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Brooke BS, Bayless K, Anderson Z, Holeman TA, Zhang C, Hales J, Buys MJ. Opioid tapering after surgery and its association with patient-reported outcomes and behavioral changes: a mixed-methods analysis. Reg Anesth Pain Med 2024; 49:699-707. [PMID: 37865394 DOI: 10.1136/rapm-2023-104807] [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: 06/30/2023] [Accepted: 10/02/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION Opioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was to evaluate how opioid tapering following surgery was associated with patient-reported outcome measures related to pain control and behavioral changes that affect quality of life. METHODS We conducted an explanatory sequential mixed-methods study at a VA Medical Center among patients with chronic opioid use who underwent a spectrum of orthopedic, vascular, thoracic, urology, otolaryngology, and general surgery procedures between 2018 and 2020. Patients were stratified based on the extent that opioid tapering was successful (complete, partial, and no-taper) by 90 days after surgery, followed by qualitative interviews of 10 patients in each taper group. Longitudinal patient-reported outcome measures related to pain intensity, interference, and catastrophizing were compared using Kruskal Wallis tests over the 90-day period after surgery. Qualitative interviews were conducted among patients in each taper group to identify themes associated with the impact of opioid tapering after surgery on quality of life. RESULTS We identified 211 patients with chronic opioid use (92% male, median age 66 years) who underwent surgery during the time period, including 42 (20%) individuals with complete tapering, 48 (23%) patients with partial tapering, and 121 (57%) patients with no taper of opioids following surgery. Patients who did not taper were more likely to have a history of opioid use disorder (10%-partial, 2%-complete vs 17%-no taper, p<0.05) and be discharged on a higher median morphine equivalent daily dose (52-partial, 30-complete vs 60-no taper; p<0.05) than patients in the partial and complete taper groups. Pain interference (-7.2-partial taper and -9.8-complete taper vs -3.5-no taper) and pain catastrophizing (-21.4-partial taper and -16.5-complete taper vs -1.7-no taper) scores for partial and complete taper groups were significantly improved at 90 days relative to baseline when compared with patients in the no-taper group (p<0.05 for both comparisons), while pain intensity was similar between groups. Finally, patients achieving complete and partial opioid tapering were more likely to report improvements in activity, mood, thinking, and sleep following surgery as compared with patients who failed to taper. CONCLUSIONS Partial and complete opioid tapering within 90 days after surgery among patients with chronic opioid use was associated with improved patient-reported measures of pain control as well as behaviors that impact a patient's quality of life.
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Affiliation(s)
- Benjamin Sands Brooke
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Teryn A Holeman
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Julie Hales
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Michael J Buys
- Anesthesiology, Salt Lake City VA Medical Center, Salt Lake City, Utah, USA
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Farronato DM, Pezzulo JD, Paulik J, Miltenberg B, Johns WL, Davis DE. The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:2213-2219. [PMID: 38548094 DOI: 10.1016/j.jse.2024.02.021] [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: 09/07/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Miltenberg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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Hess-Arcelay H, Claudio-Marcano A, Torres-Lugo NJ, Deliz-Jimenez D, Acosta-Julbe J, Hernandez G, Deliz-Jimenez D, Monge G, Ramírez N, Lojo-Sojo L. Opioid-Sparing Nonsteroid Anti-inflammatory Drugs Protocol in Patients Undergoing Intramedullary Nailing of Tibial Shaft Fractures: A Randomized Control Trial. J Am Acad Orthop Surg 2024; 32:e596-e604. [PMID: 38579315 DOI: 10.5435/jaaos-d-23-01014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/18/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics commonly used in fracture management. Although previously associated with delayed fracture healing, multiple studies have demonstrated their safety, with minimal risks of fracture healing. Given the current opioid crisis in the United States, alternate pain control modalities are essential to reduce opioid consumption. This study aims to determine whether the combination of oral acetaminophen and intravenous ketorolac is a viable alternative to opioid-based pain management in closed tibial shaft fractures treated with intramedullary nailing. METHODS We conducted a randomized controlled trial evaluating postoperative pain control and opioid consumption in patients with closed tibial shaft fractures who underwent intramedullary nailing. Patients were randomized into an NSAID-based pain control group (52 patients) and an opioid-based pain control group (44 patients). Visual analog scale (VAS) scores and morphine milligram equivalents (MMEs) were evaluated at 12-hour postoperative intervals during the first 48 hours after surgery. Nonunion and delayed healing rates were recorded for both groups. RESULTS A statistically significant decrease in MMEs was noted at every measured interval (12, 24, 36, and 48 hours) in the NSAID group compared with the opioid group ( P -value 0.001, 0.001, 0.040, 0.024, respectively). No significant change in visual analog scale scores was observed at 12, 36, and 48 hours between both groups ( P -value 0.215, 0.12, and 0.083, respectively). A significant decrease in VAS scores was observed at the 24-hour interval in the NSAID group compared with the opioid group ( P -value 0.041). No significant differences in union rates were observed between groups ( P -value 0.820). DISCUSSION Using an NSAID-based postoperative pain protocol led to a decrease in opioid consumption without affecting pain scores or union rates. Owing to the minimal risk of short-term NSAID use, their role in the perioperative management of tibia shaft fractures is justified, especially when they reduce opioid consumption markedly. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Hans Hess-Arcelay
- From the Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PR (Hess-Arcelay, Claudio-Marcano, Torres-Lugo, Deliz-Jimenez, Lojo-Sojo), the School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, PR (Acosta-Julbe, Deliz-Jimenez), the Department of General Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PR (Hernandez), the Oncologic Hospital Dr. Isaac Gonzalez Martinez, San Juan, PR (Monge), and the Department of Orthopaedic Surgery, Mayaguëz Medical Center, Mayaguëz, PR (Ramirez)
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Farronato DM, Pezzulo JD, Juniewicz R, Rondon AJ, Cox RM, Davis DE. Effects of socioeconomic burden on opioid use following total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00406-3. [PMID: 38852706 DOI: 10.1016/j.jse.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery. METHODS A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered. RESULTS Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P < .001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P = .002). CONCLUSIONS Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert Juniewicz
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander J Rondon
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan M Cox
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
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Finstad J, Røise O, Clausen T, Rosseland LA, Havnes IA. A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory. BMJ Open 2024; 14:e079161. [PMID: 38191252 PMCID: PMC10806614 DOI: 10.1136/bmjopen-2023-079161] [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: 08/23/2023] [Accepted: 12/07/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge. DESIGN Longitudinal qualitative study. SETTING AND PARTICIPANTS Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge. METHOD The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically. RESULTS Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress. CONCLUSIONS AND IMPLICATIONS The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.
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Affiliation(s)
- Jeanette Finstad
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Olav Røise
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Norwegian Trauma Registry, Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingrid Amalia Havnes
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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Upadhyyaya GK, Tewari S. Enhancing Surgical Outcomes: A Critical Review of Antibiotic Prophylaxis in Orthopedic Surgery. Cureus 2023; 15:e47828. [PMID: 38022210 PMCID: PMC10679787 DOI: 10.7759/cureus.47828] [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: 09/11/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
The postoperative burden remains significant due to the possibility of prolonged hospitalization, escalated healthcare costs, and patient distress caused by postorthopedic surgical site infections (SSIs). Orthopedic surgery is likewise faced with a significant challenge posed by these conditions. A positive association has been observed between the presence of postorthopedic SSIs and heightened susceptibility to adverse health outcomes, along with elevated rates of morbidity and mortality. Systemic antibiotic prophylaxis (SAP) reduces the risk of acquiring an SSI. Closed fractures, open fractures, arthroplasty, and percutaneous fixation each possess distinct attributes that impact the data and antimicrobial therapy. When implementing SAP, it is crucial to strike a delicate equilibrium between maintaining effective antibiotic stewardship protocols and preventing the occurrence of SSIs. This practice effectively prevents both the incidence of negative consequences and the emergence of antibiotic resistance. The objective of this study was to examine the existing literature on the use of surgical antibiotic prophylaxis in orthopedic surgery and explore the potential consequences associated with the inappropriate administration of antibiotics.
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Affiliation(s)
- Gaurav K Upadhyyaya
- Department of Orthopedics, All India Institute of Medical Sciences, Raebareli, Raebareli, IND
| | - Sachchidanand Tewari
- Department of Pharmacology, All India Institute of Medical Sciences, Raebareli, Raebareli, IND
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Villa NAE, Shum K, Atkinson A, Ong A, Muller A, Espiridion E. Prevalence and Predictors of Long-term Opioid Use After Pelvic Fractures. Am Surg 2023; 89:3710-3715. [PMID: 37144563 DOI: 10.1177/00031348231173975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Opioids are effective in short-term pain treatment; however, their long-term effectiveness is unconfirmed. Many patients are exposed to opioids after pelvic injuries with little known about persistent use afterward. We assessed the prevalence and predictors of long-term opioid use following pelvic fractures. MATERIALS AND METHODS This retrospective study enrolled 277 patients with acute pelvic fractures over five years. Daily and total morphine milligram equivalents (MME) were calculated. The primary outcome was long-term opioid use (LOU) defined as ongoing opioid use 60-90 days post-discharge. The secondary outcome was intermediate-term opioid use (IOU) defined as ongoing opioid use 30-60 days post-discharge. Univariable and logistic regression analyses were performed. RESULTS Median (interquartile range) total inpatient opioid MME was 422 (157-1667) with a median daily MME of 69 (26-145). Long-term opioid use occurred in 16%, and IOU occurred in 29%. Univariable analysis found that total and daily inpatient opioid use were each significantly associated with LOU (median MME, 1241 vs 371; median MMEs, 127.7 vs 59.2, respectively) and IOU (median MME, 1140 vs 326; median MMEs, 111.8 vs 57.9, respectively). Logistic regression analysis found daily inpatient MME ≥50 (odds ratio [OR] 3.027, 95% confidence interval [CI] 1.059-8.652]) and pelvic fracture type (Tile B/C) (OR 2.992 [CI 1.324-6.763])were independent predictors of LOU. CONCLUSION Total and daily inpatient opioid use were significantly associated with LOU and IOU. Patients who received ≥50 MME/inpatient day had a higher likelihood of LOU. This study seeks to inform clinical decisions for pain management to prevent adverse outcomes.
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Affiliation(s)
| | - Kristina Shum
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Allison Atkinson
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Adrian Ong
- Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Allison Muller
- Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Eduardo Espiridion
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
- Department of Psychiatry, Reading Hospital, Reading, PA, USA
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Robertson I, Rhon DI, Fritz JM, Velosky A, Lawson BK, Highland KB. Post-lumbar surgery prescription variation and opioid-related outcomes in a large US healthcare system: an observational study. Spine J 2023; 23:1345-1357. [PMID: 37220814 PMCID: PMC10524933 DOI: 10.1016/j.spinee.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/04/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND CONTEXT Spinal decompression and fusion procedures are one of the most common procedures performed in the United States (US) and remain associated with high postsurgical opioid burden. Despite guidelines emphasizing nonopioid pharmacotherapy strategies for postsurgical pain management, prescribing practices are likely variable and guideline-incongruent. PURPOSE The purpose of this study was to characterize patient-, care-, and system-level factors associated with opioid, nonopioid pain medication, and benzodiazepine prescribing variation in the US Military Health System (MHS). STUDY DESIGN/SETTING Retrospective study analyzing medical records from the US MHS Data Repository. PATIENT SAMPLE Adult patients (N=6,625) undergoing lumbar decompression and spinal fusion procedures from 2016 to 2021 in the MHS enrolled in TRICARE at least a year prior to their procedure and had at least one encounter beyond the 90-day postprocedure period, without recent trauma, malignancy, cauda equina syndrome, and co-occurring procedures. OUTCOME MEASURES Patient-, care-, and system-level factors influencing outcomes of discharge morphine equivalent dose (MED), 30-day opioid refill, and persistent opioid use (POU). POU was defined as dispensing of opioid prescriptions monthly for the first 3 months after surgery and then at least once between 90 and 180 days after surgery. METHODS (Generalized) linear mixed models evaluated multilevel factors associated with discharge MED, opioid refill, and POU. RESULTS The median discharge MED was 375 mg (IQR 225, 580) and days' supply was 7 days (IQR 4, 10); 36% received an opioid refill and 5%, overall, met criteria for POU. Discharge MED was associated with fusion procedures (+151-198 mg), multilevel procedures (+26 mg), policy release (-184 mg), opioid naïvty (-31 mg), race (Black -21 mg, another race and ethnicity -47 mg), benzodiazepine receipt (+100 mg), opioid-only medications (+86 mg), gabapentinoid receipt (-20 mg), and nonopioid pain medications receipt (-60 mg). Longer symptom duration, fusion procedures, beneficiary category, mental healthcare, nicotine dependence, benzodiazepine receipt, and opioid naivety were associated with both opioid refill and POU. Multilevel procedures, elevated comorbidity score, policy period, antidepressant receipt, and gabapentinoid receipt, and presurgical physical therapy were also associated with opioid refill. POU increased with increasing discharge MED. CONCLUSIONS Significant variation in discharge prescribing practices require systems-level, evidence-based intervention.
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Affiliation(s)
- Ian Robertson
- Department of Internal Medicine, Walter Reed National Military Medical Center, 9499 Palmer Rd N, Bethesda, MD, 20814, USA.
| | - Daniel I Rhon
- University of Utah, 201 Presidents' Cir, Salt Lake City, UT 84112, USA
| | - Julie M Fritz
- University of Utah, 201 Presidents' Cir, Salt Lake City, UT 84112, USA
| | - Alexander Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, 11300 Rockville Pike Suite 709, Rockville, MD 20852, USA
| | - Bryan K Lawson
- Department of Orthopedics, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234-6200, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814
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Bérubé M, Côté C, Gagnon MA, Moore L, Tremblay L, Turgeon AF, Evans D, Berry G, Turcotte V, Belzile ÉL, Dale C, Orrantia E, Verret M, Dercksen J, Martel MO, Dupuis S, Chatillon CE, Lauzier F. Interdisciplinary strategies to prevent long-term and detrimental opioid use following trauma: a stakeholder consensus study. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:933-940. [PMID: 36944264 PMCID: PMC10391591 DOI: 10.1093/pm/pnad037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. DESIGN A consensus study using the nominal group technique. SETTING Four trauma systems in Canada. SUBJECTS Participants included expert clinicians and decision makers, and people with lived experience. METHODS Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. RESULTS A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. CONCLUSION This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.
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Affiliation(s)
- Mélanie Bérubé
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Faculty of Nursing, Université Laval, Québec City, Quebec G1V 0A6, Canada
- Quebec Pain Research Network, Sherbrooke, Quebec J1H 5N4, Canada
| | - Caroline Côté
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Faculty of Nursing, Université Laval, Québec City, Quebec G1V 0A6, Canada
- Quebec Pain Research Network, Sherbrooke, Quebec J1H 5N4, Canada
| | - Marc-Aurèle Gagnon
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Department of Social Preventive Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
| | - Lorraine Tremblay
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario M4N 3M5, Canada
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada
| | - Greg Berry
- Departement of Orthopaedic Surgery, McGill University Health Centre, Montréal, Quebec H3G 1A4, Canada
| | - Valérie Turcotte
- Department of Nursing, CIUSSS du Nord-de-l’île-de-Montréal, Montréal, Quebec H4J 1C5, Canada
| | - Étienne L Belzile
- Department of Surgery, Division of Orthopeadic Surgery, CHU de Québec-Université Laval, Québec City, Quebec GIV 1Z4, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario M5T 1P8, Canada
- University of Toronto Centre for the Study of Pain (UTCSP), Toronto, Ontario M5T 1P8, Canada
| | - Eli Orrantia
- Marathon Family Health Team, Marathon, Ontario P0T 2E0, Canada
| | - Michael Verret
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario K1H 8L6, Canada
| | - Judy Dercksen
- Quesnel Primary Care Clinic, Quesnel, British Columbia V2J 2K8, Canada
| | - Marc-Olivier Martel
- Quebec Pain Research Network, Sherbrooke, Quebec J1H 5N4, Canada
- Faculty of Medicine & Dentistry, McGill University, Montréal, Quebec H3A 1G1, Canada
| | - Sébastien Dupuis
- Department of Pharmacy, CIUSSS du Nord-de-l’île-de-Montréal,Montréal, Quebec H4J 1C5, Canada
| | - Claude-Edouard Chatillon
- Division of Neurosurgery, CIUSSS de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Quebec G9A 5C5, Canada
| | - François Lauzier
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Department of Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
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10
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Pasqualini I, Rullán PJ, Deren M, Krebs VE, Molloy RM, Nystrom LM, Piuzzi NS. Team Approach: Use of Opioids in Orthopaedic Practice. JBJS Rev 2023; 11:01874474-202303000-00008. [PMID: 36972360 DOI: 10.2106/jbjs.rvw.22.00209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
» The opioid epidemic represents a serious health burden on patients across the United States. » This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions. » The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use. » Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available. » The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.
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Affiliation(s)
- Ignacio Pasqualini
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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11
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Bérubé M, Côté C, Moore L, Turgeon AF, Belzile ÉL, Richard-Denis A, Dale CM, Berry G, Choinière M, Pagé GM, Guénette L, Dupuis S, Tremblay L, Turcotte V, Martel MO, Chatillon CÉ, Perreault K, Lauzier F. Strategies to prevent long-term opioid use following trauma: a Canadian practice survey. Can J Anaesth 2023; 70:87-99. [PMID: 36163458 PMCID: PMC9513000 DOI: 10.1007/s12630-022-02328-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/10/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Practices Research Unit Research Unit (Trauma - Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC, G1V 1Z4, Canada. .,Faculty of Nursing, Université Laval, Quebec City, QC, Canada. .,Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - Caroline Côté
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Faculty of Nursing, Université Laval, Quebec City, QC Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Department of Social Preventive Medicine, Université Laval, Quebec City, QC Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada
| | - Étienne L. Belzile
- Division of Orthopedic Surgery, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC Canada
| | - Andréane Richard-Denis
- Department of Medicine, Université de Montréal, Montreal, Quebec Canada ,Research Centre of the CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON Canada ,University of Toronto Centre for the Study of Pain (UTCSP), Toronto, ON Canada
| | - Gregory Berry
- Department of Orthopaedic Surgery, McGill University Health Centre, Montreal, QC Canada
| | - Manon Choinière
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Gabrielle M. Pagé
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Line Guénette
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Pharmacy, Université Laval, Quebec City, QC Canada
| | - Sébastien Dupuis
- Department of Pharmacy, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Lorraine Tremblay
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Valérie Turcotte
- Department of Nursing, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Marc-Olivier Martel
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Medicine & Dentistry, McGill University, Montreal, QC Canada
| | - Claude-Édouard Chatillon
- Division of Neurosurgery, CIUSSS de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, QC Canada
| | - Kadija Perreault
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), CIUSSS de la Capitale-Nationale, Quebec City, QC Canada
| | - François Lauzier
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada ,Department of Medicine, Université Laval, Quebec City, QC Canada
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