Opioid Prescribing and Use Patterns in Postsurgical Facial Trauma Patients

Examining the relationship between head trauma and opioid use disorder: A systematic review

OBJECTIVE

To examine recent literature and determine common clinical risk factors between antecedent traumatic brain injury (TBI) and the following development of opioid misuse and provide a framework for clinical identification of at-risk subjects and evaluate potential treatment implications within this association.

DESIGN

A comprehensive systematic literature search of PubMed was conducted for articles between 2000 and December 2022. Studies were included if the human participant had any head trauma exposure and any chronic opioid use or dependence. After eligibility criteria were applied, 16 studies were assessed for thematic trends.

RESULTS

Opioid use disorder (OUD) risks are heightened in cohorts with head trauma exposed to opioids while in the hospital, specifically with tramadol and oxycodone. Chronic pain was the most common predictor of long-term OUD, and continuous somatic symptoms associated with the TBI can lead to long-term opioid usage. Individuals who present with coexisting psychiatric conditions pose significantly more risk associated with a higher risk of long-term opioid use.

CONCLUSION

Findings indicate that therapists and clinicians must consider a risk profile for persons with TBI and follow an integrated care approach to account for mental health, prior substance misuse, presenting somatic symptoms, and current medication regimen during evaluation.

Perioperative Management of Patients with Craniomaxillofacial Trauma

Successful surgical management of patients with facial fractures requires a detailed preoperative evaluation and postoperative management that differs from elective surgical patients. This review presents evidence-based recommendations from the surgical and anesthesiology literature that address many of the clinical questions that arise during the perioperative management of this group of patients. Surgeons and anesthesiologists must work together at numerous points and make joint decisions, especially where airway and pain management challenges may arise. The multidisciplinary nature of the decision-making process is emphasized.

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight.

METHODS

In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance.

RECOMMENDATIONS

This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.

Impact of Opioid Restriction Legislation on Prescribing Practices for Outpatient Plastic and Reconstructive Surgery

BACKGROUND

Overprescription of opioids for acute postoperative pain, plastic surgery procedures included, is contributing to the pervasive opioid epidemic in the United States. This study examines the effect of a statewide legislation limiting postoperative opioids on opioid prescription behavior among providers following outpatient plastic surgery procedures at a high-volume academic center.

METHODS

Retrospective review of all outpatient surgical encounters between June 1, 2016, and November 30, 2018, was performed. Encounters were grouped into two cohorts: prepolicy and postpolicy. Primary outcomes included total oral morphine equivalents prescribed on the day of surgery and proportion of patients prescribed greater than 210 oral morphine equivalents. Secondary outcomes included proportion of patients requiring an opioid refill within 30 days following surgery, and number of refills required.

RESULTS

The mean oral morphine equivalents prescribed on the day of surgery was reduced from 271.8 to 150.37 oral morphine equivalents ( p < 0.001) following implementation of the legislation, with an associated decrease in the standard deviation of oral morphine equivalents prescribed from 225.35 to 196.71 ( p < 0.001), suggesting a decrease in the variability of prescriber practices. Time series analysis demonstrated the decrease in oral morphine equivalents remained significant when accounting for baseline level of change in opioid prescription patterns.

CONCLUSION

This study provides evidence that legislation at the state level restricting postoperative opioid prescriptions is associated with a decrease in opioid prescriptions without an increase in the need for refills in the acute postoperative setting following outpatient plastic surgery procedures.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Pain Management Strategies After Orthopaedic Trauma: A Mixed-Methods Study with a View to Optimizing Practices

PURPOSE

To examine 1) pain management strategies within the care trajectory of orthopaedic trauma patients and patients' perception of their effectiveness, 2) adverse effects (AEs) associated with pharmacological treatments, particularly opioids and cannabis, and 3) patients' perceptions of strategies that should be applied after an orthopaedic trauma and support that they should obtain from health professionals for their use.

PATIENTS AND METHODS

This study was conducted with orthopaedic trauma patients in a level 1 trauma center. A convergent mixed-methods design was used. Data on pain experience, pain management strategies used and AEs were collected with self-administered questionnaires at hospital discharge (T1) and at 3 months after injury (T2). Patients' preferences about the pain management strategies used, the required support and AEs were further examined through semi-structured individual interviews at the same time measures. Descriptive statistics and thematic analyses were performed.

RESULTS

Seventy-one patients were recruited and 30 individual interviews were undertaken. Pharmacological pain management strategies used at T1 and T2 were mainly opioids (95.8%; 20.8%) and acetaminophen (91.5%; 37.5%). The most frequently applied non-pharmacological strategies were sleep (95.6%) and physical positioning (89.7%) at T1 and massage (46.3%) and relaxation (32.5%) at T2. Findings from quantitative and qualitative analyses highlighted that non-pharmacological strategies, such as comfort, massage, distraction, and physical therapy, were perceived as the most effective by participants. Most common AEs related to opioids were dry mouth (78.8%) and fatigue (66.1%) at T1 and insomnia (30.0%) and fatigue (20.0%) at T2. Dry mouth (28.6%) and drowsiness (14.3%) were the most reported AEs by patients using recreational cannabis. An important need for information at hospital discharge and for a personalized follow-up was identified by participants during interviews.

CONCLUSION

Despite its AEs, we found that opioids are still the leading pain management strategy after an orthopaedic trauma and that more efforts are needed to implement non-pharmacological strategies. Cannabis was taken for recreational purposes but patients also used it for pain relief. Support from health professionals is needed to promote the adequate use of these strategies.

Postoperative opioid prescribing practices in US adult trauma patients: A systematic review

BACKGROUND

Opioids have been proven effective in pain management, but overprescription can lead to addiction and abuse. Although current guidelines regarding opioid prescription for chronic and acute pain are available, they fail to address the use of opioids for pain management in traumatic injury patients who undergo operations. The primary objective of this study was to examine opioid prescribing practices for US adult trauma patients who require surgical management, based on prior history of opioid use, type of surgical practice, and age.

METHODS

PubMed and Cochrane Journals were used to identify relevant articles between October 2010 and December 29, 2020. Our primary outcome was discrepancies of morphine milligram equivalents (MMEs) prescribed to trauma patients. Significance was defined as p < 0.05.

RESULTS

Eleven studies on US trauma patients prescribed opioids were evaluated, creating a total of 30,249 patients stratified by prior opioid use, age, and race. Patterns seen among patients with prior opioid use include higher MMEs prescribed, lower likelihoods of opioid discontinuation, higher mortality rates, and higher complication rates. Orthopedic surgeons prescribed higher values of MMEs than nonorthopedic surgeons.

CONCLUSION

Higher incidences of opioid prescriptions are seen with orthopedic trauma surgery and prior opioid use by the patient. We recommend further development of national protocol implementation for acute pain management for the US trauma population.

LEVEL OF EVIDENCE

Systematic review, level III.

Claims-based measures of prescription opioid utilization: A practical guide for researchers

BACKGROUND

Given the increased attention to the opioid epidemic and the role of inappropriate prescribing, there has been a marked increase in the number of studies using claims data to study opioid use and policies designed to curb misuse. Our objective is to review the medical literature for recent studies that use claims data to construct opioid use measures and to develop a guide for researchers using these measures.

METHODS

We searched for articles relating to opioid use measured in health insurance claims data using a defined set of search terms for the years 2014-2020. Original research articles based in the United States that used claims-based measures of opioid utilization were included and information on the study population and measures of any opioid use, quantity of opioid use, new opioid use, chronic opioid use, multiple providers, and overlapping prescriptions was abstracted.

RESULTS

A total of 164 articles met inclusion criteria. Any opioid use was the most commonly included measure, defined by 85 studies. This was followed by quantity of opioids (68 studies), chronic opioid use (53 studies), overlapping prescriptions (28 studies), and multiple providers (8 studies). Each measure contained multiple, distinct definitions with considerable variation in how each was operationalized.

CONCLUSIONS

Claims-based opioid utilization measures are commonly used in research, but definitions vary significantly from study to study. Researchers should carefully consider which opioid utilization measures and definitions are most appropriate for their study and recognize how different definitions may influence study results.

Patterns of Mandibular Fractures in South Australia: Epidemiology, Treatment, and Clinical Outcomes

INTRODUCTION

The mandible is one of the most common facial bones to be injured with great clinical variability across countries caused by assaults, road traffic accidents, and falls.

METHODS

A retrospective review was conducted for adult mandibular fractures from January 2012 to January 2017 at the Royal Adelaide Hospital, Adelaide. Our aim was to describe epidemiological trends of mandibular fractures, differences for sex and age, and clinical outcomes.

RESULTS

Five hundred sixty five adult patients presented with a mandibular fracture with a male predominance (4.5:1). The mean age was 34.2 years with men 11.9 years younger than females (32.0 versus 44.1 years, P < 0.001). Assaults represented 58.2% of cases. A quarter of the cohort reported alcohol use. Assaults commonly resulted in angle and symphyseal fractures, whereas almost all falls and road traffic accident resulted in condylar or coronoid fractures. Young men were 1.9 times more likely to have mandibular fractures compared to women, whereas elderly men were 11.8% less likely (P < 0.001). The most common fracture was the angle (33.6%) and the angle/symphyseal (14.2%). Men were 2.5 times more likely to have surgery. The complication rate was 10.8% and the re-operative rate was 5.0%. Women had a significantly longer admission of 1.6 days compared to men (4.4 versus 2.8 days, P = 0.003).

CONCLUSIONS

Young men are more likely to have mandibular fractures from assaults and have surgery. Young women and elderly females are more likely to have animal and fall-related injuries resulting including in condylar fractures with associated injuries and extended length of stay.

Reduction of Opioid Prescriptions in Maxillofacial Trauma Following North Carolina STOP Act

Study Design

Retrospective cohort study.

Objective

On January 1, 2018, the Strengthen Opioid Misuse Prevention (STOP) Act was implemented to increase oversight over opioid prescriptions in North Carolina. The aim of this study is to evaluate the legislation's efficacy in reducing opioid prescriptions following facial fracture repair.

Methods

A retrospective chart review of patients who sustained maxillofacial fractures and underwent repair from January 1, 2015 through December 31, 2019 at a level 1 trauma center was performed. The North Carolina Controlled Substance Database was used to quantify perioperative opioid prescriptions in morphine milligram equivalents (MME). Average MME per patient was compared between 2 groups, patients who underwent surgery before the NC STOP Act came into effect and patients who underwent treatment after. This comparison was also performed on case type subgroups including surgically treated fractures of the orbit, mandible, midface, and multiple regions. A student's t-test was used to compare before and after groups in all analyses.

Results

Of the 253 patients who met inclusion criteria, 146 were in the before group, and 107 were in the after group. There was a statistically significant, 30.9% decrease in overall average MME prescribed after the NC STOP Act was enacted. A statistically significant decrease was noted in patients who had facial fractures of multiple regions.

Conclusion

Since the implementation of the NC STOP Act in 2018, there have been statistically and clinically significant decreases in the amount of opioids prescribed following surgical management of facial fractures.

Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures

BACKGROUND

From 2005 to 2020, the American Board of Plastic Surgery collected data on 20 common plastic surgery operations as part of the Maintenance of Certification process. These data allow the authors to examine national trends in zygomatico-orbital fracture repair over a 15-year period.

METHODS

Tracer data for zygomatico-orbital fracture repair were reviewed in cohorts from 2005 to 2013 and 2014 to 2020. Results were categorized based on their presence in evidence-based medicine articles published during this period. Differences between years were assessed using the t test or chi-square test as appropriate.

RESULTS

Four hundred thirty patients were included as of March of 2020. Average age was 37 years (range, 6 to 85 years), and 76 percent were male. Operations took place on average 10 days from injury. There were significant decreases in the use of subciliary (31.9 percent versus 10.0 percent; p < 0.001), gingival buccal (84.3 percent versus 56.4 percent; p < 0.001), and lateral brow (45.2 percent versus 22.3 percent; p < 0.001) incisions, with an increase in lower lid external incisions (15.2 percent versus 30.9 percent; p < 0.001); 2.7 percent of patients had a complication requiring readmission and 4.5 percent required reoperation. The incidence of postoperative diplopia was 7.7 percent, and the infection rate was 1.7 percent.

CONCLUSIONS

This article reviews the American Board of Plastic Surgery tracer data for zygomatico-orbital fracture repair. The Maintenance of Certification tracer data provide a national database with longer follow-up and more specific information than comparable databases. Analysis of these data over time enables the authors to describe practice trends and gives surgeons the opportunity to compare their outcomes to national norms.

Trends in opioid prescription for craniomaxillofacial trauma in the United States: An 11-year retrospective study of emergency room and office visits

BACKGROUND

Facial trauma is associated with significant long-term morbidity and pain. These patients are routinely prescribed opioid medication and are at risk for opioid dependence. Rates and trends in opioid prescription in the ambulatory setting for management of craniofacial trauma are unknown.

METHODS

The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data were analyzed from 2006 to 2016. Using International Classification of Diseases codes, 7,997,454 visits for craniomaxillofacial trauma were identified. Trends in opioid and nonopioid prescriptions were studied, with variables of interest including demographics, geographic region, expected source of payment, and injury location.

RESULTS

Over the study period, trends in both opioid and nonopioid prescriptions remained stable, with about 13.4% of all visits receiving opioid prescriptions. Patients aged 18 to 44 (P < .001) and lower face trauma (P = .047) were associated with increased rates, while Medicare and charity payers (P < .001) were associated with lower rates of opioid prescriptions. There was no significant difference in prescription rates across geographical regions, by ethnicity, or sex.

CONCLUSION

Opioid medication forms the cornerstone for ambulatory management of craniofacial trauma. Despite increased awareness and emphasis on multimodal pain management, opioid prescription trends have remained relatively stable over time.

Opioid Prescribing Patterns Among Facial Plastic and Reconstructive Surgeons in the Medicare Population

Objective: To evaluate opioid prescribing patterns among American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members in the Medicare population. Methods: Retrospective cohort study of AAFPRS members in the Medicare Part D Prescriber dataset. Results: From 2014 to 2016, there was a significant decrease in the number of days of opioids supplied per beneficiary (5.9 vs. 4.9 days, p < 0.005), as well as the opioid prescription cost per beneficiary ($14.52 vs. $11.79, p = 0.005). The highest prescription rate was found in the Midwest (20.5%) and lowest in the Northeast (14.0%), however, the difference between geographic regions was not significant (p = 0.11). There was a significant decrease in the number of total opioid days supplied per beneficiary in the South (p = 0.001), Midwest (p = 0.05), and West regions (p < 0.001). There was no significant difference in opioid prescription rate (p = 0.89) or total opioid days supplied per beneficiary (p = 0.26) when states were stratified by age-adjusted opioid-specific death rate. Conclusion: This study demonstrates a national trend toward fewer opioid days supplied and less opioid cost per Medicare beneficiary among AAFPRS members between 2014 and 2016.