First Place: A prospective, randomized controlled trial of the impact of written discharge instructions for postoperative opioids on patient pain satisfaction and on minimizing opioid risk exposure in orthopaedic surgery

Opioid exit plans for tapering postoperative pain control in noncancer patients: a systematic review

BACKGROUND

A growing number of countries have reported sharp increases in the use and harm of opioid analgesics. High rates of new opioid initiation are observed in postoperative patients. In response, various tertiary care institutions have developed opioid exit plans (OEPs) to curb potential opioid-related harm.

METHODS

PubMed and Embase were systematically searched to identify, summarize, and compare the interventional elements of OEPs for postoperative patient populations published from January 1, 2000, to June 4, 2024. Two researchers independently screened the articles for eligibility following the PRISMA 2020 guidelines, extracted the data, and assessed the study quality and risk of bias. Data synthesis was performed for study characteristics, intervention details, efficacy, and development.

RESULTS

A total of 2,585 articles were screened, eight of which met the eligibility criteria. All studies were conducted in North America and focused on orthopedic surgery patients following total hip or knee arthroplasty (n = 5) or neurosurgery (n = 3). Most studies (n = 7) included a pre-post (n = 4) or randomized clinical design (n = 3). Three studies were of good quality, and none had a low risk of bias. The interventions varied and ranged from educational sessions (n = 1) to individualized tapering protocols (n = 4) or a combination of the two (n = 2). Key elements were instructions on how to anticipate patients' postoperative need for opioid analgesics and tapering strategies based on 24-h predischarge opioid consumption. Six studies included efficacy as an endpoint in their analysis, of which four assessed statistical significance, with all four identifying that the OEPs were successful in reducing postoperative opioid use.

CONCLUSION

Despite differences in design and implementation, the identified OEPs suggest that they are efficacious in reducing outpatient opioid consumption. They provide a robust estimate of postoperative analgesic requirements and a rationale for tapering duration and rate. However, more rigorous studies are needed to evaluate their real-world effectiveness.

Compliance With Opioid Disposal Following Opioid Disposal Education in Surgical Patients: A Systematic Review

PURPOSE

The present opioid epidemic in the United States is a significant cause for concern in healthcare. In 1995, the concept of pain was introduced as the fifth vital sign. Since then, the sales of opioids have increased dramatically, as have the number of opioid deaths. The misuse and diversion of retained opioids following surgical procedures contribute to the problem. The objective of this project was to review the latest scholarly work and evaluate the findings related to patient education and disposal of opioid medications to decrease opioid misuse and increase disposal.

DESIGN

A systematic review.

METHODS

The systematic search strategy included PubMed, Ovid Technologies (OVID), and Cumulative Index of Nursing and Allied Health Literature (CINAHL) electronic databases.

FINDINGS

A total of 4 randomized controlled trials (RCTs), 2 quasi-experimental studies, and 2 quality improvement projects met the criteria for inclusion. The studies found that as many as 92% of patients had leftover unused opioids. The retention rate of opioids among surgical patients was found to be 33 to 95%. When educational material was provided about disposal, the studies found that the disposal rate was as high as 71%.

CONCLUSIONS

Patient education about opioid misuse, diversion, and disposal are essential topics that need to be addressed with patients and caregivers.

Medication Supports at Transitions Between Hospital and Other Care Settings: A Rapid Scoping Review

PURPOSE

Transitions in care (TiC) often involves managing medication changes and can be vulnerable moments for patients. Medication support, where medication changes are reviewed with patients and caregivers to increase knowledge and confidence about taking medications, is key to successful transitions. Little is known about the optimal tools and processes for providing medication support. This study aimed to identify describe patient or caregiver-centered medication support processes or tools that have been studied within 3 months following TiC between hospitals and other care settings.

METHODS

Rapid scoping review; English-language publications from OVID MEDLINE, OVID EMBASE, Cochrane Library and EBSCO CINAHL (2004-July 2019) that assessed medication support interventions delivered within 3 months following discharge were included. A subset of titles and abstracts were assessed by two reviewers to evaluate agreement and once reasonable agreement was achieved, the remainder were assessed by one reviewer. Eligibility assessment for full-text articles and data charting were completed by an experienced reviewer.

RESULTS

A total of 7671 unique citations were assessed; 60 studies were included. Half of the studies (n = 30/60) were randomized controlled trials. Most studies (n = 45/60) did not discuss intervention development, particularly whether end users were involved in intervention design. Many studies (n = 37/60) assessed multi-component interventions with written/print and verbal education components. Few studies (n = 5/60) included an electronic component. Very few studies (n = 4/60) included study populations at high risk of adverse events at TiC (eg, people with physical or intellectual disabilities, low literacy or language barriers).

CONCLUSION

The majority of studies were randomized controlled trials involving verbal counselling and/or physical document delivered to the patient before discharge. Few studies involved electronic components or considered patients at high-risk of adverse events. Future studies would benefit from improved reporting on development, consideration for electronic interventions, and improved reporting on patients with higher medication-related needs.

Postoperative Disposal of Unused Opioids: A Systematic Review

Introduction: Opioid misuse and overprescription have contributed to a national public health crisis in the United States. Postoperatively, patients are often left with unused opioids, which pose a risk for diversion if not appropriately disposed of. Patients are infrequently provided instructions on safe disposal methods of surplus opioids. Purpose: We sought to determine the current rates of disposal of unused opioids and the reported disposal mechanisms for unused opioids that were prescribed for acute postoperative pain control. Methods: A systematic review was performed of the PubMed, Cochrane, and Embase databases for relevant articles from their earliest entries through October 2, 2019. We used the search terms "opioid" or "narcotic" and "disposal" and "surgery." Studies were considered for inclusion if they reported the rate of disposal of unused opioids following surgery. A screening strategy was used to identify relevant articles using Covidence. For studies meeting inclusion criteria, relevant information was extracted. Results: Sixteen studies met inclusion criteria. We found that surplus opioid disposal rates varied widely, from 4.9% to 87.0%. Among studies with no intervention (opioid disposal education or drug disposal kit/bag), rates of opioid disposal ranged from 4.9% to 46.5%. While 7 studies used opioid disposal education as an intervention, only 3 showed a significant increase in surplus opioid disposal compared with standard care. All 3 studies that used an opioid disposal kit or bag as an intervention demonstrated significant increases in opioid disposal. Conclusions: Baseline rates of surplus opioid disposal are relatively low in the postoperative setting. Our findings suggest that opioid disposal kits significantly increase rates of surplus opioid disposal postoperatively. Further research, including a large-scale cost-benefit analysis, will be necessary prior to recommending widespread implementation of drug disposal kits or bags.

Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis

BACKGROUND

Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills.

METHODS

The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months.

RESULTS

In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], -3.39 pills; 95% confidence interval [CI], -6.40 to -0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04-1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45-1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17-2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28-1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59-1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66-6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, -4.05 pills; 95% CI, -6.59 to -1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, -2.31 pills; 95% CI, -12.21 to 7.59; P = .65; I2 = 80%).

CONCLUSIONS

Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.