Standardized Perioperative Patient Education Decreases Opioid Use after Hand Surgery: A Randomized Controlled Trial

Comparing modalities of opioid education in patients undergoing total knee arthroplasty: a randomized pilot trial

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain and routinely require opioids, yet they often lack knowledge regarding appropriate use and handling of these medications. Evidence suggests that educational interventions in various formats may help reinforce proper usage and improve postoperative pain control. The aim of this study is to compare the institution standard of care (webinar) with two novel educational interventions-one in-person and the other a video recording-that focus specifically on the use of opioids and pain control.

METHODS

This prospective, randomized pilot study included 42 patients undergoing TKA. Patients were randomized into one of three groups: (1) webinar: 50 min virtual session standard of care at Hospital for Special Surgery (HSS), (2) in-person education, or (3) video education. The primary outcomes of this study were the number of opioid refill requests through postoperative day (POD) 30 and POD 60. The secondary outcomes evaluated Numerical Rating Scale (NRS) pain scores, opioid consumption in oral morphine equivalents (OME), surveys on medication usage and opioid knowledge, reported medication storage and disposal. We hypothesize that the novel educational interventions, presented either in-person or by video, will lead to a decrease in opioid refills within 60 days compared with current education delivered through virtual webinar.

RESULTS

No significant differences were found among groups in the number of opioid refill requests, average NRS pain score, or OME consumption at any time point. Opioid refill requests ranged from 0% to 16.7% at POD 30 (Fisher's exact test, p=0.625) and from 0% to 8.3% at POD 60 (p=1.000). The median opioid refill request was zero requests per group from POD 21 to 60 (webinar 0 (0.0, 0.0), in-person 0 (0.0, 0.0), video 0 (0.0, 0.0), Kruskal-Wallis test, p=0.381). Average NRS pain scores were 5 or below for all groups on POD 1, 7 and 14. By POD 7, all groups had an average daily intake OME of 14 or below.

CONCLUSIONS

Overall, patients in each group did well with postoperative pain management after TKA and had minimal opioid refill requests. There were no statistically significant differences in outcomes of NRS pain scores or opioid usage among groups suggesting that educational interventions were similarly effective. As a pilot trial, study demonstrated successful recruitment and retention of participants, and important feedback was elicited from patients regarding education, as well. Of note, this was a pilot study and was likely underpowered to detect a difference.

TRIAL REGISTRATION NUMBER

NCT05593341.

A systematic review of morphine equivalent conversions in plastic surgery: Current methods and future directions

INTRODUCTION

Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature.

METHODS

Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation.

RESULTS

Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion.

CONCLUSION

There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.

Appendectomy Pain Medication Prescribing Variation in the U.S. Military Health System

INTRODUCTION

Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System.

MATERIALS AND METHODS

This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED).

RESULTS

Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only.

CONCLUSIONS

Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.

Efficacy of Postoperative Opioid-Sparing Regimens for Hand Surgery: A Systematic Review of Randomized Controlled Trials

PURPOSE

Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia.

METHODS

We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics.

RESULTS

Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens.

CONCLUSIONS

Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Postoperative Pain Relief After Ambulatory Laparoscopic Surgery a Nonmatched Case-Control Study

PURPOSE

To examine whether patient involvement using a Patient Decision Aid has a positive effect on pain levels, by giving them an active role in choosing a pain schedule for postoperative pain assessment and pain management.

DESIGN

A nonmatched case-control study.

METHODS

101 adults 18 years or older were included to choose between 1 of 3 possible schedules for postoperative pain management. Perioperative variables, for example, patients' assessments of pain were registered at the hospital and further variables after discharge at postoperative day 1 (POD1), POD3, and POD7, for example, patients' ability to sleep and assessment of nausea.

FINDINGS

Less pain after discharge was seen among patients choosing pain schedule II at POD1 (P = .0439). A significantly higher consumption of opioids (P = 0010) on POD1 in patients who have chosen pain schedule II.

CONCLUSIONS

Improved patient involvement by choosing a user-controlled pain schedule (pain schedule II) in postoperative pain management increased patient empowerment.

Celecoxib Decreases the Need for Rescue Analgesics after Total Knee Arthroplasty: A Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the analgesic efficacy and adverse effects of celecoxib after total knee arthroplasty. Keywords in the PubMed and Scopus databases were used to find article abstracts. Each included clinical trial was assessed using the Cochrane Collaboration risk of bias tool, and we extracted data on postoperative pain assessment using the Visual Analogue Scale (VAS) at rest, ambulation, and active range of motion, rescue analgesic intake, and adverse effects. Inverse variance tests with mean differences were used to analyze the numerical variables. The Mantel-Haenszel statistical method and the odds ratio were used to evaluate the dichotomous data. According to this qualitative assessment (n = 482), two studies presented conclusions in favor of celecoxib (n = 187), one showed similar results between celecoxib and the placebo (n = 44), and three clinical trials did not draw conclusions as to the effectiveness of celecoxib versus the placebo (n = 251). Moreover, the evaluation of the rescue analgesic intake showed that the patients receiving celecoxib had a lower intake compared to patients receiving a placebo (n = 278, I2 = 82%, p = 0.006, mean difference = -6.89, 95% IC = -11.76 to -2.02). In conclusion, the pooled analysis shows that administration of celecoxib alone results in a decrease in rescue analgesic consumption compared to a placebo after total knee surgery.

Opioid prescribing patterns for distal radius fractures in the ambulatory setting: A 10-year retrospective study

OBJECTIVE

Distal radius fractures (DRFs) are one of the most common orthopedic injuries, with most managed in the nonoperative ambulatory setting. The objectives of this study are to examine National Health Center Statistics (NHCS) data for DRF treated in the nonoperative ambulatory setting to identify opioid and nonopioid analgesic prescribing patterns and to determine demographic risk factors for prescription of these medications. Design, setting, patients, and measures: This study is a retrospective analysis of data collected by the NHCS from 2007 to 2016. Utilizing International Classification of Diseases codes, all visits to emergency departments and doctors' offices for DRFs were identified. Variables of interest included demographic data, expected payment source, and prescription of opioid or nonopioid analgesics.

RESULTS

During the study timeframe, 15,572,531 total visits for DRFs were recorded. DRF visits requiring opioid and nonopioid analgesic prescriptions increased over time. Patients aged 45-64 years were significantly more likely to receive an opioid prescription than any other age group (p < 0.05). Opioid prescription was positively correlated with the use of workers' compensation and negatively correlated with patients receiving services under charity care (p < 0.05).

CONCLUSIONS

Prescriptions of both opioid and nonopioid analgesic medications for DRF have been steadily increasing over time in the nonoperative ambulatory setting, with middle-aged adults most likely to receive an opioid prescription. Opioid prescription rates differ significantly between patients utilizing workers' compensation and patients receiving services under charity care, suggesting that socioeconomic factors play a role in prescribing patterns.

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

BACKGROUND

Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied.

OBJECTIVE

This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery.

MATERIALS AND METHODS

All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms.

RESULTS

In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001).

CONCLUSION

Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Impact of Preoperative Patient Education on Postoperative Pain, Opioid Use, and Psychological Outcomes: A Narrative Review

Background

Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use.

Objectives

The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes.

Method

The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded.

Results

From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety.

Conclusion

Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.

Improving Perioperative Pain Education for Patients Prescribed Opioids: An Integrative Review

BACKGROUND

Postoperative pain is still inadequately managed for a significant number of patients despite the extensive use of opioids. Among several pain management strategies, patient education is a vital component of perioperative pain management. However, perioperative education practices remain inconsistent and incomplete in many hospital settings.

AIM

This integrative review aims to synthesize current evidence regarding pain education interventions across all phases of perioperative care in order to promote the safe use of opioids among patients prescribed opioids.

METHODS

The literature search identified 443 records published since 2016 through Cochrane Library, PubMed, the Cumulative Index of Nursing and Allied Health Literature Plus, and Embase. This review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 12 articles met the inclusion criteria.

RESULTS

The study settings varied from a general surgery center to multiple settings in the United States or Canada, with sample sizes ranging from 27 to 536. The main themes from the analysis include the key components of education, the optimal timing and frequency of education, education delivery methods, and a multidisciplinary team approach.

CONCLUSION

The findings from this review will help nursing professionals across surgical specialties identify effective educational approaches for patients prescribed opioids during the perioperative period. Developing education interventions based on these findings would enhance the quality and effectiveness of pain education, improve patient understanding and their preparedness to manage pain at home, and, ultimately, promote the safe use of opioids postoperatively.

A Retrospective Study Analyzing Opioid Prescription Practices in Hand Surgery from 2013 to 2019

Background

The potential for opioid prescription medication addiction and abuse has been a growing concern in healthcare. It is not uncommon for hand surgery patients to be overprescribed opioid medication for postoperative pain management. The objective of this study was to characterize changes in opioid prescription practices of hand surgeons treating Medicare Part D patients from 2013 to 2019.

Methods

A retrospective analysis of Medicare Part D prescriber data from 2013 to 2019 was conducted. This database provides information on drugs paid for under the Medicare Part D Prescription Drug Program. For each prescriber and medication, the dataset includes the total number of prescriptions dispensed (original prescriptions and number of refills), and total medication cost.

Results

In 2013, the 10 most common medications prescribed totaled 114,409 prescriptions, with 89,701 (78.4%) opioid prescriptions. In 2019, the 10 most common medications prescribed totaled 164,955 prescriptions, with 109,665 (66.5%) opioid prescriptions. Although total opioid prescriptions dropped, there was a 22% increase in the total number of prescriptions written. The two most common medications prescribed, hydrocodone-acetaminophen and oxycodone-acetaminophen, totaled 75,796 in 2013, compared with 76,518 in 2019. The overall number of prescriptions for nonsteroidal anti-inflammatory drugs increased by 157%, and the percentage of total opioids prescribed declined by 7.9%.

Conclusions

The increase in total opioid prescriptions from 2013 to 2019 by hand surgeons in the Medicare Part D Prescription Drug Program lags behind the recommended shift to nonopioid pain management. The reasons for the overall rise in prescriptions deserve further exploration.

Reducing Opioid Exposure Following Common Ambulatory Hand Surgery: A Systematic Review

BACKGROUND

The opioid epidemic is a health crisis in the United States. Physicians contribute to this problem by overprescribing opioids. Ambulatory hand surgery (AHS) is common in the United States and associated with overprescribing of opioids. Education and guidance regarding the effectiveness of nonopioid compared with opioid interventions for pain management following ambulatory hand procedures are lacking. We assessed the current literature to suggest evidence-based protocols for postoperative analgesia.

METHODS

A systematic review was performed using PubMed, Web of Science, and Cochrane Library. Studies comparing nonopioid with opioid treatments for pain management following AHS were identified. Studies investigating opioid-sparing strategies after AHS were also identified. Evidence was examined to determine efficacy of nonopioid interventions and to provide recommendations for optimal nonopioid protocols and opioid-sparing strategies.

RESULTS

A total of 510 studies were identified in the search with 18 meeting inclusion criteria. High-level evidence demonstrated efficacy of nonopioid interventions for pain management following AHS (levels I and II evidence). Results provided evidence-based guidelines for recommendations of nonopioid treatment protocols and opioid-sparing strategies (levels I and II evidence).

CONCLUSIONS

Our review demonstrated nonopioid interventions are adequate in multiple aspects of pain management compared with opioid treatments. Recommendations were established for two nonopioid treatment protocols, and for an opioid-sparing intervention (levels I and II evidence). The evidence provided in this review should be strongly considered for pain management guidance following AHS and provides a means to decrease opioid overprescribing in the United States.

Team Approach: Use of Opioids in Orthopaedic Practice

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The opioid epidemic represents a serious health burden on patients across the United States.

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This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions.

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The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use.

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Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available.

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The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.

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.

Evidenced-Based Opioid Prescribing Recommendations Following Hand and Upper-Extremity Surgery

The United States’ opioid epidemic has taken an immense toll over the past 2 decades when assessed by morbidities, mortalities, and economic costs. Prescription opioids are a substantial contribution to this public health emergency, and it is critical for health care providers to practice good analgesic stewardship. Interventions have effectively curtailed opioid overuse, including prescription drug monitoring programs, educational initiatives, and multimodal analgesia strategies. Surgeons, particularly hand surgeons or those who perform musculoskeletal procedures, have been implicated as high-volume opioid prescribers. Guidelines for appropriate opioid dosing and analgesic management strategies after common hand and upper-extremity surgeries are sparse and offer an area for meaningful improvement. We sought to generate comprehensive, evidence-based recommendations for postoperative analgesia regimens for common hand and upper-extremity procedures.

Influence of perioperative opioid-related patient education: A systematic review and meta-analysis

OBJECTIVE

To determine the role of perioperative protocolized opioid-specific patient education on opioid consumption for individuals undergoing surgical procedures.

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) that compared protocolized perioperative opioid-specific patient education to the usual care for adult individuals undergoing surgical interventions. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes.

RESULTS

In total, 15 RCTs that enrolled 2546 participants were deemed eligible. Protocolized opioid-specific patient education showed a significant reduction in postoperative opioid consumption and postoperative pain score compared to usual care (SMD= -0.15, 95% confidence interval [CI]: -0.28 to -0.03 and SMD= -0.17, 95% CI: -0.28 to -0.06, respectively). No significant difference was found between the protocolized opioid-specific patient education and the usual care in terms of the number of refill requests (RR=0.82, 95% CI: 0.50-1.34), patients with opioid leftovers (RR=0.92, 95% CI: 0.78-1.08), and patients taking opioids after hospital discharge.

CONCLUSIONS

This meta-analysis demonstrated that protocolized opioid-specific patient education significantly reduces postoperative opioid consumption and pain score but has no influence on the number of opioid refill requests, opioid leftovers, and opioid use after hospital discharge.

PRACTICE IMPLICATIONS

Healthcare professionals may offer opioid-related educational sessions for the surgical patients during the perioperative period through a video-based material that emphasizes the role of alternative analgesics to opioids, patients' expectations about the post-operative pain, and the potential side effects of opioid consumptions.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery

BACKGROUND

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME).

RESULTS

A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation.

CONCLUSION

Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Patient risk screening to improve transitions of care in surgical opioid prescribing: a qualitative study of provider perspectives

Introduction

In patients undergoing surgical procedures, transitions in opioid prescribing occur across multiple providers during the months before and after surgery. These transitions often result in high-risk and uncoordinated prescribing practices, especially for surgical patients with prior opioid exposure. However, perspectives of relevant providers about screening and care coordination to address these risks are unknown.

Methods

We conducted qualitative interviews with 24 surgery, primary care, and anesthesia providers in Michigan regarding behaviors and attitudes about screening surgical patients to inform perioperative opioid prescribing in relation to transitions of care. We used an interpretive description framework to topically code interview transcripts and synthesize underlying themes in analytical memos.

Results

Providers believed that coordinated, multidisciplinary approaches to identify patients at risk of poor pain and opioid-related outcomes could improve transitions of care for surgical opioid prescribing. Anesthesia and primary care providers saw value in knowing patients’ preoperative risk related to opioid use, while surgeons’ perceptions varied widely. Across specialties, most providers favored a screening tool if coupled with actionable recommendations, sufficient resources, and facilitated coordination between specialties. Providers identified a lack of pain specialists and a dearth of actionable guidelines to direct interventions for patients at high opioid-related risk as major limitations to the value of patient screening.

Discussion

These findings provide context to address risk from prescription opioids in surgical transitions of care, which should include identifying high-risk patients, implementing a coordinated plan, and emphasizing actionable recommendations.

Shared Decision-Making Tool for Opioid Prescribing After Ambulatory Orthopedic Surgery in Veterans: A Randomized Controlled Clinical Trial

Purpose

We examined whether an educational, shared-decision-making tool designed to empower patients, individualize pain management, and maximize use of nonopioid, over-the-counter analgesics reduces opioid use and waste while maintaining adequate pain relief.

Methods

We developed an educational, shared-decision-making tool regarding postoperative pain medication for outpatient hand surgery. Patients randomized to groups with and without the tool were surveyed for 4 weeks after surgery. Survey variables included Patient-Reported Outcomes Measurement Information System pain intensity and pain interference scores, as well as the number of oxycodone or over-the-counter pills taken. Results were compared using chi-squared, Wilcoxon rank-sum, and Welch’s t tests.

Results

Fifty-three patients participated: 25 in the shared-tool group and 28 in the no-tool group. The mean age was 60 years, with more women in the no-tool group than the shared-tool group (n =17 versus 11, respectively). The shared-tool group averaged 6.4 prescribed oxycodone pills, versus 10 for the no-tool group (P < .01). The median numbers of oxycodone pills taken the first week after surgery were 2 (interquartile range, 6) for the shared-tool group and 3 (interquartile range, 6) for the no-tool group (P = .97). Patient-reported outcome measures for pain intensity and pain interference were not significantly different for weeks 1, 3, and 4 after surgery. Pain interference was significantly lower in week 2 in the shared-tool group (difference, −4.4; 95% confidence interval, −8.57 to −0.30; P = .04).

Conclusions

The shared-tool group had equivalent or better pain control and were prescribed a lower number of opioid pain pills than the no-tool group. Both groups used nonopioid medications, with no difference in the types of over-the-counter medications used. Shared decision-making strategies could be applied to other outpatient orthopedic surgical settings, and may reduce the amount of opioids prescribed without compromising pain control.

Type of study/level of evidence

Therapeutic II.

Preoperative Opioid Use Results in Greater Postoperative Opioid Consumption After Thumb Basal Joint Arthroplasty

Purpose

Thumb basal joint arthroplasty surgery is a common hand surgery after which patients often require opioids. To better understand safe opioid consumption patterns, this study sought to identify risk factors for filling a second prescription and/or prolonged opioid use (prescription over 6 months after the surgery). Preoperative opioid use was hypothesized to show an association with greater postoperative opioid use.

Methods

A retrospective review of consecutive patients who underwent primary thumb basal joint arthroplasty was conducted, yielding 110 patients for analysis. Demographic and clinical data were collected. Opioid prescription data were extracted from 6 months before the surgery to 9 months after the surgery using a state prescription drug monitoring program. Bivariate and multivariate analyses were performed for filling a second opioid prescription or filling an opioid prescription over 6 months after the surgery.

Results

All the patients filled their initial postoperative prescription. Of the 110 patients, 26.4% filled an opioid prescription before the surgery, 42% filled a second postoperative prescription, and 14.5% were still consuming opioids over 6 months after the surgery. Patients using preoperative opioids had 7-fold higher odds of filling a second opioid prescription and 37-fold higher odds of prolonged use. No other demographic or clinical factors, including the type of procedure or number of initial opioids prescribed, were associated with increased use of postoperative opioids. Of all the opioid prescriptions filled after the initial postoperative prescription, only 9.3% were prescribed by a surgeon’s office.

Conclusions

Patients who undergo thumb basal joint arthroplasty with preoperative opioid use have much greater odds of filling a second opioid prescription and prolonged use after the surgery. Low initial surgeon-provided opioid dosages did not correlate to filling a second prescription, indicating that lower initial doses are feasible. Finally, nearly all opioid-naïve patients who filled a second opioid prescription received them from providers other than a surgeon, indicating the need for greater communication with nonsurgical providers simultaneously caring for patients in the perioperative period.

Type of study/level of evidence

Therapeutic III.

The Effect of an Electronic Prescribing Policy for Opioids on Physician Prescribing Patterns Following Common Upper Extremity Procedures

Purpose

We evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed.

Methods

We retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed.

Results

A total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60], P = .03) and CMC arthroplasty (283 [SD, 147] vs 217 [SD, 92], P < .01). There was also a significant decrease in the total number of tablets prescribed for ganglion excision (11 [SD, 5.7] vs 6.8 [SD, 8.0], P < .01), CMC arthroplasty (36 [SD, 13] vs 29 [SD, 12], P < .01), and DRF ORIF (31 [SD, 8.6] vs 28 [SD, 8.5], P = .04). The number of patients receiving any opioid prescription also significantly decreased following CTR (30% vs 51%, P = .03) and ganglion excision (11% vs 53%, P < .01).

Conclusions

The initiation of state-mandated ePrescribing was associated with a decreased number of opioids—both MMEs and tablets—prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions.

Type of study/level of evidence

Therapeutic III.

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.