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Harbell MW, Cohen J, Balfanz G, Methangkool E. Mitigating and preventing perioperative opioid-related harm. Curr Opin Anaesthesiol 2024:00001503-990000000-00225. [PMID: 39247993 DOI: 10.1097/aco.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW Although necessary for treatment of acute pain, opioids are associated with significant harm in the perioperative period and further intervention is necessary perioperatively to mitigate opioid-related harm. RECENT FINDINGS Opioid-naive patients are often first exposed to opioids when undergoing surgery, which can result in significant harm. Despite their benefits in reducing acute postsurgical pain, they are also associated with risks ranging from mild (e.g., pruritis, constipation, nausea) to potentially catastrophic (e.g. opioid-induced ventilatory impairment, respiratory depression, death). Overprescribing of opioids can lead to opioid diversion and drug driving. In this review, we will discuss opioid-related harm and what strategies can be used perioperatively to mitigate this harm. Interventions such as optimizing nonopioid analgesia, implementing Enhanced Recovery after Surgery programs, effective respiratory monitoring, patient education and opioid stewardship programs will be discussed. SUMMARY We will review policy and guidelines regarding perioperative opioid management and identify challenges and future directions to mitigate opioid-related harm.
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Affiliation(s)
- Monica W Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Jonathan Cohen
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, Florida
| | - Greg Balfanz
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Emily Methangkool
- Department of Anesthesiology, Olive View-UCLA Medical Center, Los Angeles, California, USA
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Bansal N, Armitage CJ, Hawkes RE, Tinsley S, Ashcroft DM, Chen LC. Decoding behaviour change techniques in opioid deprescribing strategies following major surgery: a systematic review of interventions to reduce postoperative opioid use. BMJ Qual Saf 2024:bmjqs-2024-017265. [PMID: 39074984 DOI: 10.1136/bmjqs-2024-017265] [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: 02/23/2024] [Accepted: 07/11/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND AND OBJECTIVES METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's d effect sizes were calculated. BCTs were identified using a validated taxonomy. RESULTS 22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward. CONCLUSIONS Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors. PROSPERO REGISTRATION NUMBER CRD42022290060.
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Affiliation(s)
- Neetu Bansal
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health,Manchester Academic Health Science Centre, Oxford Road, University of Manchester, Manchester, UK
| | - Christopher J Armitage
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Rhiannon E Hawkes
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Sarah Tinsley
- Pharmacy Department, Royal Stoke University Hospitals, Stoke-on-Trent, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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3
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Huang YT, Dixon WG, O’Neill TW, Jani M. Postoperative opioids administered to inpatients with major or orthopaedic surgery: A retrospective cohort study using data from hospital electronic prescribing systems. PLoS One 2024; 19:e0305531. [PMID: 38917135 PMCID: PMC11198745 DOI: 10.1371/journal.pone.0305531] [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: 02/02/2024] [Accepted: 06/02/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission is challenging to access. Modified-release(MR) preparations have been especially associated with harm, whilst certain populations such as the elderly or those with renal impairment may be vulnerable to complications. This study aimed to assess postoperative opioid utilisation patterns during hospital stay for people admitted for major/orthopaedic surgery. METHODS Patients admitted to a teaching hospital in the North-West of England between 2010-2021 for major/orthopaedic surgery with an admission for ≥1 day were included. We examined opioid administrations in the first seven days post-surgery in hospital, and "first 48 hours" were defined as the initial period. Proportions of MR opioids, initial immediate-release(IR) oxycodone and initial morphine milligram equivalents (MME)/day were calculated and summarised by calendar year. We also assessed the proportion of patients prescribed an opioid at discharge. RESULTS Among patients admitted for major/orthopaedic surgery, 71.1% of patients administered opioids during their hospitalisation. In total 50,496 patients with 60,167 hospital admissions were evaluated. Between 2010-2017 MR opioids increased from 8.7% to 16.1% and dropped to 11.6% in 2021. Initial use of oxycodone IR among younger patients (≤70 years) rose from 8.3% to 25.5% (2010-2017) and dropped to 17.2% in 2021. The proportion of patients on ≥50MME/day ranged from 13% (2021) to 22.9% (2010). Of the patients administered an opioid in hospital, 26,920 (53.3%) patients were discharged on an opioid. CONCLUSIONS In patients hospitalised with major/orthopaedic surgery, 4 in 6 patients were administered an opioid. We observed a high frequency of administered MR opioids in adult patients and initial oxycodone IR in the ≤70 age group. Patients prescribed with ≥50MME/day ranged between 13-22.9%. This is the first published study evaluating UK inpatient opioid use, which highlights opportunities for improving safer prescribing in line with latest recommendations.
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Affiliation(s)
- Yun-Ting Huang
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
| | - William G. Dixon
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, United Kingdom
| | - Terence W. O’Neill
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, United Kingdom
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, United Kingdom
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Nolan R, Angelov S, Geoghegan L, O'Sullivan M, Anderson C, Coffey D, Dennehy O, Shanley E, Iohom G, Moran P, Nolan P, O'Gara A. Postoperative opioid prescribing patterns in Ireland: a retrospective multicentre analysis. Br J Anaesth 2024; 132:982-983. [PMID: 38538513 DOI: 10.1016/j.bja.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/28/2024] [Accepted: 02/05/2024] [Indexed: 04/22/2024] Open
Affiliation(s)
- Rachel Nolan
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland.
| | - Sophia Angelov
- Department of Anaesthesiology, Cork University Hospital, Cork, Ireland
| | - Laoise Geoghegan
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
| | - Mai O'Sullivan
- Department of Anaesthesiology, Galway University Hospital, Galway, Ireland
| | - Cian Anderson
- Department of Anaesthesiology, Cork University Hospital, Cork, Ireland
| | - Daniel Coffey
- Department of Anaesthesiology, Cork University Hospital, Cork, Ireland
| | - Oscar Dennehy
- Department of Anaesthesiology, Cork University Hospital, Cork, Ireland
| | - Eoghan Shanley
- Department of Anaesthesiology, Galway University Hospital, Galway, Ireland
| | - Gabriella Iohom
- Department of Anaesthesiology, Cork University Hospital, Cork, Ireland
| | - Peter Moran
- Department of Anaesthesiology, Galway University Hospital, Galway, Ireland
| | - Philip Nolan
- Kathleen Lonsdale Institute, Maynooth University, Maynooth, Ireland
| | - Aine O'Gara
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
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Marichez A, Eude A, Martenot M, Celerier B, Capdepont M, Rullier E, Denost Q, Fernandez B. Low-impact laparoscopy in colorectal resection-A multicentric randomised trial comparing low-pressure pneumoperitoneum plus microsurgery versus low-pressure pneumoperitoneum alone: The PAROS II trial. Colorectal Dis 2023; 25:2403-2413. [PMID: 37897108 DOI: 10.1111/codi.16787] [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: 05/23/2023] [Revised: 08/22/2023] [Accepted: 09/17/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Low-pressure pneumoperitoneum (LLP) in laparoscopy colorectal surgery (CS) has resulted in reduced hospital stay and lower analgesic consumption. Microsurgery (MS) in CS is a technique that has a significant impact with respect to postoperative pain. The combination of MS plus LLP, known as low-impact laparoscopy (LIL), has never been applied in CS. Therefore, this trial will assess the efficacy of LLP plus MS versus LLP alone in terms of decreasing postoperative pain 24 h after surgery, without taking opioids. METHOD PAROS II will be a prospective, multicentre, outcome assessor-blinded, randomised controlled phase III clinical trial that compares LLP plus MS versus LLP alone in patients undergoing laparoscopic surgery for colonic or upper rectal cancer or benign pathology. The primary outcome will be the number of patients with postoperative pain 24 h after the surgery, as defined by a visual analogue scale rating ≤3 and without taking opioids. Overall, PAROS II aims to recruit 148 patients for 50% of patients to reach the primary outcome in the LLP plus MS arm, with 80% power and an 5% alpha risk. CONCLUSION The PAROS II trial will be the first phase III trial to investigate the impact of LIL, including LLP plus MS, in laparoscopic CS. The results may improve the postoperative recovery experience and decrease opioid consumption after laparoscopic CS.
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Affiliation(s)
- Arthur Marichez
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
- University Bordeaux, INSERM, BRIC, U 1312, Bordeaux, France
| | - Audrey Eude
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Mathieu Martenot
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Bertrand Celerier
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Maylis Capdepont
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
- University Bordeaux, INSERM, BRIC, U 1312, Bordeaux, France
| | - Eric Rullier
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, Tivoli Hospital, Bordeaux, France
| | - Benjamin Fernandez
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
- University Bordeaux, INSERM, BRIC, U 1312, Bordeaux, France
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Meldon A, Davey MG, Joyce WP. Evaluating opioid prescribing patterns following discharge from elective surgical procedures: a worrying trend during the 'opioid crisis' - an audit of elective surgical procedures. Ir J Med Sci 2023; 192:2993-2999. [PMID: 37081287 DOI: 10.1007/s11845-023-03363-0] [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: 09/02/2022] [Accepted: 04/03/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The 'opioid crisis' has reached epidemic proportions globally. Importantly, 30% of opioid dependency stem from opioids obtained on hospital discharge prescriptions. AIM The aim of this study is to evaluate opioid prescription patterns on discharge of post-operative patients in an Irish Hospital. METHODS A retrospective cohort study was undertaken in a single institution during the 5 year eligibility period (January 2017-October 2021). Comparisons in opioid prescription patterns following minor (inguinal hernia repair (IHR), intermediate (laparoscopic cholecystectomy (LC)) and major (colonic resection (CR)) were made. Descriptive statistics were performed using SPSS version 26.0 RESULTS: In total, 300 patients were included in this study with mean age 59.6 years (range: 20-92). Of these, 112 patients underwent IHR (37.3%), 116 patients underwent LC (38.7%), and 72 patients underwent CR (24.0%). The mean age at diagnosis was 61 years, 53 years and 58 years for IHR, LC and CR, respectively (P < 0.001). Patients undergoing CR were more likely to have greater comorbidity burden (3.1 vs. 1.2 (IHR) vs. 1.8 (LC) respectively (P = 0.030). On discharge, 27.8% of CR patients received opioids (20/72) compared to 24.1% of IHR (28/116) and 15.9% of LC (18/113) patients, respectively (P = 0.126). CONCLUSION We observed considerable variability in opioid prescribing patterns following minor, intermediate and major operations in our centre. Care is required when prescribing opioids in the post-operative setting, and opioid prescription guidelines are required to both tackle and prevent an escalation of this 'opioid crisis'.
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Affiliation(s)
- Aengus Meldon
- Department of Surgery, Galway Clinic, Doughiska, Co. Galway , H91 HHT0, Republic of Ireland.
| | - Matthew G Davey
- Department of Surgery, Galway Clinic, Doughiska, Co. Galway , H91 HHT0, Republic of Ireland
| | - William P Joyce
- Department of Surgery, Galway Clinic, Doughiska, Co. Galway , H91 HHT0, Republic of Ireland
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Baamer RM, Humes DJ, Toh LS, Knaggs RD, Lobo DN. Temporal trends and patterns in initial opioid prescriptions after hospital discharge following colectomy in England over 10 years. BJS Open 2023; 7:zrad136. [PMID: 38146708 PMCID: PMC10750262 DOI: 10.1093/bjsopen/zrad136] [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: 10/10/2023] [Accepted: 10/21/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND While opioid analgesics are often necessary for the management of acute postoperative pain, appropriate prescribing practices are crucial to avoid harm. The aim was to investigate the changes in the proportion of people receiving initial opioid prescriptions after hospital discharge following colectomy, and describe trends and patterns in prescription characteristics. METHODS This was a retrospective cohort study. Patients undergoing colectomy in England between 2010 and 2019 were included using electronic health record data from linked primary (Clinical Practice Research Datalink Aurum) and secondary (Hospital Episode Statistics) care. The proportion of patients having an initial opioid prescription issued in primary care within 90 days of hospital discharge was calculated. Prescription characteristics of opioid type and formulation were described. RESULTS Of 95 155 individuals undergoing colectomy, 15 503 (16.3%) received opioid prescriptions. There was a downward trend in the proportion of patients with no prior opioid exposure (opioid naive) who had a postdischarge opioid prescription (P <0.001), from 11.4% in 2010 to 6.7% in 2019 (-41.3%, P <0.001), whereas the proportions remained stable for those prescribed opioids prior to surgery, from 57.5% in 2010 to 58.3% in 2019 (P = 0.637). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Prescriptions for morphine and oxycodone rose significantly by 76.6% and 31.0% respectively, while tramadol prescribing dropped by 48.0%. The most commonly prescribed opioid formulations were immediate release (83.9%), followed by modified release (5.8%) and transdermal (3.2%). There was a modest decrease in the prescribing of immediate-release formulations from 86.0% in 2010 to 82.0% in 2019 (P <0.001). CONCLUSION Over the 10 years studied, there was a changing pattern of opioid prescribing following colectomy, with a decrease in the proportion of opioid-naive patients prescribed postdischarge opioids.
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Affiliation(s)
- Reham M Baamer
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - David J Humes
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Li Shean Toh
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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Baamer RM, Humes DJ, Toh LS, Knaggs RD, Lobo DN. Predictors of persistent postoperative opioid use following colectomy: a population-based cohort study from England. Anaesthesia 2023; 78:1081-1092. [PMID: 37265223 PMCID: PMC10953341 DOI: 10.1111/anae.16055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/03/2023]
Abstract
This retrospective cohort study on adults undergoing colectomy from 2010 to 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data to determine the prevalence of persistent postoperative opioid use following colectomy, stratified by pre-admission opioid exposure, and identify associated predictors. Based on pre-admission opioid exposure, patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and previously exposed (opioid prescription within 7-12 months before admission). Persistent postoperative opioid use was defined as requiring an opioid prescription within 90 days of discharge, along with one or more opioid prescriptions 91-180 days after hospital discharge. Multivariable logistic regression analyses were conducted to obtain odds ratios for predictors of persistent postoperative opioid use. Among the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 6791 (45.0%) were opioid-naïve, 7528 (49.9%) were currently exposed and 762 (5.0%) were previously exposed. From the whole cohort, 7540 (8.1%) developed persistent postoperative opioid use. Patients with pre-operative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group; 305 (9.8%) from the previously exposed group; and 1918 (2.5%) from the opioid-naïve group. The odds of developing persistent opioid use were higher among individuals who used long-acting opioid formulations in the 180 days before colectomy than those who used short-acting formulations (odds ratio 3.41 (95%CI 3.07-3.77)). Predictors of persistent opioid use included: previous opioid exposure; high deprivation index; multiple comorbidities; use of long-acting opioids; white race; and open surgery. Minimally invasive surgical approaches were associated with lower odds of persistent opioid use and may represent a modifiable risk factor.
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Affiliation(s)
- R. M. Baamer
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
- Department of Pharmacy Practice, Faculty of PharmacyKing Abdulaziz UniversityJeddahSaudi Arabia
| | - D. J. Humes
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
| | - L. S. Toh
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
| | - R. D. Knaggs
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
- Pain Centre Versus ArthritisUniversity of NottinghamNottinghamUK
| | - D. N. Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing ResearchSchool of Life SciencesUniversity of Nottingham, Queen's Medical CentreNottinghamUK
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Thomas C, Ayres M, Pye K, Yassin D, Howell SJ, Alderson S. Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review. Perioper Med (Lond) 2023; 12:34. [PMID: 37430326 DOI: 10.1186/s13741-023-00312-4] [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: 06/13/2022] [Accepted: 05/19/2023] [Indexed: 07/12/2023] Open
Abstract
Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.
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Affiliation(s)
- C Thomas
- Department of Anaesthesia, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK.
| | - M Ayres
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Pye
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Yassin
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Institute of Health Research, University of Leeds, Leeds, UK
| | - S Alderson
- Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Griffiths H, Kent B, Martin D. Exploring incidence and risk factors for persistent postoperative opioid use in adult surgical patients: a systematic review protocol. JBI Evid Synth 2023; 21:805-811. [PMID: 36730288 DOI: 10.11124/jbies-22-00106] [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: 02/03/2023]
Abstract
OBJECTIVE The objective of this review is to determine the incidence of persistent postsurgical use of opioids in adult patients and the associated risk factors. INTRODUCTION Surgery has been identified as an independent risk factor for unwarranted chronic opioid use, contributing to opioid-related harm in the community. Persistent opioid use after surgery is associated with morbidity and mortality from opioid-related adverse events, indicating a significant yet mitigable public health concern. There is substantial variation in the reported incidence and risk factors for postoperative opioid use, which require evaluation for future evidence-based risk-reduction strategies. INCLUSION CRITERIA This review will include studies investigating the persistent use of opioids after 90 postoperative days in adult (≥18 y) patients undergoing surgery of any type, including patients with cancer pain. Selected evidence must report on opioid use prior to surgery. Analytical and descriptive observational studies, and experimental and quasi-experimental studies, published in the previous decade will be eligible for inclusion. METHODS The proposed study methods follow the JBI methodology for systematic reviews of prevalence and incidence. A systematic search will be conducted in PubMed, Embase, CINAHL, Cochrane Central, and Web of Science, and a search of gray literature will include Google Scholar and ClinicalTrials.gov. Study selection, critical appraisal, and data extraction will be performed by 2 independent reviewers aided by the relevant JBI systematic review tools. We aim to produce a narrative synthesis of results and conduct a meta-analysis where feasible, in addition to subgroup analyses of suitable populations. The results are intended to promote safe, evidence-based postoperative opioid prescribing when considering risk factors for persistent postoperative opioid use. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42022320691.
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Affiliation(s)
- Harry Griffiths
- Peninsula Medical School, University of Plymouth, Plymouth, Devon, UK
| | - Bridie Kent
- The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, University of Plymouth, Plymouth, Devon, UK
| | - Daniel Martin
- Intensive Care, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
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Walsh K, Gezer N, Gaborit L, Zhou W, Banerjee A. Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital. Aust J Rural Health 2023. [PMID: 36745537 DOI: 10.1111/ajr.12965] [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: 03/27/2022] [Revised: 12/21/2022] [Accepted: 01/01/2023] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. METHODS A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. OUTCOME MEASURES To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. RESULTS 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. CONCLUSIONS This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.
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Affiliation(s)
- Kelsey Walsh
- ANU Medical School, Garran, Australian Capital Territory, Australia
| | - Nesha Gezer
- ANU Medical School, Garran, Australian Capital Territory, Australia
| | - Lorane Gaborit
- ANU Medical School, Garran, Australian Capital Territory, Australia
| | - William Zhou
- ANU Medical School, Garran, Australian Capital Territory, Australia
| | - Arnab Banerjee
- Goulburn Base Hospital, ANU Medical School, Goulburn, New South Wales, Australia
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Quinlan J, Levy N, Lobo DN, Macintyre PE. No place for routine use of modified-release opioids in postoperative pain management. Br J Anaesth 2022; 129:290-293. [PMID: 35843745 DOI: 10.1016/j.bja.2022.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022] Open
Abstract
Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. Recognition that modified-release opioids show lack of benefit and increased risk of harm compared with immediate-release opioids in the acute, postoperative setting has become clear. Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.
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Affiliation(s)
- Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
| | - Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia; Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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13
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Levy N, McNally SA, Lobo DN. The need to improve opioid prescribing and data collection in patients undergoing orthopaedic surgery. Anaesthesia 2022; 77:854-857. [PMID: 35762197 DOI: 10.1111/anae.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - S A McNally
- Department of Trauma and Orthopaedics, East Sussex Healthcare NHS Trust, Eastbourne, Sussex, UK
- Honorary Clinical Professor, Brighton and Sussex Medical School, Brighton, UK
| | - D N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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14
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Donnelly A, Cox FJ. Raising patient and carer awareness of the risks of postoperative opioids. Br J Pain 2022; 16:260-262. [PMID: 35646338 PMCID: PMC9136994 DOI: 10.1177/20494637221103169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Affiliation(s)
- Amy Donnelly
- Perioperative Medicine Fellow, St Vincent's University Hospital, Dublin, Ireland
| | - Felicia J Cox
- Nurse Consultant Pain Management, Royal Brompton & Harefield NHS Foundation Trust, London, UK
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15
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Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails. J Clin Med 2022; 11:jcm11020468. [PMID: 35054162 PMCID: PMC8781195 DOI: 10.3390/jcm11020468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 12/10/2022] Open
Abstract
The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.
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Affiliation(s)
- William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, School of Health and Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
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17
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Albrecht E, Brummett CM. If you cannot measure it, you cannot improve it. Anaesthesia 2021; 76:1304-1307. [PMID: 33858036 DOI: 10.1111/anae.15480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- E Albrecht
- Department of Anaesthesia, Lausanne University Hospital, Lausanne, Switzerland
| | - C M Brummett
- Co-Director of the Michigan Opioid Prescribing Engagement Network (Michigan OPEN), University of Michigan Medical School, Ann Arbor, MI, USA
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