Patterns of opioid use for lower limb trauma patients during the first 6 months after discharge

Guidance recommends that prescribed opioids for acute pain should not be continued beyond the expected period of healing and may lead to long-term use if a large supply is provided or repeat prescriptions are requested. This project investigated how opioids are used by opioid-naïve trauma patients in the first 6 months following discharge from hospital. The findings indicate that patients are frequently discharged from hospital with an opioid prescription and for some this will continue beyond the recommended maximum duration of 3 months and will include dose escalation. Clinicians should be aware of the potential risks associated with prolonged opioid use, including the increased risk of accidental overdose and potential death, and be able to identify which patients are at most risk. Screening for indicators for long-term use may prove more useful than formal risk stratification tools in an acute pain population.

Impact of Implementing Screening and Interventions to Target Prevention of Opioid Misuse and Accidental Overdose in the Inpatient Setting

Introduction: There are limited publications supporting the use of screening tools to implement upstream prevention of opioid-related problems. Opioid and Naloxone Education (ONE) is utilized in outpatient pharmacies to screen and identify patients at risk of opioid-related problems and make interventions. Objectives: To implement ONE in the inpatient setting to promote prevention of opioid-related problems and overdose risk mitigation. Methods: For this pilot, ONE screening tool was completed via chart review and patient interview for inpatients prescribed an opioid. Risk scores were calculated and recommendations were provided. Outcomes evaluated included morphine milligram equivalents (MME) prior to hospitalization, inpatient screening pre-, post-, and at discharge; naloxone orders at discharge; and comparison of overdose risk from different sources. Results: The control group (n = 44) had a mean MME decrease of 1.5, and following implementation of pharmacist interventions, the experimental group (n = 45) observed a mean MME decrease of 28.6 (P = .0001). For the threshold of 50 MME, 8.6% of patients in the control group had a change from >50 MME to <50 MME at 24 hour follow up. This change occurred in 29% of patients in the experimental group (P = .03). For non-opioid analgesics, 6.8% of patients in the control group had non-opioid analgesic orders added or increased compared to 26.6% in the experimental group (P = .01). Conclusion: Screening for opioid misuse and accidental overdose risk appears impactful in the inpatient setting. Screening and appropriate risk-based intervention was associated with decreases in total daily MME and increased non-opioid analgesics.

Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty

BACKGROUND

We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway.

METHODS

This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups.

RESULTS

At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results.

CONCLUSIONS

A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial

BACKGROUND

Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption.

METHODS

In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey.

RESULTS

Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455).

CONCLUSIONS

This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

Supply of opioids and information provided to patients after surgery in an Australian hospital: A cross-sectional study

Opioids are commonly prescribed to manage pain after surgery. However, excessive supply on discharge can increase patients' risk of persistent opioid use and contribute to the reservoir of unused opioids in the community that may be misused. This study aimed to evaluate the use of opioids in Australian surgical patients after discharge and patient satisfaction with the provision of opioid information after discharge. This prospective cohort study was conducted at a tertiary referral and teaching hospital. Surgical patients were called 7-28 days after discharge to identify their opioid use and the information that they received after discharge. In total, 66 patients responded. Most patients underwent orthopaedic surgery (45.5%; 30/66). The median days of opioids supplied on discharge was 5 (IQR 3-5). In total, 40.9% (27/66) of patients had >50% of their opioids remaining. Patients undergoing orthopaedic surgery were less likely to have >50% of their opioids remaining (P = 0.045), whilst patients undergoing urological or renal surgeries were significantly more likely (P = 0.009). Most patients recalled receiving information about their opioids (89.4%; 59/66). However, the majority (51.5%; 34/66) did not recall receiving any information about the signs of opioid toxicity and interactions between opioids and alcohol. In conclusion, around 40% of patients had more than half of their opioid supply remaining after they ceased taking their opioid. Although most patients recalled receiving information about their opioids, more than half did not recall receiving any information about the signs of opioid toxicity or interactions between opioids and alcohol.

Health and quality of life after discharge from hospital: A prospective study on opioid treatment for acute pain after trauma or surgery

OBJECTIVES

The aim of this study was to examine opioid use, health, quality of life, and pain after discharge from hospital in opioid naïve patients receiving opioid treatment for sub acute pain after trauma or surgery.

METHODS

A prospective cohort with a four-week follow-up was conducted. Of the 62 patients included, 58 remained in the follow-up. The following questionnaires were assessed: Numeric Rating Scale for pain (NRS), EQ-5D-5L (health-related quality of life) and EQ-VAS (self-reported health). Paired t-test, two-sample t-test and chi square test were used in the study.

RESULTS

Every fourth participant still received opioid treatment at follow-up, and reported no significant increase in EQ-VAS. Overall, an improvement in EQ-5D-5L (0.569 (SD = 0.233) to 0.694 (SD = 0.152), p < 0.001) and EQ-VAS (55 (SD = 20) to 63 (SD = 18), p = 0.001) from baseline to follow-up was found. Pain intensity decreased in the same period (6.4 (SD = 2.2) to 3.5 (SD = 2.6), p < 0.001). An unmet need for information regarding pain management was reported by 32% of the participants.

CONCLUSIONS

Our findings show that patients with acute pain, treated with opioids, reported improved pain intensity, health-related quality of life and self-reported health four weeks after discharge. There is room for improvement regarding the provision of patient information on pain management.

Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review

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.

Effects of Opioid-Limiting Legislation and Increased Provider Awareness on Postoperative Opioid Use and Complications After Hip Arthroscopy

Background

On August 31, 2017, Ohio passed legislation that regulates how opioids can be prescribed postoperatively. Studies have shown that such legislation is successful in reducing the morphine milligram equivalents (MMEs) prescribed after certain orthopaedic procedures.

Purpose

(1) To determine if the opioid prescription-limiting legislation in Ohio reduced the cumulative MMEs prescribed after hip arthroscopy without significantly affecting the rates of emergency department (ED) visits, hospital readmissions, and reoperations within 90 days postoperatively, and (2) to assess risk factors associated with increased postoperative opioid dosing.

Study Design

Cohort study; Level of evidence, 3.

Methods

This study included patients who underwent primary and revision hip arthroscopy at a single institution over a 4-year period. The prelegislation (PRE) and postlegislation (POST) groups were defined as patients who underwent surgery before August 31, 2017, and on/after this date, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively, and patient medical records were reviewed to collect demographic, medical, surgical, and readmission data. Inverse probability weighting-adjusted mean treatment effect regression models were used to measure the difference in mean outcomes between the PRE and POST cohorts.

Results

A total of 546 patients (228 PRE, 318 POST) were identified. There was a 25% reduction in the cumulative MMEs prescribed to the POST group as compared with the PRE group during the first 90 days postoperatively (840 vs 1125 MME, respectively; P < .01). The legislation was associated with a significant decrease in the cumulative MMEs prescribed in the first 90 postoperative days (mean treatment effect = -280.6; P < .01), and there were no significant between-group differences in the frequency of ED encounters (8.8% PRE, 11.6% POST; P = .32), hospital readmissions (1.3% PRE, 0.9% POST; P = .70), or reoperations (0.9% PRE, 0.6% POST; P ≥ .99) during this period. Preoperative opioid use was a significant independent risk factor for increased cumulative MMEs in the first 90 days postoperatively (β = 275; P < .01).

Conclusion

Opioid prescription-limiting legislation in Ohio was associated with significant reductions in opioid MMEs dosing in the 90-day period following hip arthroscopy. This legislation had no significant effect on ED utilization, hospital readmissions, or reoperations within the same period. Preoperative opioid use was a significant risk factor for increased MME dosing after hip arthroscopy.

Trends and correlated outcomes in population-level prescription opioid and transdermal fentanyl use in Israel

BACKGROUND

In the last twenty years, there was a documented increase in prescription opioid procurement in Israel. However, there is still little evidence of the association between opioid procurement rates, health service utilisation in secondary care, and enrollment rates to substance use disorder treatment programmes. In this study, we show trends in the reports of opioid-related hospitalisations, emergency department visits, enrollment to community-based outpatient treatment for Prescription Opioid Use Disorder and opioid-related mortality rates. Additionally, we examine potential correlations between these health service utilisation rates and prescription opioid procurement rates at the population level, with a focus on transdermal fentanyl.

METHODS

A longitudinal study at the population level. We used seven-year data on indicators of opioid-related morbidity, prescription opioid procurement data for 2015-2021, and six-year opioid-related mortality data for 2015-2020. We measure the correlation between procurement rates of prescription opioids in Oral Morphine Equivalent per capita, and aggregated rates obtained from hospital administrative data for hospitalisations, emergency department visits, and patient enrolment in specialised prescription opioid use disorder outpatient treatment in the community setting.

RESULTS

Between 2015 and 2021, procurement rates in primary care per capita for all prescription opioids increased by 85%, while rates of transdermal fentanyl procurement increased by 162%. We found a significant positive correlation at the population level, between annual opioid procurement rates, and rates per population of opioid-related visits to emergency departments (r = 0.96, p value < 0.01, [CI 0.74-0.99]), as well as a positive correlation with the rates per population of patient enrolment in specialised prescription opioid use disorder outpatient treatment (r = 0.93, p value = 0.02, [CI 0.58-0.99]). Opioid-related mortality peaked in 2019 at 0.31 deaths per 100,000 but decreased to 0.20 deaths per 100,000 in 2020.

CONCLUSION

Data shows that all-opioid and transdermal fentanyl procurement has increased yearly between 2015 and 2021. This increase is positively correlated with a growing demand for community-based Prescription Opioid Use Disorder outpatient treatment. Efforts to reduce opioid-related morbidity may require effective approaches toward appropriate prescribing, monitoring, and further increasing access to prescription opioid outpatient treatment.

Evaluating Adherence of Evidence-Based Post-Operative Discharge Opioid Prescribing Guidelines and Patient Outcomes Two Weeks Post-Discharge

Introduction

There is a growing public health concern regarding inappropriate prescribing practices of discharge analgesia. A tertiary Australian hospital first developed its Postoperative Inpatients Discharge Analgesia Guidelines after an initial audit in 2015. Adherence to the guidelines were evaluated in 2016 and 2017 which show reduced compliance from 93.5% in 2016 to 83.4% in 2017.

Aim

To assess ongoing compliance with the guidelines five years following its implementation and to evaluate patient outcome in terms of its clinical impact and minimization of harmful events.

Methods

Prescribing data were obtained for discharge analgesic medication for 200 surgical patients from August 2019 to April 2020. Records were assessed against the hospital's Postoperative Inpatients Discharge Analgesia Guidelines and compared with equivalent data from the previous 2015, 2016, and 2017 audits. Patients were interviewed by telephone two weeks after hospital discharge.

Results

Prescribing of analgesia was most compliant with overall guidelines for paracetamol (100% unchanged from 2017), followed by celecoxib (98%, up from 96% in 2017), tramadol IR (89% up from 74% in 2017), and pregabalin (89% up from 50% in 2017). Two weeks after discharge, 112 (56%) patients were surveyed and reported a mean pain-score of 2 (95% CI 1.5-2.5) out of 10 at that time. Thirty-two (29%) patients interviewed were still taking pain medication, with 17 (53%) taking medication supplied from the hospital. Seventy-eight (88%) patients stored their pain medication in an unlocked location. Among those no longer taking analgesia, 28 (43%) had unused pain medications, and only two (6%) had returned these to a community pharmacist.

Conclusion

This study found that compliance with hospital discharge analgesia prescribing guidelines has increased, although there is room for improvement. Follow-up of the participants reveals high rates of unused opioids, improper storage and disposal of their pain medication.

Impact of a prescriber and patient educational intervention on discharge analgesia prescribing and hospital readmission rates following elective unilateral total hip and knee arthroplasty

Introduction

Pain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution.

Methods

Two cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge.

Results

There was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001).

Conclusion

We have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.

Editorial Commentary: Periarticular and Intra-Articular Injections May Do the Right Thing for Patients' Pain but May Be the Wrong Thing for Their Articular Cartilage: Be Careful

Periarticular and intra-articular injections are regularly used by orthopaedic surgeons both in the clinic and operative setting. These injections include the use of local anesthetics, nonsteroidal anti-inflammatories, steroidal anti-inflammatories, and other classes of pharmaceuticals. Local anesthetics can be injected alone or in conjunction with other pharmaceuticals to maximize pain control and to minimize narcotic use as part of a multimodal pain control algorithm. Use of intra-articular local anesthetics has been shown to improve postoperative pain scores and reduce intravenous and oral narcotic consumption and narcotic-related side effects, such as constipation, sedation, depression, respiratory depression, and long-term abuse potential. However, there have been reports of chondrolysis and other side effects from these injections. In general, it can be said that lidocaine is more chondrotoxic than bupivacaine and that methylprednisolone is more chondrotoxic when combined with either lidocaine or bupivacaine. Ropivacaine with steroid maybe less chondrotoxic, but this has yet to be established. It has been shown that ropivacaine with steroids may be toxic to chondrocytes as well as bovine tenocytes. In addition, it can be generalized that longer exposures, such as an indwelling, intra-articular catheter, are more chondrotoxic than shorter exposures, such as an intra-articular injection. Greater concentrations of lidocaine and bupivacaine (i.e., 1% vs 2% and 0.25% vs 0.5%, respectively) are more toxic to chondrocytes. Cellular morphine studies have resulted in conflicting reports of whether or not it is chondrotoxic. Both ketorolac and acetaminophen have been shown to decrease postoperative pain, but ketorolac also has been shown to be chondrotoxic in a human chondrocyte model. Doing the right thing for our patients' pain may be the wrong thing for their articular cartilage. Expansion of indications for these injections should be approached with caution.

Persistent opioid use after hospital discharge in Australia: a systematic review

ObjectiveThis systematic review identified studies that provided an estimate of persistent opioid use following patient discharge from hospital settings in Australia.MethodsA literature search was performed on 5 December 2020, with no date restrictions to identify studies that reported a rate of persistent opioid use following patient discharge from Australian Hospitals. The search strategy combined all terms relating to the themes 'hospital patients', 'prescribing', 'opioids' and 'Australia'. Studies that dealt solely with cancer, palliative care or addiction medicine were excluded. The databases searched in this review were Embase, PubMed, Scopus, CINAHL, and International Pharmaceutical Abstracts. Studies were assessed for bias using the Newcastle-Ottawa Scale and considered against international literature.ResultsIn total, 13 publications are included for final analysis in this review. Of these, 11 articles relate to post-surgical opioid use. With one exception, studies were of a 'good' quality. Methods of data collection in included studies were a mixture of those conducting follow up of patients directly over time and those utilising dispensing databases. Persistent opioid use among surgical patients generally ranged from 3.9 to 10.5% at between 2 and 4 months after discharge.ConclusionsHow rates of persistent opioid use following hospital encounters in Australia are established, and how long after discharge rates are reported, is heterogeneous. Literature primarily relates to post-surgical patients, with very few studies investigating other settings such as encounters with the emergency department.

Balanced Opioid Prescribing via a Clinical Trade-Off: Pain Relief vs. Adverse Effects of Discomfort, Dependence, and Tolerance/Hypersensitivity

In the backdrop of the opioid epidemic, opioid prescribing has distinct medical and social challenges. Overprescribing contributes to the ongoing opioid epidemic, whereas underprescribing yields inadequate pain relief. Moreover, opioids have serious adverse effects including tolerance and increased sensitivity to pain, paradoxically inducing more pain. Prescribing trade-offs are recognized but not modeled in the literature. We study the prescribing decisions for chronic, acute, and persistent pain types to minimize the cumulative pain that incorporates opioid adverse effects (discomfort and dependence) and the risk of tolerance or hypersensitivity (THS) developed with opioid use. After finding closed-form solutions for each pain type, we analytically investigate the sensitivity of acute pain prescriptions and examine policies on incorporation of THS, patient handover, and adaptive treatments. Our analyses show that the role of adverse effects in prescribing decisions is as critical as that of the pain level. Interestingly, we find that the optimal prescription duration is not necessarily increasing with the recovery time. We show that not incorporating THS or information curtailment at patient handovers leads to overprescribing that can be mitigated by adaptive treatments. Last, using real-life pain and opioid use data from two sources, we estimate THS parameters and discuss the proximity of our model to clinical practice. This paper has a pain management framework that leads to tractable models. These models can potentially support balanced opioid prescribing after their validation in a clinical setting. Then, they can be helpful to policy makers in assessment of prescription policies and of the controversy around over- and underprescribing.

Pain Control and Opioid Use in ICU should be a Quality Parameter

How to cite this article: Garg SK, Garg P. Pain Control and Opioid Use in ICU should be a Quality Parameter. Indian J Crit Care Med 2021; 25(10):1205–1206.

Opioid Prescription After Cardiac Surgery

OBJECTIVES

To characterise short-term and long-term opioid prescription patterns after cardiac surgery.

DESIGN, SETTING AND PARTICIPANTS

We obtained data from a single Australian tertiary hospital from November 2012 to July 2019 and included 2,205 patients who underwent a primary cardiac surgical procedure.

MAIN OUTCOME AND MEASURES

The primary outcome was the dose of opioids at hospital discharge. Secondary outcomes included factors associated with high dose opioid prescriptions and persistent opioids use after cardiac surgery.

RESULTS

Overall, 76.4% of study patients were prescribed opioids at hospital discharge, with a median discharge prescription of 150 mg oral morphine equivalents. Moreover, 52.8% of discharge opioid prescriptions were as slow-release formulations and 60.0% of all discharge prescriptions were for patients who had received no opioids the day before discharge. In the subset of our patients with long-term data, 14.0% were still receiving opioids at 3-12 months after cardiac surgery.

CONCLUSIONS

In cardiac surgical patients, opioid prescriptions at discharge were common, most were at higher than recommended doses and more than half were slow-release formulations. Such prescription was associated with one in seven patients continuing to receive opioids 3-12 months after surgery.

Abuse Deterrent Formulations in Constraining the Abuse Potential of Prescription Medicines: A Myth or Truth

BACKGROUND

Diverse pain killers used for the management of varied categories of pain are being misused in order to have extreme pleasant effect by a large number of populations. To overcome the misuse of prescription drugs, regulatory bodies have given stress on development of abuse resistance.

METHODS

We studied numerous literatures: (1) Research and review papers including the guidelines for pain management, abuse, and abuse deterrence; (2) Description and categorization of pain along with the management approaches; (3) advantages and disadvantages of the abuse deterrent formulations were described.

RESULTS

Abuse deterrent formulations are the contemporary remedial treatment for pain with reduced prospects of being abused. But these comprise the huge expense in contrast to the generic drugs as well as the non-deterrent branded equivalents.

CONCLUSION

Many challenges are faced throughout the development of abuse deterrent formulations. These formulations displayed substantial drop in abuse incidences but it may lead to other modes of abuse which may prove more harmful for the users.

The opioid epidemic from the acute care hospital front line

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

Semi-automated tracking of pain in critical care patients using artificial intelligence: a retrospective observational study

Monitoring the pain intensity in critically ill patients is crucial because intense pain can cause adverse events, including poor survival rates; however, continuous pain evaluation is difficult. Vital signs have traditionally been considered ineffective in pain assessment; nevertheless, the use of machine learning may automate pain assessment using vital signs. This retrospective observational study was performed at a university hospital in Sendai, Japan. Objective pain assessments were performed in eligible patients using the Critical-Care Pain Observation Tool (CPOT). Three machine-learning methods—random forest (RF), support vector machine (SVM), and logistic regression (LR)—were employed to predict pain using parameters, such as vital signs, age group, and sedation levels. Prediction accuracy was calculated as the harmonic mean of sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Furthermore, 117,190 CPOT assessments were performed in 11,507 eligible patients (median age: 65 years; 58.0% males). We found that pain prediction was possible with all three machine-learning methods. RF demonstrated the highest AUROC for the test data (RF: 0.853, SVM: 0.823, and LR: 0.787). With this method, pain can be objectively, continuously, and semi-automatically evaluated in critically ill patients.

Adolescents' Perspectives on Prescription Opioid Misuse and Medication Safety

OBJECTIVES

This study explored adolescents' perspectives on prescription opioids, opioid safety and misuse, and sources of opioid information.

METHODS

High school students participated in focus groups that elicited information about adolescent perspectives on prescription opioids and opioid safety. Demographic information was collected. Focus groups consisted of 5 to 8 student participants and 2 moderators. Focus groups were audio-recorded and professionally transcribed. Transcript content was thematically analyzed using NVivo.

RESULTS

A total of 54 high school students (59% female, 44% white, 44% Latino) participated in 8 focus groups. Participants ranged from ages 14 to 18 years and grades 9 to 12. Five major themes emerged: 1) perceptions of prescription opioids and misuse; 2) prevalence of prescription opioid misuse; 3) reasons for prescription opioid misuse; 4) consequences of prescription opioid misuse; and 5) sources of medication information. Participants identified examples of misuse and reasons for and consequences of teen opioid misuse, including mental and physical health challenges, peer and family influences, and addiction. Sources of opioid-related information included family, peers, online Web sites, and television shows.

CONCLUSIONS

Adolescents had some knowledge pertaining to prescription opioids, but they had misconceptions related to safety. Participants were aware of safety risks and negative consequences of misuse. Adolescents obtained medication information from various sources, including health care professionals, family and peers, and online sources. Educational efforts that target adolescents should provide opportunities for addressing misconceptions about safe and responsible use of medications.

Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

BACKGROUND

The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics.

METHODS

We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status.

DISCUSSION

We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis.

TRIAL REGISTRATION

The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783 ) on November 25, 2019, retrospectively registered.

Acetaminophen, bupivacaine, Duramorph, and Toradol: A comparison of chondrocyte viability and gene expression changes in osteoarthritic human chondrocytes

BACKGROUND

A multitude of chemical agents are currently used intra-articularly to decrease pain after orthopaedic procedures including total knee arthroplasty. However, the possible deleterious effects of these injectable chemicals on chondrocyte viability have not been weighed against their potential benefits. Using a human osteoarthritic chondrocyte model, the purpose of this study was to assess the potential for cartilage damage caused by bupivacaine, Toradol, Duramorph, and acetaminophen from surgical local anesthesia.

METHODS

Human distal femur and proximal tibia cross sections were obtained during total knee arthroplasty and divided into control group and experimental groups treated by bupivacaine, Toradol, Duramorph, and acetaminophen respectively. Chondrocytes obtained from enzymatically digested cartilage were cultured using a 3D alginate bead culture method to ensure lower rates of dedifferentiation. Chondrocyte bead cultures were exposed to the study chemicals. The gene expression and chondrocyte viability were measured by RT-PCR and flow cytometry, respectively.

RESULTS

Compared with untreated group bupivacaine treatment led to the greatest cellular apoptosis with 30.5 ± 11% dead cells (P = 0.000). Duramorph and acetaminophen did not result in a significant increase in cell death. Bupivacaine treatment led to an increase in Caspase 3 gene expression (P = 0.000) as well as the acetaminophen treatment (P = 0.001) when compared to control.

CONCLUSION

Our data demonstrated that Duramorph and Toradol were not cytotoxic to human chondrocytes and may be better alternatives to the frequently used and more cytotoxic bupivacaine. Acetaminophen did not result in increased cell death; however, it did show increased caspase 3 gene expression and caution should be considered.

Anxiety sensitivity and pain intensity independently predict opioid misuse and dependence in chronic pain patients

The United States (US) population consumes an estimated 68% of the world's prescribed opioids each year, and over 2 million adults in the US suffer from an opioid use disorder. Although chronic pain populations are among the highest risk segments of the general population for opioid misuse and dependence, there is little understanding of individual risk characteristics that may contribute to greater risk for these outcomes among this group. The present investigation explored the concurrent role of anxiety sensitivity and pain intensity and their interaction in relation to opioid misuse and dependence among 429 adults with chronic pain (73.9% female, M_age = 38.32 years, SD = 11.07). Results revealed that both anxiety sensitivity and pain intensity were associated with opioid misuse and dependence. There was no evidence of an interaction for either outcome. Post-hoc analyses indicated that of the lower-order anxiety sensitivity facets, physical and mental incapacitation concerns contributed to variance in opioid misuse and only mental incapacitation concerns contributed to variance in opioid dependence. Overall, the current findings suggest the importance of assessing anxiety sensitivity in screening for opioid-related problems among persons with chronic pain, as it may represent a distinct pathway to poorer opioid-related outcomes among this group.

Perioperative opioid use and misuse

Prescribed opioid misuse in North America is a public health crisis, with huge social, medical and economic repercussions. Surgery is an identified driver for persistent opioid use and misuse. The UK has also seen a surge in opioid consumption per capita and it is now necessary for primary and secondary care to work together to mitigate the problem of perioperative prescribed opioid misuse.This review discusses the identified drivers for persistent opioid use following surgery and discusses the remedial actions that must be taken by all stakeholders to mitigate the UK developing its own perioperative prescribed opioid crisis.

Comparison of Opioid-Free Anesthesia Versus Opioid-Containing Anesthesia for Elective Laparoscopic Surgery (COFA: LAP): A Protocol Measuring Recovery Outcomes

The administration of opioids is a central element in contemporary anesthetic techniques in Australia; however, opioids have a range of side effects. As an alternative, opioid-free anesthesia (OFA) is an emerging mode of anesthesia intended to avoid these side effects. This study is the first to publish the use of OFA in Australia and is conducted in a regional Queensland Health Service. The design will utilize a randomized clinical trial (RCT) to investigate the impact of OFA for patients having an elective laparoscopic cholecystectomy (n = 40) or tubal ligation (n = 40). Participant outcomes to be measured include: Quality of Recovery (QoR-15); Oral Morphine Equivalent Daily Dose (OMEDD) at 24-h post-operatively; time to first opioid (TTFO) dose; post-operative nausea and vomiting (PONV); Post Anesthetic Care Unit length of stay (PACU-LOS); and hospital length of stay (LOS). The findings may challenge the essentiality of opioids in the peri-operative period, which in turn would influence the future intra-operative management of surgical patients. Ultimately, a reduction in anesthesia-associated opioid use will support a more general decline in opioid use.

Ninety-day Postoperative Narcotic Use After Hospitalization for Orthopaedic Trauma

BACKGROUND

The purpose of this study was to compare narcotic use in the 90-day postoperative period across orthopaedic trauma, spine, and adult reconstruction patients and examine whether patient-reported pain scores at discharge correlate with narcotic use during the 90-day postoperative period.

METHODS

Electronic medical record query was done between 2012 and 2015 using diagnosis-related groups for spine, adult reconstruction, and trauma procedures. Demographics, length of stay (LOS), visual analog scale pain scores during hospitalization, and narcotics prescribed in the 90-day postoperative period were collected. Multivariate analysis and linear regression were done.

RESULTS

Five thousand thirty patients were analyzed. Spine patients had the longest LOS, highest mean pain during LOS, and were prescribed the most morphine in the 90-day postoperative period. Linear regression revealed that pain scores at discharge markedly influence the quantity of narcotics prescribed in the 90-day postoperative period.

DISCUSSION

Patient-reported pain at hospital discharge was associated with increased narcotic use in the 90-day postoperative period.

The Persistence of Opioid Use Following Surgical Admission: An Australian Single-Site Retrospective Cohort Study

Background

Acute pain is common following surgery, with opioids frequently employed in its management. Studies indicate that commencing an opioid during a hospital admission increases the likelihood of long-term use. This study aimed to identify the prevalence of opioid persistence amongst opioid-naïve patients following surgery as well as the indication for use.

Methods

A retrospective review of patients who underwent a surgical procedure at the Royal Hobart Hospital, Tasmania, Australia, between August and September 2016 was undertaken. Patients were linked to the Tasmanian real-time prescription monitoring database to ascertain if they were subsequently dispensed a Schedule 8 opioid (morphine, codeine oxycodone, buprenorphine, hydromorphone, fentanyl, methadone, or tapentadol) and the indication for use.

Results

Of the 3275 hospital admissions, 1015 opioid-naïve patients were eligible for inclusion. Schedule 8 opioids were dispensed at or within 2 days of discharge in 41.7% of admissions. Thirty-nine (3.9%) patients received prescribed opioids 2-months post-discharge; 1.8% of the patients were approved by State Health to be prescribed Schedule 8 opioids regularly for a chronic condition at 6 months, and 1.3% received infrequent or one-off prescriptions for Schedule 8 opioids at 6 months. Thirteen (1.3%) patients continued Schedule 8 opioids for at least 6 months following their surgery, with the indication for treatment either related to the surgery or the condition which surgery was sought for.

Conclusion

This study found that there was a low rate of Schedule 8 opioid persistence following surgery, indicating post-surgical pain is not a significant driver for persistent opioid use.

What Happens to Unused Opioids After Total Joint Arthroplasty? An Evaluation of Unused Postoperative Opioid Disposal Practices

BACKGROUND

This study evaluates the fate of unused opioids after total hip arthroplasty (THA) and total knee arthroplasty (TKA) at our facility.

METHODS

Medication disposal after primary elective THA and TKA was classified as appropriate (in accordance with United States Food and Drug Administration guidelines) or inappropriate for all patients undergoing these procedures during the second half of the fiscal year 2015.

RESULTS

In total, 199 THAs and 144 TKAs met inclusion criteria. Total pills prescribed were 55,635. Approximately 8925 (16%) of pills were unused. About 39.9% of patients disposed of unused opioids appropriately, while 60.1% of patients reported still having (18.5%), not knowing where they were (8.2%), or other (33.4%). There was no significant association with the type of opioid prescribed.

CONCLUSION

A large volume of unused opioids were improperly disposed of after total joint arthroplasty.

Post-discharge opioid use and handling in surgical patients: A multicentre prospective cohort study

Our aim was to determine the frequency and characteristics of post-surgery prescription of opioid medication and to describe patients’ handling of discharge opioid medications. We performed a multicentre prospective cohort study of adult patients undergoing elective or emergency surgery with a postoperative stay of one or more nights, with phone follow-up at two weeks after hospital discharge. The main outcome measures included the proportion of patients prescribed discharge opioid medications, post-discharge opioid use, opioid storage and disposal. Of the 1450 eligible surgical patients, opioids were dispensed on discharge to 858 (59%, 95% confidence interval (CI) (57%–62%)), with immediate-release oxycodone the most common medication. Of the 581 patients who were discharged with opioid medication and completed follow-up, 27% were still requiring opioids two weeks after discharge. Post-discharge opioid consumption was highly variable in the study cohort. The majority (70%) of patients had leftover opioids and only a small proportion (5%) reported disposal of the surplus. In a multivariate model, patients with characteristics of age 45 years or less (odds ratio, OR = 1.78, 95% CI (1.36–2.33) versus older than 45 years), American Society of Anesthesiologists’ physical status (ASA) scores of 1 or 2 (OR = 1.96, 95% CI (1.52–2.53) versus ASA score 3 to 5), higher anticipated surgical pain (OR = 1.45, 95% CI (1.08–1.94) severe versus moderate, OR = 17.48, 95% CI (5.79–52.69) severe versus nil/mild) and public funding status (OR = 1.89, 95% CI (1.36–2.64) versus other) were more likely ( P < 0.001) to receive discharge opioids. Post-surgery prescription of opioids is common and supply is often excessive. Post-discharge opioid handling included suboptimal storage and disposal.

Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study

BACKGROUND

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better analgesia and reduces opioid use compared with conventional repeated dosing of short-duration opioids. This investigation tested the hypothesis that in same-day ambulatory surgery, intraoperative methadone, compared with short-duration opioids, reduces opioid consumption and pain, and determined an effective intraoperative induction dose of methadone for same-day ambulatory surgery.

METHODS

A double-blind, dose-escalation protocol randomized 60 patients (2:1) to intraoperative single-dose intravenous methadone (initially 0.1 then 0.15 mg/kg ideal body weight) or conventional as-needed dosing of short-duration opioids (eg, fentanyl, hydromorphone; controls). Intraoperative and postoperative opioid consumption, pain, and opioid side effects were assessed before discharge. Patient home diaries recorded pain, opioid use, and opioid side effects daily for 30 days postoperatively. Primary outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30 days opioid consumption, pain intensity, and opioid side effects.

RESULTS

Median (interquartile range) methadone doses were 6 (5-6) and 9 (8-9) mg in the 0.1 and 0.15 mg/kg methadone groups, respectively. Total opioid consumption (morphine equivalents) in the postanesthesia care unit was significantly less compared with controls (9.3 mg, 1.3-11.0) in subjects receiving 0.15 mg/kg methadone (0.1 mg, 0.1-3.3; P < .001) but not 0.1 mg/kg methadone (5.0 mg, 3.3-8.1; P = .60). Dose-escalation ended at 0.15 mg/kg methadone. Total in-hospital nonmethadone opioid use after short-duration opioid, 0.1 mg/kg methadone, and 0.15 mg/kg methadone was 35.3 (25.0-44.0), 7.1 (3.7-10.0), and 3.3 (0.1-5.8) mg morphine equivalents, respectively (P < .001 for both versus control). In-hospital pain scores and side effects were not different between groups. In the 30 days after discharge, patients who received methadone 0.15 mg/kg had less pain at rest (P = .02) and used fewer opioid pills than controls (P < .0001), whereas patients who received 0.1 mg/kg had no difference in pain at rest (P = .69) and opioid use compared to controls (P = .08).

CONCLUSIONS

In same-day discharge surgery, this pilot study identified a single intraoperative dose of methadone (0.15 mg/kg ideal body weight), which decreased intraoperative and postoperative opioid requirements and postoperative pain, compared with conventional intermittent short-duration opioids, with similar side effects.

Comparing cost and effectiveness of IVPCA morphine with perioperative multimodal analgesia of oral etoricoxib and oxycontin: A retrospective study

Introduction

Good pain control modality for post total knee replacement promotes patient's comfort and facilitates functional recovery, which may prevent post-operative complications; and shorten hospital stay. Therefore, manage pain efficiently and effectively have financial implications to the hospital. This retrospective study analyzed the clinical outcomes and costs of the intravenous (IV) patient-controlled analgesia (PCA) with a new perioperative multimodal analgesia (PMA) of using etoricoxib and oxycontin.

Methods

This retrospective study analyzed a total of 102 inpatients, 53 received both IVPCA and regular oral analgesics from September 2016 to February 2017, while 49 received preemptive oral etoricoxib before surgery and duly together with oxycontin and paracetamol after surgery from September 2017 to February 2018. Pain scores as the primary outcome were measured by Numeric Rating Scale (0–10) at rest (NRS-R) and on movement (NRS-M). They were analyzed by one-way analysis of covariance (ANCOVA). Other outcomes included side effects from analgesics, range of motion (ROM^o), patient satisfaction, length of hospital stay and costs of medications.

Results

Patients in PMA group achieved better outcomes than PCA group. NRS-M of PMA group shown lower mean pain score and (standard error) than PCA group (2.96 [0.31] vs 4.26 [0.29]; p = 0.003), side effects from analgesics (18% vs 45%), ROM≥ 90° (55.1% vs 30.2%), patient satisfaction (8.97 vs 7.5 out of 10; p = 0.005), and length of hospital stay (6 days vs 8 days; p < 0.001). Moreover, the medication cost of PMA was 59.9% lower than PCA regimen.

Conclusions

This PMA approach achieved better outcomes and saved hospital costs.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway

BACKGROUND

Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty.

METHODS

Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls.

RESULTS

Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment.

CONCLUSIONS

An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.

Acute Experimental Pain Responses in Methadone- and Buprenorphine/Naloxone-Maintained Patients Administered Additional Opioid or Gabapentin: A Double-Blind Crossover Pilot Study

Objective

The study objective was to identify the analgesic efficacy of three different pharmacological strategies in patients receiving methadone or buprenorphine as opioid agonist treatment (OAT). The three pharmacological approaches, a) increasing maintenance methadone/buprenorphine dose by 30%, b) adding oxycodone, or c) adding a single dose of gabapentin, were compared with a control condition of the participant’s usual OAT dose.

Design

A randomized, controlled, double-blinded, double-dummy, within-subject crossover study.

Subjects

Nine participants on stable doses of methadone and eight participants on stable doses of buprenorphine were recruited.

Setting

An outpatient opioid treatment clinic in inner city Sydney, Australia.

Methods

The cold pressor tolerance test was used to examine experimental pain threshold and tolerance. Ratings of subjective drug effects and safety measures (physiological and cognitive) were assessed.

Results

There was no difference in the primary outcome measures of pain thresholds or tolerance between the conditions examined. Interindividual variability was evident. Differences in some subjective measures were identified, including lower pain recall, lower “bad effects,” and higher global satisfaction in the additional methadone condition. In the buprenorphine arm, increased drug liking and “bad effects” were detected with oxycodone administration, while increased subjective intoxication was identified with gabapentin.

Conclusions

There was no evidence of an objective improvement in analgesia with any condition compared with control. Further research is required to optimize pain management strategies in this population.

Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study

OBJECTIVE

To determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study using administrative health claims database from the Australian Government Department of Veterans' Affairs (DVA). DVA gold card holders aged between 18 and 100 years who were admitted to hospital for a surgical admission between 1 January 2014 and 30 December 2015 and naïve to opioid therapy prior to admission were included in the study. Gold card holders are eligible for all health services that DVA funds.

MAIN OUTCOME MEASURES

The outcome of interest was time to cessation of opioids, with follow-up occurring over 12 months. Cessation was defined as a period without an opioid prescription that was equivalent to three times the estimated supply duration. The proportion who became chronic opioid users was defined as those who continued taking opioids for greater than 90 days post discharge. Cumulative incidence function with death as a competing event was used to determine time to cessation of opioids post discharge.

RESULTS

In 2014-2015, 24 854 persons were admitted for a surgical admission. In total 3907 (15.7%) were discharged on opioids. In total 3.9% of those discharged on opioids became chronic users of opioids. The opioid that the patients were most frequently discharged with was oxycodone; oxycodone alone accounted for 43%, while oxycodone with naloxone accounted for 8%.

CONCLUSIONS

Opioid initiation post-surgical hospital admission leads to chronic use of opioids in a small percentage of the population. However, given the frequency at which surgical procedures occur, this means that a large number of people in the population may be affected. Post-discharge assessment and follow-up of at-risk patients is important, particularly where psychosocial elements such as anxiety and catastrophising are identified.

Prescription of opioids to post-operative orthopaedic patients at time of discharge from hospital: a prospective observational study

BACKGROUND AND AIMS

Excessive opioid prescribing can lead to adverse consequences including stockpiling, misuse, dependency, diversion and mortality. Increased prescriptions to post-operative inpatients as part of their discharge planning may be a significant contributor. Primary aims included comparing the amount of opioids prescribed, consumed, left unused and their relationship with pain and functionality.

METHODS

A total of 132 consecutive patients who underwent elective orthopaedic surgery were prospectively audited. Daily oral morphine equivalent (DME) of opioids prescribed was compared with opioids consumed and amount left unused 7-10 days after discharge. For analysis, patients were split into three groups: total knee replacement (TKR), hand surgery (Hands), and miscellaneous (Misc).

RESULTS

The mean dose of opioid prescribed per patient was 108.5 mg DME. TKR consumed 33-35% more opioids than Misc (p=0.0283) and Hands (p=0.0975). Age was a significant independent factor for opioid consumption in the 50th and 75th percentiles of Hands (p≤0.05). An average of 36 mg DME per patient was left unused with Hands having the highest median DME (37 mg) unused. In the total cohort, 26% of patients were discharged with more DME than their last 24 h as an inpatient and had at least 50% of their tablets left unused at follow-up.

CONCLUSIONS

Over-prescription of opioids occurs at discharge which can increase the risk of harm. New intervention is needed to optimise prescribing practises.

IMPLICATIONS

Changes to prescribing habits and workplace culture are required to minimise unnecessary opioid prescribing but will be challenging to implement. A multi-layered approach of electronic prescribing, opioid stewardship and targeted educational awareness programmes is recommended.

The effect of guideline implementation on discharge analgesia prescribing (two years on)

The provision of appropriate discharge analgesia can be challenging and is often prescribed by some of the most junior members of the medical team. Opioid abuse has been considered a growing public health crisis and physician overprescribing is a major contributor. In 2015 an initial audit of discharge analgesia at the Royal Perth Hospital led to the development of discharge analgesia guidelines. Compliance with these guidelines was assessed by a follow-up audit in 2016, which showed improved practice. This audit assesses discharge analgesia prescribing practices two years following guideline implementation. Dispensing data were obtained for analgesic medication over a three-month period from April to July 2017 and 100 unique patients were chosen using computer generated randomisation. Patients’ medical records were assessed against the hospital’s Postoperative Inpatients Discharge Analgesia Guidelines. The data collected were then compared with equivalent data from the previous 2015 and 2016 audits. Overall 83.4% of the 170 discharge analgesia prescriptions written were compliant with guidelines. The highest overall compliance rates were achieved for paracetamol (100%, up from 95.9% in 2016), celecoxib (96%, down from 100% in 2016), and oxycodone immediate release (IR) (74%, down from 88.9% in 2016). The quantity of oxycodone IR given on discharge complied with quantity guidelines in only 56% of cases. Overall there has been a significant and sustained improvement in appropriateness of discharge analgesia prescribing since 2015, though the results from 2017 show less compliance than 2016 and that achieving compliance with quantity guidelines is an ongoing challenge. This demonstrates the challenge of obtaining high adherence to guidelines over a longer time period.

Predictors of chronic prescription opioid use after orthopedic surgery: derivation of a clinical prediction rule

Background

Prescription opioid use at high doses or over extended periods of time is associated with adverse outcomes, including dependency and abuse. The aim of this study was to identify mediating variables that predict chronic opioid use, defined as three or more prescriptions after orthopedic surgery.

Methods

Individuals were ages between 18 and 50 years and undergoing arthroscopic hip surgery between 2004 and 2013. Two categories of chronic opioid use were calculated based on individuals (1) having three or more unique opioid prescriptions within 2 years and (2) still receiving opioid prescriptions > 1 year after surgery. Univariate elationships were identified for each predictor variable, then significant variables (P > 0.15) were entered into a multivariate logistic regression model to identify the most parsimonious group of predictor variables for each chronic opioid use classification. Likelihood ratios were derived from the most robust groups of variables.

Results

There were 1642 participants (mean age 32.5 years, SD 8.2, 54.1% male). Nine predictor variables met the criteria after bivariate analysis for potential inclusion in each multivariate model. Eight variables: socioeconomic status (from enlisted rank family), prior use of opioid medication, prior use of non-opioid pain medication, high health-seeking behavior before surgery, a preoperative diagnosis of insomnia, mental health disorder, or substance abuse were all predictive of chronic opioid use in the final model (seven variables for three or more opioid prescriptions; four variables for opioid use still at 1 year; all< 0.05). Post-test probability of having three or more opioid prescriptions was 93.7% if five of seven variables were present, and the probability of still using opioids after 1 year was 69.6% if three of four variables were present.

Conclusion

A combination of variables significantly predicted chronic opioid use in this cohort. Most of these variables were mediators, indicating that modifying them may be feasible, and the potential focus of interventions to decrease the risk of chronic opioid use, or at minimum better inform opioid prescribing decisions. This clinical prediction rule needs further validation.

Complexities of Perioperative Pain Management in Orthopedic Trauma

PURPOSE OF REVIEW

This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period.

RECENT FINDINGS

Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.