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Peri K, Honeycutt L, Wennberg E, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E, Moiz A, Martel MO, Eisenberg MJ. Efficacy of interventions targeted at physician prescribers of opioids for chronic non-cancer pain: an overview of systematic reviews. BMC Med 2024; 22:76. [PMID: 38378544 PMCID: PMC10877926 DOI: 10.1186/s12916-024-03287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND To combat the opioid crisis, interventions targeting the opioid prescribing behaviour of physicians involved in the management of patients with chronic non-cancer pain (CNCP) have been introduced in clinical settings. An integrative synthesis of systematic review evidence is required to better understand the effects of these interventions. Our objective was to synthesize the systematic review evidence on the effect of interventions targeting the behaviours of physician opioid prescribers for CNCP among adults on patient and population health and prescriber behaviour. METHODS We searched MEDLINE, Embase, and PsycInfo via Ovid; the Cochrane Database of Systematic Reviews; and Epistemonikos. We included systematic reviews that evaluate any type of intervention aimed at impacting opioid prescriber behaviour for adult CNCP in an outpatient setting. RESULTS We identified three full texts for our review that contained 68 unique primary studies. The main interventions we evaluated were structured prescriber education (one review) and prescription drug monitoring programmes (PDMPs) (two reviews). Due to the paucity of data available, we could not determine with certainty that education interventions improved outcomes in deprescribing. There is some evidence that PDMPs decrease the number of adverse opioid-related events, increase communication among healthcare workers and patients, modify healthcare practitioners' approach towards their opioid prescribed patients, and offer more chances for education and counselling. CONCLUSIONS Our overview explores the possibility of PDMPs as an opioid deprescribing intervention and highlights the need for more high-quality primary research on this topic.
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Affiliation(s)
- Katya Peri
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Lucy Honeycutt
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Erica Wennberg
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Temerty Faculty of Medicine and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sarah B Windle
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Kristian B Filion
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Genevieve Gore
- Schulich Library of Science and Engineering, McGill University, Montreal, QC, Canada
| | - Irina Kudrina
- Departments of Family Medicine and of Anesthesia, McGill University, Montreal, QC, Canada
| | - Elena Paraskevopoulos
- Departments of Family Medicine, Royal Ottawa Mental Health Center and Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Areesha Moiz
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Marc O Martel
- Faculty of Dentistry and Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Mark J Eisenberg
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
- Department of Medicine, McGill University, Montreal, QC, Canada.
- Division of Cardiology, Jewish General Hospital, Jewish General Hospital, McGill University, 3755 Cote Ste-Catherine Road, Suite H-421, Montreal, QC, H3T 1E2, Canada.
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Winter J, Cruise B, Peters BR, Islur A. Pain Medication Prescribing Patterns in Augmentation Mammoplasty. Plast Surg (Oakv) 2023; 31:270-274. [PMID: 37654542 PMCID: PMC10467444 DOI: 10.1177/22925503211034828] [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: 05/12/2021] [Accepted: 06/22/2021] [Indexed: 09/02/2023] Open
Abstract
Background The rate of opioid prescribing after low-risk surgical procedures has increased over the past decade, and surgeons are responsible for prescribing approximately one-third of all opioid medications. There is additional supporting evidence that patients only consume about half of the opioids prescribed to them after outpatient plastic surgery. Currently, there is no literature to provide surgeons with reference ranges for how much opioid medication will adequately provide analgesia for patients after undergoing bilateral breast augmentation (BBA) surgery. Objective To quantify the amount of opioid medication required to adequately control pain for patients after undergoing BBA and use these data to provide recommendations on opioid prescribing practices. Methods Cross-sectional prospective data were obtained through a take-home medication and pain tracking questionnaire for 56 patients after they underwent either subpectoral or subglandular BBA. Patients documented their pain scores on a 0 to 10 analogue scale and documented the type and amount of pain medication they took for a 7-day period. Results Our study demonstrated that patients in the subglandular BBA group required an average of either 25 ± 1.2 Tylenol #3 or 19.3 ± 2.3 Tramacet tablets, and the subpectoral group required 27.7 ± 1.7 Tylenol #3 or 25.6 ± 0.9 Tramacet tablets over a 7-day period. There was no statistically significant difference between the 2 surgical groups. Conclusion We propose a reference range of medication required on average for patients undergoing BBA to obtain adequate pain control in the initial postoperative period that falls within the most recent Canadian guidelines for safe opioid prescribing practices.
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Affiliation(s)
- Jessica Winter
- Section of Plastic Surgery, Department of Surgery, Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Braden Cruise
- Undergraduate Medical Education, Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Blair R. Peters
- Section of Plastic Surgery, Department of Surgery, Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Avi Islur
- Section of Plastic Surgery, Department of Surgery, Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- First Gland Cosmetic Clinic, Manitoba, Winnipeg, Manitoba, Canada
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Zamri M, Lans J, Jupiter JB, Eberlin KR, Garg R, Chen NC. Factors Associated with Prolonged Opioid Use after CMC Arthroplasty. J Hand Microsurg 2023; 15:196-202. [PMID: 37388557 PMCID: PMC10306983 DOI: 10.1055/s-0041-1736003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background Higher rates of prolonged opioid use have been reported in patients who undergo thumb carpometacarpal (CMC) arthroplasty compared with other hand procedures. Therefore, the aim of this study is to identify the risk factors associated with prolonged postoperative opioid use after CMC arthroplasty, along with reporting the number of patients who filled an opioid prescription more than 30 days postoperatively. Materials and Methods Retrospectively, 563 opioid-naïve patients who underwent CMC arthroplasty were included. A manual chart review was performed to collect patient characteristics, and opioid use was determined based on opioid prescription by a physician. Prolonged opioid use was defined as an opioid prescription at 90 to 180 days postoperatively. A multivariable analysis was performed to identify independent factors associated with an opioid prescription at 90 to 180 days postoperatively. Patients had a median age of 60.4 years (interquartile range [IQR]: 55.5-66.9) and had a median follow-up of 7.6 years (IQR: 4.3-12.0). Results The rates of postoperative opioid use ranged from 6.2% (53 out of 563 patients) at 30 to 59 days postoperatively to 3.9% (22 out of 563 patients) at 150 to 180 days postoperatively. In total, 17.1% (96 out of 563 patients) received a second opioid prescription more than 30 days following surgery, of which 10.8% (61 out of 563 patients) were between 90 and 180 days postoperatively. Older age, defined as a median of 63 years (IQR: 57.10-69.88) ( p = 0.027, odds ratio [OR] = 1.04) and a history of psychiatric disease ( p = 0.049, OR = 1.86) were independently associated with prolonged opioid use. Conclusion A prolonged opioid use rate of roughly 11% was found in opioid-naïve patients who underwent CMC arthroplasty. In patients at risk (older patients or psychiatric history) of prolonged opioid use, careful postoperative pain management is recommended.
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Affiliation(s)
- Meryam Zamri
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jonathan Lans
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Jesse B. Jupiter
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Kyle R. Eberlin
- Hand Surgery Service, Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Rohit Garg
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Neal C. Chen
- Hand and Upper Extremity Service, Division of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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An Education Intervention to Raise Awareness Reduces Self-reported Opioid Overprescribing by Plastic Surgery Residents. Ann Plast Surg 2022; 89:600-609. [DOI: 10.1097/sap.0000000000003247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Impact of Opioid Restriction Legislation on Prescribing Practices for Outpatient Plastic and Reconstructive Surgery. Plast Reconstr Surg 2022; 150:213-221. [PMID: 35588099 DOI: 10.1097/prs.0000000000009239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Hoppe D, Karimi L, Khalil H. Mapping the research addressing prescription drug monitoring programs: A scoping review. Drug Alcohol Rev 2022; 41:803-817. [PMID: 35106867 DOI: 10.1111/dar.13431] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/19/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
ISSUES Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice. APPROACH A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021. KEY FINDINGS A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use. IMPLICATIONS Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement. CONCLUSION Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.
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Affiliation(s)
- Dimi Hoppe
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Leila Karimi
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Hanan Khalil
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Picco L, Lam T, Haines S, Nielsen S. How prescription drug monitoring programs influence clinical decision-making: A mixed methods systematic review and meta-analysis. Drug Alcohol Depend 2021; 228:109090. [PMID: 34600255 DOI: 10.1016/j.drugalcdep.2021.109090] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Opioid prescribing, for chronic non-cancer pain, has increased substantially in the past two decades and is associated with significant harms. Various public health approaches have been adopted to address these harms including the implementation of prescription drug monitoring programs (PDMPs). This systematic review aims to identify how PDMP use influences healthcare providers' clinical decision-making. METHODS Six databases were searched for literature up until April 2021. Empirical studies were included, with no restrictions placed on year, location, language or study design. Thematic analysis of the identified articles was conducted and where possible, meta-analyses were conducted using a random effect model in Stata. RESULTS Forty-one articles related to 39 studies were included. All studies were conducted in the United States, published between 2005 and 2021 and most (n = 28) related to one state-level PDMP. PDMP utilisation influenced healthcare providers' clinical decision-making across seven broad themes: (i) the supply of controlled substances, (ii) refusal to prescribe or treat, (iii) risk mitigation strategies, (iv) communication, (v) education and counselling, (vi) referrals and care coordination and (vii) stigma. CONCLUSIONS PDMP use influenced healthcare providers' clinical decision-making, resulting in both intended and unintended outcomes for patients. PDMPs are a public health initiative designed to reduce harms associated with increased opioid prescribing, yet their use is associated with multiple unintended outcomes. Targeted research is needed to understand the impact of healthcare providers' clinical decision-making after PDMP utilisation, and the clinical outcomes for patients identified through these tools.
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Affiliation(s)
- Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston 3199, Victoria, Australia.
| | - Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston 3199, Victoria, Australia.
| | - Sarah Haines
- Turner Institute for Brain and Mental Health, Monash University, Clayton 3800, Victoria, Australia.
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston 3199, Victoria, Australia.
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Dickson-Gomez J, Christenson E, Weeks M, Galletly C, Wogen J, Spector A, McDonald M, Ohlrich J. Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2021; 15:1178221821992349. [PMID: 33854323 PMCID: PMC8013627 DOI: 10.1177/1178221821992349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/12/2021] [Indexed: 11/23/2022]
Abstract
Background and aims: Prescription Drug Monitoring Programs (PDMPs) were designed to curb opioid misuse and diversion by tracking scheduled medications prescribed by medical providers and dispensed by pharmacies. The effects of PDMPs on opioid prescription, misuse and overdose rates have been mixed due in part to variability in states’ PDMPs and difficulties measuring this complexity, and a lack of attention to implementation and enforcement of PDMP components. The current study uses qualitative interviews with key informants from 3 states with different PDMPs, Connecticut, Kentucky and Wisconsin to explore differences in the characteristics of the PDMPs in each state; how they are implemented, monitored and enforced; and unintended negative consequences of these programs. Methods: We conducted in-depth interviews with key informants from each state representing the following sectors: PDMP and pain clinic regulation agencies, Medicaid programs, state licensing boards, pharmacies, emergency medicine departments, pain management clinics, first responders, drug courts, drug treatment programs, medication assisted treatment (MAT) providers, and harm reduction organizations. Interview guides explored participants’ experiences with and opinions of PDMPs according to their roles. Data analysis was conducted using a collaborative, constant comparison method. Results: While all 3 states had mandated registration and reporting requirements, the states differed in the implementation and enforcement of these and the extent to which provider prescribing was monitored. These, in turn, influenced how medical providers perceived the PDMP and changed how providers prescribed opioids. Unintended consequences of state PDMPs included under-prescribing for pain and “dumping” patients who were long term users of opioids or who had developed opioid use disorders and may explain the increase in illicit heroin or opioid use. Conclusion: State PDMPs with similar mandates may differ greatly in implementation and enforcement. These differences are important to consider when determining the effects of PDMPs on opioid misuse and overdose.
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Affiliation(s)
- Julia Dickson-Gomez
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Erika Christenson
- Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Carol Galletly
- Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Wogen
- Department of Public Health Sciences, University of Connecticut, Farmington, CT, USA
| | - Antoinette Spector
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Madelyn McDonald
- Center for Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - Jessica Ohlrich
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
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