Study. THE JOURNAL OF PAIN 2022; 23:1790-1798. [PMID: 35753662 DOI: 10.1016/j.jpain.2022.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 10/17/2022]
Abstract
In United States military veterans, chronic pain represents a risk factor for opioid and alcohol misuse, yet few studies have examined interactions among chronic pain, opioid prescription, and opioid and alcohol misuse. Previous work found substantial risk of co-morbid alcohol and opioid misuse in a community sample of opioid-prescribed individuals with chronic pain, a finding expanded upon here. Specifically, 211 veterans assessed within a chronic pain treatment service for opioid-prescribed individuals completed self-report measures of opioid misuse, alcohol misuse, pain intensity, depression, pain catastrophizing, and post-traumatic stress symptoms (PTS). Based on the substance misuse measures, 32% (n = 68) were misusing neither opioids nor alcohol, 23% (n = 48) were misusing both opioids and alcohol, 40% (n = 84) were misusing opioids alone, and 5% (n = 11) were misusing alcohol alone. Group comparisons indicated that individuals not misusing either substance were less distressed in comparison to those who were misusing opioids alone or both substances. The latter groups differed in PTS. Overall, misuse frequencies mirrored previous work, with approximately 1 of 3 misusing opioids and approximately 1 of 5 misusing both substances. There is a need for increased focus on both polysubstance misuse and the development of integrated treatment.
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Affiliation(s)
- Kevin E Vowles
- School of Psychology, Queen's University Belfast & Belfast Centre for Chronic Pain Rehabilitation, Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom.
| | - Zachary S Schmidt
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico VA Healthcare System, Albuquerque, New Mexico, United States of America
| | - C Graham Ford
- Durham Veterans Affairs Medical Center, Durham, North Carolina, United States of America
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Radic M, Parlier-Ahmad AB, Wills B, Martin CE. Social determinants of health and emergency department utilization among adults receiving buprenorphine for opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100062. [PMID: 35783992 PMCID: PMC9248991 DOI: 10.1016/j.dadr.2022.100062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Individuals with opioid use disorder (OUD) use the emergency department (ED) at high rates. Medication treatment for OUD (MOUD) is associated with reduced ED utilization. However, individuals receiving MOUD still utilize ED services at higher rates than the general population. The objective of this study is to compare the psychosocial and clinical characteristics of those who do and do not utilize ED services based on the Healthy People 2030 framework regarding social determinants of health (SDoH) among a sample of individuals receiving MOUD. METHODS Participants receiving buprenorphine for OUD at an outpatient addiction clinic completed a cross-sectional survey between July and September 2019. A 6-month prospective medical record review was conducted. The primary outcome was ED visit (yes/no) during the 6-month study period. Demographic, psychosocial, and clinical characteristics were gathered from survey measures and chart abstraction. Chi square and T-tests tested differences by ED utilization. RESULTS Participants (n=142) were 54.9% female and 68.8% Black, with an average age of 43.2 years (SD=12.5). Of the participants, 38.7% visited the ED in the study period, primarily for infectious or musculoskeletal causes. Participants with an ED visit were more likely to be Black (p=.011), have less social support (p=.030), more medical comorbidities (p=.008) including chronic pain (p=.045), and more visits with an addiction provider in the study period (p=.009). CONCLUSIONS Factors associated with ED utilization among individuals receiving buprenorphine for OUD include low social support and medical comorbidities, including chronic pain. More research is needed on modifiable SDoH that influence ED utilization.
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Affiliation(s)
- Maja Radic
- Virginia Commonwealth University School of Medicine, 1201 E Marshall St, Richmond, VA 23298, USA
| | - Anna Beth Parlier-Ahmad
- Department of Psychology, Virginia Commonwealth University, 806 W. Franklin St., Richmond, VA 23284, USA
| | - Brandon Wills
- Department of Emergency Medicine, Virginia Commonwealth University, 1250 E. Marshall St., Richmond, VA 23298, USA
| | - Caitlin E. Martin
- Department of Obstetrics and Gynecology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St., Richmond, VA 23298, USA
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23
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Hamour AF, Laliberte F, Levy J, Xu J, Park E, Lin V, de Almeida J, Strychowsky J, Eskander A, Monteiro E. Overprescription of opioid analgesia is common following ambulatory Otolaryngology-Head and Neck surgery procedures: A multicenter study. World J Otorhinolaryngol Head Neck Surg 2022; 8:145-151. [PMID: 35782395 PMCID: PMC9242421 DOI: 10.1002/wjo2.19] [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: 04/14/2021] [Accepted: 09/02/2021] [Indexed: 11/28/2022] Open
Abstract
Background The rise in the use of prescription opioids for postoperative analgesia within surgery has mirrored an increased trend of opioid-related morbidity within Canada and the United States. This study prospectively studied daily pain levels and medication requirements postoperatively in patients undergoing elective Otolaryngology-Head and Neck surgery procedures. Methods Patients were asked to prospectively document their pain level and medication use daily for 7 days postoperatively. A final survey was used to quantify unused medication left at home and clarify each patient's disposal plan. We included patients undergoing elective outpatient or short stay surgeries from three tertiary care centers in Toronto, Ontario from September 2016 to September 2017. Previous opioids users or patients suffering from chronic pain were excluded. Results A final cohort of 56 eligible adult patients were included in the study. The most common procedures were thyroidectomy (n = 19), endoscopic sinus surgery (n = 10), tympanoplasty/ossiculoplasty (n = 7), and cochlear implant (n = 5). Most patients received a prescription for acetaminophen/codeine (n = 29, 51.8%) or acetaminophen/oxycodone (n = 22, 39.3%) and used on average 29% of their initial prescription. Patients most commonly opted to keep their unused narcotics at home (n = 23, 41%). A total of 710 tablets of narcotics were overprescribed in our study population, 351 of which were kept in patients' home for future use. Conclusion There is a clear tendency to overestimate postoperative pain resulting in significant overprescription of opioids among Otolaryngologists.
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Affiliation(s)
- Amr F. Hamour
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Frederick Laliberte
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Jordan Levy
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Jason Xu
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Edward Park
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Vincent Lin
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - John de Almeida
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Julie Strychowsky
- Department of Otolaryngology‐Head and Neck SurgeryLondon Health Sciences CentreLondonOntarioCanada
| | - Antoine Eskander
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Eric Monteiro
- Department of Otolaryngology‐Head and Neck SurgeryMount Sinai HospitalTorontoOntarioCanada
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Peluso H, Mujadzic H, Abougergi MS, Mujadzic T, Azefor TB, Caffrey J. Opioid dependence and treatment outcomes among patients with burn injury. Burns 2022; 48:774-784. [PMID: 34922783 DOI: 10.1016/j.burns.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 06/24/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with burn injuries cause significant healthcare economic burden, often utilising extra-hospital resources, caregiving, and specialized care. METHODS We present a retrospective cohort analysis of the hospitalized patients in the USA with a primary diagnosis of burn injury. Opioid dependence was identified using ICD-10 CM codes. The 30-day all-cause readmission rate was the main outcome while secondary outcomes were inhospital mortality rate, resource utilization which included hospital length of stay, total hospitalization costs and charges and surgical procedures for burn injury treatment as well as the most important five principal diagnoses for admission and readmission. RESULTS Out of 22,348 patients included in the study, 597 had opioid dependence. Older patients (43 years, range: 38.6-47.2 years) as well as males (70.8%) were more likely to be opioid dependent. Opioid dependence was associated with higher 30-day readmission rates (aOR: 1.83, 95% confidence interval (CI): 1.30-2.57, p-value: <0.01), higher total hospitalization costs (aMD: $14,981, CI: $3820-$26,142, p-value: 0.01), total hospitalization charges (aMD: $47,078, CI: -$5093 to $89,063, p-value: 0.03), and a shorter mean length of stay (aMD: 5.13 days, CI: 2.60-7.66, p-value: <0.01). However, patients with and without opioid dependence had similar in-hospital mortality rates (aOR: 0.27, CI: 0.06-1.28, p-value: 0.10). CONCLUSION We are the first to our knowledge to report the association of treatment outcomes and opioid dependence in patients hospitalized at the national level with a burn injury. We show that there were higher 30-day all-cause readmission rates and in-hospital resource utilization among patients with opioid-dependence.
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Affiliation(s)
- Heather Peluso
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Temple University Hospital and Lewis Katz School of Medicine, Philadelphia, PA, USA; Catalyst Medical Consulting, 722 Elmbrook Drive, Simpsonville, SC 29681, USA.
| | - Hata Mujadzic
- Department of Internal Medicine, Prisma Health Midlands, 5 Medical Park Road, Columbia, SC 29203, USA.
| | - Marwan S Abougergi
- Catalyst Medical Consulting, 722 Elmbrook Drive, Simpsonville, SC 29681, USA; Division of Gastroenterology, Department of Internal Medicine, Prisma Health Midlands, 5 Medical Park Road, Columbia, SC 29203, USA.
| | - Tariq Mujadzic
- Department of Surgery, Division of Plastic Surgery, Prisma Health Midlands, 5 Medical Park Road, Columbia, SC 29203, USA.
| | - Tangwan B Azefor
- Department of Anesthesia & Critical Care Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD 21224, USA.
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University Medical Center, Burn Unit, Bayview Campus, 4940 Eastern Ave, Baltimore, MD 21224, USA.
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25
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Champagne-Langabeer T, Cardenas-Turanzas M, Ugalde IT, Bakos-Block C, Stotts AL, Cleveland L, Shoptaw S, Langabeer JR. The Impact of Pediatric Opioid-Related Visits on U.S. Emergency Departments. CHILDREN 2022; 9:children9040524. [PMID: 35455568 PMCID: PMC9030094 DOI: 10.3390/children9040524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/25/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022]
Abstract
Background: While there is significant research exploring adults’ use of opioids, there has been minimal focus on the opioid impact within emergency departments for the pediatric population. Methods: We examined data from the Agency for Healthcare Research, the National Emergency Department Sample (NEDS), and death data from the Centers for Disease Control and Prevention. Sociodemographic and financial variables were analyzed for encounters during 2014–2017 for patients under age 18, matching diagnoses codes for opioid-related overdose or opioid use disorder. Results: During this period, 59,658 children presented to an ED for any diagnoses involving opioids. The majority (68.5%) of visits were related to overdoses (poisoning), with a mean age of 11.3 years and a majority female (53%). There was a curvilinear relationship between age and encounters, with teens representing the majority of visits, followed by infants. The highest volume was seen in the Southern U.S., with over 58% more opioid visits than the next highest region (Midwest). Charges exceeded USD 157 million, representing 2% of total ED costs, with Medicaid responsible for 54% of the total. Conclusions: With increases in substance use among children, there is a growing need for pediatric emergency physicians to recognize, refer, and initiate treatments.
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Affiliation(s)
- Tiffany Champagne-Langabeer
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
- Correspondence:
| | - Marylou Cardenas-Turanzas
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
| | - Irma T. Ugalde
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA;
| | - Christine Bakos-Block
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
| | - Angela L. Stotts
- Department of Family and Community Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA;
| | - Lisa Cleveland
- UTHealth San Antonio, School of Nursing, San Antonio, TX 78229, USA;
| | - Steven Shoptaw
- Center for Behavioral and Addiction Medicine, Department of Family Medicine, University of California, Los Angeles, CA 90024, USA;
| | - James R. Langabeer
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA;
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26
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Luo J, Collier W, Magno-Padron D, Tieman J, Pires G, Moss W, Rosales M, Kim J, Agarwal JP, Kwok AC. Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah. Popul Health Manag 2022; 25:472-479. [PMID: 35353618 DOI: 10.1089/pop.2021.0275] [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: 11/13/2022] Open
Abstract
In the United States, the top 1% and top 5% of health care spenders account for 23% and 50% of total health care spending, respectively. These high spenders have been coined the term super utilizers (SU). The aim of this study was to identify the characteristics associated with these patients to aid in developing public health interventions aimed at transitioning patients out of the SU category and thus ultimately helping to control health care costs. The authors utilized the Utah All-Payer Claims Database and Utah Population Database from 2013 to 2015 to identify demographics, comorbid conditions, health care utilization, and cost characteristics of persistent super utilizers (PSU) (≥3 hospitalizations per year for 3 years) of health care compared with persistent nonsuper utilizers (PNSU) (<3 hospitalizations per year for 3 years). Multivariable logistic regression was utilized to identify the characteristics associated with PSU versus PNSU. Higher outpatient/Emergency Department/noninpatient (eg, visits with imaging and Centers for Medicare & Medicaid Services preventive visits) health care utilization and spending, and prevalence of comorbid disease and psychosocial conditions were associated with PSU. In multivariable analysis, factors such as heart disease, chronic kidney disease (CKD), diabetes, alcohol abuse, and depression were statistically significantly associated with higher odds of PSU, with the most noteworthy being CKD (odds ratio [OR] 6.85, 95% confidence interval [95% CI] 5.84-8.02; P < 0.001), alcohol abuse (OR 5.90, 95% CI 4.49-7.69; P < 0.001), and heart diseases (OR 4.41, 95% CI 3.74-5.18; P < 0.001). The annual health care cost of a PSU is about 11.5 times greater than a PNSU ($54,776 vs. $4801; P < 0.001).
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Affiliation(s)
- Jessica Luo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Willem Collier
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David Magno-Padron
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joshua Tieman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Giovanna Pires
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Whitney Moss
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Megan Rosales
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jaewhan Kim
- Department of Physical Therapy and Athletic Training, and CTSI Health Economics Core, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jayant P Agarwal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alvin C Kwok
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Matjasko JL, Chovnick G, Bradford J, Treves-Kagan S, Usher K, Vaughn E, Ingoldsby E. Strengthening Communities: A Qualitative Assessment of Opportunities for the Prevention of Adverse Childhood Experiences in the Wake of the Opioid Crisis. JOURNAL OF CHILD AND FAMILY STUDIES 2022; 31:1145-1157. [PMID: 35002194 PMCID: PMC8722648 DOI: 10.1007/s10826-021-02202-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
The opioid crisis is a significant challenge for health and human service systems that serve children, youth, and families across the United States. Between 2000 and 2017, the number of foster care entries, a type of adverse childhood experience (ACE), attributable to parental drug use increased by 147%. Nevertheless, there is variation in the burden of opioid overdose and foster care rates across the U.S., suggesting community supports and systems to support families affected by substance use also vary. This qualitative study sampled communities experiencing high and low rates of overdose mortality and foster care entries (i.e., a qualitative comparison group) to better understand what might protect some counties from high overdose mortality and foster care entries. The sample included six counties from three states that were selected based on their rates of opioid overdose mortality and foster care entries. Using purposive sampling within counties, interview and discussion group participants included multi-sector community partners, parents whose children had been removed due to parental substance use, and caregivers caring for children who had been removed from their homes. Across all counties, prevention was not front-of-mind. Yet, participants from communities experiencing high rates of overdose mortality and foster care entries identified several factors that might help lessen exposure to substance use and ACEs including more community-based prevention services for children and youth. Both parents and caregivers across all communities also described the need for additional supports and services. Participants also described the impact of COVID-19 on services, including greater utilization of mental health and substance use treatment services and the challenges with engaging children and youth on virtual platforms. The implications for prevention are discussed, including the need to encourage primary prevention programs in communities.
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Affiliation(s)
- Jennifer L. Matjasko
- Division of Violence Prevention, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341 USA
| | - Gary Chovnick
- 2635 Century Center Parkway, ICF, Suite 1000, Atlanta, GA 30345 USA
| | - Joivita Bradford
- Division of Violence Prevention, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341 USA
| | - Sarah Treves-Kagan
- Division of Violence Prevention, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341 USA
| | - Kristen Usher
- 2635 Century Center Parkway, ICF, Suite 1000, Atlanta, GA 30345 USA
| | - Elizabeth Vaughn
- 2635 Century Center Parkway, ICF, Suite 1000, Atlanta, GA 30345 USA
| | - Erin Ingoldsby
- James Bell Associates, 3033 Wilson Blvd. Suite 650, Arlington, VA 22201 USA
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28
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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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Mostafavi H, Dadashi M, Armani Kia A, Ahmadi D, Pirzeh R, Eskandari Z. The effect of bilateral tDCS over dorsolateral prefrontal cortex on the cognitive abilities of men with opioid use disorder under methadone therapy: A sham-controlled clinical trial. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background/aim
Opioid use disorder (OUD) can have negative impact on cognitive functions. This study aims to evaluate the effect of bilateral transcranial direct-current stimulation (tDCS) over the right/left dorsolateral prefrontal cortex (DLPFC) on the cognitive abilities of OUD men.
Methods
This study is a double-blind sham-controlled randomized clinical trial with a pretest/posttest design. Participants were 31 men with OUD living in Zanjan, Iran, assigned to three groups of left anode/right cathode tDCS, right anode/left cathode tDCS, and sham tDCS. The two active groups received tDCS (2 mA) at 10 sessions each for 10–20 min. The Cognitive Abilities Questionnaire (CAQ) in Persian was used to measure their cognitive abilities before and after intervention. Collected data were analyzed in SPSS v.22 software.
Results
Bilateral DLPFC stimulation resulted in a significant improvement in cognitive flexibility, planning, decision making, inhibitory control/selective attention, and memory of patients in the two active tDCS groups, while the sham tDCS had no significant effect on their cognitive abilities.
Conclusion
Bilateral tDCS over DLPFC, as an effective and complementary treatment, can improve the cognitive abilities of men with OUD.
Trial registration: This study is a double-blind sham-controlled clinical trial (Parallel, IRCT20170513033946N5. Registered 19 Jan 2019, https://en.irct.ir/trial/36081).
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Rosen LJ, Galili T, Kott J, Rees V. Beyond "Safe and Effective": The urgent need for high-impact smoking cessation medications. Prev Med 2021; 150:106567. [PMID: 33957153 DOI: 10.1016/j.ypmed.2021.106567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
Smoking cessation medications (SCMs) are an evidence-based cornerstone of comprehensive tobacco control programs globally. However, the impact of SCMs on population smoking prevalence is controversial, with inconsistencies between randomized controlled trials (RCTs) and population-based observational studies. We estimated SCM impact on permanent cessation and population smoking prevalence by extrapolating efficacy estimates from meta-analyses of RCTs, using the standard population impact formula: efficacy*reach. We calculated the potential SCM impact under a range of assumptions for permanent cessation (20%,14%), behavioral support (yes/no), reach (40%-2%), and underlying smoking prevalence. Assuming behavioral support for all, depending on reach, 8%-0.3% of smokers are expected to quit permanently. Without behavioral support, permanent cessation is estimated to be 6.4%-0.2%. Assuming an underlying population smoking prevalence of 14%, (current U.S. prevalence), the maximum impact on population smoking prevalence is 1.12%. Impact on prevalence increases with increasing underlying country-specific levels of prevalence. With current U.S. levels of reach, behavioral support and smoking prevalence, we estimate that, based on a single course of treatment, 2.3% of smokers would quit permanently, contributing to a 0.3% decrease in population level smoking prevalence. Even under ideal conditions, the potential of current first-line SCMs to increase cessation in a substantial proportion of smokers, and reduce population smoking prevalence, is limited. In order to avert the predicted billion tobacco-caused deaths in this century, "safe and effective" medications are not sufficient: SCMs with high population impact are urgently needed. Policies to ensure the availability and accessibility of highly efficacious SCMs, with behavioral support, are crucial.
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Affiliation(s)
- Laura J Rosen
- Dept. of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Israel; Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard T. Chan School of Public Health, Boston, MA, USA.
| | - Tal Galili
- Department of Statistics and Operations Research, The Sackler Faculty of Exact Sciences, Tel Aviv University, Tel Aviv 69978, Ramat-Aviv, Israel.
| | | | - Vaughan Rees
- Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard T. Chan School of Public Health, Boston, MA, USA
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31
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Wehler CJ, Panchal NH, Cotchery DL, Farooqi OA, Ferguson DK, Foran D, Hakki OW, Silva R, Smith GM, Gibson G. Alternatives to opioids for acute pain management after dental procedures: A Department of Veterans Affairs consensus paper. J Am Dent Assoc 2021; 152:641-652. [PMID: 34325780 DOI: 10.1016/j.adaj.2021.03.022] [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: 10/27/2020] [Revised: 03/11/2021] [Accepted: 03/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Opioid misuse is a widespread public health problem, and opioids are often prescribed in the dental environment. These recommendations provide alternatives to opioids to reduce or eliminate dental procedure-related acute pain. METHODS A multidisciplinary working group developed these clinical recommendations to specifically address procedure-related acute pain. These recommendations, which are based on published peer-reviewed research and guidelines, include therapies used before, during, and after dental procedures. When evidence is not definitive, the best practices, which are based on experts' consensus, are included. The recommendations are not intended to be exhaustive. RESULTS These recommendations are a summary of the evidence and best practices for opioid alternatives to treat acute pain related to dental procedures. CONCLUSIONS Dental providers should prioritize opioid stewardship when managing procedure-related pain with strategies such as thorough preprocedure pain assessment, minimally invasive techniques, preemptive analgesia, intraprocedure pain management, and appropriately selected postprocedure pharmacologic therapy. PRACTICAL IMPLICATIONS These recommendations are a concise resource for clinical providers. It is important to address patients' procedure-related pain, using nonopioids whenever possible. Alternatives are outlined, allowing providers to make informed decisions.
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Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations Executive Summary. Otolaryngol Head Neck Surg 2021; 164:687-703. [PMID: 33822678 DOI: 10.1177/0194599821996303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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Affiliation(s)
| | - James Whit Mims
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - John D Cramer
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Dickerson
- NorthShore University Health System, Evanston, Illinois, USA.,University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Adam J Folbe
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Deepa J Galaiya
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna H Messner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Allison Paisley
- University of Pennsylvania Otorhinolaryngology, Philadelphia, Pennsylvania, USA
| | - Ahmad R Sedaghat
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Angela K Sturm
- Angela Sturm, MD, PLLC, Houston, Texas, USA.,University of Texas Medical Branch, Galveston, Texas, USA
| | - Erin M Lambie
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Chung AS, Crandall D, Revella J, Adeniyi B, Chang YHH, Chang MS. Does Local Administration of Liposomal Bupivacaine Reduce Pain and Narcotic Consumption in Adult Spinal Deformity Surgery? Global Spine J 2021; 11:896-902. [PMID: 32677519 PMCID: PMC8258814 DOI: 10.1177/2192568220931053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine if local administration of liposomal bupivacaine (LB) reduces postoperative pain scores and narcotic use in spinal deformity patients. METHODS Adult patients undergoing elective spinal fusion (7 or more levels) for scoliosis or kyphosis were selected for inclusion. Patients received either periincisional injections of combined liposomal and standard bupivacaine (n = 90, group L) or standard bupivacaine only (n = 69, group C). Perioperative pain scores (VAS [visual analogue scale]), opioid use, length of stay, functional outcome (ODI [Oswestry Disability Index]), and perioperative complications were recorded. No external funding was received for this study. RESULTS A total of 159 patients met inclusion criteria (mean age was 54.2 years of age). No significant baseline demographic differences were noted between the 2 groups. Group L experienced slight improvements in pain control on postoperative day (POD) 1 (P = .02). No difference in pain scores were otherwise noted. Group L transitioned off of intravenous (IV) narcotics faster with 52.6% less IV use by POD3 (P = .03). No differences in total narcotic consumption, perioperative complications, lengths of stay, and functional outcome scores were otherwise noted between the 2 cohorts. CONCLUSIONS The use of LB in adult spinal deformity surgery does not appear to provide clinically important improvements in postoperative pain at the manufacturer's recommended dosage. Furthermore, while patients receiving LB may transition more quickly off of IV narcotics, this does not appear to translate into an overall decrease in narcotic consumption, hasten return of bowel function, or decrease hospital lengths of stay. Future prospective randomized control trials are warranted. The use of varying dosages of LB may also help further clarify the true efficacy of LB in the setting of spinal deformity surgery.
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Affiliation(s)
- Andrew S. Chung
- Sonoran Spine Center, Phoenix, AZ, USA,Andrew S. Chung, Sonoran Spine Center, 1255 W Rio Salado Pkwy #107, Tempe, AZ 85281, USA.
| | - Dennis Crandall
- Sonoran Spine Center, Phoenix, AZ, USA,Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
| | - Jan Revella
- Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
| | - Biodun Adeniyi
- Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
| | | | - Michael S. Chang
- Sonoran Spine Center, Phoenix, AZ, USA,Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
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Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg 2021; 164:S1-S42. [PMID: 33822668 DOI: 10.1177/0194599821996297] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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Affiliation(s)
| | - James Whit Mims
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - John D Cramer
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Dickerson
- NorthShore University Health System, Evanston, Illinois, USA.,University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Adam J Folbe
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Deepa J Galaiya
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna H Messner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Allison Paisley
- University of Pennsylvania Otorhinolaryngology, Philadelphia, Pennsylvania, USA
| | - Ahmad R Sedaghat
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Angela K Sturm
- Angela Sturm, MD, PLLC, Houston, Texas, USA.,University of Texas Medical Branch, Galveston, Texas, USA
| | - Erin M Lambie
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Drug Utilization for Pain Management during Perioperative Period of Total Knee Arthroplasty in China: A Retrospective Research Using Real-World Data. ACTA ACUST UNITED AC 2021; 57:medicina57050451. [PMID: 34066351 PMCID: PMC8148133 DOI: 10.3390/medicina57050451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/24/2021] [Accepted: 04/28/2021] [Indexed: 11/17/2022]
Abstract
Background and Objective: Total knee arthroplasty (TKA) is one of the most painful procedures and perioperative pain usually requires the use of many analgesics to relieve it. The appropriate use of analgesics to relieve patient pain is an important issue of TKA. To characterize the drug utilization for pain management during perioperative period of TKA in China using real-world data of electronic medical records. Materials and Methods: This research used the data of all inpatients who received TKA at 145 hospitals covered 31 provinces in China from 1 January 2016 to 31 December 2018. The exclusion criteria included pregnancy and cancer diagnosis. In the analysis of drug utilization mode (DUM), medicines were classified into 5 groups: non-steroidal anti-inflammatory drugs (NSAIDs), opioids, non-opioid central analgesics, acetaminophen and others. Results: Among the 2017 patients included in this study, there were 1537 (76.20%) female and 480 (23.80%) male, aged 65.77 ± 7.73 years. Regarding the surgery characteristics, 1658 (82.20%) were unilateral; 1220 (60.49%) was graded Level 4; 1312 (65.05%) used local anesthesia as the main anesthesia method, and 1450 (71.89%) lasted for more than 2 h. The most common DUM was “NSAIDs + opioids” (55.92%), followed by “NSAIDs only” (17.85%), and “NSAIDs + Opioids + Non-opioid central analgesics” (17.15%). The results of the Chi-square test showed that differences in DUM were associated with surgery types, surgery levels, surgery duration, and types of anesthesia used. Up to 81.14% of the total drug expenses for pain management was spent on NSAIDs. Due to the limitation of database, this study could not subdivide operation stages, anesthesia methods, dosage forms of drugs. Conclusion: In China, the use of analgesics in perioperative period of TKA was diversified and influenced by a number of surgery characteristics. The rational use of analgesics should be considered in combination with surgery type, surgery level, surgery duration and anesthesia method.
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Magel JS, Gordon AJ, Fritz JM, Kim J. The Influence of an Opioid Use Disorder on Initiating Physical Therapy for Low Back Pain: A Retrospective Cohort. J Addict Med 2021; 15:226-232. [PMID: 33074851 PMCID: PMC8050136 DOI: 10.1097/adm.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Low back pain (LBP) is common among patients with an opioid use disorder (OUD). The extent to which patients with an OUD initiate physical therapy for LBP is unknown. The aim of this study was to examine the association between a history of an OUD and initiation of physical therapy for LBP within 60 days of a primary care provider (PCP) visit for this condition. METHODS Claims from a single state-wide all payer claims database from June 30, 2013 and August 31, 2015 were used to establish a retrospective cohort of patients who consulted a PCP for a new episode of LBP. The outcome measure was patients who had at least 1 physical therapy claim within 60-days after the PCP visit. After propensity score matching on covariates, logistic regression was used to compare the outcome of patients with a history of an OUD to patients without an OUD. RESULTS Propensity score matching resulted in 1360 matched pairs of participants. The mean age was 47.2 years (15.9) and 55.9% were female. Compared to patients without an OUD, patients with an OUD were less likely to initiate physical therapy for LBP (adjusted odds ratio = 0.65, 95% confidence intervals:0.49-0.85). CONCLUSIONS After a visit to a PCP for a new episode of care for LBP, patients with a history of an OUD are less likely to initiate physical therapy.
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Affiliation(s)
- John S Magel
- Department of Physical Therapy and Athletic Training, University of Utah, UT (JSM, JMF, JK); Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA) and Greater Intermountain Node (GIN), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (AG)
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Eskandari Z, Mostafavi H, Hosseini M, Mousavi SE, Ramazani S, Dadashi M. A sham-controlled clinical trial to examine the effect of bilateral tDCS on craving, TNF-α and IL-6 expression levels, and impulsivity of males with opioid use disorder. J Addict Dis 2021; 39:347-356. [PMID: 33719920 DOI: 10.1080/10550887.2021.1883208] [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] [Indexed: 10/21/2022]
Abstract
BACKGROUND Opioid use disorder (OUD) is one of the problems and concerns of all countries in the world. On the other hand, transcranial direct current stimulation (tDCS) has been used as a new therapeutic intervention in various psychiatric disorders. OBJECTIVE This study aimed to investigate the effect of bilateral tDCS on the expression levels of tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), craving and impulsive behaviors of male patients with OUD. METHODS This is a double-blind sham-controlled clinical trial. Participants were 31 male patients with OUD divided into three groups of left anode/right cathode tDCS, right anode/left cathode tDCS, and sham tDCS. They received active tDCS (2 mA, 20 min), applied over their dorsolateral prefrontal cortex (DLPFC) for 10 consecutive days. Expression levels of IL-6 and TNF-α cytokines were measured using ELISA method, and the Desires for Drug Questionnaire and the Barratt Impulsiveness Scale version 11 were used to assess the craving and impulsivity of subjects, respectively. RESULTS Both active and sham tDCS could significantly reduce drug craving in subjects (p < 0.05). Active tDCS over the right/left DLPFC significantly reduced impulsivity and its dimensions (overall, attentional, motor, and nonplanning) compared to the sham tDCS (p < 0.05). It could also reduce the expression levels of IL-6 and TNF-α, but the difference was not statistically significant. CONCLUSIONS The active tDCS over the right/left DLPFC, as a noninvasive and complementary treatment, can be used along with other common methods for the treatment of patients with OUD. It can improve their cognitive functions by reducing impulsivity.
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Affiliation(s)
- Zakaria Eskandari
- Faculty of Medicine, Department of Clinical Psychology and Addiction Studies, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Hossein Mostafavi
- Faculty of Medicine, Department of Physiology, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Masoumeh Hosseini
- Faculty of Medicine, Department of Physiology, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Seyedeh Elnaz Mousavi
- Faculty of Medicine, Department of Clinical Psychology, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Shokoufe Ramazani
- Faculty of Educational Sciences and Psychology, Department of Educational Sciences, University of Mohaghegh Ardabili, Ardabil, Iran
| | - Mohsen Dadashi
- Faculty of Medicine, Department of Clinical Psychology, Social Determinants of Health Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
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Bursua A, Mudreac A, Koppen L, Larson C, Park YS, Sreedhar R. Effect of Default Order Standardization on Opioid Prescribing Patterns. Jt Comm J Qual Patient Saf 2021; 47:431-437. [PMID: 33896745 DOI: 10.1016/j.jcjq.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid misuse, overprescribing, dependency, and overdose remains a significant concern in the United States. A quality improvement study was conducted at the University of Illinois Hospital & Health Sciences System to determine the effect of standardizing the default orders for hydrocodone-acetaminophen products implemented on June 22, 2016. METHODS Prior to the intervention, default orders had variable dose tablet numbers (1 or 2) and dosing frequencies (every 4 or 6 hours), and no default dispense quantity. Defaults were modified to 1 tablet every 6 hours as needed for pain and dispense quantities of 3 and 5 days' supply were added. Number of tablets per order, dosing frequency, and days' supply prescribed between January 1, 2016, and June 21, 2016, were compared to those placed between June 22, 2016, and December 31, 2016. Opioid doses were converted into morphine milligram equivalents (MME). Analyses were performed to determine the effect of the intervention on daily opioid dose and number of days' supply prescribed. RESULTS 22,052 orders were included in this study. Following the intervention, the number of tablets prescribed was reduced by an average of 19,832 tablets per month. Every 6 hours dosing (as opposed to every 4 hours) increased by 21.52 percentage points. Prescriptions with ≥ 50 MME/day dropped by 5.8 percentage points, and > 3 days' supply decreased by 2.54 percentage points. Linear regression demonstrated an increase in opioid prescriptions with daily < 50 MME (odds ratio [OR] = 1.72, p < 0.001) and ≤ 3 days' supply (OR = 1.27, p < 0.001). CONCLUSION Default electronic health record settings strongly influence prescribing patterns.
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Som A, Santosa KB, Skolnick GB, Lapidus JB, Waljee JF, Patel KB. Opioid Use among Adolescents Undergoing Surgical Repair of Facial Trauma. Plast Reconstr Surg 2021; 147:690-698. [PMID: 33587556 DOI: 10.1097/prs.0000000000007643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND New persistent opioid use has been quantified among adults undergoing surgery; less is known about the risk among adolescents. The authors examine new persistent opioid use in opioid-naive adolescent patients who underwent operative repair of facial fractures. METHODS Using the IBM MarketScan Commercial Database, the authors performed a retrospective analysis of patients aged 11 to 17 years who underwent facial fracture repair between 2006 and 2015. The incidences of prolonged opioid use and potentially inappropriate opioid prescriptions were determined. RESULTS Of 4892 patients, 78.5 percent filled a prescription. Among these patients, 7.9 percent had prolonged opioid use. Significant risk factors included older age (i.e., age 15 to 17 years) (OR, 1.579; 95 percent CI, 1.173 to 2.126 compared to younger patients), multiple comorbidities (OR, 3.005; 95 percent CI, 1.193 to 7.568), mandible fracture (OR, 1.614; 95 percent CI, 1.213 to 2.146), and multiple fractures (OR, 1.542; 95 percent CI, 1.002 to 2.372). Overall, 24.1 percent received a potentially inappropriate opioid prescription. Mandible fracture repair was associated with increased risk (OR, 2.753; 95 percent CI, 2.275 to 3.331) of potentially inappropriate opioid prescription. CONCLUSIONS Nearly one in 12 adolescents met criteria for prolonged opioid use; nearly one in four received a potentially inappropriate opioid prescription. Significant risk factors included mandible fracture, older age, multiple comorbidities, and multiple fractures. Like adults, many adolescents are at high risk for potentially inappropriate opioid prescriptions and prolonged opioid use following surgical repair. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Avira Som
- From the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - Katherine B Santosa
- From the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - Gary B Skolnick
- From the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - Jodi B Lapidus
- From the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - Jennifer F Waljee
- From the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - Kamlesh B Patel
- From the Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan
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Brummett CM, Evans-Shields J, England C, Kong AM, Lew CR, Henriques C, Zimmerman NM, Sun EC. Increased health care costs associated with new persistent opioid use after major surgery in opioid-naive patients. J Manag Care Spec Pharm 2021; 27:760-771. [PMID: 33624534 PMCID: PMC8177715 DOI: 10.18553/jmcp.2021.20507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Opioid use after surgery is associated with increased health care utilization and costs. Although some studies show that surgical patients may later become persistent opioid users, data on the association between new persistent opioid use after surgery and health care utilization and costs are lacking. OBJECTIVE: To compare health care utilization and costs after major inpatient or METHODS: The IBM MarketScan Research databases were used to identify opioid-naive patients with major inpatient or outpatient surgeries and at least 1 year of continuous enrollment before and after this index surgery. Cohorts were stratified by new persistent opioid utilization status, setting of surgery (inpatient, outpatient), and payer (commercial, Medicare, Medicaid). Patients were considered new persistent opioid users if they had at least 1 opioid claim 4-90 days after index surgery and at least 1 opioid claim 91-180 days after index surgery. Patients with opioid prescription claims between 1 year and 15 days before their index event were excluded. Health care utilization and costs (excluding index surgery) were measured in the 1-year period after surgery. Predicted costs and cost ratios were estimated using multivariable log-linked gamma-family generalized linear models. RESULTS: In the inpatient cohorts, 827,583 commercial, 186,154 Medicare, and 104,734 Medicaid patients were included in the study, and the incidence of new persistent opioid use in these cohorts was 4.1%, 5.6%, and 7.1%, respectively. In the outpatient cohorts, 1,542,565 commercial, 390,876 Medicare, and 94,878 Medicaid patients were selected, with 2.0%, 1.5%, and 6.4% new persistent opioid use, respectively. Across all 3 payers in both surgical settings, patients with new persistent opioid use had a higher comorbidity burden and more use of concomitant medications in the baseline period. In the 1-year period after index surgery, patients with new persistent opioid use had more inpatient admissions, emergency department visits, and ambulance/paramedic service use than patients without persistent use, regardless of payer and setting. Patients with new persistent opioid use had approximately 5 times more opioid prescriptions and also had more nonopioid pharmacy claims than those without persistent use across all cohorts. After covariate adjustment, predicted 1-year total health care costs were significantly higher for patients with new persistent opioid use compared with those without persistent use for all comparisons (commercial inpatient: $29,499 vs. $11,798; Medicare inpatient: $34,455 vs. $21,313; Medicaid inpatient: $14,622 vs. $6,678; commercial outpatient: $18,751 vs. $7,517; Medicare outpatient ($26,411 vs. $13,577; Medicaid outpatient: $12,381 vs. $6,784; all P < 0.001). CONCLUSIONS: New persistent opioid use after major surgery in opioid-naive patients is associated with increased health care utilization and costs in the year after surgery across all surgical settings and payers. DISCLOSURES: Funding for this study was provided by Heron Therapeutics, which participated in analysis and interpretation of data, drafting, reviewing, and approving the publication. All authors contributed to the analysis and interpretation of the data and development of the publication and maintained control over the final content. England and Evans-Shields are employees of Heron Therapeutics. Kong, Lew, Zimmerman, and Henriques are employees of IBM Watson Health, which was compensated by Heron Therapeutics for conducting this research. Brummett is a paid consultant for Heron Therapeutics, Vertex Pharmaceuticals, and Alosa Health and provides expert testimony. He further reports receipt of research funding from MDHHS (Sub K Michigan Open), NIDA (Centralized Pain Opioid Non-Responsiveness R01 DA038261-05), NIH0DHHS-US-16 PAF 07628 (R01 NR017096-05), NIH-DHHS (P50 AR070600-05 CORT), NIH-DHHS-US (K23 DA038718-04), NIH-DHHS-US-16-PAF06270 (R01 HD088712-05), NIH-DHHS-US-17-PAF02680 (R01 DA042859-05), and UM Michigan Genomics Initiative and holds a patent for peripheral perineural dexmedetomidine. Sun reports funding from the National Institute on Drug Abuse (K08DA042314) as well as consulting fees from the Mission Lisa Foundation that are unrelated to this work.
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Affiliation(s)
- Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | | | | | | | | | | | | | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine and Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University Medical Center, Stanford, CA
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Day-Storms JJ, Kren EM, Bush J, Souslova T, Kerr W, Baird GS. The Hidden Cost of the Opioid Epidemic in the United States: Drug Screening in Insurance Claims. Ther Drug Monit 2021; 43:25-34. [PMID: 33315761 PMCID: PMC7972296 DOI: 10.1097/ftd.0000000000000856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The opioid crisis has had a substantial financial impact on the health care system in the United States. This study evaluates how health plans have been affected financially and shows how a laboratory benefit management (LBM) program can be used to address related drug testing in an outpatient setting. METHODS Monthly claims data from private health plans were collected from June 1, 2016 to February 29, 2020. The total number of claims (units) for definitive and presumptive drug testing were calculated and the number of paid claims recorded. Claims distribution by laboratory type and medical code billed, the paid rate and compound annual growth rate, and the test distribution and paid rate of rendering providers who had submitted a minimum of 1000 claims were determined. RESULTS In total, 2,004,230 drug testing claims were submitted. After the LBM program was implemented, the percentage of paid claims for definitive drug testing (Healthcare Common Procedure Coding System code G0483) decreased and the paid rate for the low-cost tests (HCPCS code G0480) in physician office and independent laboratory settings increased. The compound annual growth rate for G0483 claims submitted indicated a 70.5% and 31.9% decrease in payments to physician offices and independent laboratories, respectively, for the period ending February 2020. CONCLUSIONS An LBM program can positively address policy enforcement while reducing unnecessarily complex tests and limiting potential fraud, waste, and abuse by directing testing toward laboratories amenable to cost-efficient contractual savings. Moreover, for definitive drug testing, the enforcement of the use of Healthcare Common Procedure Coding System codes and a move toward more cost-efficient tests (G0480), when clinically applicable, supported by clinical practice guidelines, or evidence-based medicine, is an approach to providing medical benefits while maintaining health costs.
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Affiliation(s)
| | - Erin M. Kren
- Avalon Healthcare Solutions, Tampa, Florida; and
| | - Jason Bush
- Avalon Healthcare Solutions, Tampa, Florida; and
| | | | - William Kerr
- Avalon Healthcare Solutions, Tampa, Florida; and
| | - Geoffrey S. Baird
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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Bradford JL, Turner B, Van Berkel MA. Effect of Liposomal Bupivacaine on Postoperative Opioid Requirements for Total Hip Arthroplasty, Total Knee Arthroplasty, Laminectomy, Hysterectomy, and Abdominoplasty Procedures. Hosp Pharm 2021. [DOI: 10.1177/0018578719867648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Purpose: Opioid use postoperatively has been linked to adverse events and an increase in opioid dependency. This retrospective study evaluated the effect of using liposomal bupivacaine (LB) for postoperative pain control on total opioid consumption, pain control, serious opioid-related adverse events (ORAEs), and hospital length of stay (LOS) in total knee arthroplasty (TKA), total hip arthroplasty (THA), laminectomy, hysterectomy, and abdominoplasty procedures when compared with a control group. Methods: Patients receiving LB from August 1, 2017, to February 1, 2018, for the aforementioned procedures were included for evaluation, and patients undergoing similar procedures who did not receive LB served as the control group. The principal outcome was opioid consumption through postoperative day 5 or discharge, whichever came first, assessed by morphine milligram equivalents (MMEs). Secondary outcomes included pain scores within 72 hours postoperation, hospital LOS, and serious ORAEs. Results: A total of 323 patients were identified for inclusion in the study: TKA, n = 144; THA, n = 48; laminectomy, n = 73; hysterectomy, n = 30; and abdominoplasty, n = 28. Liposomal bupivacaine use was associated with reduced postoperative opioid consumption compared with alternative therapies with a median 71 MME (25%-75%; interquartile range [IQR] = 32.5-148.5) versus 102 MME (25%-75%; IQR = 57-165), P < .005. However, higher numeric pain scores were reported in the LB group compared with the control group for postoperative day 0 with a median of 5.5 (25%-75%; IQR = 4.5-7.4) versus 5.5 (25%-75%; IQR = 4-7) in the control group ( P < .001) and on postoperative day 1 with a median of 6 (25%-75%; IQR = 4.5-7) versus 5.5 (25%-75%; IQR = 4.3-7), P < .001. There was no difference in hospital LOS or ORAEs. Conclusion: In this retrospective analysis of pain management after TKA, THA, laminectomy, hysterectomy, and abdominoplasty procedures, patients receiving LB consumed significantly less opioid medications. However, this was not associated with clinically meaningful improvements in pain scores, hospital LOS, or serious ORAEs.
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43
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Zheng BX, Malik A, Xiong M, Bekker A, Tao YX. Nerve trauma-caused downregulation of opioid receptors in primary afferent neurons: Molecular mechanisms and potential managements. Exp Neurol 2020; 337:113572. [PMID: 33340498 DOI: 10.1016/j.expneurol.2020.113572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 12/18/2022]
Abstract
Neuropathic pain is the most common clinical disorder destroying the quality of patient life and leading to a marked economic and social burden. Opioids are still last option for pharmacological treatment of this disorder, but their antinociceptive effects are limited in part due to the downregulation of opioid receptors in the primary afferent neurons after peripheral nerve trauma. How this downregulation occurs is not completely understood, but recent studies have demonstrated that peripheral nerve trauma drives the alterations in epigenetic modifications (including DNA methylation, histone methylation and mciroRNAs), expression of transcription factors, post-transcriptional modifications (e.g., RNA methylation) and protein translation initiation in the neurons of nerve trauma-related dorsal root ganglion (DRG) and that these alternations may be associated with nerve trauma-caused downregulation of DRG opioid receptors. This review presents how opioid receptors are downregulated in the DRG after peripheral nerve trauma, specifically focusing on distinct molecular mechanisms underlying transcriptional and translational processes. This review also discusses how this downregulation contributes to the induction and maintenance of neuropathic pain. A deeper understanding of these molecular mechanisms likely provides a novel avenue for prevention and/or treatment of neuropathic pain.
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Affiliation(s)
- Bi-Xin Zheng
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Ayma Malik
- Rutgers Graduate School of Biomedical Sciences, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Ming Xiong
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Alex Bekker
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA
| | - Yuan-Xiang Tao
- Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA; Department of Physiology, Pharmacology & Neuroscience, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA; Department of Cell Biology & Molecular Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ 07103, USA.
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Silverman LI, Heaton W, Farhang N, Saxon LH, Dulatova G, Rodriguez-Granrose D, Flanagan F, Foley KT. Perspectives on the Treatment of Lumbar Disc Degeneration: The Value Proposition for a Cell-Based Therapy, Immunomodulatory Properties of Discogenic Cells and the Associated Clinical Evaluation Strategy. Front Surg 2020; 7:554382. [PMID: 33392242 PMCID: PMC7772215 DOI: 10.3389/fsurg.2020.554382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
Low back pain (LBP) is a serious medical condition that affects a large percentage of the population worldwide. One cause of LBP is disc degeneration (DD), which is characterized by progressive breakdown of the disc and an inflamed disc environment. Current treatment options for patients with symptomatic DD are limited and are often unsuccessful, so many patients turn to prescription opioids for pain management in a time when opioid usage, addiction, and drug-related deaths are at an all-time high. In this paper, we discuss the etiology of lumbar DD and currently available treatments, as well as the potential for cell therapy to offer a biologic, non-opioid alternative to patients suffering from the condition. Finally, we present an overview of an investigational cell therapy called IDCT (Injectable Discogenic Cell Therapy), which is currently under evaluation in multiple double-blind clinical trials overseen by major regulatory agencies. The active ingredient in IDCT is a novel allogeneic cell population known as Discogenic Cells. These cells, which are derived from intervertebral disc tissue, have been shown to possess both regenerative and immunomodulatory properties. Cell therapies have unique properties that may ultimately lead to decreased pain and improved function, as well as curb the numbers of patients pursuing opioids. Their efficacy is best assessed in rigorous double-blinded and placebo-controlled clinical studies.
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Affiliation(s)
- Lara Ionescu Silverman
- DiscGenics Inc., Salt Lake City, UT, United States.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Will Heaton
- DiscGenics Inc., Salt Lake City, UT, United States
| | | | | | | | | | | | - Kevin T Foley
- DiscGenics Inc., Salt Lake City, UT, United States.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States.,Semmes-Murphey Clinic, Memphis, TN, United States
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Tat QL, Joksimovic SM, Krishnan K, Covey DF, Todorovic SM, Jevtovic-Todorovic V. Preemptive Analgesic Effect of Intrathecal Applications of Neuroactive Steroids in a Rodent Model of Post-Surgical Pain: Evidence for the Role of T-Type Calcium Channels. Cells 2020; 9:cells9122674. [PMID: 33322727 PMCID: PMC7763050 DOI: 10.3390/cells9122674] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/30/2020] [Accepted: 12/10/2020] [Indexed: 12/02/2022] Open
Abstract
Preemptive management of post-incisional pain remains challenging. Here, we examined the role of preemptive use of neuroactive steroids with activity on low-voltage activated T-type Ca2+ channels (T-channels) and γ-aminobutyric acid A (GABAA) receptors in the development and maintenance of post-incisional pain. We use neuroactive steroids with distinct effects on GABAA receptors and/or T-channels: Alphaxalone (combined GABAergic agent and T-channel inhibitor), ECN (T-channel inhibitor), CDNC24 (GABAergic agent), and compared them with an established analgesic, morphine (an opioid agonist without known effect on either T-channels or GABAA receptors). Adult female rats sustained the skin and muscle incision on the plantar surface of the right paw. We injected the agents of choice intrathecally either before or after the development of post-incisional pain. The pain development was monitored by studying mechanical hypersensitivity. Alphaxalone and ECN, but not morphine, are effective in alleviating mechanical hyperalgesia when administered preemptively whereas morphine provides dose-dependent pain relief only when administered once the pain had developed. CDNC24 on the other hand did not offer any analgesic benefit. Neuroactive steroids that inhibit T-currents—Alphaxalone and ECN—unlike morphine, are effective preemptive analgesics that may offer a promising therapeutic approach to the treatment of post-incisional pain, especially mechanical hypersensitivity.
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Affiliation(s)
- Quy L. Tat
- Department of Anesthesiology, School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA; (Q.L.T.); (S.M.J.); (S.M.T.)
| | - Srdjan M. Joksimovic
- Department of Anesthesiology, School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA; (Q.L.T.); (S.M.J.); (S.M.T.)
| | - Kathiresan Krishnan
- Department of Developmental Biology, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA; (K.K.); (D.F.C.)
| | - Douglas F. Covey
- Department of Developmental Biology, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA; (K.K.); (D.F.C.)
- Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Slobodan M. Todorovic
- Department of Anesthesiology, School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA; (Q.L.T.); (S.M.J.); (S.M.T.)
- Neuroscience Graduate Program, School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA; (Q.L.T.); (S.M.J.); (S.M.T.)
- Correspondence: ; Tel.: +1-720-848-6723
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Educating Nurses on the Use of the Clinical Opiate Withdrawal Scale to Improve Care of Adult Patients Undergoing Buprenorphine Induction. J Addict Nurs 2020; 31:229-235. [PMID: 33264194 DOI: 10.1097/jan.0000000000000361] [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
INTRODUCTION Opioid addiction disease has become a global health and social problem complicated by drug misuse and abuse (Pearlman, 2016; Rettig & Yarmolinsky, 1995; Watkins, 2016). Buprenorphine, a partial opioid agonist, is an effective treatment for opioid addiction disease (Loreck et al., 2016). Its induction can trigger severe precipitated withdrawal in opioid-dependent patients whose mu receptors are occupied opioids (American Society of Addiction Medicine, 2015). Knowledge of assessing a patient's level of withdrawal using a validated tool is key to successful transition from other opioids to buprenorphine. AIM The aim of this study was to evaluate the effectiveness of training nurses on the use of the Clinical Opioid Withdrawal Scale (COWS) screening instrument by assessing their confidence in assessing and satisfaction with communicating withdrawal information crucial for patient safety. METHOD Ten registered nurses and three nurse practitioners working at a mental health community service center completed two surveys at three time points (Pre, Post, and Post-90 days). The first survey measured nurses' confidence in assessing, whereas the second survey measured their satisfaction with communicating withdrawal symptoms. RESULTS The means' (M) magnitude for both assessment and satisfaction scores increased with time (across Pre, Post, and Post-90). Standard deviations tended to become smaller. Improvements were noted in nurses' confidence in the assessment of and satisfaction in communicating withdrawal symptoms after the intervention. CONCLUSION Participants expressed increased knowledge, confidence, and satisfaction with the COWS screening instrument. Ultimately, the patients benefited from the participants having more experience, education, skills, and confidence in monitoring withdrawal symptoms depicted by aggregate data of COWS screenings postintervention.
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Sanyal C. Economic burden of opioid crisis and the role of pharmacist-led interventions. J Am Pharm Assoc (2003) 2020; 61:e70-e74. [PMID: 33279425 DOI: 10.1016/j.japh.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
Opioids are often used to treat pain and improve function. Canada and the United States are one of the highest users of opioids per capita worldwide and are experiencing the devastating consequences of the opioid crisis. The objectives of this commentary are 2-fold: first, highlight the economic burden of the opioid crisis in the United States and Canada; second, define the role of pharmacists to address this crisis. A body of literature delineates the cost of this crisis to health care system, lost productivity, and law enforcement. Contemporary data indicate that the economic burden of the opioid crisis was $78.5 billion and $3.5 billion in the United States and Canada, respectively. Community pharmacists are often the first health care providers who identify issues with opioid prescriptions, signs of misuse, abuse, and diversion. Contemporary studies highlight their critical role to address this crisis by ensuring the safe and appropriate use of opioids, which can decrease morbidity, mortality, use of health services and societal resources, and costs. The expanding scope of practice and the amendment of existing regulations and legislations have the potential to maximize the contribution of pharmacists to address this crisis. Pharmacists should be reimbursed for the services they provide to be sustainable.
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The cost of opioid use disorder and the value of aversion. Drug Alcohol Depend 2020; 217:108382. [PMID: 33183909 PMCID: PMC7737485 DOI: 10.1016/j.drugalcdep.2020.108382] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/30/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The objective of this study was twofold. First, to update and estimate the economic burden of opioid use disorder (OUD) to the U.S. from the perspectives of the healthcare sector, taxpayer, and society, overall and by age. Second, to estimate the mean present value of averting an OUD, overall and by age, for use in economic evaluations of prevention-focused interventions. METHODS This was a retrospective secondary analysis using 2018 data from the National Survey on Drug Use and Health, and the CDC WONDER Database on all U.S. persons, at least 12 years old, with an OUD, or who died of opioid overdose. Total OUD-related costs were estimated according to age and stakeholder perspective. Mean costs weighted by insurance type and the probability of mortality were estimated for each age, then used to estimate the mean present value of OUD aversion according to age and stakeholder perspective. RESULTS The total annual OUD-related costs to the U.S. in 2018 were $786.8 billion to society, $93 billion to taxpayers, and $89.1 billion to the healthcare sector. The mean present value of averting an OUD, across all ages, was $2.2 million, $325,125, and $244,030 from the societal, taxpayer, and healthcare sector perspectives, respectively. CONCLUSIONS AND RELEVANCE The age-specific values of averting an OUD allow for more robust and targeted economic evaluations of competing interventions to reduce the burden of opioids on multiple stakeholders. The rise in the annual OUD-related cost largely reflects the increase in overdose deaths attributable to synthetic opioids (e.g., fentanyl).
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Krajina Kmoniček I, Kvolik S, Pinotić K, Ištvanić T, Mraovic B, Marjanovic K. Epidural analgesia for acute ischemic pain after intra-arterial zolpidem injection in opioid-addicted patient-A case report. Clin Case Rep 2020; 8:3445-3449. [PMID: 33363949 PMCID: PMC7752646 DOI: 10.1002/ccr3.3445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/13/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
A patient taking opioid maintenance therapy unintentionally injected dissolved zolpidem pills into the femoral artery and suffered acute limb ischemia. High amounts of opioids with supplemental therapies were inefficient for intractable ischemic pain, suggesting the presence of opioid-induced hyperalgesia (OIH). Epidural analgesia efficiently relieved pain and symptoms of OIH.
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Affiliation(s)
| | - Slavica Kvolik
- Department of AnesthesiologyOsijek University HospitalOsijekCroatia
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
| | - Kresimir Pinotić
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of SurgeryOsijek University HospitalOsijekCroatia
| | - Tomislav Ištvanić
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of SurgeryOsijek University HospitalOsijekCroatia
| | - Boris Mraovic
- Department of Anesthesiology & Perioperative MedicineSchool of MedicineUniversity of MissouriColumbiaMOUSA
| | - Ksenija Marjanovic
- Faculty of MedicineJosip Juraj Strossmayer University of OsijekOsijekCroatia
- Department of PathologyOsijek University HospitalOsijekCroatia
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Thakur T, Chewning B, Zetes N, Lee JT. Pharmacy intervention to facilitate transparent opioid-risk and safety communication. J Am Pharm Assoc (2003) 2020; 60:1015-1020. [DOI: 10.1016/j.japh.2020.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022]
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