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Chu C, Rolig B, van der Heide DM, Joseph S, Galet C, Skeete DA. Education of trauma patients on opioids and pain management: A quality improvement project. Surgery 2024:S0039-6060(24)00714-1. [PMID: 39389819 DOI: 10.1016/j.surg.2024.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 08/08/2024] [Accepted: 09/09/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Our acute care surgery team sustainably launched a pain management quality improvement project to reduce opioid prescriptions without affecting pain control in our elective surgery patients that was adopted on the inpatient acute care surgery service. Consequently, we implemented patient education on opioids and pain management aiming at decreasing opioid use without compromising pain management for acutely injured patients on the trauma service. METHODS Trauma patients admitted from August 1, 2021, to July 31, 2022, and discharged to home were included. Pain management education started on February 2022. Demographics, injury severity scores (ISSs), preadmission opioid and adjunct use, and type/dose of opioids and nonopioid adjuncts prescribed 24 hours predischarge and at discharge were collected. Opioids were converted to oral morphine milligram equivalents (MME). Phone calls for pain and opioid prescription refills were collected. The pre- and posteducation groups were compared using univariate analysis. Multivariate analyses were conducted to identify factors associated with phone calls for pain and opioid refills. RESULTS Three hundred sixty-eight patients were included, 200 pre- and 168 posteducation. MME prescribed at discharge was positively associated with 24-hour predischarge MME (B = 0.010 [0.007-0.012], P < .001) and negatively associated with preinjury opioid use (B = -0.405 [-0.80 to -0.008], P = .045). Patient education led to an increased number of adjuncts prescribed (P < .008), decreased phone calls for pain (OR = 0.356 [0.165-0.770], P = .009), and decreased opioid refills (OR = 0.297 [0.131-0.675], P = .004), but no change in opioid prescriptions. CONCLUSION Patient education on opioids and pain management led to decreased phone calls for inadequate pain management and decreased number of opioid refills.
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Affiliation(s)
- Carolina Chu
- Carver College of Medicine, Department of Surgery, University of Iowa, Iowa City, IA
| | - Braden Rolig
- Carver College of Medicine, Department of Surgery, University of Iowa, Iowa City, IA
| | - Dana M van der Heide
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, IA. https://www.twitter.com/heide_dana
| | - Sharon Joseph
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, IA. https://www.twitter.com/sharonj077
| | - Colette Galet
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, IA. https://www.twitter.com/ColetteGalet
| | - Dionne A Skeete
- Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, IA.
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Lawson J, Ngaage LM, El Masry S, Giladi AM. Efficacy of Postoperative Opioid-Sparing Regimens for Hand Surgery: A Systematic Review of Randomized Controlled Trials. J Hand Surg Am 2024; 49:541-556. [PMID: 38703147 DOI: 10.1016/j.jhsa.2024.02.007] [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: 10/19/2023] [Revised: 02/06/2024] [Accepted: 02/14/2024] [Indexed: 05/06/2024]
Abstract
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.
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Affiliation(s)
- Jonathan Lawson
- the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Georgetown University School of Medicine, Washington, DC
| | - Ledibabari M Ngaage
- the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Seif El Masry
- the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; Georgetown University School of Medicine, Washington, DC
| | - Aviram M Giladi
- the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Candelaria A, Marek L, Kanda D, Griego J, Rutledge T. Developing and Implementing a Patient-Centered Opioid Prescribing Algorithm among Gynecological Oncology Patients. J Womens Health (Larchmt) 2024. [PMID: 38709003 DOI: 10.1089/jwh.2023.0998] [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: 05/07/2024] Open
Abstract
Background: The opioid epidemic is a public health crisis. However, opioid prescription recommendations have not been established in gynecological oncology, and guidelines that incorporate patient-reported pain are lacking. Objectives: The article aims to evaluate prescribing patterns, utilization, and patient-reported pain control in gynecological oncology patients at a large tertiary academic center. Methods: This was a two-phase, prospective cohort study. For Phase 1, patients undergoing hysterectomy through the gynecological oncology division at the University of New Mexico were enrolled. Postoperative opioid use was collected and standardized to oral morphine milligram equivalents (MMEs). The factors associated with outpatient opioid use were used to develop an opioid prescription algorithm. In Phase 2, we evaluated the implementation of the prescription algorithm. For both phases, patients completed a demographic survey, satisfaction survey, and validated pain questionnaires. Results: In Phase 1, the amount of opioids used was significantly lower than the amount of opioids prescribed. Factors that correlated with postoperative opioid use included surgical procedures and last 24-hour inpatient MME use. A standardized opioid prescription algorithm was developed by incorporating these factors. In Phase 2, the opioid prescribing algorithm there was no significant difference in pain scores between the two phases. Conclusions: Opioids were substantially overprescribed in gynecological oncology patients undergoing hysterectomy. Our study found that the surgical route and last 24-hour MME inpatient usage were reliable predictors of outpatient opioid use. We developed and implemented a standardized opioid prescription algorithm that was validated by comparing the pain control measures in the two phases.
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Affiliation(s)
- Ashlee Candelaria
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Lauren Marek
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Deborah Kanda
- UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | - Jamie Griego
- Rush University Medical Center, Chicago, Illinois, USA
| | - Teresa Rutledge
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
- UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
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Chen YH, Xenitidis A, Hoffmann P, Matthews L, Padmanabhan SG, Aravindan L, Ressler R, Sivam I, Sivam S, Gillispie CF, Sadhasivam S. Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia. Expert Rev Clin Pharmacol 2024; 17:455-465. [PMID: 38626303 PMCID: PMC11116045 DOI: 10.1080/17512433.2024.2343915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 04/12/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder. AREAS COVERED Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic. EXPERT OPINION The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Paul Hoffmann
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leslie Matthews
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Ruth Ressler
- Department of Biochemistry and Molecular Biology, The College of Wooster, Wooster, Ohio, USA
| | - Inesh Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Sahana Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Chase F. Gillispie
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia 25701
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kumar U, Macko AR, Kang N, Darian NG, Salek FO, Khalpey Z. Perioperative Cannabinoids Significantly Reduce Postoperative Opioid Requirements in Patients Undergoing Coronary Artery Bypass Graft Surgery. Cureus 2024; 16:e58566. [PMID: 38765405 PMCID: PMC11102566 DOI: 10.7759/cureus.58566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/22/2024] Open
Abstract
Background Opioids, commonly used to control pain associated with surgery, are known to prolong the duration of mechanical ventilation and length of hospital stay. A wide range of adjunctive strategies are currently utilized to reduce postoperative pain, such as local and regional nerve blocks, nerve cryoablation, and adjunctive medications. We hypothesized that dronabinol (a synthetic cannabinoid) in conjunction with standard opioid pain management will reduce opioid requirements to manage postoperative pain. Methods Sixty-eight patients who underwent isolated first-time coronary artery bypass graft surgery were randomized to either the control group, who received only standard opioid-based analgesia, or the dronabinol group, who received dronabinol (a synthetic cannabinoid) in addition to standard opioid-based analgesia. Dronabinol was given in the preoperative unit, before extubation in the ICU, and after extubation on the first postoperative day. Preoperative, intraoperative, and postoperative parameters were compared under an IRB-approved protocol. The primary endpoints were the postoperative opioid requirement, duration of mechanical ventilation, and ICU length of stay, and the secondary endpoints were the duration of inotropic support needed, left ventricular ejection fraction (LVEF), and the change in LVEF. This study was undertaken at Northwest Medical Center, Tucson, AZ, USA. Results Sixty-eight patients were randomized to either the control group (n = 37) or the dronabinol group (n = 31). Groups were similar in terms of demographic features and comorbidities. The total postoperative opioid requirement was significantly lower in the dronabinol group [39.62 vs 23.68 morphine milligram equivalents (MMEs), p = 0.0037], representing a 40% reduction. Duration of mechanical ventilation (7.03 vs 6.03h, p = 0.5004), ICU length of stay (71.43 vs 63.77h, p = 0.4227), and inotropic support requirement (0.6757 vs 0.6129 days, p = 0.7333) were similar in the control and the dronabinol groups. However, there was a trend towards lower durations in each endpoint in the dronabinol group. Interestingly, a significantly better preoperative to postoperative LVEF change was observed in the dronabinol group (3.51% vs 6.45%, p = 0.0451). Conclusions Our study found a 40% reduction in opioid use and a significantly greater improvement in LVEF in patients treated with adjunctive dronabinol. Mechanical ventilation duration, ICU length of stay, and inotropic support requirement tended to be lower in the dronabinol group, though did not reach statistical significance. The results of this study, although limited by sample size, are very encouraging and validate our ongoing investigation.
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Affiliation(s)
- Ujjawal Kumar
- Clinical Medicine, University of Cambridge, Cambridge, GBR
- Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
| | - Antoni R Macko
- Surgery, Midwestern University Arizona College of Osteopathic Medicine, Glendale, USA
| | - Nayoung Kang
- Pharmacy, Providence St. Joseph Hospital Orange, Orange, USA
| | | | | | - Zain Khalpey
- Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
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Jankulov A, As-Sanie S, Zimmerman C, Virzi J, Srinivasan S, Choe HM, Brummett CM. Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study. J Pain Res 2024; 17:667-675. [PMID: 38375407 PMCID: PMC10875180 DOI: 10.2147/jpr.s432262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/28/2023] [Indexed: 02/21/2024] Open
Abstract
Purpose The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy. Patients and Methods The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert. Results 332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives. Conclusion Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.
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Affiliation(s)
- Alexandra Jankulov
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | - Sawsan As-Sanie
- Department of Obstetrics & Gynecology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Christopher Zimmerman
- Department of Health Information and Technology Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jessica Virzi
- Department of Precision Health, University of Michigan Health System, Ann Arbor, MI, USA
| | - Sudharsan Srinivasan
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hae Mi Choe
- Department of Health Information and Technology Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI, USA
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7
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Cabo JJS, Miller NL. Nonopioid Pain Management Pathways for Stone Disease. J Endourol 2024; 38:108-120. [PMID: 38009214 DOI: 10.1089/end.2023.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.
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Affiliation(s)
- Jackson J S Cabo
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicole L Miller
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Chen VJ, Guan LS, Bokoch MP, Langnas E, Kothari R, Croci R, Campbell LJ, Quan D, Freise C, Guan Z. Mismatched Postsurgical Opioid Prescription to Liver Transplant Patients: A Retrospective Cohort Study From a Single High-volume Transplant Center. Transplantation 2024; 108:483-490. [PMID: 38259180 DOI: 10.1097/tp.0000000000004728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Improper opioid prescription after surgery is a well-documented iatrogenic contributor to the current opioid epidemic in North America. In fact, opioids are known to be overprescribed to liver transplant patients, and liver transplant patients with high doses or prolonged postsurgical opioid use have higher risks of graft failure and death. METHODS This is a retrospective cohort study of 552 opioid-naive patients undergoing liver transplant at an academic center between 2012 and 2019. The primary outcome was the discrepancy between the prescribed discharge opioid daily dose and each patient's own inpatient opioid consumption 24 h before discharge. Variables were analyzed with Wilcoxon and chi-square tests and logistic regression. RESULTS Opioids were overprescribed in 65.9% of patients, and 54.3% of patients who required no opioids the day before discharge were discharged with opioid prescriptions. In contrast, opioids were underprescribed in 13.4% of patients, among whom 27.0% consumed inpatient opioids but received no discharge opioid prescription. The median prescribed opioid daily dose was 333.3% and 56.3% of the median inpatient opioid daily dose in opioid overprescribed and underprescribed patients, respectively. Importantly, opioid underprescribed patients had higher rates of opioid refill 1 to 30 and 31 to 90 d after discharge, and the rate of opioid underprescription more than doubled from 2016 to 2019. CONCLUSIONS Opioids are both over- and underprescribed to liver transplant patients, and opioid underprescribed patients had higher rates of opioid refill. Therefore, we proposed to prescribe discharge opioid prescriptions based on liver transplant patients' inpatient opioid consumption to provide patient-centered opioid prescriptions.
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Affiliation(s)
- Victoria J Chen
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- Brown University, Providence, RI
| | - Lucy S Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Rhiannon Croci
- UCSF Health Informatics, University of California, San Francisco, San Francisco, CA
| | - Liam J Campbell
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- University of the Incarnate Word School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX
| | - David Quan
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Chris Freise
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
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Moon PK, Wei EX, Hamid MS, Borghi JA, Megwalu UC. Nonopioid Versus Opioid Analgesics After Thyroid and Parathyroid Surgery: A Systematic Review. Otolaryngol Head Neck Surg 2024; 170:13-19. [PMID: 37595107 DOI: 10.1002/ohn.503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/20/2023] [Accepted: 08/04/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To determine whether nonopioid analgesic regimens, taken after discharge for thyroid and parathyroid surgery have noninferior pain outcomes in comparison to opioid analgesic regimens. Secondarily, we sought to determine if nonopioid analgesic regimens decrease the number of opioid medications taken after thyroid and parathyroid surgery, and to assess adverse events associated with opioid versus nonopioid regimens. DATA SOURCES PubMed, Embase, Cochrane. REVIEW METHODS A comprehensive search of the literature was performed according to the PRISMA guidelines, and identified 1299 nonduplicate articles for initial review of which 2 randomized controlled trials (RCTs) were identified as meeting all eligibility criteria. Meta-analysis was not conducted due to heterogeneity in the data and statistical analyses. RESULTS Both RCTs included in this systematic review found no significant differences in postoperative pain scores between individuals discharged with a nonopioid only analgesic regimen compared to analgesic regimen that included oral opioid medications. One study reported significantly increased number of postoperative calls related specifically to pain in the nonopioid arm compared to the opioid arm (15.6% vs. 3.2%, P = .045). CONCLUSION This systematic review of RCTs revealed a limited number of studies examining nonopioid versus opioid postoperative pain medications among adults who undergo thyroid and parathyroid surgery. Among the 2 RCTs on this topic, there is a shared finding that nonopioid analgesic regimens are noninferior to opioid analgesic regimens in managing postoperative pain after thyroid and parathyroid surgery, supporting the use of nonopioid pain regimens given the risk of opioid dependence associated with prescription opioid medications.
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Affiliation(s)
- Peter K Moon
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Eric X Wei
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Marzan S Hamid
- Stanford University School of Medicine, Stanford, California, USA
| | - John A Borghi
- Lane Medical Library, Stanford University School of Medicine, Stanford, California, USA
| | - Uchechukwu C Megwalu
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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Beaulieu-Jones BR, Marwaha JS, Kennedy CJ, Le D, Berrigan MT, Nathanson LA, Brat GA. Comparing Rationale for Opioid Prescribing Decisions after Surgery with Subsequent Patient Consumption: A Survey of the Highest Quartile of Prescribers. J Am Coll Surg 2023; 237:835-843. [PMID: 37702392 DOI: 10.1097/xcs.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions-from nudges to reminders-have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown. STUDY DESIGN Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure-as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption. RESULTS During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%). CONCLUSIONS The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Jayson S Marwaha
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Chris J Kennedy
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Danny Le
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA (Le)
| | - Margaret T Berrigan
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Larry A Nathanson
- Emergency Medicine (Nathanson), Beth Israel Deaconess Medical Center, Boston, MA
| | - Gabriel A Brat
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
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11
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Shuey B, Zhang F, Rosen E, Goh B, Trad NK, Wharam JF, Wen H. Massachusetts' opioid limit law associated with a reduction in postoperative opioid duration among orthopedic patients. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad068. [PMID: 38756368 PMCID: PMC10986237 DOI: 10.1093/haschl/qxad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 05/18/2024]
Abstract
Postoperative orthopedic patients are a high-risk group for receiving long-duration, large-dosage opioid prescriptions. Rigorous evaluation of state opioid duration limit laws, enacted throughout the country in response to the opioid overdose epidemic, is lacking among this high-risk group. We took advantage of Massachusetts' early implementation of a 2016 7-day-limit law that occurred before other statewide or plan-wide policies took effect and used commercial insurance claims from 2014-2017 to study its association with postoperative opioid prescriptions greater than 7 days' duration among Massachusetts orthopedic patients relative to a New Hampshire control group. Our sample included 14 097 commercially insured, opioid-naive adults aged 18 years and older undergoing elective orthopedic procedures. We found that the Massachusetts 7-day limit was associated with an immediate 4.23 percentage point absolute reduction (95% CI, 8.12 to 0.33 percentage points) and a 33.27% relative reduction (95% CI, 55.36% to 11.19%) in the percentage of initial fills greater than 7 days in the Massachusetts relative to the control group. Seven-day-limit laws may be an important state-level tool to mitigate longer duration prescribing to high-risk postoperative populations.
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Affiliation(s)
- Bryant Shuey
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
- Present address: Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Edward Rosen
- Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Brian Goh
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
- Present address: Department of Orthopedic Surgery, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Nicolas K Trad
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - James Franklin Wharam
- Department of Medicine, Duke University, Durham, NC 27710, United States
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27708, United States
| | - Hefei Wen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
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Srinivasan S, Gunaseelan V, Jankulov A, Chua KP, Englesbe M, Waljee J, Bicket M, Brummett CM. Association Between Payer Type and Risk of Persistent Opioid Use After Surgery. Ann Surg 2023; 278:e1185-e1191. [PMID: 37334751 PMCID: PMC10631504 DOI: 10.1097/sla.0000000000005937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVE To assess whether the risk of persistent opioid use after surgery varies by payer type. BACKGROUND Persistent opioid use is associated with increased health care utilization and risk of opioid use disorder, opioid overdose, and mortality. Most research assessing the risk of persistent opioid use has focused on privately insured patients. Whether this risk varies by payer type is poorly understood. METHODS This cross-sectional analysis of the Michigan Surgical Quality Collaborative database examined adults aged 18 to 64 years undergoing surgical procedures across 70 hospitals between January 1, 2017 and October 31, 2019. The primary outcome was persistent opioid use, defined a priori as 1+ opioid prescription fulfillment at (1) an additional opioid prescription fulfillment after an initial postoperative fulfillment in the perioperative period or at least 1 fulfillment in the 4 to 90 days after discharge and (2) at least 1 opioid prescription fulfillment in the 91 to 180 days after discharge. The association between this outcome and payer type was evaluated using logistic regression, adjusting for patient and procedure characteristics. RESULTS Among 40,071 patients included, the mean age was 45.3 years (SD 12.3), 24,853 (62%) were female, 9430 (23.5%) were Medicaid-insured, 26,760 (66.8%) were privately insured, and 3889 (9.7%) were covered by other payer types. The rate of POU was 11.5% and 5.6% for Medicaid-insured and privately insured patients, respectively (average marginal effect for Medicaid: 2.9% (95% CI 2.3%-3.6%)). CONCLUSIONS Persistent opioid use remains common among individuals undergoing surgery and higher among patients with Medicaid insurance. Strategies to optimize postoperative recovery should focus on adequate pain management for all patients and consider tailored pathways for those at risk.
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Affiliation(s)
| | - Vidhya Gunaseelan
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Alexandra Jankulov
- Oakland University William Beaumont School of Medicine, Oakland University, Rochester Hills, MI
| | - Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health and Evaluation Research Center, University of Michigan, Ann Arbor, MI
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Michael Englesbe
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Mark Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
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Campbell LJ, Mummaneni PV, Letchuman V, Langnas E, Agarwal N, Guan LS, Croci R, Vargas E, Reisner L, Bickler P, Chou D, Chang E, Guan Z. Mismatched opioid prescription in patients discharged after neurological surgeries: a retrospective cohort study. Pain 2023; 164:2615-2621. [PMID: 37326642 DOI: 10.1097/j.pain.0000000000002966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/22/2023] [Indexed: 06/17/2023]
Abstract
ABSTRACT Although postsurgical overprescription has been well-studied, postsurgical opioid underprescription remains largely overlooked. This retrospective cohort study was to investigate the extent of discharge opioid overprescription and underprescription in patients after neurological surgeries. Six thousand nine hundred forty-nine adult opioid-naive patients who underwent inpatient neurosurgical procedures at the University of California San Francisco were included. The primary outcome was the discrepancy between individual patient's prescribed daily oral morphine milligram equivalent (MME) at discharge and patient's own inpatient daily MME consumed within 24 hours of discharge. Analyses include Wilcoxon, Mann-Whitney, Kruskal-Wallis, and χ 2 tests, and linear or multivariable logistic regression. 64.3% and 19.5% of patients were opioid overprescribed and underprescribed, respectively, with median prescribed daily MME 360% and 55.2% of median inpatient daily MME in opioid overprescribed and underprescribed patients, respectively. 54.6% of patients with no inpatient opioid the day before discharge were opioid overprescribed. Opioid underprescription dose-dependently increased the rate of opioid refill 1 to 30 days after discharge. From 2016 to 2019, the percentage of patients with opioid overprescription decreased by 24.8%, but the percentage of patients with opioid underprescription increased by 51.2%. Thus, the mismatched discharge opioid prescription in patients after neurological surgeries presented as both opioid overprescription and underprescription, with a dose-dependent increased rate of opioid refill 1 to 30 days after discharge in opioid underprescription. Although we are fighting against opioid overprescription to postsurgical patients, we should not ignore postsurgical opioid underprescription.
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Affiliation(s)
- Liam J Campbell
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Lucy S Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Rhiannon Croci
- UCSF Health Informatics, University of California San Francisco, San Francisco, CA, United States
| | - Enrique Vargas
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Lori Reisner
- Department of Clinical Pharmacology, University of California San Francisco, San Francisco, CA, United States
| | - Phil Bickler
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, Columbia University, New York, NY, United States
| | - Edward Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
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McCauley JL, Ward RC, Taber DJ, Basco WT, Gebregziabher M, Reitman C, Moran WP, Cina RA, Lockett MA, Ball SJ. Surgical prescription opioid trajectories among state Medicaid enrollees. J Opioid Manag 2023; 19:465-488. [PMID: 38189189 DOI: 10.5055/jom.0832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN Retrospective cohort. SETTING Administrative claims data. PATIENTS AND PARTICIPANTS Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS None. MAIN OUTCOME MEASURES Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.
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Affiliation(s)
- Jenna L McCauley
- Addiction Science Division, Department of Psychiatry, The Medical University of South Carolina, Charleston, South Carolina. ORCID: https://orcid.org/0000-0001-8406-2329
| | - Ralph C Ward
- Public Health Sciences, The Medical University of South Carolina, Charleston, South Carolina
| | - David J Taber
- The Medical University of South Carolina, Charleston, South Carolina
| | - William T Basco
- The Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Public Health Sciences, The Medical University of South Carolina, Charleston, South Carolina
| | - Charles Reitman
- Department of Orthopaedics and Physical Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - William P Moran
- College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Cina
- The Medical University of South Carolina, Charleston, South Carolina
| | - Mark A Lockett
- The Medical University of South Carolina, Charleston, South Carolina
| | - Sarah J Ball
- College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
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15
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Lee DJ, Grose E, Brenna CTA, Philteos J, Lightfoot D, Kirubalingam K, Chan Y, Palmer JN, Adappa ND, Lee JM. The benefits and risks of non-steroidal anti-inflammatory drugs for postoperative analgesia in sinonasal surgery: a systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:1738-1757. [PMID: 36762711 DOI: 10.1002/alr.23140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) have emerged as an alternative to opioids for optimal postoperative pain management. However, the adoption of NSAIDs in sinonasal surgery has been impeded by a theoretical concern for postoperative bleeding. Our objective is to systematically review the efficacy and safety of NSAIDs for patients undergoing sinonasal surgery. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, and the WHO International Clinical Trials Registry Platform were searched from inception to January 27, 2022. Randomized controlled trials (RCTs) and comparative observational studies in any language were considered. Screening, data extraction, and risk of bias assessment were performed in duplicate. Our outcomes were postoperative pain scores, requirement for rescue analgesia, and postoperative adverse events (epistaxis, nausea/vomiting). RESULTS Out of 4661 records, 15 RCTs (enrolling 1210 patients) and two observational studies were included. Following endoscopic sinus surgery, there was no difference in pain scores between NSAIDs and non-NSAIDs groups (standardized mean differences [SMD] 0.44 units better, 95% CI -0.18 to 1.05). Following septorhinoplasty, NSAIDs decreased pain scores compared to non-NSAID regimens (SMD 1.14 units better, 95% CI 0.61 to 1.67 units better). Overall, NSAIDs reduced the need for rescue medication with a relative risk (RR) of 0.45 (95% CI 0.24 to 0.84). In addition, NSAIDs decreased the risk of nausea with an RR of 0.62 (95% CI 0.42 to 0.91) and did not increase the risk of epistaxis (RR 0.72, 95% CI 0.23-2.22). CONCLUSION Among patients undergoing sinonasal surgery, NSAIDs are beneficial in postoperative pain management and avoidance of postoperative nausea without increasing the risk of postoperative epistaxis.
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Affiliation(s)
- Daniel J Lee
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elysia Grose
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Connor T A Brenna
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Philteos
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - David Lightfoot
- St. Michael's Hospital Health Sciences Library, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Yvonne Chan
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - James N Palmer
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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Maganty A, Williams SB. Re: Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery. Eur Urol 2023; 84:139-140. [PMID: 36967361 PMCID: PMC10625443 DOI: 10.1016/j.eururo.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/07/2023] [Indexed: 06/18/2023]
Abstract
The authors prospectively evaluated the implementation of a prespecified protocol to eliminate post-discharge opioid prescription after major urologic cancer surgery at a single center among a predominantly opioid naïve population. The intervention included both provider and patient education along with a standardized regimen for non-opioid analgesia during the inpatient stay and after discharge. Use of a standardized protocol nearly eliminated opioid prescriptions after major urologic cancer surgery without adversely impacting patient reported pain control and satisfaction, unplanned visits, and complications.
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Affiliation(s)
- Avinash Maganty
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - Stephen B Williams
- Division of Urology, University of Texas Medical Branch, Galveston, TX, USA
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17
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Stonner MM, Skladman R, Bettlach CLR, Kennedy C, Mackinnon SE. Recruiting hand therapists improves disposal of unused opioid medication. J Hand Ther 2023; 36:507-513. [PMID: 35909068 DOI: 10.1016/j.jht.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Opioids often remain unused after upper extremity surgery, and leftover prescriptions are frequently diverted. When administered in a hand surgery clinic, an educational brochure outlining a simple method of opioid disposal has been shown to improve disposal rates after surgery. PURPOSE To understand whether administration of an opioid disposal educational brochure in a hand therapy clinic would increase opioid disposal rates, compared to a hand surgery clinic. STUDY DESIGN Prospective cohort study. METHODS Patients who presented to a hand therapy clinic postoperatively were recruited to participate in this prospective cohort study. An educational brochure outlining a simple method of opioid disposal was made available at the hand therapy and surgery clinics. A questionnaire was later issued to obtain: location of brochure receipt, demographic information, pre- and post-operative opioid use history, and opioid disposal patterns. Chi-square tests and multivariable binary logistic regression assessed associations between medication disposal and explanatory variables. RESULTS Patients who received the brochure were significantly more likely to dispose of excess opioid medication, compared to those who did not receive the brochure (57.1% vs 10.8%, p < .001). Patients who received the brochure at the hand therapy clinic were significantly more likely to dispose of excess opioids (86.4%) compared to those who received the brochure at the surgery clinic (25.0%). Older age was predictive of increased disposal (p =.028*). There were no significant associations between gender, length of follow-up, or surgery type with the incidence of opioid disposal. CONCLUSION Recruiting both hand therapists and surgeons in the distribution of a simple, educational brochure on opioid disposal can increase disposal rates. Patients who received the brochure from the hand therapist were more likely to dispose of excess opioids. The longstanding patient-therapist relationship creates an opportunity for educational initiatives and discussion of stigmatized topics, such as opioid use.
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Affiliation(s)
- Macyn M Stonner
- Program in Occupational Therapy, Milliken Hand Rehabilitation Center, Washington University School of Medicine, St. Louis, MO, USA.
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carrie L Roth Bettlach
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carie Kennedy
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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18
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Knudsen MG, Kotha VS, Wee C, Lesko RP, Swanson M, Kumar A, Davidson EH. Does Facial Fracture Management Require Opioids? A Pilot Trial of a Narcotic-Minimizing Analgesia Protocol for Operative Facial Trauma. J Craniofac Surg 2023; 34:1199-1202. [PMID: 36710392 DOI: 10.1097/scs.0000000000009190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/10/2022] [Indexed: 01/31/2023] Open
Abstract
Opioid minimization in the acute postoperative phase is timely in the era of the opioid epidemic. The authors hypothesize that patients with facial trauma receiving multimodal, narcotic-minimizing pain management in the perioperative period will consume fewer morphine milligram equivalents (MMEs) while maintaining adequate pain control compared with a traditional analgesia protocol. An IRB-approved pilot study evaluating isolated facial trauma patients compared 10 consecutive prospective patients of a narcotic-minimizing pain protocol beginning in August 2020 with a retrospective, chart-reviewed cohort of 10 consecutive patients before protocol implementation. The protocol was comprised of multimodal nonopioid pharmacotherapy given preoperatively (acetaminophen, celecoxib, and pregabalin). Postoperatively, patients received intravenous (IV) ketorolac, scheduled acetaminophen, ibuprofen, and gabapentin. Oxycodone was reserved for severe uncontrolled pain. The control group had no standardized protocol, though opioids were ad libitum. Consumed MMEs and verbal Numeric Rating Scale (vNRS) pain scores (0-10) were prospectively tracked and compared with retrospective data. Descriptive and inferential statistics were run. At all recorded postoperative intervals, narcotic-minimizing subjects consumed significantly fewer MMEs than controls [0-8 h, 21.5 versus 63.5 ( P = 0.002); 8-16 h, 4.9 versus 20.6 ( P = 0.02); 16-24 h, 3.3 versus 13.9 ( P = 0.03); total 29.5 versus 98.0 ( P = 0.003)]. At all recorded postoperative intervals, narcotic-minimizing subjects reported less pain (vNRS) than controls (0-8 h, 7.7 versus 8.1; 8-16 h, 4.4 versus 8.0; 16-24 h 4.3 versus 6.9); significance was achieved at the 8 to 16-hour time point ( P = 0.006). A multimodal, opioid-sparing analgesia protocol significantly reduces opioid use in perioperative facial trauma management without sacrificing satisfactory pain control for patients.
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Affiliation(s)
- Margarete Grace Knudsen
- Department of Plastic and Reconstructive Surgery, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, OH
| | - Vikas S Kotha
- Department of Plastic and Reconstructive Surgery, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, OH
| | - Corinne Wee
- Department of Plastic and Reconstructive Surgery, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, OH
| | - Robert P Lesko
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Marco Swanson
- Department of Plastic and Reconstructive Surgery, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, OH
| | - Anand Kumar
- Department of Plastic & Reconstructive Surgery, The Mercer University School of Medicine, Savannah, GA
| | - Edward H Davidson
- Department of Plastic and Reconstructive Surgery, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, OH
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Fender Z, Bleicher J, Johnson JE, Phan K, Powers D, Stoddard G, Brooke BS, Huang LC. Improving pain management and safe opioid use after surgery: A DMAIC-based quality intervention. Surg Open Sci 2023; 13:27-34. [PMID: 37351188 PMCID: PMC10282558 DOI: 10.1016/j.sopen.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/16/2023] [Accepted: 04/10/2023] [Indexed: 06/24/2023] Open
Abstract
Background Multimodal perioperative patient education and expectation-setting can reduce post-operative opioid use while maintaining pain control and satisfaction. As part of a quality-improvement project, we developed a standardized model for perioperative education built upon the American College of Surgeons (ACS) Safe and Effective Pain Control After Surgery (SEPCAS) brochure to improve perioperative education regarding opioid use and pain control. Material and methods Our study was designed within the Define, Measure, Analyze, Improve, Control (DMAIC) quality-improvement framework. Patients were surveyed about the adequacy of their perioperative education regarding pain control and use of prescription opioid medication. After gathering baseline data, a multimodal educational intervention based on the SEPCAS brochure was implemented. Survey responses were then compared between groups. Results Twenty-seven subjects were included from the pre-intervention period, and thirty-nine were included from the post-intervention period (n = 66). Those in the post-intervention period were more likely to report receiving the appropriate amount of education regarding recognizing the signs of opioid overdose and how to safely store and dispose of opioid medications. The majority of patients who received the SEPCAS brochure reported that it was useful in their post-operative recovery and that it should be given to every patient undergoing surgery. Conclusions The ACS SEPCAS brochure is an effective tool for improving patient preparation to safely store and dispose of their opioid medication and recognize the signs of opioid overdose. The brochure was also well received by patients and perceived as an effective educational material.
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Affiliation(s)
- Zachary Fender
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Josh Bleicher
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Kathy Phan
- Division of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Damien Powers
- Division of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Gregory Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Lyen C. Huang
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
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20
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Howard R, Brown CS, Lai YL, Gunaseelan V, Brummett CM, Englesbe M, Waljee J, Bicket MC. Postoperative Opioid Prescribing and New Persistent Opioid Use: The Risk of Excessive Prescribing. Ann Surg 2023; 277:e1225-e1231. [PMID: 35129474 PMCID: PMC10537242 DOI: 10.1097/sla.0000000000005392] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate the association between postoperative opioid prescribing and new persistent opioid use. SUMMARY BACKGROUND DATA Opioid-nave patients who develop new persistent opioid use after surgery are at increased risk of opioid-related morbidity and mortality. However, the extent to which postoperative opioid prescribing is associated with persistent postoperative opioid use is unclear. METHODS Retrospective study of opioid-naïve adults undergoing surgery in Michigan from 1/1/2017 to 10/31/2019. Postoperative opioid prescriptions were identified using a statewide clinical registry and prescription fills were identified using Michigan's prescription drug monitoring program. The primary outcome was new persistent opioid use, defined as filling at least 1 opioid prescription between post-discharge days 4 to 90 and filling at least 1 opioid prescription between post-discharge days 91 to 180. RESULTS A total of 37,654 patients underwent surgery with a mean age of 52.2 (16.7) years and 20,923 (55.6%) female patients. A total of 31,920 (84.8%) patients were prescribed opioids at discharge. Six hundred twenty-two (1.7%) patients developed new persistent opioid use after surgery. Being prescribed an opioid at discharge was not associated with new persistent opioid use [adjusted odds ratio (aOR) 0.88 (95% confidence interval (CI) 0.71-1.09)]. However, among patients prescribed an opioid, patients prescribed the second largest [12 (interquartile range (IQR) 3) pills] and largest [20 (IQR 7) pills] quartiles of prescription size had higher odds of new persistent opioid use compared to patients prescribed the smallest quartile [7 (IQR 1) pills] of prescription size [aOR 1.39 (95% CI 1.04-1.86) andaOR 1.97 (95% CI 1.442.70), respectively]. CONCLUSIONS In a cohort of opioid-naïve patients undergoing common surgical procedures, the risk of new persistent opioid use increased with the size of the prescription. This suggests that while opioid prescriptions in and of themselves may not place patients at risk of long-term opioid use, excessive prescribing does. Consequently, these findings support ongoing efforts to mitigate excessive opioid prescribing after surgery to reduce opioid-related harms.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Mark C Bicket
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
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21
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Johnson E, Yoshida M, Hallway A, Byrnes M, Waljee J, Englesbe M, Howard R. "I Prefer to Stay Away": A Qualitative Study of Patients in an Opioid-Sparing Pain Management Protocol. Ann Surg 2023; 277:596-602. [PMID: 34787984 DOI: 10.1097/sla.0000000000005087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to explore beliefs and behaviors of opioid pain medications among patients undergoing elective surgery. BACKGROUND Opioid dependence after surgery is a major contributor to the ongoing opioid epidemic. Recent efforts by surgeons and health systems have sought to improve the education patients receive regarding safe opioid use after surgery; however, little is known about patients' pre-existing beliefs surrounding opioids. METHODS Semistructured interviews were conducted with patients who underwent 1 of 4 common elective surgical procedures at 1 institution. Patients were specifically asked about their knowledge and beliefs about opioids before surgery and their opinions of opioid-sparing recovery after surgery. Coding was conducted through iterative steps, beginning with an initial cycle of rapid analysis, followed by focused coding, and thematic analysis. RESULTS Twenty-one patients were interviewed. Three major themes emerged regarding patient opinions about using opioids after surgery. First, there was widespread awareness among patients about opioid medications, and preoperatively, patients had specific intentions about using opioids, often informed by this awareness. Second, patients described a spectrum of opioid related behavior which both aligned and conflicted with preoperative intentions. Third, there was tension among patients about opioid-free postoperative recovery, with patients expressing support, opposition, and emphasis on tailoring recovery to patient needs. CONCLUSIONS Patients undergoing common surgical procedures often arrive at their surgical encounter with strong, pre-formed opinions about opioids. Eliciting these preexisting opinions may help surgeons better counsel patients about safe opioid use after surgery.
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Affiliation(s)
- Emily Johnson
- University of Michigan Medical School, Ann Arbor, MI
| | - Maxwell Yoshida
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
| | | | - Mary Byrnes
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, Mi
| | - Jennifer Waljee
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Section of Transplant Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Ryan Howard
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, Mi
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22
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Ciampa ML, Liang J, O'Hara TA, Joel CL, Sherman WE. Shared decision-making for postoperative opioid prescribing and preoperative pain management education decreases excess opioid burden. Surg Endosc 2023; 37:2253-2259. [PMID: 35918546 DOI: 10.1007/s00464-022-09464-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Managing postoperative pain requires an individualized approach in order to balance adequate pain control with risk of persistent opioid use and narcotic abuse associated with inappropriately outsized narcotic prescriptions. Shared decision-making has been proposed to address individual pain management needs. We report here the results of a quality improvement initiative instituting prescribing guidelines using shared decision-making and preoperative pain expectation and management education to decrease excess opioid pills after surgery and improve patient satisfaction. METHODS Pre-intervention prescribing habits were obtained by retrospective review perioperative pharmacy records for patients undergoing general surgeries in the 24 months prior to initiation of intervention. Patients scheduled to undergo General Surgery procedures were given a survey at their preoperative visit. Preoperative education was performed by the surgical team as a part of the Informed Consent process using a standardized handout and patients were asked to choose the number of narcotic pills they wished to obtain within prescribing recommendations. Postoperative surveys were administered during or after their 2-week postoperative visit. RESULTS 131 patients completed pre-intervention and post-intervention surveys. The average prescription size decreased from 12.29 oxycodone pills per surgery prior to institution of pathway to 6.80 pills per surgery after institution of pathway (p < 0.001). The percentage of unused pills after surgery decreased from an estimated 70.5% pre-intervention to 48.5% (p < 0.001) post-intervention. 61.1% of patients with excess pills returned or planned to return medication to the pharmacy with 16.8% of patients reporting alternative disposal of excess medication. Patient-reported satisfaction was higher with current surgery compared to prior surgeries (p < 0.001). CONCLUSION Institution of procedure-specific prescribing recommendations and preoperative pain management education using shared decision-making between patient and provider decreases opioid excess burden, resulting in fewer unused narcotic pills entering the community. Furthermore, allowing patients to participate in decision-making with their provider results in increased patient satisfaction.
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Affiliation(s)
- Maeghan L Ciampa
- Department of General Surgery, Dwight D Eisenhower Army Medical Center, 300 East Hospital Rd, Fort Gordon, GA, 30901, USA.
| | - Joy Liang
- Department of General Surgery, Dwight D Eisenhower Army Medical Center, 300 East Hospital Rd, Fort Gordon, GA, 30901, USA
| | - Thomas A O'Hara
- Department of General Surgery, Dwight D Eisenhower Army Medical Center, 300 East Hospital Rd, Fort Gordon, GA, 30901, USA
| | - Constance L Joel
- Department of General Surgery, Dwight D Eisenhower Army Medical Center, 300 East Hospital Rd, Fort Gordon, GA, 30901, USA
| | - William E Sherman
- Department of General Surgery, Dwight D Eisenhower Army Medical Center, 300 East Hospital Rd, Fort Gordon, GA, 30901, USA
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23
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Canick JE, Bhardwaj A, Patel A, Kuziez D, Larsen R, Misra S, Pearson B, Smith BD, Rohde RL, Adjei Boakye E, Kahmke RR, Osazuwa-Peters N. Sociodemographic Differences in Patient-Reported Pain and Pain Management of Patients With Head and Neck Cancer in a Community Oncology Setting. JCO Oncol Pract 2023; 19:e397-e406. [PMID: 36480772 PMCID: PMC10022872 DOI: 10.1200/op.22.00132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 09/20/2022] [Accepted: 10/12/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE While pain is prevalent among survivors of head and neck cancer (HNC), there is a lack of data on pain management in the community oncology setting. We described sociodemographic correlates and disparities associated with patient-reported pain among patients with HNC. METHODS We used the 2017-2021 nationwide community oncology data set from Navigating Cancer, which included electronic patient-reported outcomes. We identified a retrospective cohort of patients diagnosed with HNC (N = 25,572), with ≥ 1 patient-reported pain event. We adjusted for demographic (sex, age, smoking history, marital status) and clinical (cancer site) factors associated with pain reporting and pain resolution by new pain prescription on the basis of race (White v non-White patients), using multivariate logistic regression models. RESULTS Our analytic cohort included 2,331 patients, 90.58% White, 58.62% married, with an average age of 66.47 years. Of these, 857 patients (36.76%) reported ≥ 1 pain event during study period. Mean resolution time (in minutes) for pain incidents was significantly longer for White patients than non-White patients (99.6 ± 3.2 v 74.9 ± 7.2, P < .05). After adjusting for covariates, smoking was associated with a 25% increased odds of reporting pain incidents (adjusted odds ratio [aOR], 1.25; 95% CI, 1.03 to 1.52). There was no statistically significant difference in odds of pain reporting between White versus non-White patients (aOR, 0.97; 95% CI, 0.73 to 1.30). However, White patients were significantly more likely to receive new prescription for pain than non-White patients (aOR, 2.52; 95% CI, 1.09 to 5.86). CONCLUSION We found racial differences in patient-reported pain management, with White patients significantly more likely to receive new pain prescriptions. As pain management is a mainstay in cancer care, equity in pain management is critical to optimize quality of life for patients with HNC.
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Affiliation(s)
- Julia E. Canick
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
| | | | | | - Duaa Kuziez
- Wake Forest School of Medicine, Department of Surgery, Winston-Salem, NC
| | | | | | | | - Blaine D. Smith
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
| | - Rebecca L. Rohde
- Medical College of Wisconsin, Department of Otolaryngology & Communication Sciences, Milwaukee, WI
| | - Eric Adjei Boakye
- Henry Ford Health System, Department of Otolaryngology-Head & Neck Surgery, Detroit, MI
- Henry Ford Health System, Department of Population Health Sciences, Detroit, MI
| | - Russel R. Kahmke
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Nosayaba Osazuwa-Peters
- Duke University School of Medicine, Department of Head and Neck Surgery & Communication Sciences, Durham, NC
- Duke Cancer Institute, Durham, NC
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC
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24
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Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy. Surgery 2023; 173:864-869. [PMID: 36336504 DOI: 10.1016/j.surg.2022.07.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/03/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy. METHODS In a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts. RESULTS There were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001). CONCLUSION Performing a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.
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25
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Boudiab EM, Lapkus M, Reilly J, Studzinski D, Czako P, Asbahi M, Schostak M, Schmidt C, Nagar S. Cervical Endocrine Surgery With a Novel Opioid-Limited Perioperative Protocol. Am Surg 2023; 89:355-361. [PMID: 34114505 DOI: 10.1177/00031348211025736] [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: 11/15/2022]
Abstract
BACKGROUND Recent studies have demonstrated that patients undergoing cervical endocrine surgery could be comfortably discharged with minimal opioid analgesia. However, no study to date has examined the efficacy of limiting administration of opioids intraoperatively. We have developed a novel protocol for patients undergoing cervical endocrine surgery that eliminates perioperative opioids. We sought to determine the efficacy of this protocol and its impact on opioid use at discharge. METHODS We conducted a prospective opt-in opioid-limited surgery program study to opioid-naive patients scheduled for cervical endocrine surgery beginning in August 2019. Postoperatively, nonopioid analgesia was encouraged, but patients were also given a low dose prescription for opioids at discharge. Patients were then matched with 2 retrospective control groups, patients from 2014-2016 and 2017-2018, in order to account for increased public awareness of opioid-prescribing patterns. Primary end points included perioperative opioid use. Secondary end points included postoperative pain scores and complications. RESULTS 218 patients underwent cervical endocrine surgery with our opioid-limited protocol between August 2019 and February 2020. Nine patients received opioids intraoperatively (4%) and 109 (50%) filled their opioid prescriptions at discharge. Compared to retrospective control groups, the average oral morphine equivalents (OME) administered intraoperatively and prescribed postoperatively were significantly lower (P < .0001). Pain scores and complication rates were similar in all groups (P = .7247). DISCUSSION Our novel opioid-limited surgery protocol used in conjunction with preoperative counseling is an effective approach for pain control in patients undergoing cervical endocrine surgery and limits opioid exposure throughout the perioperative period.
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Affiliation(s)
- Elizabeth M Boudiab
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Morta Lapkus
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Jordan Reilly
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Diane Studzinski
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Peter Czako
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Moumen Asbahi
- Department of Anesthesiology, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Michael Schostak
- Department of Anesthesiology, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Carol Schmidt
- Department of Anesthesiology, 7005Beaumont Health System, Royal Oak, MI, USA
| | - Sapna Nagar
- Department of General Surgery, 7005Beaumont Health System, Royal Oak, MI, USA
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Medairos R, Lankford J, Everett R, Berger G, Weierstahl K, Woehlck H, Jacobsohn K, Johnson S. Impact of Acetazolamide on Perioperative Pain Control in Robotic Assisted Laparoscopic Prostatectomy. Urology 2023; 172:126-130. [PMID: 36481203 DOI: 10.1016/j.urology.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the efficacy of peri-operative acetazolamide for pain control in robotic assisted laparoscopic prostatectomy (RALP). Prior studies have demonstrated that preoperative acetazolamide decreased postoperative referred pain in the postsurgical period for laparoscopic procedures. The proposed mechanism is acetazolamide mediated inhibition of carbonic anhydrase, thereby preventing formation of carbonic acid and subsequent peritoneal acidosis with referred pain. This has yet to be demonstrated in the setting of RALP. METHODS AND MATERIALS Patients undergoing RALP were randomized to receive either preoperative saline or acetazolamide prior to the procedure. Overall pain scores were recorded at multiple time points post operatively, as well as total morphine equivalents administered for adjunctive pain control. RESULTS Thirty-one patients were included in the study: 16 patients (51.6%) received perioperative acetazolamide, and 15 patients (48.4%) received perioperative saline as placebo. Overall pain scores were similar for patients receiving acetazolamide compared to placebo at various time points: first responsive (3.5 ± 3.1 vs 4.1 ± 1.7, P = .28), immediately prior to leaving PACU (2.8 ± 2.9 vs 2.9 ± 2.9, P = .48), at 4 hours post-procedure (3.1 ± 3.0 vs 2.9 ± 1.8, P = .362), or at 24 hours post-procedure (2.3 ± 1.7 vs 2.2 ± 1.6, P = .5). Shoulder tip pain was not present in either cohort. No statistically significant difference was observed for total morphine equivalents delivered between acetazolamide and placebo (17.3 vs 20.5, P= .2, respectively). CONCLUSION Acetazolamide does not appear to impact overall pain or shoulder tip pain in the observed cohort of patients undergoing RALP.
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Affiliation(s)
| | | | - Ross Everett
- Medical College of Wisconsin in Milwaukee, Milwaukee, WI
| | - Garrett Berger
- Medical College of Wisconsin in Milwaukee, Milwaukee, WI
| | | | - Harvey Woehlck
- Medical College of Wisconsin in Milwaukee, Milwaukee, WI
| | | | - Scott Johnson
- Medical College of Wisconsin in Milwaukee, Milwaukee, WI
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Zhong R, Zou Y, Bao S, Chen Y, Huang G, Wang L, Chen L, Zhong M, Liang W. Analgesic Efficacy of an Ultrasound-Guided Transversus Thoracis Plane Block Combined with an Intermediate Cervical Plexus Block on Postoperative Pain Relief After Trans-Areolar Endoscopic Thyroidectomy: A Single Center Prospective Randomized Controlled Study. J Pain Res 2023; 16:1059-1067. [PMID: 36998539 PMCID: PMC10045307 DOI: 10.2147/jpr.s402902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/19/2023] [Indexed: 04/01/2023] Open
Abstract
Purpose This study aimed to investigate the analgesic effect of ultrasound-guided transversus thoracis plane block (TTPB) combined with intermediate cervical plexus block (ICPB) in the early postoperative period after trans-areolar endoscopic thyroidectomy. Patients and Methods A total of 62 female patients undergoing trans-areolar endoscopic thyroidectomy were randomly classified to the TTPB combined with ICPB group with ropivacaine (block group) or superficial cervical plexus block group (control group). The primary outcome measures were resting visual analogue scale (VAS) in the chest area at 6 h after surgery. The secondary outcome measures included chest resting and movement VAS score, neck resting and movement VAS score within 24 h after surgery, intraoperative remifentanil consumption, postoperative analgesia rate and analgesic requirements and patient satisfaction score for pain management at discharge. Results Compared with the control group, the block group at rest showed consistently lower VAS scores in the chest area at 6 and 12 h after operation; the block group at rest showed lower VAS scores in the neck at 6, 12 and 24 h after operation. Regarding movement, the VAS scores of the chest and neck area at 2, 6, 12 and 24 h after the operation were lower in the block group than in the control group. The consumption of remifentanil, rate of postoperative analgesic requirements, and consumption of postoperative rescue analgesia in the block group were lower than those in the control group. Satisfaction with pain treatment at discharge was higher in the block group than in the control group. Conclusion Ultrasound-guided TTPB combined with ICPB provides good analgesic effect in the early postoperative period after trans-areola endoscopic thyroidectomy.
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Affiliation(s)
- Ruipeng Zhong
- Gannan Medical University, Ganzhou, People’s Republic of China
- Department of Anesthesiology,Ganzhou People’s Hospital, Ganzhou, People’s Republic of China
| | - Yun Zou
- Anesthesia Surgery Center, the First Affiliated Hospital of Gannan Medical University, Ganzhou, People’s Republic of China
| | - ShuZhen Bao
- Department of Anesthesiology,Ganzhou People’s Hospital, Ganzhou, People’s Republic of China
| | - YiJian Chen
- Department of Anesthesiology,Ganzhou People’s Hospital, Ganzhou, People’s Republic of China
| | - Guiming Huang
- Department of Anesthesiology,Ganzhou People’s Hospital, Ganzhou, People’s Republic of China
| | - Lifeng Wang
- Anesthesia Surgery Center, the First Affiliated Hospital of Gannan Medical University, Ganzhou, People’s Republic of China
| | - Li Chen
- Anesthesia Surgery Center, the First Affiliated Hospital of Gannan Medical University, Ganzhou, People’s Republic of China
| | - Maolin Zhong
- Anesthesia Surgery Center, the First Affiliated Hospital of Gannan Medical University, Ganzhou, People’s Republic of China
| | - Weidong Liang
- Anesthesia Surgery Center, the First Affiliated Hospital of Gannan Medical University, Ganzhou, People’s Republic of China
- Correspondence: Weidong Liang, Anesthesia Surgery Center, the First Affiliated Hospital of Gannan Medical University, No. 128, Jinling West Road, Economic and Technological Development Zone, Ganzhou, Jiangxi Province, 341000, People’s Republic of China, Tel +86 15970122157, Email
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28
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Dbeis R, Assani K, Fadaee N, Huynh D, Khader A, Towfigh S. An anti-inflammatory bundle may help avoid opioids for low-risk outpatient procedures. J Perioper Pract 2023; 33:30-36. [PMID: 35322707 DOI: 10.1177/17504589211031069] [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: 01/10/2023]
Abstract
BACKGROUND Currently, over half of drug overdose deaths are due to opioids. Opioid alternatives may be prescribed to help curb the opioid epidemic. However, little is known about their efficacy for acute postoperative pain. METHODS We studied patients who underwent low-risk outpatient surgery. Perioperatively, all patients were started on an anti-inflammatory bundle consisting of multimodal pain remedies. Opioids were available to the patients postoperatively. Pain scores and opioid use were recorded. RESULTS Over 18 months, 120 patients underwent low-risk outpatient surgery and all used the anti-inflammatory bundle. All patients had a significant decrease in postoperative pain scores (p = 0.001). There was no significant difference in postoperative pain scores between those who followed the anti-inflammatory bundle alone and those who also used opioids (mean 2.2 vs 3.1/10). Twenty-five (21%) patients were using opioids preoperatively and 50 (42%) postoperatively. Of those using opioids preoperatively, six (24%) patients used the anti-inflammatory bundle alone and avoided opioids postoperatively. CONCLUSIONS For 58% of our patients, an anti-inflammatory bundle alone provided adequate pain control after a low-risk outpatient operation, such as hernia repair. Our practice uses the anti-inflammatory bundle for all patients. Our goal is to reduce both the need for opioids and the surgeon's contribution to the opioid epidemic.
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Affiliation(s)
- Rachel Dbeis
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | - Khadij Assani
- Department of Medicine, Skagit Valley Hospital, Mount Vernon, WA, USA
| | - Negin Fadaee
- Beverly Hills Hernia Center, Beverly Hills, CA, USA
| | - Desmond Huynh
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ali Khader
- Department of Radiology, Beth Israel Lahey Health, Boston, MA, USA
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29
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Howard R, Brown CS, Lai YL, Gunaseelan V, Chua KP, Brummett C, Englesbe M, Waljee J, Bicket MC. The Association of Postoperative Opioid Prescriptions with Patient Outcomes. Ann Surg 2022; 276:e1076-e1082. [PMID: 34091508 PMCID: PMC8787466 DOI: 10.1097/sla.0000000000004965] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids. SUMMARY OF BACKGROUND DATA Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks. METHODS We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups. RESULTS In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids ( P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%- 85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)]. CONCLUSIONS Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
| | - Vidhya Gunaseelan
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Kao-Ping Chua
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Chad Brummett
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, Michigan
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, Michigan
| | - Mark C Bicket
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, Michigan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
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30
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Cina RA, Ward RC, Basco WT, Taber DJ, Gebregziabher M, McCauley JL, Lockett MA, Moran WP, Mauldin PD, Ball SJ. Incidence and patterns of persistent opioid use in children following appendectomy. J Pediatr Surg 2022; 57:912-919. [PMID: 35688690 DOI: 10.1016/j.jpedsurg.2022.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. STUDY DESIGN A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. RESULTS 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). CONCLUSION Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert A Cina
- Department of Surgery, The Medical University of South Carolina, 10 McClennan Banks Drive, MSC 918
- SJCH 2190, Charleston, SC 29425, USA.
| | - Ralph C Ward
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - William T Basco
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC, USA
| | - David J Taber
- Department of Surgery, The Medical University of South Carolina, 10 McClennan Banks Drive, MSC 918
- SJCH 2190, Charleston, SC 29425, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Science, The Medical University of South Carolina, Charleston, SC, USA
| | - Mark A Lockett
- Department of Surgery, The Medical University of South Carolina, 10 McClennan Banks Drive, MSC 918
- SJCH 2190, Charleston, SC 29425, USA
| | - William P Moran
- Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D Mauldin
- Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Sarah J Ball
- Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
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Howard R, Gunaseelan V, Brummett C, Waljee J, Englesbe M, Telem D. New Persistent Opioid Use After Inguinal Hernia Repair. Ann Surg 2022; 276:e577-e583. [PMID: 33065653 PMCID: PMC8289484 DOI: 10.1097/sla.0000000000004560] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the incidence of new persistent opioid use after inguinal hernia repair as well as its associated risk factors. SUMMARY OF BACKGROUND DATA The development of new persistent opioid use after surgery is a common complication; however, its incidence following inguinal hernia repair has not been described. Given that roughly 800,000 inguinal hernia repairs are performed annually in the USA, any incidence could have profound implications for patients. METHODS A retrospective cross-sectional study of the incidence of new persistent opioid use after inguinal hernia repair using a national database of de-identified administrative health claims of opioid-naïve patients undergoing surgery from 2008 to 2016. RESULTS During the study period, 59,795 opioid-naïve patients underwent inguinal hernia repair and met inclusion criteria. Mean (SD) age was 57.8 (16.1) years and 55,014 (92%) patients were male. Nine hundred twenty-two (1.5%) patients continued filling opioids prescriptions for at least 3 months after surgery. The most significant risk factor for developing new persistent opioid use after surgery was filling an opioid prescription in the 30 days before surgery (odds ratio 4.34, 95% confidence interval 3.75-5.01). These prescriptions were provided by surgeons in 52% of cases and primary care physicians in 16% of cases. Other risk factors for new persistent opioid use included receiving a larger opioid prescription, having more comorbidities, having a major postoperative complication, and certain mental health disorders and pain disorders. CONCLUSIONS After undergoing inguinal hernia repair, 1.5% of patients developed new persistent opioid use. Filling an opioid prescription in the 30 days before surgery had the strongest association with this complication.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Chad Brummett
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Dana Telem
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
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Pritchard KT, Baillargeon J, Lee WC, Raji MA, Kuo YF. Trends in the Use of Opioids vs Nonpharmacologic Treatments in Adults With Pain, 2011-2019. JAMA Netw Open 2022; 5:e2240612. [PMID: 36342717 PMCID: PMC9641539 DOI: 10.1001/jamanetworkopen.2022.40612] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
IMPORTANCE Chronic pain prevalence among US adults increased between 2010 and 2019. Yet little is known about trends in the use of prescription opioids and nonpharmacologic alternatives in treating pain. OBJECTIVES To compare annual trends in the use of prescription opioids, nonpharmacologic alternatives, both treatments, and neither treatment; compare estimates for the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; and estimate the association between calendar year and pain treatment based on the severity of pain interference. DESIGN, SETTING, AND PARTICIPANTS A serial cross-sectional analysis was conducted using the nationally representative Medical Expenditure Panel Survey to estimate the use of outpatient services by cancer-free adults with chronic or surgical pain between calendar years 2011 and 2019. Data analysis was performed from December 29, 2021, to August 5, 2022. EXPOSURES Calendar year (2011-2019) was the primary exposure. MAIN OUTCOMES AND MEASURES The association between calendar year and mutually exclusive pain treatments (opioid vs nonpharmacologic vs both vs neither treatment) was examined. A secondary outcome was the prevalence of nonpharmacologic treatments (acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy). All analyses were stratified by pain type. RESULTS Among the unweighted 46 420 respondents, 9643 (20.4% weighted) received surgery and 36 777 (79.6% weighted) did not. Weighted percentages indicated that 41.7% of the respondents were aged 45 to 64 years and 55.0% were women. There were significant trends in the use of pain treatments after adjusting for demographic factors, socioeconomic status, health conditions, and pain severity. For example, exclusive use of nonpharmacologic treatments increased in 2019 for both cohorts (chronic pain: adjusted odds ratio [aOR], 2.72; 95% CI, 2.30-3.21; surgical pain: aOR, 1.53; 95% CI, 1.13-2.08) compared with 2011. The use of neither treatment decreased in 2019 for both cohorts (chronic pain: aOR, 0.43; 95% CI, 0.37-0.49; surgical pain: aOR, 0.59; 95% CI, 0.46-0.75) compared with 2011. Among nonpharmacologic treatments, chiropractors and physical therapists were the most common licensed healthcare professionals. CONCLUSIONS AND RELEVANCE Among cancer-free adults with pain, the annual prevalence of nonpharmacologic pain treatments increased and the prevalent use of neither opioids nor nonpharmacologic therapy decreased for both chronic and surgical pain cohorts. These findings suggest that, although access to outpatient nonpharmacologic treatments is increasing, more severe pain interference may inhibit this access.
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Affiliation(s)
- Kevin T. Pritchard
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, School of Public and Population Health, University of Texas Medical Branch, Galveston
| | - Jacques Baillargeon
- Department of Epidemiology, School of Public and Population Health, University of Texas Medical Branch, Galveston
| | - Wei-Chen Lee
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Mukaila A. Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Yong-Fang Kuo
- Department of Biostatistics and Data Science, School of Public and Population Health, University of Texas Medical Branch, Galveston
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Premachandran P, Nippak P, Begum H, Meyer J, McFarlan A. Opioid prescribing practices in trauma patients at discharge: An exploratory retrospective chart analysis. Medicine (Baltimore) 2022; 101:e31047. [PMID: 36281201 PMCID: PMC9592494 DOI: 10.1097/md.0000000000031047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This study examined the opioid prescribing patterns at discharge in the trauma center of a major Canadian hospital and compared them to the guidelines provided by the Illinois surgical quality improvement collaborative (ISQIC), a framework that has been recognized as being associated with reduced risk. This was a retrospective chart review of patient data from the trauma registry between January 1, 2018, and October 31, 2019. A total of 268 discharge charts of naïve opioid patients were included in the analysis. A Morphine Milligram Equivalents per day (MME/day) was computed for each patient who was prescribed opioids and compared with standard practice guidelines. About 75% of patients were prescribed opioids. More males (75%) than females (25%) were prescribed opioids to patients below 65 years old (91%). Best practice guidelines were followed in most cases. Only 16.6% of patients were prescribed over 50 mg MME/day, the majority (80.9%) were prescribed opioids for =<3 days and only 1% for >7 days. Only 7.5% were prescribed extended-release opioids and none were strong like fentanyl. Patients received a multimodal approach with alternatives to opioids in 88.9% of cases and 82.9% had a plan for opioid discontinuation. However, only 23.6% received an acute pain service referral. The majority of the prescriptions provided adhered to the best practice guidelines outlined by the ISQIC framework. These results are encouraging with respect to the feasibility of implementing opioid prescription guidelines effectively. However, routine monitoring is necessary to ensure that adherence is maintained.
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Affiliation(s)
- Priyanka Premachandran
- School of Health Services Management, Ted Rogers School of Management, Ryerson University, Toronto, Ontario, Canada
| | - Pria Nippak
- School of Health Services Management, Ted Rogers School of Management, Ryerson University, Toronto, Ontario, Canada
- *Correspondence: Pria Nippak, School of Health Services Management, Ted Rogers School of Management, Ryerson University, 8th floor, 2068, Toronto, Ontario, Canada (e-mail: )
| | - Housne Begum
- School of Health Services Management, Ted Rogers School of Management, Ryerson University, Toronto, Ontario, Canada
| | - Julien Meyer
- School of Health Services Management, Ted Rogers School of Management, Ryerson University, Toronto, Ontario, Canada
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Kirkegaard A, Wagner Z, Mariano LT, Martinez MC, Yan XS, Romanelli RJ, Watkins KE. Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial. BMJ Open 2022; 12:e061980. [PMID: 36123066 PMCID: PMC9486294 DOI: 10.1136/bmjopen-2022-061980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Surgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment and opioid diversion. This study tests the effectiveness of two behavioural nudges, one based on peer behaviour and one based on best practice guidelines, in reducing excessive postoperative opioid prescriptions. METHODS AND ANALYSIS The study will be conducted at 19 hospitals within a large healthcare delivery system in northern California, USA. Three surgical specialties (general surgery, orthopaedic surgery and obstetric/gynaecological surgery) at each hospital will be randomised either to a control group or to one of two active intervention arms. One intervention is grounded in the theory of injunctive norms, and provides feedback to surgeons on their postoperative opioid prescribing relative to prescribing guidelines endorsed by their institution. The other intervention draws from the theory of descriptive norms, and provides feedback similar to the first intervention but using peers' behaviour rather than guidelines as the benchmark for the surgeon's prescribing behaviour. The interventions will be delivered by a monthly email. Both interventions will be active for twelve months. The effects of each intervention relative to the control group and to each other will be tested using a four-level hierarchical model adjusted for multiple hypothesis testing. ETHICS AND DISSEMINATION Using behavioural nudges rather than rigid policy changes allows us to target excessive prescribing without preventing clinicians from using their clinical judgement to address patient pain. All study activities have been approved by the RAND Human Subjects Protection Committee (ID 2018-0988). Findings will be disseminated through conference presentations, peer-reviewed publications and social media accounts. TRIAL REGISTRATION NUMBER NCT05070338.
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Affiliation(s)
| | | | | | - Meghan C Martinez
- Center for Health Systems Research (West), Palo Alto, California, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research (East), Walnut Creek, California, USA
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McMaster KL, Rudzianski NJ, Byrnes CM, Galet C, Carnahan R, Allan L. Decreasing opioid prescribing at discharge while maintaining adequate pain management is sustainable. SURGERY IN PRACTICE AND SCIENCE 2022; 10. [PMID: 36188337 PMCID: PMC9526357 DOI: 10.1016/j.sipas.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Katie L. McMaster
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, USA
| | | | - Cheryl M. Byrnes
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, USA
| | - Colette Galet
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, USA
- Corresponding author. (C. Galet)
| | - Ryan Carnahan
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, USA
| | - Lauren Allan
- Department of Surgery, Division of Acute Care Surgery, University of Iowa, Iowa City, IA, USA
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36
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Ghaddaf AA, Alsharef JF, Alhindi AK, Bahathiq DM, Khaldi SE, Alowaydhi HM, Alshehri MS. Influence of perioperative opioid-related patient education: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2022; 105:2824-2840. [PMID: 35537899 DOI: 10.1016/j.pec.2022.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/01/2022] [Accepted: 04/27/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Abdullah A Ghaddaf
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Jawaher F Alsharef
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Abeer K Alhindi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Dena M Bahathiq
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Shahad E Khaldi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Hanin M Alowaydhi
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Mohammed S Alshehri
- College of Medicine, King Saud bin Abdulaziz University for health sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Surgery/Orthopedic section, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
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37
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Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study. Can J Anaesth 2022; 69:974-985. [DOI: 10.1007/s12630-022-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/15/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
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Trends in opioid dispensing after common abdominal and orthopedic surgery procedures in British Columbia: a retrospective cohort analysis. Can J Anaesth 2022; 69:986-996. [PMID: 35768720 PMCID: PMC9244383 DOI: 10.1007/s12630-022-02272-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/15/2022] [Accepted: 03/27/2022] [Indexed: 11/27/2022] Open
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Rodriguez-Monguio R, Lun Z, Kehr K, Agustin JP, San Agustin-Nordmeier K, Huynh C, Reisner L. Hospital admission medication reconciliation in high-risk prescription opioid users. Res Social Adm Pharm 2022; 18:3379-3385. [PMID: 34972641 DOI: 10.1016/j.sapharm.2021.11.010] [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: 06/05/2021] [Revised: 11/01/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND No studies have assessed the clinical significance of medication reconciliation in surgical patients using high-risk extended-release/long-acting (ER/LA) opioid medications. OBJECTIVES We assessed differences in the perioperative use of opioid analgesics in patients who underwent medication reconciliation upon hospital admission compared to patients who did not and identified predictors of perioperative use of opioids. METHODS Retrospective observational quasi-experimental study including adult non-cancer patients who underwent elective surgery at UCSF Medical Center in the period January 2017 through December 2019 and received at least one opioid analgesic during surgical hospitalization. The primary study outcome was perioperative use of opioids measured in daily oral morphine equivalents (OME). Secondary outcomes were predictors of perioperative use of opioids after adjusting for baseline differences between groups. RESULTS We identified 402 patients. Of them, 59.5% were female. The mean patient age was 58.5 years. Most patients underwent neurological or orthopedic surgery (each 40.8%). Over 94.3% of our patients underwent medication reconciliation upon hospital admission, with 78.4% completed by a pharmacy staff. Medication reconciliation evidenced that 5.5% patients were not taking the ER/LA opioids on their medication history list. Inactive ER/LA opioids were discontinued during hospitalization. None of the patients with inactive ER/LA opioids had those opioids restarted at hospital discharge. In addition, patients (26.9%) were successfully converted from ER/LA to SA opioids. After adjusting for patients' demographic and clinical characteristics, surgical procedure type and post-operative pain, opioid formulation conversion was the main predictor of perioperative use of opioids per hospitalization day. Switching patients from ER/LA to SA opioids reduced the mean daily use of OME by 66.03 units (p < 0.02) without adversely impacting postoperative pain. CONCLUSIONS Medication reconciliation upon hospital admission reduced unnecessary exposure to opioids in hospitalized surgical patients.
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Affiliation(s)
- Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA; Medication Outcomes Center, University of California San Francisco (UCSF), USA; Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco (UCSF), USA.
| | - Zhixin Lun
- Medication Outcomes Center, University of California San Francisco (UCSF), USA
| | - Kendall Kehr
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA
| | - Janelle P Agustin
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA
| | | | - Christine Huynh
- Department of Clinical Pharmacy, University of California San Francisco (UCSF), USA
| | - Lori Reisner
- Department of Pharmaceutical Services, University of California San Francisco (UCSF) Medical Center, USA
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Clarke C, McClure A, Allen L, Hartford L, Van Koughnett JA, Gray D, Murphy PB, Vinden C, Leslie K, Vogt KN. Opioid use after outpatient elective general surgery: quantifying the burden of persistent use. Br J Pain 2022; 16:361-369. [PMID: 36032343 PMCID: PMC9411755 DOI: 10.1177/20494637211032907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Purpose Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135-225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.
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Affiliation(s)
- Collin Clarke
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
- Western University, London, ON, Canada
| | - Andrew McClure
- Institute for Clinical Evaluative Sciences (ICES) Western, London, ON, Canada
| | - Laura Allen
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - Luke Hartford
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - Julie Ann Van Koughnett
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
- Western University, London, ON, Canada
| | - Daryl Gray
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
- Western University, London, ON, Canada
| | - Patrick B Murphy
- Division of Acute Care Surgery, Medical College of Wisconsin, WI, USA
| | - Chris Vinden
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
- Western University, London, ON, Canada
| | - Ken Leslie
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
- Western University, London, ON, Canada
| | - Kelly N Vogt
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
- Western University, London, ON, Canada
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Klemt C, Harvey MJ, Robinson MG, Esposito JG, Yeo I, Kwon YM. Machine learning algorithms predict extended postoperative opioid use in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:2573-2581. [PMID: 34984528 DOI: 10.1007/s00167-021-06812-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Adequate postoperative pain control following total knee arthroplasty (TKA) is required to achieve optimal patient recovery. However, the postoperative recovery may lead to an unnaturally extended opioid use, which has been associated with adverse outcomes. This study hypothesizes that machine learning models can accurately predict extended opioid use following primary TKA. METHODS A total of 8873 consecutive patients that underwent primary TKA were evaluated, including 643 patients (7.2%) with extended postoperative opioid use (> 90 days). Electronic patient records were manually reviewed to identify patient demographics and surgical variables associated with prolonged postoperative opioid use. Five machine learning algorithms were developed, encompassing the breadth of state-of-the-art machine learning algorithms available in the literature, to predict extended opioid use following primary TKA, and these models were assessed by discrimination, calibration, and decision curve analysis. RESULTS The strongest predictors for prolonged opioid prescription following primary TKA were preoperative opioid duration (100% importance; p < 0.01), drug abuse (54% importance; p < 0.01), and depression (47% importance; p < 0.01). The five machine learning models all achieved excellent performance across discrimination (AUC > 0.83), calibration, and decision curve analysis. Higher net benefits for all machine learning models were demonstrated, when compared to the default strategies of changing management for all patients or no patients. CONCLUSION The study findings show excellent model performance for the prediction of extended postoperative opioid use following primary total knee arthroplasty, highlighting the potential of these models to assist in preoperatively identifying at risk patients, and allowing the implementation of individualized peri-operative counselling and pain management strategies to mitigate complications associated with prolonged opioid use. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Christian Klemt
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael Joseph Harvey
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Matthew Gerald Robinson
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - John G Esposito
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ingwon Yeo
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Abujbarah SM, Jogerst K, Kosiorek HE, Ahmad S, Cronin PA, Casey W, Craner R, Rebecca A, Pockaj BA. Postoperative Hematomas in the Era of Outpatient Mastectomy: Is Ketorolac Really to Blame? Ann Surg Oncol 2022; 29:6395-6403. [PMID: 35849298 DOI: 10.1245/s10434-022-12141-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/16/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols following mastectomy with or without implant-based breast reconstruction (IBBR) include ketorolac for multimodal perioperative analgesia. There are concerns that ketorolac could be associated with increased risk of postoperative hematoma formation. METHODS Retrospective review of patients undergoing mastectomy with or without IBBR between January 2013 and December 2019 at a single institution. Patients received 15 mg, 30 mg, or no ketorolac depending on ERAS protocol adherence, patient characteristics, and surgeon preference. Clinically significant hematoma was defined as requiring surgical intervention on day of surgery or postoperative day 1. Patients were compared by demographics, surgical characteristics, ketorolac dose, and hematoma prevalence. Univariable and multivariable logistic regression evaluated hematoma formation odds. RESULTS Eight hundred patients met inclusion criteria: 477 received ketorolac. Those who received ketorolac were younger, had lower ASA scores, were more likely to have bilateral procedures and undergo concomitant IBBR, had longer operative times, were less likely to take antiplatelet or anticoagulation medications, had higher PACU pain scores, and had higher incidence of hematomas requiring surgical intervention. Of the cohort, 4.4% had clinically significant hematomas. The 15 mg and 30 mg ketorolac groups had similar prevalence (6.0% vs 5.8%, p = 0.95). On univariable regression, there were increased odds of hematoma formation in patients who were younger, had bilateral procedures, had longer OR times, and who received ketorolac. On multivariable regression, none of the prior variables remained significant. CONCLUSION After accounting for associations with longer operative times, concomitant IBBR, and bilateral procedures, ketorolac administration did not remain an independent risk factor for hematoma formation.
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Affiliation(s)
- Sami M Abujbarah
- Mayo Clinic Alix School of Medicine, Arizona Campus, Scottsdale, AZ, USA
| | - Kristen Jogerst
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Heidi E Kosiorek
- Department of Research-Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Sarwat Ahmad
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Patricia A Cronin
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - William Casey
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Craner
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alanna Rebecca
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Narcotic sparing postoperative analgesic strategies after pancreatoduodenectomy: analysis of practice patterns for 1004 patients. HPB (Oxford) 2022; 24:1145-1152. [PMID: 35151580 DOI: 10.1016/j.hpb.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Improved post-operative outcomes have been demonstrated in gastrointestinal procedures where a narcotic sparing strategy has been utilized. Data for pancreaticoduodenectomy (PD) patients is limited. This study reviews an institutional database for outcomes based on initial analgesic strategy. METHODS 1004 consecutive patients who underwent PD at Emory University between 2010 and 2017, were included in the analysis. Patients were divided into groups based on primary analgesic strategy employed: epidural alone (EPI), patient controlled opiate analgesia (PCA), dual (dual-PCA/EPI) and other (non-PCA/EPI). Postoperative outcomes for each group were analyzed utilizing univariate and multivariate linear regression. RESULTS 448 (44.6%) patients were treated with EPI, 300 (29.9%) were given a PCA, 78 (7.8%) had dual-PCA/EPI and 178 (17.7%) had non-PCA/EPI analgesia. On univariate analysis, increased BMI (p = 0.030), PCA use (p < 0.001), venous thromboembolism (VTE) (p < 0.001), post-operative pancreatic fistula (POPF) (p < 0.001) and Ileus/delayed gastric emptying (DGE) (p < 0.001) were all correlated with increased LOS. On multivariate linear regression, VTE (b-coefficient 9.07, p = 0.004) POPF (8.846, p = 0.001), Ileus/DGE (4.464, p = 0.004) and PCA use (1.75, p = 0.003) were associated with significantly increased LOS. CONCLUSION A primary narcotic sparing strategy is associated with a significantly reduced LOS and lower rates of Ileus/DGE. Mean opiate usage was significantly lower in the EPI and non-EPI/PCA groups.
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Lockett MA, Ward RC, McCauley JL, Taber DJ, Gebregziabher M, Cina RA, Basco WT, Mauldin PD, Ball SJ. New chronic opioid use in Medicaid patients following cholecystectomy. Surg Open Sci 2022; 9:101-108. [PMID: 35755164 PMCID: PMC9218552 DOI: 10.1016/j.sopen.2022.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/06/2022] [Accepted: 05/14/2022] [Indexed: 11/20/2022] Open
Abstract
Background Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received ≥ 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically.
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Affiliation(s)
- Mark A Lockett
- Department of Surgery, The Medical University of South Carolina, Charleston, SC
| | - Ralph C Ward
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Science, The Medical University of South Carolina, Charleston, SC
| | - David J Taber
- Department of Surgery, The Medical University of South Carolina, Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC
| | - Robert A Cina
- Department of Surgery, The Medical University of South Carolina, Charleston, SC
| | - William T Basco
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC
| | - Patrick D. Mauldin
- Department of Medicine, The Medical University of South Carolina, Charleston, SC
| | - Sarah J Ball
- Department of Medicine, The Medical University of South Carolina, Charleston, SC
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Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention's 2016 opioid prescribing guideline. BMC Anesthesiol 2022; 22:141. [PMID: 35546657 PMCID: PMC9097447 DOI: 10.1186/s12871-022-01678-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention's (CDC) March 2016 opioid prescribing guideline did not include prescribing recommendations for surgical pain. Although opioid over-prescription for surgical patients has been well-documented, the potential effects of the CDC guideline on providers' opioid prescribing practices for surgical patients in the United States remains unclear. METHODS We conducted an interrupted time series analysis (ITSA) of 37,009 opioid-naïve adult patients undergoing inpatient surgery from 2013-2019 at an academic medical center. We assessed quarterly changes in the discharge opioid prescription days' supply, daily and total doses in oral morphine milligram equivalents (OME), and the proportion of patients requiring opioid refills within 30 days of discharge. RESULTS The discharge opioid prescription declined by -0.021 (95% CI, -0.045 to 0.003) days per quarter pre-guideline versus -0.201 (95% CI, -0.223 to -0.179) days per quarter post-guideline (p < 0.0001). Likewise, the mean daily and total doses of the discharge opioid prescription declined by -0.387 (95% CI, -0.661 to -0.112) and -7.124 (95% CI, -9.287 to -4.962) OME per quarter pre-guideline versus -2.307 (95% CI, -2.560 to -2.055) and -20.68 (95% CI, -22.66 to -18.69) OME per quarter post-guideline, respectively (p < 0.0001). Opioid refill prescription rates remained unchanged from baseline. CONCLUSIONS The release of the CDC opioid guideline was associated with a significant reduction in discharge opioid prescriptions without a concomitant increase in the proportion of surgical patients requiring refills within 30 days. The mean prescription for opioid-naïve surgical patients decreased to less than 3 days' supply and less than 50 OME per day by 2019.
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Long JB, Morgan BM, Boyd SS, Davies MF, Kunselman AR, Stetter CM, Andreae MH. A randomized trial of standard vs restricted opioid prescribing following midurethral sling. Am J Obstet Gynecol 2022; 227:313.e1-313.e9. [PMID: 35550371 DOI: 10.1016/j.ajog.2022.05.010] [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: 01/03/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. OBJECTIVE This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens. STUDY DESIGN Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points. RESULTS Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval, -∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P<.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P<.001). CONCLUSION Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.
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Aglio LS, Mezzalira E, Mendez-Pino L, Corey SM, Fields KG, Abbakar R, Baez LA, Kelly-Aglio NJ, Vetter T, Jamison RN, Edwards RR. Surgical Prehabilitation: Strategies and Psychological Intervention to Reduce Postoperative Pain and Opioid Use. Anesth Analg 2022; 134:1106-1111. [PMID: 35427271 DOI: 10.1213/ane.0000000000005963] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Linda S Aglio
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Computational Neurosurgical Outcome Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabetta Mezzalira
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Laura Mendez-Pino
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah M Corey
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kara G Fields
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reem Abbakar
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leah A Baez
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicole J Kelly-Aglio
- Computational Neurosurgical Outcome Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Robert N Jamison
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert R Edwards
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abdelwahab M, Marques S, Howard J, Huang A, Lechner M, Olds C, Capasso R. Incidence and risk factors of chronic opioid use after sleep apnea surgery. J Clin Sleep Med 2022; 18:1805-1813. [PMID: 35393936 DOI: 10.5664/jcsm.9978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To assess the incidence and risk factors of chronic opioid use after OSA surgery. METHODS Using IBM MarketScan research database, adults (>18) who underwent a variety of sleep surgery procedures between 2007 and 2015, were identified. Subjects with one year of insurance coverage before and after the surgical procedure were included. Additional anesthesia event(s) in the year following the procedure of interest, and those who filled an opioid prescription within the year prior to surgery (not naïve) were excluded. Outcomes included rates of persistent opioid use (additional opioid prescriptions filled 90-180 days postoperatively), prolonged use (additional opioid prescriptions filled 181-365 days postoperatively) and inappropriate use (>100 MME). Evaluated variables include demographics, surgical procedures, and comorbidities. RESULTS A total of 10,766 surgical procedures met inclusion criteria. There was a trend of increased rates of perioperative opioid prescription. After multivariable logistic regression analysis, perioperative opioid prescription and smoking were independent risk factors for inappropriate opioid use (OR= 31.51, p<0.001; OR= 1.41, p=0.016 respectively). Opioid prescription and hypertension were independent risk factors for persistent opioid use (OR=37.8, p<0.001, OR=1.38, p=0.008). Perioperative opioid prescription, previous opioid dependence diagnosis, smoking and male gender were associated with continuous prolonged opioid use (OR=73.1, 8.13, 1.95, 1.55, respectively; p<0.001, 0.020, 0.024, 0.032, respectively). CONCLUSIONS While efforts by different societies are being implemented to control the opioid crisis, we found that perioperative opioid prescription for airway surgery targeting OSA is an independent risk factor for persistent, prolonged, and inappropriate opioid use.
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Affiliation(s)
- Mohamed Abdelwahab
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Sandro Marques
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Javier Howard
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Allen Huang
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Matt Lechner
- UCL Cancer Institute and Academic Head and Neck Centre, UCL Division of Surgery and Interventional Science, University College London, London, UK.,Roxbury Institute, Beverly Hills, California
| | | | - Robson Capasso
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
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Mou Z, Chau H, Kalavacherla S, Radgoudarzi N, Soliman SI, Zhao B, Mekeel K. Tailored order set in the electronic health record decreases postoperative opioid prescriptions. Surgery 2022; 172:677-682. [DOI: 10.1016/j.surg.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/22/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
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50
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Codner JA, Falconer EA, Ashley DW, Sweeney JF, Saeed MI, Langer JM, Shaffer VO, Finley CR, Solomon G, Sharma J. Georgia Quality Improvement Programs Multi-Institutional Collection of Postoperative Opioid Data Using ACS-NSQIP Abstraction. Am Surg 2022; 88:1510-1516. [PMID: 35333645 DOI: 10.1177/00031348221082286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Excessive postoperative opioid prescribing contributes to opioid misuse throughout the US. The Georgia Quality Improvement Program (GQIP) is a collaboration of ACS-NSQIP participating hospitals. GQIP aimed to develop a multi-institutional opioid data collection platform as well as understand our current opioid-sparing strategy (OSS) usage and postoperative opioid prescribing patterns. METHODS This study was initiated 7/2019, when 4 custom NSQIP variables were developed to capture OSS usage and postoperative opioid oral morphine equivalents (OMEs). After pilot collection, our discharge opioid variable required optimization for adequate data capture and was expanded from a free text option to 4 drop-down selection variables. Data collection then continued from 2/2020-5/2021. Logistic regression was used to determine associations with OSS usage. Average OMEs were calculated for common general surgery procedures and compared to national guidelines. RESULTS After variable optimization, the percentage where a total discharge prescription OME could be calculated increased from 26% to 70% (P < .001). The study included 820 patients over 10 operations. There was a significant variation in OSS usage between GQIP centers. Laparoscopic cases had higher odds of OSS use (1.92 (1.38-2.66)) while OSS use had lower odds in black patients on univariate analysis (.69 (.51-.94)). On average 7 out of the 10 cases had higher OMEs prescribed compared to national guidelines recommendations. CONCLUSION Developing a multi-institutional opioid data collection platform through ACS-NSQIP is feasible. Preselected drop-down boxes outperform free text variables. GQIP future quality improvement targets include variation in OSS use and opioid overprescribing.
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Affiliation(s)
- Jesse A Codner
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Elissa A Falconer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Dennis W Ashley
- Department of Surgery, 5223Navicent Health Medical Center, Macon, GA, USA
| | - John F Sweeney
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Muhammad I Saeed
- Department of Surgery, 1421Augusta University School of Medicine, Augusta, GA, USA
| | - Jason M Langer
- Department of Surgery, 232321Phoebe Putney Memorial, Albany, GA, USA
| | - Virginia O Shaffer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Charles R Finley
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Gina Solomon
- Department of Surgery, Georgia Quality Improvement Program, Atlanta, GA, USA
| | - Jyotirmay Sharma
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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