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Liu O, Leon D, Gough E, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Farronato DM, Pezzulo JD, Paulik J, Miltenberg B, Johns WL, Davis DE. The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00222-2. [PMID: 38548094 DOI: 10.1016/j.jse.2024.02.021] [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: 09/07/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Miltenberg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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Moore M, Shendrik I, Roof MA, Sicat CS, Meftah M, Schwarzkopf R, Rozell JC. Outcomes of medicaid patients undergoing TJA with previous positive urine toxicology screens. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3555-3560. [PMID: 37225946 DOI: 10.1007/s00590-023-03591-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Previous studies have demonstrated that patients with positive preoperative urine toxicology (utox) screens prior to total joint arthroplasty (TJA) have higher readmission rates, greater complication rates, and longer hospital stays compared to patients with negative screens. The aim of this study was to investigate the effect of postponing surgery for patients with positive preoperative utox in the Medicaid population. METHODS This retrospective, observational study reviewed the Medicaid ambulatory database at a large, academic orthopedic specialty hospital for patients with a utox screen prior to TJA from 2012 to 2020. Patients were categorized into three groups: (1) controls with negative preoperative utox or a utox consistent with prescription medications (Utox-) with TJA completed as scheduled; (2) positive preoperative utox with TJA rescheduled and surgery completed on a later date (R-utox+); (3) positive preoperative utox inconsistent with prescription medications with TJA completed as scheduled (S-utox+). Primary outcomes included mortality, 90-day readmission rate, complication rate, and length of stay. RESULTS Of the 300 records reviewed, 185 did not meet inclusion criteria. The remaining 115 patients included 80 (69.6%) Utox-, 5 (6.3%) R-utox+, and 30 (37.5%) S-utox+. Mean follow-up time was 49.6 months. Hospital stays trended longer in the Utox- group (3.7 ± 2.0 days vs. 3.1 ± 1.6 S-utox+ vs.2.5 ± 0.4 R-utox+, p = 0.20). Compared to the R-utox+group, the S-utox+ group trended toward lower home discharge rates (p = 0.20), higher in-hospital complication rates (p = 0.85), and more all-cause 90-day emergency department visits (p = 0.57). There were no differences in postoperative opioid utilization between groups (p = 0.319). Duration of postoperative narcotic use trended toward being longer in the Utox- patients (820.7 ± 1073.8 days vs. 684.6 ± 1491.8 S-utox+ vs. 585.1 ± 948.3 R-utox+, p = 0.585). Surgical time (p = 0.045) and revision rates (p = 0.72) trended toward being higher in the S-utox+ group. CONCLUSIONS Medicaid patients with positive preoperative utox who had surgeries postponed trended towards shorter hospital stays and greater home discharge rates. Larger studies should be conducted to analyze the implications of a positive preoperative utox on risk profiles and outcomes following TJA in the Medicaid population. Study design Retrospective cohort study.
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Affiliation(s)
- Michael Moore
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA.
| | - Irina Shendrik
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Mackenzie A Roof
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Chelsea Sue Sicat
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Morteza Meftah
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- NYU Langone Orthopedic Hospital, NYU Langone Health, 334 East 26Th Street, New York, NY, 10003, USA
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Dickerson DM, Mariano ER, Szokol JW, Harned M, Clark RM, Mueller JT, Shilling AM, Udoji MA, Mukkamala SB, Doan L, Wyatt KEK, Schwalb JM, Elkassabany NM, Eloy JD, Beck SL, Wiechmann L, Chiao F, Halle SG, Krishnan DG, Cramer JD, Ali Sakr Esa W, Muse IO, Baratta J, Rosenquist R, Gulur P, Shah S, Kohan L, Robles J, Schwenk ES, Allen BFS, Yang S, Hadeed JG, Schwartz G, Englesbe MJ, Sprintz M, Urish KL, Walton A, Keith L, Buvanendran A. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med 2023:rapm-2023-104435. [PMID: 37185214 DOI: 10.1136/rapm-2023-104435] [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: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.
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Affiliation(s)
- David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Randall M Clark
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mercy A Udoji
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Health Care System, Decatur, Georgia, USA
| | | | - Lisa Doan
- Department of Anesthesiology, PerioperativeCare and Pain Medicine, New York University School of Medicine, New York, New York, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperativeand Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Stacy L Beck
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Maternal Fetal Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, USA
| | - Steven G Halle
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Wael Ali Sakr Esa
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
- Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Jaime Baratta
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | | | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shalini Shah
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer Robles
- Department of Urology Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian F S Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Yang
- Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | | | - Gary Schwartz
- AABP Integrative Pain Care, Melville, New York, USA
- Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Michael Sprintz
- Sprintz Center for Pain and Recovery, Shenandoah, Texas, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Lauren Keith
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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6
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Arora S, Bronkema C, Majdalany SE, Corsi N, Rakic I, Piontkowski A, Sood A, Davis MJ, Modonutti D, Novara G, Rogers CG, Abdollah F. Impact of preexisting opioid dependence on morbidity, length of stay, and inpatient cost of urological oncological surgery. World J Urol 2023; 41:1025-1031. [PMID: 36754878 DOI: 10.1007/s00345-023-04306-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVES To determine the incidence of preexisting opioid dependence in patients undergoing elective urological oncological surgery. In addition, to quantify the impact of preexisting opioid dependence on outcomes and cost of common urologic oncological procedures at a national level in the USA. METHODS We used the National Inpatient Sample (NIS) to study 1,609,948 admissions for elective partial/radical nephrectomy, radical prostatectomy, and cystectomy procedures. Trends of preexisting opioid dependence were studied over 2003-2014. We use multivariable-adjusted analysis to compare opioid-dependent patients to those without opioid dependence (reference group) in terms of outcomes, namely major complications, length of stay (LOS), and total cost. RESULTS The incidence of opioid dependence steadily increased from 0.6 per 1000 patients in 2003 to 2 per 1000 in 2014. Opioid-dependent patients had a significantly higher rate of major complications (18 vs 10%; p < 0.001) and longer LOS (4 days (IQR 2-7) vs 2 days (IQR 1-4); p < 0.001), when compared to the non-opioid-dependent counterparts. Opioid dependence also increased the overall cost by 48% (adjusted median cost $18,290 [IQR 12,549-27,715] vs. $12,383 [IQR 9225-17,494] in non-opioid-dependent, p < 0.001). Multivariable analysis confirmed the independent association of preexisting opioid dependence with major complications, length of stay in 4th quartile, and total cost in 4th quartile. CONCLUSIONS The incidence of preexisting opioid dependence before elective urological oncology is increasing and is associated with adverse outcomes after surgery. There is a need to further understand the challenges associated with opioid dependence before surgery and identify and optimize these patients to improve outcomes.
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Affiliation(s)
- Sohrab Arora
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.,Vattikuti Urology Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202-2689, USA
| | - Chandler Bronkema
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Sami E Majdalany
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Nicholas Corsi
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.,Wayne State University School of Medicine, Detroit, MI, USA
| | - Ivan Rakic
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.,Wayne State University School of Medicine, Detroit, MI, USA
| | - Austin Piontkowski
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.,Wayne State University School of Medicine, Detroit, MI, USA
| | - Akshay Sood
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.,Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew J Davis
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Daniele Modonutti
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.,Department of Oncological and Surgical Sciences, Urology Clinic, University of Padova, Padua, Italy
| | - Giacomo Novara
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padova, Padua, Italy
| | - Craig G Rogers
- Vattikuti Urology Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202-2689, USA
| | - Firas Abdollah
- Vattikuti Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA. .,Vattikuti Urology Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202-2689, USA. .,Wayne State University School of Medicine, Detroit, MI, USA.
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7
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Association between Preoperative Medication Lists and Postoperative Hospital Length of Stay after Endoscopic Transsphenoidal Pituitary Surgery. J Clin Med 2022; 11:jcm11195829. [PMID: 36233696 PMCID: PMC9572419 DOI: 10.3390/jcm11195829] [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: 09/01/2022] [Revised: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Endoscopic transsphenoidal surgery is the most common technique for the resection of pituitary adenoma. Data on factors associated with extended hospital stay after this surgery are limited. We aimed to characterize the relationship between preoperative medications and the risk of prolonged postoperative length of stay after this procedure. Methods: This single-center, retrospective cohort study included all adult patients scheduled for transsphenoidal pituitary surgery from 1 July 2016 to 31 December 2019. Anatomical Therapeutic Chemical codes were used to identify patients’ preoperative medications. The primary outcome was a prolonged postoperative hospital length of stay. Secondary outcomes included unplanned admission to the Intensive Care Unit, and in-hospital and one-year mortality. We developed a descriptive logistic model that included preoperative medications, obesity and age. Results: Median postoperative length of stay was 3 days for the 704 analyzed patients. Patients taking ATC-H drugs were at an increased risk of prolonged length of stay (OR 1.56, 95% CI 1.26−1.95, p < 0.001). No association was found between preoperative ATC-H medication and unplanned ICU admission or in-hospital mortality. Patients with multiple preoperative ATC-H medications had a significantly higher mean LOS (5.4 ± 7.6 days) and one-year mortality (p < 0.02). Conclusions: Clinicians should be aware of the possible vulnerability of patients taking systemic hormones preoperatively. Future studies should test this medication-based approach on endoscopic transsphenoidal pituitary surgery populations from different hospitals and countries.
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8
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Parrish JM, Vakharia RM, Benson DC, Hoyt AK, Jenkins NW, Kaplan JRM, Rush AJ, Roche MW, Aiyer AA. Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure. Foot Ankle Spec 2022; 15:305-311. [PMID: 32857596 DOI: 10.1177/1938640020950105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs. METHODS Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ2 test, logistic regression, and a t test. A P value <.05 was considered statistically significant. RESULTS There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls. CONCLUSION The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction. LEVELS OF EVIDENCE Level III: Retrospective cohort study.
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Affiliation(s)
- James M Parrish
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, Florida
| | - Rushabh M Vakharia
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Dillon C Benson
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, Florida
| | - Aaron K Hoyt
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, Florida
| | - Nathaniel W Jenkins
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, Florida
| | | | - Augustus J Rush
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, Florida
| | - Martin W Roche
- Orthopedic Research Institute, Holy Cross Hospital, Ft Lauderdale, Florida
| | - Amiethab A Aiyer
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, Florida
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9
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Perlmutter B, Wynia E, McMichael J, Tu C, Scheman J, Simon R, Walsh RM, Augustin T. Effect of pre-operative opioid exposure on surgical outcomes in elective laparoscopic cholecystectomy. Am J Surg 2021; 223:764-769. [PMID: 34193351 DOI: 10.1016/j.amjsurg.2021.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The effects of varying levels of pre-operative opioids on post-operative outcomes following elective laparoscopic cholecystectomy is largely unknown. METHODS Patients who underwent elective laparoscopic cholecystectomy from 2012 to 2019 were reviewed and categorized by the number of outpatient opioid prescriptions received in the 90 days preceding surgery: none (Naïve), one (1 Rx), two (2 Rx), or three or more (Chronic). Operative time, hospital length of stay, and 30-day readmission rate were analyzed. RESULTS Of the 11911 patients identified, 2958 (24.8%) used opioids pre-operatively. Among patients with an overnight admission, the Naïve, 1 Rx, and 2 Rx cohorts had a shorter length of stay compared to the Chronic cohort. The Naïve group had the lowest 30-day readmission rate (5.0%) followed by the 1 Rx (5.9%), 2 Rx and Chronic groups (9.1% and 8.7%, respectively) (p < 0.001). CONCLUSIONS Prevalence of pre-operative opioid use is high and warrants surgeon assessment to minimize adverse post-operative outcomes.
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Affiliation(s)
- Breanna Perlmutter
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Elisabeth Wynia
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA; United States Air Force. The Views Expressed in This Paper are Those of the authors and do not Reflect the Official Policy Or Stance of the Department of the Air Force, Department of Defense, Or the U.S. Government, USA
| | - John McMichael
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Judith Scheman
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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10
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Doan LV, Padjen K, Ok D, Gover A, Rashid J, Osmani B, Avraham S, Wang J, Kendale S. Relation between preoperative benzodiazepines and opioids on outcomes after total joint arthroplasty. Sci Rep 2021; 11:10528. [PMID: 34006976 PMCID: PMC8131602 DOI: 10.1038/s41598-021-90083-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/06/2021] [Indexed: 11/09/2022] Open
Abstract
To examine the association of preoperative opioids and/or benzodiazepines on postoperative outcomes in total knee and hip arthroplasty, we retrospectively compared postoperative outcomes in those prescribed preoperative opioids and/or benzodiazepines versus those who were not who underwent elective total knee and hip arthroplasty at a single urban academic institution. Multivariable logistic regression was performed for readmission rate, respiratory failure, infection, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used for length of stay. After exclusions, there were 4307 adult patients in the study population, 2009 of whom underwent total knee arthroplasty and 2298 of whom underwent total hip arthroplasty. After adjusting for potential confounders, preoperative benzodiazepine use was associated with increased odds of readmission (p < 0.01). Preoperative benzodiazepines were not associated with increased odds of respiratory failure nor increased length of stay. Preoperative opioids were not associated with increased odds of the examined outcomes. There were insufficient numbers of infection and cardiac events for analysis. In this study population, preoperative benzodiazepines were associated with increased odds of readmission. Preoperative opioids were not associated with increased odds of the examined outcomes. Studies are needed to further examine risks associated with preoperative benzodiazepine use.
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Affiliation(s)
- Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.
| | - Kristoffer Padjen
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Deborah Ok
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Adam Gover
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Jawad Rashid
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Bijan Osmani
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Shirley Avraham
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.,Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Samir Kendale
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
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11
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Urman RD, Khanna AK, Bergese SD, Buhre W, Wittmann M, Le Guen M, Overdyk FJ, Di Piazza F, Saager L. Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial. J Clin Anesth 2021; 70:110167. [PMID: 33493688 DOI: 10.1016/j.jclinane.2021.110167] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/21/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE Opioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression. DESIGN Prospective observational trial. SETTING 16 general care medical and surgical wards in Asia, Europe, and the United States. PATIENTS 1335 patients receiving parenteral opioids. INTERVENTIONS Blinded, alarm-silenced continuous capnography and pulse oximetry monitoring. MEASUREMENTS Opioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO2 ≤ 85%, or ETCO2 ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event. RESULTS Across all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5-76.7) MME, 31.0 (6.2-99.0) MME, and 7.2 (1.7-18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424-0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322-0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression. CONCLUSIONS Despite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. REGISTRATION NUMBER: www.clinicaltrials.gov, ID: NCT02811302.
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Affiliation(s)
- Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Sergio D Bergese
- Department of Anesthesiology, and Neurological Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Wolfgang Buhre
- Department of Anesthesiology, University Medical Center, Maastricht, Netherlands
| | - Maria Wittmann
- Department of Anaesthesiology, University Hospital Bonn, Bonn, Germany
| | - Morgan Le Guen
- Department of Anaesthesiology, Hôpital Foch, Suresnes, France
| | | | - Fabio Di Piazza
- Medtronic Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | - Leif Saager
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University Medical Center Goettingen, Germany; Outcomes Research Consortium, Cleveland, OH, USA
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12
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Tian C, Maeda A, Okrainec A, Anvari M, Jackson T. Impact of preoperative opioid use on health outcomes after bariatric surgery. Surg Obes Relat Dis 2020; 16:768-776. [DOI: 10.1016/j.soard.2020.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/27/2020] [Accepted: 02/14/2020] [Indexed: 01/23/2023]
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13
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Shadbolt C, Abbott JH, Camacho X, Clarke P, Lohmander LS, Spelman T, Sun EC, Thorlund JB, Zhang Y, Dowsey MM, Choong PFM. The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action. Front Surg 2020; 7:4. [PMID: 32133370 PMCID: PMC7041404 DOI: 10.3389/fsurg.2020.00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/29/2020] [Indexed: 12/27/2022] Open
Abstract
Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.
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Affiliation(s)
- Cade Shadbolt
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ximena Camacho
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia
| | - Philip Clarke
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Tim Spelman
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Rigshospitalet, Copenhagen, Denmark
| | - Eric C Sun
- Department of Anaesthesiology, Perioperative and Pain Medicine and Department of Health Research and Policy, Stanford University, Stanford, CA, United States
| | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Yuting Zhang
- Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, University of Melbourne, Carlton, VIC, Australia
| | - Michelle M Dowsey
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Peter F M Choong
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
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