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Esparham A, Mehri A, Maher W, Khorgami Z. Impact of opioid-related disorders on complications in patients undergoing bariatric surgery: a propensity score-matched analysis of the national inpatient sample. Surg Endosc 2024:10.1007/s00464-024-11057-6. [PMID: 39085669 DOI: 10.1007/s00464-024-11057-6] [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: 04/27/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND The opioid crisis caused a huge health concern in the United States. Despite this, few studies have examined the influence of opioid-related disorders (OD) on outcomes after bariatric surgery. The major goal of this study is to determine the impact of OD on in-hospital outcomes for patients undergoing bariatric surgery. METHOD The National Inpatient Sample (NIS) database from 2016 to 2020 was used to evaluate patients with OD who underwent bariatric operations including sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. The non-OD comparison group was created using a propensity score match (1:1). Weighted analysis was carried out utilizing NIS-provided weights. The odds ratios were obtained using multivariate logistic regression. RESULTS A total of 159,455 patients who underwent bariatric surgery were evaluated. Propensity score matching and weighted analysis were used to compare 11,025 in the OD group and 11,025 in the non-OD group. OD was an independent predictor for postoperative complications (odds ratio: 1.29, 95% confidence interval: 1.19-1.39, p < 0.001). Among complications, OD was a predictor for bleeding complications, postoperative nausea and vomiting, anastomotic leak, and mechanical ventilation. In addition, the OD group experienced significantly longer lengths of stay (LOS) and a higher total hospital charges. CONCLUSION In patients undergoing bariatric surgery, OD is associated with a significantly higher risk of postoperative complications, as well as increased LOS and total hospital charges. These patients may benefit from further preoperative optimization, including decreasing the opioid dose and closer postoperative monitoring.
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Affiliation(s)
- Ali Esparham
- School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Mehri
- School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - William Maher
- Department of Surgery, University of Oklahoma College of Community Medicine, 1919 S. Wheeling Avenue, Suite 600, Tulsa, OK, 74104-5638, USA
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Community Medicine, 1919 S. Wheeling Avenue, Suite 600, Tulsa, OK, 74104-5638, USA.
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2
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Selznick A, Kruse C, Al-Mohrej OA, Valente G, Khan M, Al-Asiri J, Petrisor B. The Role of Preoperative Opioid Use in Foot and Ankle Surgery: A Systematic Review. J Foot Ankle Surg 2024; 63:305-311. [PMID: 37923116 DOI: 10.1053/j.jfas.2023.10.003] [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: 12/07/2022] [Revised: 09/18/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023]
Abstract
Prescription opioids, particularly for treating musculoskeletal pain, are a significant contributor to the opioid epidemic in North America. There is also evidence to suggest that chronic use of opioids is associated with poor outcomes after orthopedic surgery. However, whether this association is relevant in foot and ankle surgery is still unclear. Accordingly, a systematic review of the literature was undertaken to assess the impact of preoperative opioid use in patients undergoing foot and ankle surgery concerning postoperative pain, complications, and postoperative opioid dependence. Four databases, including EMBASE, MEDLINE, PubMed, and CINAHL, were searched to March 2022 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use after foot and ankle surgery. A total of 22,092 patients were included in the final synthesis of 8 studies. Most of which were level 3 evidence (5 studies). Around 18% of the patients used opioids preoperatively. Preoperative opioid use was associated with more quantities and prolonged use of opioids postoperatively. Two studies showed an increased risk of complications postoperatively in patients who used opioids preoperatively compared to the nonopioid group. Preoperative opioid use in patients undergoing foot and ankle surgeries is associated with increased and prolonged use of opioids postoperatively and may therefore predict the potential for misuse.
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Affiliation(s)
- Asher Selznick
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton ON, Canada
| | - Colin Kruse
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton ON, Canada
| | - Omar A Al-Mohrej
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada; Section of Orthopedic Surgery, Department of Surgery, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia.
| | - Giuseppe Valente
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
| | - Moin Khan
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
| | - Jamal Al-Asiri
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
| | - Bradley Petrisor
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton ON, Canada
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3
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Rim F, Liu SS, Kelly M, Kim D, Sideris A, Langford DJ. Preoperative pain screening and optimisation by a perioperative pain service to support complex surgical patients: no patient left behind. Br J Anaesth 2024; 132:437-439. [PMID: 38087742 DOI: 10.1016/j.bja.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 01/21/2024] Open
Affiliation(s)
- Faye Rim
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Spencer S Liu
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Mary Kelly
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA
| | - Dae Kim
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Alexandra Sideris
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Dale J Langford
- Department of Anesthesiology, Critical Care & Pain Management, Pain Prevention Research Center at Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY, USA; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA.
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4
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Zubieta CS, Shabet C, Lin J, Muzaurieta A, Arora A, Maghsoodi N, Brummett CM, Edelman A. Financial model for a transitional pain service at a large tertiary academic center in the USA. Reg Anesth Pain Med 2023:rapm-2023-104992. [PMID: 38124160 DOI: 10.1136/rapm-2023-104992] [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: 09/09/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023]
Abstract
Approximately 1 in 10 patients undergoing surgery is considered at high risk for poor pain and opioid-related outcomes due to chronic pain or persistent opioid use prior to surgery, leading to increased hospital lengths of stay, emergency department visits, hospital readmissions, and worse long-term outcomes. Multidisciplinary transitional pain services (TPSs) have been shown to effectively identify and optimize high-risk patients before surgery, leading to a reduction in healthcare utilization. We conducted a series of semistructured interviews, a literature search, and a financial analysis to develop a reproducible business case for establishing a TPS. These interviews involved discussions with clinicians and administrators at Michigan Medicine, as well as leaders of TPS initiatives at peer institutions across the USA and Canada. The aim was to understand possible operational structures and potential sources of revenue and cost savings that needed inclusion in our model. Subsequently, the authors developed a modifiable financial modeling tool, which is freely available for download and adaptable to any healthcare institution. The model suggests that the primary source of cost savings can be attributed to a reduction in length of stay. Furthermore, several operational options exist for incorporating a TPS that performs at breakeven or positive net profit. This tool and these findings are important for informing health systems of operational and financial considerations when implementing a TPS program. Future research should evaluate this financial tool's reproducibility in community health system contexts.
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Affiliation(s)
- Caroline S Zubieta
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Christina Shabet
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - James Lin
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Aurelio Muzaurieta
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Akul Arora
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Nazanin Maghsoodi
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Ross School of Business, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Research Institute, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony Edelman
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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5
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Gazendam AM, Ghert M, Gundle KR, Hayden JB, Doung YC. Opioid Use in Surgical Management in Musculoskeletal Oncology. J Bone Joint Surg Am 2023; 105:10-14. [PMID: 37466574 DOI: 10.2106/jbjs.22.00887] [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] [Indexed: 07/20/2023]
Abstract
BACKGROUND Opioid prescribing in the context of orthopaedic surgery has been recognized as having a critical role in the ongoing opioid epidemic. Given the negative consequences of chronic opioid use, great efforts have been made to reduce both preoperative and postoperative opioid prescribing and consumption in orthopaedic surgery. Musculoskeletal oncology patients represent a unique subset of patients, and there is a paucity of data evaluating perioperative opioid consumption and the risk for chronic use. The objective of the present study was to describe opioid consumption patterns and evaluate predictors of chronic opioid use in musculoskeletal oncology patients undergoing limb-salvage surgery and endoprosthetic reconstruction. METHODS The present study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) trial and included musculoskeletal oncology patients undergoing lower-extremity endoprosthetic reconstruction. The primary outcome was the incidence of opioid consumption over the study period. A multivariate binomial logistic regression model was created to explore predictors of chronic opioid consumption at 1 year postoperatively. RESULTS Overall, 193 (33.6%) of 575 patients were consuming opioids preoperatively. Postoperatively, the number of patients consuming opioids was 82 (16.7%) of 492 at 3 months, 37 (8%) of 460 patients at 6 months, and 28 (6.6%) of 425 patients at 1 year. Of patients consuming opioids preoperatively, 12 (10.2%) of 118 had continued to consume opioids at 1 year postoperatively. The adjusted regression model found that only surgery for metastatic bone disease was predictive of chronic opioid use (odds ratio, 4.90; 95% confidence interval, 1.54 to 15.40; p = 0.007). Preoperative opioid consumption, older age, sex, longer surgical times, reoperation rates, and country of origin were not predictive of chronic use. CONCLUSIONS Despite a high prevalence of preoperative opioid use, an invasive surgical procedure, and a high rate of reoperation, few patients had continued to consume opioids at 1 year postoperatively. The presence of metastases was associated with chronic opioid use. These results are a substantial departure from the existing orthopaedic literature evaluating other patient populations, and they suggest that specific prescribing guidelines are warranted for musculoskeletal oncology patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aaron M Gazendam
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Ghert
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kenneth R Gundle
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - James B Hayden
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
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6
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Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg 2023:00000539-990000000-00608. [PMID: 37450650 DOI: 10.1213/ane.0000000000006623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.
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Affiliation(s)
- Jamie M Kitzman
- From the Department of Anesthesiology, Division of Pediatric Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Veronika V Mesheriakova
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
| | - Amber N Borucki
- Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California
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7
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Goplen CM, Pedersen ME, Ramadi A, Beaupre LA. Opioid prescribing practices prior to elective foot and ankle surgery: a population-based evaluation using health administrative data from a tertiary hospital in Canada. BMC PRIMARY CARE 2022; 23:116. [PMID: 35549666 PMCID: PMC9097109 DOI: 10.1186/s12875-022-01722-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Complex elective foot and ankle surgery is known to be painful so most patients are prescribed opioids at the time of surgery; however, the number of patients prescribed opioids while waiting for surgery in Canada is unknown. Our primary objective was to describe the pre and postoperative prescribing practices for patients in Alberta, Canada undergoing complex elective foot and ankle surgery. Secondarily, we evaluated postoperative opioid usage and hospital outcomes.
Methods
In this population-based retrospective analysis, we identified all adult patients who underwent unilateral elective orthopedic foot and ankle surgery at a single tertiary hospital between May 1, 2015 and May 31, 2017. Patient and surgical data were extracted from a retrospective chart review and merged with prospectively collected, individual level drug dispensing administrative data to analyze opioid dispensing patterns, including dose, duration, and prescriber for six months before and after foot and ankle surgery.
Results
Of the 100 patients, 45 had at least one opioid prescription dispensed within six months before surgery, and of these, 19 were long-term opioid users (> 90 days of continuous use). Most opioid users obtained opioid prescriptions from family physicians both before (78%) and after (65%) surgery. No preoperative non-users transitioned to long-term opioid use postoperatively, but 68.4% of the preoperative long-term opioid users remained long-term opioid users postoperatively. During the index hospitalization, preoperative long-term opioid users consumed higher doses of opioids (99.7 ± 120.5 mg/day) compared to opioid naive patients (28.5 ± 36.1 mg/day) (p < 0.001). Long-term opioid users stayed one day longer in hospital than opioid-naive patients (3.9 ± 2.8 days vs 2.7 ± 1.1 days; p = 0.01).
Conclusions
A significant number of patients were dispensed opioids before and after foot and ankle surgery with the majority of prescriptions coming from primary care practitioners. Patients who were prescribed long-term opioids preoperatively were more likely to continue to use opioids at follow-up and required larger in-hospital opioid dosages and stayed longer in hospital. Further research and education for both patients and providers are needed to reduce the community-based prescribing of opioid medication pre-operatively and provide alternative pain management strategies prior to surgery to improve postoperative outcomes and reduce long-term postoperative opioid use.
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Dahlem CH, Schepis TS, McCabe SE, Rank AL, Teter CJ, Kcomt L, McCabe VV, Voepel-Lewis T. Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications. J Addict Nurs 2022; 33:218-232. [PMID: 37140410 PMCID: PMC10162467 DOI: 10.1097/jan.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
ABSTRACT The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.
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Affiliation(s)
- Chin Hwa Dahlem
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Ty S. Schepis
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychology, Texas State University, San Marcos, Texas, USA
| | - Sean Esteban McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron L. Rank
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Regional One Physicians, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christian J. Teter
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Research Pharmacy Core, McLean Hospital, Belmont, Massachusetts, USA
- Marblehead NeuroPsychiatric Rx, LLC, Marblehead, Massachusetts, USA
| | - Luisa Kcomt
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Vita V. McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Terri Voepel-Lewis
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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Jimenez AE, Cicalese KV, Chakravarti S, Porras JL, Azad TD, Jackson CM, Gallia G, Bettegowda C, Weingart J, Mukherjee D. Substance Use Disorders Are Independently Associated with Hospital Readmission Among Patients with Brain Tumors. World Neurosurg 2022; 166:e358-e368. [PMID: 35817348 DOI: 10.1016/j.wneu.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Research on the effects of substance use disorders (SUDs) on postoperative outcomes within neurosurgical oncology has been limited. Therefore, the present study sought to quantify the effect of having a SUD on hospital length of stay, postoperative complication incidence, discharge disposition, hospital charges, 90-day readmission rates, and 90-day mortality rates following brain tumor surgery. METHODS The present study used data from patients who received surgical resection for brain tumor at a single institution between January 1, 2017, and December 31, 2019. The Mann-Whitney U test was used for bivariate analysis of continuous variables and Fisher exact test was used for bivariate analysis of categorical variables. Multivariate analysis was conducted using logistic regression models. RESULTS Our study cohort included a total of 2519 patients, 124 (4.9%) of whom had at least 1 SUD. More specifically, 90 (3.6%) patients had an alcohol use disorder, 27 (1.1%) had a cannabis use disorder, and 12 (0.5%) had an opioid use disorder. On bivariate analysis, 90-day hospital readmission was the only postoperative outcome significantly associated with a SUD (odds ratio 2.21, P = 0.0011). When controlling for patient age, sex, race, marital status, insurance, brain tumor diagnosis, 5-factor modified frailty index score, American Society of Anesthesiologists score, and surgery number, SUDs remained significantly and independently associated with 90-day readmission (odds ratio 1.82, P = 0.013). CONCLUSIONS In patients with brain tumor, SUDs significantly and independently predict 90-day hospital readmission after surgery. Targeted management of patients with SUDs before and after surgery can optimize patient outcomes and improve the provision of high-value neurosurgical care.
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Affiliation(s)
- Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle V Cicalese
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose L Porras
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Wood MD, West NC, Sreepada R, Loftsgard KC, Petersen L, Robillard J, Page P, Ridgway R, Chadha NK, Portales-Casamar E, Görges M. Identifying risk factors, patient reported experience and outcome measures, and data capture tools for an individualized pain prediction tool in pediatrics: a focus group study (Preprint). JMIR Perioper Med 2022; 5:e42341. [DOI: 10.2196/42341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022] Open
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11
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Markovits J, Blaha O, Zhao E, Spiegel D. Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial. Reg Anesth Pain Med 2022; 47:rapm-2022-103493. [PMID: 35715013 DOI: 10.1136/rapm-2022-103493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/02/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hypnosis decreases perioperative pain and has opioid-sparing potential but has not been rigorously studied in knee arthroplasty. This trial investigates the impact of perioperative hypnosis on inpatient opioid use following total knee arthroplasty. METHODS This prospective randomized controlled trial was conducted at a single academic medical center. The hypnosis arm underwent a scripted 10 min hypnosis session prior to surgery and had access to the recorded script. The control arm received hypnosis education only. The primary outcome was opioid use in milligram oral morphine equivalents per 24 hours during hospital admission. A secondary analysis was performed for patients taking opioids preoperatively. RESULTS 64 primary knee arthroplasty patients were randomized 1:1 to hypnosis (n=31) versus control (n=33) and included in the intent-to-treat analysis. The mean (SD) postoperative opioid use in oral morphine equivalents per 24 hours was 70.5 (48.4) in the hypnosis versus 90.7 (74.4) in the control arm, a difference that was not statistically significant (difference -20.1; 95% CI -51.8 to 11.4; p=0.20). In the subgroup analysis of the opioid-experienced patients, there was a 54% daily reduction in opioid use in the hypnosis group (82.4 (56.2) vs 179.1 (74.5) difference of -96.7; 95% CI -164.4 to -29.0; p=<0.01), equivalent to sparing 65 mg of oxycodone per day. CONCLUSION Perioperative hypnosis significantly reduced inpatient opioid use among opioid-experienced patients only. A larger study examining these findings is warranted. TRIAL REGISTRATION NUMBER NCT03308071.
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Affiliation(s)
- Jessie Markovits
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Ondrej Blaha
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, USA
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Emma Zhao
- Stanford University School of Medicine, Stanford, California, USA
- Psychiatry, University of Vermont Medical Center, Burlington, Vermont, USA
| | - David Spiegel
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
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12
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Association of Prehabilitation With Postoperative Opioid Use in Colorectal Surgery: An Observational Cohort Study. J Surg Res 2022; 273:226-232. [DOI: 10.1016/j.jss.2021.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/09/2021] [Accepted: 12/27/2021] [Indexed: 11/19/2022]
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Outpatient Opioid Prescribing Habits in Pediatric Patients With Bone Sarcomas After Undergoing Primary Tumor Resection. J Pediatr Orthop 2022; 42:e501-e506. [PMID: 35220336 DOI: 10.1097/bpo.0000000000002109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The majority of children with bone sarcomas experience pain. Opioids remain the mainstay treatment of cancer-related pain in children. The patterns of outpatient opioid prescription after surgery for primary bone sarcomas remains unknown. The purpose of this study is to evaluate the patterns of outpatient opioid prescription in patients with bone sarcomas after resection of the primary tumor, and to assess for factors that may lead to increased opioid dosing in these patients. METHODS A retrospective chart review of 28 patients with bone sarcomas undergoing primary tumor resection was performed. Demographic, medical, surgical, and pharmacological data was collected from all patients. The total morphine milligram equivalents (MMEs) prescribed after patient discharge were compared at 30-day intervals. The MMEs were then stratified by tumor location, presence of metastasis at time of surgery, and preoperative opioid use. Independent predictors of increased 30-day and total 120-day opioid utilization were evaluated. RESULTS Patients with preoperative opioid use were prescribed significantly more opioids in every 30-day postoperative interval and for the 120-day total. When stratified by tumor location, patients with primary tumors in the pelvis had significantly greater postoperative opioid utilization when compared with patients with tumors located in the lower and upper extremities during postoperative days 61 to 90 (5970 vs. 1060.4 and 0 MMEs, respectively, P=0.048) and during postoperative days 91 to 120 (6450 vs. 829.6 and 0 MMEs, respectively, P=0.015). Older age, diagnosis of osteosarcoma, increased length of stay postoperatively and presence of metastases were associated with a higher 30-day postoperative opioid utilization. CONCLUSION Multiple factors were associated with increased opioid use including preoperative opioid use, longer postoperative stay in the hospital, metastatic disease, and primary sarcomas in the pelvis. The patient's sex, body mass index, race, type of insurance, type of surgery performed, reoperation during the same admission and use of nonopioid adjuvants had no effect on opioid use. The results of this study can be used to stratify the average opioid requirement of pediatric patients undergoing primary bone sarcoma resection. LEVEL OF EVIDENCE Level IV.
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Mierke A, Ramos O, Chung J, Cheng WK, Danisa O. Effect of Preoperative Opiate Use on Outcomes After Posterior Lumbar Surgery. Cureus 2022; 14:e22663. [PMID: 35371693 PMCID: PMC8964089 DOI: 10.7759/cureus.22663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The prescription opioid epidemic and widespread use of narcotic medications have introduced new challenges when treating patients undergoing spine surgery. Given the ubiquity of preoperative opioid consumption amongst patients undergoing spine surgery, further research is needed to characterize perioperative risks. Our goal is to compare outcomes following primary lumbar decompression, instrumentation, and fusion based on preoperative opioid prescriptions. Methods Patients older than 18 years of age who underwent a primary one- to two-level lumbar decompression, instrumentation, and fusion were included in the study. Patients with known malignancy, surgery involving three or more lumbar levels, current or previous use of neuromodulation, revision surgery, anterior or far lateral interbody fusions, acute fractures, or other concurrent procedures were excluded. Patients were divided into chronic opioid therapy (COT; over six months), acute opioid therapy (AOT; up to six months), and opiate-naïve groups. Opioid prescriptions, demographics, smoking status, readmission rates within one year, and reoperation rates within two years were recorded based on electronic medical record documentation. Results Out of 416 patients identified, 114 patients met the inclusion criteria. Thirty-eight patients (33.3%) were on COT, 38 patients (33.3%) were on AOT, and 38 patients (33.3%) were opioid naïve preoperatively. Readmission rates within one year for COT, AOT, and opioid naïve patients were 34.2%, 26.3%, and 10.5%, respectively (p=0.047). Reoperation rates within two years for COT, AOT, and opioid naïve patients were 34.2%, 15.8%, and 13.2%, respectively (p=0.049). We also found current or former smokers were more likely to be on AOT or COT than never smokers (78.4% vs. 57.1%; p=0.017). Conclusion Long-term opiate use is associated with an increased risk for readmission within one year and revision within two years. Physicians should discuss the increased risks of readmission and revision surgery associated with lumbar decompression and fusion seen in patients on preoperative opioid therapy.
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Abstract
This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.
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Chung BA, Sweitzer B. Optimization of patients with chronic pain and previous opioid use disorders. Int Anesthesiol Clin 2022; 60:48-55. [PMID: 34897221 DOI: 10.1097/aia.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brian A Chung
- Department of Anesthesiology, Northwestern Memorial Hospital, Chicago, Illinois
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Tang R, Santosa KB, Vu JV, Lin LA, Lai YL, Englesbe MJ, Brummett CM, Waljee JF. Preoperative Opioid Use and Readmissions Following Surgery. Ann Surg 2022; 275:e99-e106. [PMID: 32187028 PMCID: PMC7935087 DOI: 10.1097/sla.0000000000003827] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the association between preoperative opioid exposure and readmissions following common surgery. SUMMARY BACKGROUND DATA Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown. METHODS We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type. RESULTS Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29). CONCLUSIONS Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.
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Affiliation(s)
- Ruiqi Tang
- Medical Student, University of Michigan Medical School
| | - Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| | | | - Lewei A. Lin
- Assistant Professor, Department of Psychiatry, Michigan Medicine Medicine and Research Investigator, VA Ann Arbor Healthcare System
| | - Yen-Ling Lai
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN)
| | - Michael J. Englesbe
- Darling Professor of Surgery, Section of Transplantation, Department of Surgery, Michigan Medicine
| | - Chad M. Brummett
- Associate Professor, Division of Pain Medicine, Department of Anesthesiology, Michigan Medicine
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
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Preoperative Opioid Utilization Patterns and Postoperative Opioid Utilization: A Retrospective Cohort Study. Anesthesiology 2021; 135:1015-1026. [PMID: 34731242 DOI: 10.1097/aln.0000000000004026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes. METHODS Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization. RESULTS The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes. CONCLUSIONS Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization. EDITOR’S PERSPECTIVE
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Quinlan J, Levy N, Lobo DN, Macintyre PE. Preoperative opioid use: a modifiable risk factor for poor postoperative outcomes. Br J Anaesth 2021; 127:327-331. [PMID: 34090682 DOI: 10.1016/j.bja.2021.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
| | - Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
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20
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Shumaker L, Nocera A, Selph P. Enhanced Recovery After Surgery in the Urinary Diversion Population: Are Protocols Applied Differently in the Benign Indication Population? Urology 2021; 166:50-55. [PMID: 34474041 DOI: 10.1016/j.urology.2021.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 08/08/2021] [Accepted: 08/19/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To retrospectively evaluate enhanced recovery after surgery (ERAS) protocol administration, hospital length of stay, 30-day readmission, and complication rates among cystectomy and/or urinary diversion patients with benign or malignant indication. MATERIALS AND METHODS Data was extracted retrospectively for cystectomy and/or urinary diversion performed at our institution from June 2016 to May 2019. Descriptive statistics, Chi squared, Wilcoxon rank-sum, binary logistic regression, and linear regression functions in R 4.0.4 (R Foundation), R Package "Tidverse" V1.3.0.9, and RStudio V1.44.1106 (RStudio, PBC) were used to analyze data. RESULTS 102 patients met selection criteria with 36 and 66 patients in the benign and malignant indication cohorts, respectively. Significant differences between cohorts included BMI, age, opioid exposure, and spinal anomalies. The malignant cohort had higher ERAS completion rates for preoperative and intraoperative protocols (41% and 53% vs 14% and 19%). The mean ERAS item administration for benign and malignant indication patients differed significantly (2.9 vs 4.2, P < 0.01). Logistic regression demonstrated benign indication was significantly associated with ERAS failure (OR 4.25, 95% CI 1.18 - 21.03, P = 0.043). Higher ERAS item administration sum was associated with shorter hospitalizations and lower complication rates (P = < 0.01, P = 0.019). No association was observed for 30-day readmission. CONCLUSION The benign urinary diversion/cystectomy population more frequently possesses characteristics adverse to ERAS protocol completion and in our study received fewer ERAS protocol items. This was associated with longer hospitalizations and higher postoperative complication rates. Population-specific ERAS protocols targeted at increasing ERAS completion could reduce morbidity.
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Affiliation(s)
- Luke Shumaker
- Department of Urology, University of Alabama at Birmingham.
| | - Alex Nocera
- Department of Urology, University of Alabama at Birmingham
| | - Patrick Selph
- Department of Urology, University of Alabama at Birmingham
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21
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Macintyre PE. The opioid epidemic from the acute care hospital front line. Anaesth Intensive Care 2021; 50:29-43. [PMID: 34348484 DOI: 10.1177/0310057x211018211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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22
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Lui B, Weinberg R, Milewski AR, Ma X, Bustillo MA, Mack PF, White RS. Impact of preoperative opioid use disorder on outcomes following lumbar-spine surgery. Clin Neurol Neurosurg 2021; 208:106865. [PMID: 34388600 DOI: 10.1016/j.clineuro.2021.106865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/31/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Opioid use disorder (OUD) has previously been shown to negatively impact postoperative outcomes. As the number of spine surgeries continues to rise annually, more patients with preexisting OUD will be seen in operating rooms. Our retrospective cohort study aims to expand on the independent association between preoperative OUD and outcomes following lumbar-spine surgery. PATIENTS AND METHODS Using 2007-2014 data from the State Inpatient Databases (SID) for the states of California (2007-2011), Florida, New York, Maryland, and Kentucky, we identified patients ≥18 years of age undergoing lumbar-spine surgery. Our primary variable of interest was present-on-admission OUD. Outcomes of interest included a range of postoperative complications divided into those specific to spinal surgery and general surgical complications, length of stay (LOS), 30- and 90-day readmission rates, and total hospital charges. RESULTS Of the 267,976 patients undergoing lumbar-spine surgery, 1902 patients were identified as having OUD. After adjusting for patient- and hospital-level confounders, we found that patients with OUD were more likely to experience complications related specifically to spine surgery (aOR = 1.51, 95%CI = 1.33-1.71) as well as general postoperative complications (aOR = 1.63, 95%CI = 1.36-1.96) compared to those without OUD. OUD was additionally associated with longer LOS (aIRR = 1.29, CI = 1.24-1.34) and higher total charges (aIRR = 1.14, CI = 1.11-1.18). Whereas no statistically significant difference was detected for 30-day-readmission rates, patients with OUD experienced higher rates of readmission within 90 days of discharge (aOR = 1.20, CI = 1.08-1.35). CONCLUSIONS Our study strengthens the evidence that patients with OUD fare poorly after lumbar-spine surgery. More research is needed to determine whether reducing opioid use before surgery can mitigate the postoperative risks associated with OUD.
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Affiliation(s)
- Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, United States of America
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, United States of America
| | - Andrew R Milewski
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, United States of America
| | - Xiaoyue Ma
- Department of Population Health Sciences, Weill Cornell Medicine, New York City, NY, United States of America
| | - Maria A Bustillo
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, United States of America
| | - Patricia F Mack
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, United States of America
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York City, NY, United States of America.
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Rim F, Donofrio J, Peterson C, Liu S. Impact of Structured Patient-Centered Preoperative Pain Consult and Interventions From a Dedicated Perioperative Pain Service: A Case Series of 4 Patients. A A Pract 2021; 14:e01279. [PMID: 32909722 DOI: 10.1213/xaa.0000000000001279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Opioid-tolerant individuals have greater risk of perioperative complications and worse clinical outcomes. A preoperative screening process and structured approach to opioid-tolerant patients was developed to identify and optimize these patients before elective surgery.
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Affiliation(s)
- Faye Rim
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York.,Department of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York
| | - Justin Donofrio
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Christine Peterson
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Spencer Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
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24
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Samuel AM, Lovecchio FC, Premkumar A, Vaishnav AS, Kim HJ, Qureshi SA. Association of Duration of Preoperative Opioid Use with Reoperation After One-level Anterior Cervical Discectomy and Fusion in Nonmyelopathic Patients. Spine (Phila Pa 1976) 2021; 46:E719-E725. [PMID: 33290380 DOI: 10.1097/brs.0000000000003861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine that rates of preoperative opioid use in patients undergoing single-level anterior discectomy and fusion (ACDF) without myelopathy and determine the association with reoperations over 5 years. SUMMARY OF BACKGROUND DATA Preoperative opioid use before cervical spine surgery has been linked to worse postoperative outcomes. However, no studies have determined the association of duration and type of opioid used with reoperations after ACDF. METHODS Patients undergoing single-level ACDF without myelopathy between 2007 and 2016 with at least 5-year follow-up were identified in one private insurance administrative database. Preoperative opiate use was divided into acute (within 3 months), subacute (acute use and use between 3 and 6 months), and chronic (subacute use and use before 6 months) and by the opiate medication prescribed (tramadol, oxycodone, and hydrocodone). Postoperative rates of additional cervical spine surgery were determined at 5 years and multivariate logistic regression was used to determine the association of preoperative opiates with additional surgery. RESULTS Of 445 patients undergoing single-level ACDF without myelopathy, 66.3% were taking opioid medications before surgery. The most commonly used preoperative opioid was hydrocodone (50.3% acute use, 24.7% chronic use). Opioid-naïve patients had a 5-year reoperation rate of 4.7%, compared to 25.0%, 15.5%, and 23.3% with chronic preoperative use of tramadol, hydrocodone, and oxycodone. In multivariate analysis, controlling for age, sex, and Charlson Comorbidity Index, chronic use of hydrocodone (odds ratio [OR] = 2.08, P = 0.05), oxycodone (OR = 4.46, P < 0.01), and tramadol (OR = 4.01, P = 0.01) were all associated with increased reoperations. However, acute use of hydrocodone, oxycodone, and tramadol was not associated with reoperations (P > 0.05). CONCLUSION Both subacute and chronic use of common lower-dose opioid medications is associated with increased reoperations after single-level ACDF in nonmyelopathic patients. This information is critical when counseling patients preoperatively and developing preoperative opioid cessation programs.Level of Evidence: 3.
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Affiliation(s)
| | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
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25
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O'Rourke MJ, Keshock MC, Boxhorn CE, Correll DJ, O'Glasser AY, Gazelka HM, Urman RD, Mauck K. Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:1325-1341. [PMID: 33618850 DOI: 10.1016/j.mayocp.2020.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/15/2020] [Accepted: 06/29/2020] [Indexed: 01/31/2023]
Abstract
There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.
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Affiliation(s)
- Michael J O'Rourke
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL; Department of Anesthesia, Edward Hines Jr Veteran Affairs Hospital, Hines, IL.
| | - Maureen C Keshock
- Department of Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH
| | - Christine E Boxhorn
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Boston, MA
| | - Darin J Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Avital Y O'Glasser
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Srivastava D, Hill S, Carty S, Rockett M, Bastable R, Knaggs R, Lambert D, Levy N, Hughes J, Wilkinson P. Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom. Br J Anaesth 2021; 126:1208-1216. [PMID: 33865553 DOI: 10.1016/j.bja.2021.02.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
There are significant concerns regarding prescription and misuse of prescription opioids in the perioperative period. The Faculty of Pain Medicine at the Royal College of Anaesthetists have produced this evidence-based expert consensus guideline on surgery and opioids along with the Royal College of Surgery, Royal College of Psychiatry, Royal College of Nursing, and the British Pain Society. This expert consensus practice advisory reproduces the Faculty of Pain Medicine guidance. Perioperative stewardship of opioids starts with judicious opioid prescribing in primary and secondary care. Before surgery, it is important to assess risk factors for continued opioid use after surgery and identify those with chronic pain before surgery, some of whom may be taking opioids. A multidisciplinary perioperative care plan that includes a prehabilitation strategy and intraoperative and postoperative care needs to be formulated. This may need the input of a pain specialist. Emphasis is placed on optimum management of pain pre-, intra-, and postoperatively. The use of immediate-release opioids is preferred in the immediate postoperative period. Attention to ensuring a smooth care transition and communication from secondary to primary care for those taking opioids is highlighted. For opioid-naive patients (patients not taking opioids before surgery), no more than 7 days of opioid prescription is recommended. Persistent use of opioid needs a medical evaluation and exclusion of chronic post-surgical pain. The lack of grading of the evidence of each individual recommendation remains a major weakness of this guidance; however, evidence supporting each recommendation has been rigorously reviewed by experts in perioperative pain management.
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Affiliation(s)
- Devjit Srivastava
- Department of Anaesthesia and Pain Medicine, Raigmore Hospital, Inverness, UK.
| | - Susan Hill
- Department of Vascular Surgery, University Hospital Wales, Cardiff, UK
| | - Suzanne Carty
- Anaesthetics and Pain Medicine, Taunton and Somerset NHS Foundation Trust, Taunton, Somerset, UK
| | - Mark Rockett
- Anaesthesia and Pain Medicine, Plymouth Hospitals NHS Trust, Plymouth, UK
| | | | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - David Lambert
- Department of Cardiovascular Sciences, Division of Anaesthesia Critical Care & Pain Management, Leicester Royal Infirmary, Leicester, UK
| | - Nicholas Levy
- Anaesthesia and Perioperative Medicine, West Suffolk Hospital, Bury St Edmunds, Suffolk, UK
| | - John Hughes
- Pain Management Unit, James Cook University Hospital, Middlesbrough, UK
| | - Paul Wilkinson
- Department of Anaesthesia, Newcastle Pain Management Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne, Newcastle, UK
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Anastasio AT, Niu S, Kim EJ, Rhee JM. Evaluating Single-Surgeon Bias Toward Recommending Corrective Procedures for Cervical Spondylotic Myelopathy Based on Demographic Factors and Comorbidities in a 484-Patient Cohort. Global Spine J 2021; 11:167-171. [PMID: 32875846 PMCID: PMC7882819 DOI: 10.1177/2192568219896296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES An increasing focus has been placed on removing implicit (unconscious) bias from the surgical selection process. In spine surgery, there is the potential for implicit bias to affect the decision to either operate on a patient or not, given lack of definitive surgical indications for many elective procedures. The objective of this study was to analyze the surgical decision making of a single spine surgeon in an effort to understand surgical decision-making trends based on certain demographic factors. METHODS This was a retrospective study of 484 patients who had undergone a corrective procedure for cervical myelopathy by an orthopedic spine surgeon at our institution. The preoperative modified Japanese Orthopaedic Association score served as the metric of severity of disease for cervical myelopathy. The factors that have been associated with implicit bias that were evaluated were smoking status, narcotic use status, gender, body mass index, and age. RESULTS Multivariate linear regression analysis showed that even after controlling for comorbidities and confounders, the only variable which predicted likelihood to operate on a patient of a milder symptomology was age (odds ratio [OR] = -0.138; (confidence interval [CI] = -0.034 to -0.006). The other factors (smoking status, narcotic use status, gender, and body mass index) were not associated with surgical decision making. CONCLUSIONS Our study demonstrates absence of association between commonly studied areas of implicit bias and the decision to operate on a patient with milder symptomology at initial presentation of cervical spondylotic myelopathy.
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Affiliation(s)
| | - Shuo Niu
- Emory University Hospital, Atlanta, GA, USA
| | | | - John M. Rhee
- Emory University Hospital, Atlanta, GA, USA,John M. Rhee, Department of Orthopaedic Surgery, Emory University, Emory Spine Center, 59 Executive Park South, Atlanta, GA 30329, USA.
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Samuel AM, Lovecchio FC, Premkumar A, Louie PK, Vaishnav AS, Iyer S, McAnany SJ, Albert TJ, Gang CH, Qureshi SA. Use of Higher-strength Opioids has a Dose-Dependent Association With Reoperations After Lumbar Decompression and Interbody Fusion Surgery. Spine (Phila Pa 1976) 2021; 46:E203-E212. [PMID: 33079910 DOI: 10.1097/brs.0000000000003751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to identify an association between preoperative opioid use and reoperations rates. SUMMARY OF BACKGROUND DATA Chronic opioid use is a public health crisis in the United States and has been linked to worse outcomes after lumbar spine surgery. However, no studies have identified an association between preoperative opioid use and reoperations rates. METHODS A retrospective cohort study was conducted using patients from one private insurance database who underwent primary lumbar decompression/discectomy (LDD) or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Preoperative use of five specific opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release oxycodone) was categorized as acute (within 3 months), subacute (acute use and use between 3 and 6 months), or chronic (subacute use and use before 6 months). Multivariate regression, controlling for multilevel surgery, age, sex, and Charlson Comorbidity Index, was used to determine the association of each medication on reoperations within 5 years. RESULTS A total of 11,551 patients undergoing LDD and 3291 patients undergoing PLIF/TLIF without previous lumbar spine surgery were identified. In the LDD group, opioid-naïve patients had a 5-year reoperation rate of 2.8%, compared with 25.0% and 8.0 with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of oxycodone was associated with increased reoperations (odds ratios [OR] = 1.4, 2.0, and 2.3, for acute, subacute, and chronic use; P < 0.01). Chronic use of hydromorphone was also associated with increased reoperations (OR = 7.5, P < 0.01).In the PLIF/TLIF group, opioid-naïve patients had a 5-year reoperation rate of 11.3%, compared with 66.7% and 16.8% with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of hydromorphone was associated with increased reoperations (OR = 2.9, 4.0, and 14.0, for acute, subacute, and chronic use; P < 0.05). CONCLUSION Preoperative use of the higher-potency opioid medications is associated with increased reoperations after LDD and PLIF/TLIF in a dose-dependent manner. Surgeons should use this data for preoperative opioid cessation counseling and individualized risk stratification.Level of Evidence: 3.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | - Steven J McAnany
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | - Todd J Albert
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
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Blevins Peratikos M, Weeks HL, Pisansky AJB, Yong RJ, Stringer EA. Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and Persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States: A Large Retrospective Cohort Study of Administrative Claims Data. PAIN MEDICINE 2021; 21:521-531. [PMID: 31120529 PMCID: PMC7060398 DOI: 10.1093/pm/pnz083] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective Between 17% and 40% of patients undergoing elective arthroplasty are preoperative opioid users. This US study analyzed patients in this population to illustrate the relationship between preoperative opioid use and adverse surgical outcomes. Design Retrospective study of administrative medical and pharmaceutical claims data. Subjects Adults (aged 18+) who received elective total knee, hip, or shoulder replacement in 2014–2015. Methods A patient was a preoperative opioid user if opioid prescription fills occurred in two periods: 1–30 and 31–90 days presurgery. Zero-truncated Poisson (incidence rate ratio [IRR]), logistic (odds ratio [OR]), Cox (hazard ratio [HR]), and quantile regressions modeled the effects of preoperative opioid use and opioid dose, adjusted for demographics, comorbidities, and utilization. Results Among 34,792 patients (38% hip, 58% knee, 4% shoulder), 6,043 (17.4%) were preoperative opioid users with a median morphine equivalent daily dose of 32 mg. Preoperative opioid users had increased length of stay (IRR = 1.03, 95% CI = 1.02 to 1.05), nonhome discharge (OR = 1.10, 95% CI = 1.00 to 1.21), and 30-day unplanned readmission (OR = 1.43, 95% CI = 1.17 to 1.74); experienced 35% higher surgical site infection (HR = 1.35, 95% CI = 1.14 to 1.59) and 44% higher surgical revision (HR = 1.44, 95% CI = 1.21 to 1.71); had a median $1,084 (95% CI = $833 to $1334) increase in medical spend during the 365 days after discharge; and had a 64% lower rate of opioid cessation (HR = 0.34, 95% CI = 0.33 to 0.35) compared with patients not filling two or more prescriptions across periods. Conclusions Preoperative opioid users had longer length of stay, increased revision rates, higher spend, and persistent opioid use, which worsened with dose. Adverse outcomes after elective joint replacement may be reduced if preoperative opioid risk is managed through increased monitoring or opioid cessation.
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Affiliation(s)
- Meridith Blevins Peratikos
- axialHealthcare Inc, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hannah L Weeks
- axialHealthcare Inc, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew J B Pisansky
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - R Jason Yong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To identify gaps in opioid prescription immediately prior to spinal fusion and to study the effect of such simulated "opioid weaning/elimination" on risk of long-term postoperative opioid use. SUMMARY OF BACKGROUND DATA Numerous studies have described preoperative opioid duration and dose thresholds associated with sustained postoperative opioid use. However, the benefit and duration of preoperative opioid weaning before spinal fusion has not been elaborated. METHODS Humana commercial insurance data (2007-Q1 2017) was used to study primary cervical and lumbar/thoracolumbar fusions. More than 5000 total morphine equivalents in the year before spinal fusion were classified as chronic preoperative opioid use. Based on time between last opioid prescription (<14-days' supply) and spinal fusion, chronic opioid users were divided as; no gap, >2-months gap (2G) and >3-months gap (3G). Primary outcome measure was long-term postoperative opioid use (>5000 total morphine equivalents between 3 and 12-mo postoperatively). The effect of "opioid gap" on risk of long-term postoperative opioid use was studied using multiple-variable logistic regression analyses. RESULTS 17,643 patients were included, of whom 3590 (20.3%) had chronic preoperative opioid use. Of these patients, 41 (1.1%) were in the 3G group and 106 (3.0%) were in the 2G group. In the 2G group, 53.8% patients ceased to have long-term postoperative use as compared with 27.8% in NG group. This association was significant on logistic regression analysis (OR 0.30, 95% CI: 0.20-0.46, P < 0.001). CONCLUSIONS Chronic opioid users whose last opioid prescription was >2-months prior to spinal fusion and less than 14-days' supply had significantly lower risk of long-term postoperative opioid use. We have simulated "opioid weaning" in chronic opioid users undergoing major spinal fusion and our analysis provides an initial reference point for current clinical practice and future clinical studies.Level of Evidence: 3.
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Harris AB, Zhang B, Marrache M, Puvanesarajah V, Raad M, Hassanzadeh H, Bicket M, Jain A. Chronic Opioid Use Following Lumbar Discectomy: Prevalence, Risk Factors, and Current Trends in the United States. Neurospine 2020; 17:879-887. [PMID: 33401866 PMCID: PMC7788426 DOI: 10.14245/ns.2040122.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/03/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Lumbar discectomy is commonly performed for symptomatic lumbar disc herniation. We aimed to examine prescribing patterns and risk factors for chronic opioid use following lumbar discectomy.
Methods Using a private insurance claims database, patients were identified who underwent primary lumbar discectomy from 2010–2015 and had 1-year of continuous enrollment postoperatively. Patients were excluded with spinal fusion. The strength of opioid prescriptions was quantified using morphine milligram equivalents daily (MMED). Univariate and multivariate logistic regression models were built to examine risk factors associated with chronic postoperative opioid use.
Results A total of 5,315 patients were included in the study (mean age, 59 years; 50% female). 1,198 of patients (23%) used chronic opioids postoperatively. Chronic opioid use declined significantly from 27% in 2010 to 17% in 2015, p < 0.001. In addition, there were significantly fewer patients receiving high and very high-dose opioid prescriptions from 2010–2015, p < 0.001. The median duration that patients used opioids postoperatively was 211 days in 2010 (interquartile range [IQR], 29–356 days), and decreased significantly to 44 days (IQR, 10–294 days) in 2015. The strongest factors associated with chronic opioid use were preoperative opioid use (odds ratio [OR], 4.0), drug abuse (OR, 2.6), depression (OR, 1.6), surgery in the west (OR, 1.6) or south (OR, 1.6), anxiety (OR, 1.5), or 30-day readmission (OR, 1.4).
Conclusion Chronic opioid use following primary lumbar discectomy has declined from 2010–2015. A variety of factors are associated with chronic opioid use. Preoperative recognition of some of these risk factors may aid in perioperative management and counseling.
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Affiliation(s)
- Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Mark Bicket
- Department of Anesthesiology, The Johns Hopkins University, Baltimore, MD, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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33
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Schug SA. Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge. Med J Aust 2020; 213:409-410. [DOI: 10.5694/mja2.50818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Charipova K, Gress KL, Urits I, Viswanath O, Kaye AD. Management of Patients With Chronic Pain in Ambulatory Surgery Centers. Cureus 2020; 12:e10408. [PMID: 33062525 PMCID: PMC7550221 DOI: 10.7759/cureus.10408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
In the setting of increasingly streamlined surgical techniques and perioperative care, the United States healthcare system is seeing a steady rise in the number of procedures being carried out at ambulatory surgery centers. Concurrently, awareness and diagnosis of both chronic pain conditions and substance use disorders have also improved in recent years. As a result of these two shifts, the demographic characteristics of patients undergoing procedures at ambulatory surgery centers are actively evolving. Chronic pain and substance use disorders are difficult to manage in both the outpatient and inpatient settings and present unique challenges in the context of perioperative planning. Both conditions are associated with worsened postoperative outcomes, including refractory pain, decreased functional status, increased length of stay, increased readmission rates, and increased economic costs. There has been a recent movement to include a preoperative risk stratification calculation for these patients, followed by the implementation of enhanced recovery after surgery (ERAS) protocols in these patient cohorts. Taking a step further, patients benefit when standard ERAS protocols are augmented by integrating designated pain specialists into the ambulatory surgery team. This multimodal and multidisciplinary approach must be assessed in the context of the human and financial resources of a given institution and surgery center, but has been shown to improve the quality and safety of perioperative care effectively.
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Affiliation(s)
- Karina Charipova
- Medicine, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Kyle L Gress
- Medicine, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Ivan Urits
- Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Omar Viswanath
- Anesthesiology, University of Arizona College of Medicine, Phoenix, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Sodhi N, Anis HK, Acuña AJ, Vakharia RM, Gold PA, Garbarino LJ, Mahmood BM, Ehiorobo JO, Grossman EL, Higuera CA, Roche MW, Mont MA. Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study. Clin Orthop Relat Res 2020; 478:1752-1759. [PMID: 32662956 PMCID: PMC7371033 DOI: 10.1097/corr.0000000000001390] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular. QUESTIONS/PURPOSES Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder? METHODS All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder. RESULTS Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001). CONCLUSIONS After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Nipun Sodhi
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Hiba K Anis
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J Acuña
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rushabh M Vakharia
- R. M. Vakharia, M. W. Roche, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Peter A Gold
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Luke J Garbarino
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Bilal M Mahmood
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joseph O Ehiorobo
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Eric L Grossman
- E. L. Grossman, Rothman Orthopaedic Institute, New York, NY, USA
| | - Carlos A Higuera
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Martin W Roche
- R. M. Vakharia, M. W. Roche, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Michael A Mont
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
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Agarwal N, Salvetti DJ, Nowicki KW, Alan N, Ghandoke GS, Kanter AS, Okonkwo DO, Hamilton DK. Preoperative Chronic Opiate Use and Patient Reported Outcomes Following Adult Spinal Reconstructive Surgery. World Neurosurg 2020; 143:e166-e171. [PMID: 32698082 DOI: 10.1016/j.wneu.2020.07.084] [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: 04/20/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preoperative chronic narcotic use has been linked to poor outcomes after surgery for degenerative spinal disorders in the form of lower health-related quality of life scores, higher revision rates, increased infections, lower likelihood of return to work, and higher 90-day readmission rates. This study evaluated the impact of preoperative chronic narcotic use on patient reported outcome measures following adult spinal reconstructive surgery. METHODS Patients who underwent adult spinal reconstructive surgery over 2 years at our institution were identified from a prospectively maintained spine registry. These patients were grouped into chronic opiate users as defined by a 6-month duration of use with a minimum morphine equivalent dose of 30 mg/day. Patient reported outcome measures were collected prospectively. RESULTS Of 140 patients included for analysis, 30 (21.4%) patients were categorized as chronic opiate users. No differences were identified in mean preoperative patient reported outcome measures, including Oswestry Disability Index, health state, visual analog scale, and EQ-5D indices. At both 6 weeks and 6 months postoperatively, patients in the opiate group demonstrated significantly worse mean visual analog scale back pain scores relative to the nonopiate group. At 6 months postoperatively and at the last known clinical follow-up, Oswestry Disability Index scores were higher in the opiate group. CONCLUSIONS Chronic opiate use before adult spinal reconstructive surgery was associated with worse pain and disability following intervention. Further work is needed to understand the role of opiate weaning as part of a larger prehabilitation strategy for adult spinal reconstructive surgery.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David J Salvetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kamil W Nowicki
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nima Alan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gurpreet S Ghandoke
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study. BMC Musculoskelet Disord 2020; 21:398. [PMID: 32571280 PMCID: PMC7310486 DOI: 10.1186/s12891-020-03413-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Retrospective studies have found that daily opioid use pre-arthroplasty predicts worse longer-term service, clinical and patient-reported outcomes. Prospective studies are needed to confirm these observations. This prospective, exploratory study aimed to determine: the proportion of total knee or hip arthroplasty (TKA, THA) patients who use opioids regularly (daily) pre-surgery; if opioid use pre-surgery is associated with acute and sub-acute outcomes to 12-weeks post-surgery. Methods Consecutive patients undergoing primary TKA or THA were prospectively enrolled pre-surgery and followed-up by telephone to 12-weeks post-surgery. Acute-care (oral morphine equivalent dosage (OMED), length of stay, discharge to inpatient rehabilitation, complications) and 12-week outcomes (Oxford Knee or Hip Score, Euroqol ‘today’ health score, current use of opioids, and complications including readmissions) were monitored. Unadjusted and adjusted Odds Ratios (ORs) (95% Confidence Interval, CI), Rate Ratios and β coefficients (standard error) were calculated. Results Five Hundred Twenty-One patients were included (TKA n = 381). 15.7% (95%CI 12.6 to 18.9) used opioids regularly pre-surgery. 86.8% (452/521) were available for follow-up at 12-weeks. In unadjusted analyses, pre-surgical opioid use was significantly associated with higher average acute daily OMED [β 0.40 (0.07), p < 0.001], presence of an acute complication [OR 1.75 (1.02 to 3.00)], and ongoing use of opioids at 12-weeks [OR 5.06 (2.86 to 8.93)]. After adjusting for covariates, opioid use pre-surgery remained significantly associated with average acute daily OMED [β 0.40 (0.07), p < 0.001] and ongoing use at 12-weeks [OR 5.38 (2.89 to 9.99)]. Conclusion People who take daily opioids pre-surgery have significantly greater odds for greater opioid consumption acutely and ongoing use post-surgery. Adequately powered prospective studies are required to confirm whether pre-surgical opioid use is or is not associated with poorer joint and quality of life scores or a complication in the short-term.
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Ren M, Bryant BR, Harris AB, Kebaish KM, Riley LH, Cohen DB, Skolasky RL, Neuman BJ. Opioid use after adult spinal deformity surgery: patterns of cessation and associations with preoperative use. J Neurosurg Spine 2020; 33:490-495. [PMID: 32502988 DOI: 10.3171/2020.3.spine20111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years. METHODS Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05). RESULTS The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5-82), high-dose use (aOR 7.3, 95% CI 1.1-48), and long-term use (aOR 17, 95% CI 2.2-123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8-10,546) but not long-term use (aOR 4.0, 95% CI 0.18-91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8-261) but not at 6 months (aOR 4.3, 95% CI 0.95-24). CONCLUSIONS Patients' preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.
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Vu JV, Cron DC, Lee JS, Gunaseelan V, Lagisetty P, Wixson M, Englesbe MJ, Brummett CM, Waljee JF. Classifying Preoperative Opioid Use for Surgical Care. Ann Surg 2020; 271:1080-1086. [PMID: 30601256 PMCID: PMC7092502 DOI: 10.1097/sla.0000000000003109] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery. BACKGROUND Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use. METHODS We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group. RESULTS Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001). CONCLUSION Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jay S Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Pooja Lagisetty
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor VA
| | - Matthew Wixson
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
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Tian C, Maeda A, Okrainec A, Anvari M, Jackson T. Impact of preoperative opioid use on health outcomes after bariatric surgery. Surg Obes Relat Dis 2020; 16:768-776. [DOI: 10.1016/j.soard.2020.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/27/2020] [Accepted: 02/14/2020] [Indexed: 01/23/2023]
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Kaye AD, Kandregula S, Kosty J, Sin A, Guthikonda B, Ghali GE, Craig MK, Pham AD, Reed DS, Gennuso SA, Reynolds RM, Ehrhardt KP, Cornett EM, Urman RD. Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies. Best Pract Res Clin Anaesthesiol 2020; 34:255-267. [PMID: 32711832 DOI: 10.1016/j.bpa.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 01/26/2023]
Abstract
There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences Provost, Chief Academic Officer, Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Sandeep Kandregula
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Bangalore, Karnataka, 560029, India.
| | - Jennifer Kosty
- Department of Neurosurgery, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Anthony Sin
- Department of Neurosurgery, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Bharat Guthikonda
- Department of Neurosurgery, LSU Health Shreveport, Shreveport, LA, USA.
| | - G E Ghali
- Department of Oral & Maxillofacial Surgery, Craniofacial Surgery/Head & Neck Surgery, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Madelyn K Craig
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Alex D Pham
- Department of Anesthesiology, LSU Health New Orleans, 1542 Tulane Ave, Room 659, New Orleans, LA, 70112, USA.
| | - Devin S Reed
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Sonja A Gennuso
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
| | | | - Ken Philip Ehrhardt
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
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Shadbolt C, Abbott JH, Camacho X, Clarke P, Lohmander LS, Spelman T, Sun EC, Thorlund JB, Zhang Y, Dowsey MM, Choong PFM. The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action. Front Surg 2020; 7:4. [PMID: 32133370 PMCID: PMC7041404 DOI: 10.3389/fsurg.2020.00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/29/2020] [Indexed: 12/27/2022] Open
Abstract
Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.
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Affiliation(s)
- Cade Shadbolt
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ximena Camacho
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia
| | - Philip Clarke
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Tim Spelman
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Rigshospitalet, Copenhagen, Denmark
| | - Eric C Sun
- Department of Anaesthesiology, Perioperative and Pain Medicine and Department of Health Research and Policy, Stanford University, Stanford, CA, United States
| | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Yuting Zhang
- Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, University of Melbourne, Carlton, VIC, Australia
| | - Michelle M Dowsey
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Peter F M Choong
- Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
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Weyker PD, Webb CAJ. Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system. Pain Manag 2019; 10:23-41. [PMID: 31852383 DOI: 10.2217/pmt-2019-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.
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Affiliation(s)
- Paul David Weyker
- Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA
| | - Christopher Allen-John Webb
- Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA.,Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
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Vakharia RM, Sabeh KG, Cohen-Levy WB, Sodhi N, Mont MA, Roche MW. Opioid Disorders Are Associated With Thromboemboli Following Primary Total Knee Arthroplasty. J Arthroplasty 2019; 34:2957-2961. [PMID: 31451391 DOI: 10.1016/j.arth.2019.07.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/24/2019] [Accepted: 07/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Opioid use disorder (OUD) is defined as a problematic pattern of opioid abuse and dependency leading to problems or distress. The purpose of this study is to investigate whether OUD patients undergoing primary total knee arthroplasty (TKA) have higher rates of venous thromboembolisms (VTEs), readmissions, and costs of care. METHODS Patients undergoing TKA with OUD were identified and matched to controls in a 1:4 ratio according to age, gender, comorbidity index, and comorbidities within the Medicare database. Ninety-day VTEs, 90-day readmissions, and costs of care were compared. A P-value less than .01 was considered statistically significant. RESULTS The study yielded 54,480 patients with (n = 10,929) and without (n = 43,551) OUD undergoing primary TKA. Matching was successful as there were no significant differences in baseline characteristics. OUD patients were found to have greater odds of VTEs (odds ratio 2.27, P < .0001) 90 days following primary TKA. OUD patients were found to have greater odds of 90-day readmissions (odds ratio 1.39, P < .0001) in addition to incurring higher day of surgery ($13,360.73 vs $11,911.94, P < .0001) and 90-day costs ($18,380.89 vs $15,565.57, P < .0001) compared to controls. CONCLUSION After adjusting for confounders, this analysis of 54,480 patients identified that patients with OUD have higher rates of VTEs, readmissions, and costs following primary TKA. In addition to using these data to help educate and counsel patients, the study should be used to help further regulate and control opioid prescriptions written by healthcare professionals.
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Affiliation(s)
| | - Karim G Sabeh
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Wayne B Cohen-Levy
- Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL
| | - Nipun Sodhi
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Michael A Mont
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY; Department of Orthopaedic Surgery, Cleveland Clinic Hospital, Cleveland, OH
| | - Martin W Roche
- Holy Cross Hospital, Orthopedic Research Institute, Fort Lauderdale, FL
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Owodunni OP, Zaman MH, Ighani M, Grant MC, Bettick D, Sateri S, Magnuson T, Gearhart S. Opioid tolerance impacts compliance with enhanced recovery pathway after major abdominal surgery. Surgery 2019; 166:1055-1060. [DOI: 10.1016/j.surg.2019.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 08/03/2019] [Accepted: 08/07/2019] [Indexed: 12/15/2022]
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Perioperative use of opioids: Current controversies and concerns. Best Pract Res Clin Anaesthesiol 2019; 33:341-351. [DOI: 10.1016/j.bpa.2019.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
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Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, Gan TJ, Mythen MG, Miller TE, Shaw AD, Thacker JKM, McEvoy MD, Geiger TM, Gordon DB, Grant MC, Grocott M, Gupta R, Hah JM, Hurley RW, Kent ML, King AB, Oderda GM, Sun E, Wu CL. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg 2019; 129:553-566. [DOI: 10.1213/ane.0000000000004018] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Tourneur JM, Weissbrich C, Putensen C, Hilbert T. Feasibility of a protocol to wean patients from continuous renal replacement therapy: A retrospective pilot observation. J Crit Care 2019; 53:236-243. [PMID: 31280144 DOI: 10.1016/j.jcrc.2019.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/13/2019] [Accepted: 06/29/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the feasibility of a protocol-based algorithm to wean acute kidney injury (AKI) patients from continuous renal replacement therapy (CRRT). METHODS The protocol was introduced on one of two similarly equipped ICUs, while on the other (reference) ICU, CRRT discontinuation was based on clinical judgement. Patients were allocated to either ICU and were subjected to physician- or protocol-directed weaning, respectively. According to the algorithm, periodical withdrawal trials (WTs) were mandatory. Interventions were recommended (administration of diuretics, fluid, vasopressors, inotropes, or human albumin) to achieve specific goals (sufficient urine output, balanced fluid status, adequate renal perfusion pressure, optimal oxygen delivery, normoalbuminemia). Clearly stated criteria defined when to abort a WT and to resume RRT for one cycle, followed by another WT. RESULTS Urine output and ScvO2 during WTs were higher with protocol-directed weaning, as well as the amount of administered fluids. WT abort ratio was 48% with a tendency to prolonged WT duration, compared to 64% in the reference patients. No relevant adverse side effects were observed. CONCLUSION Our data show the feasibility of a structured approach to wean AKI patients from RRT that bundles established interventions and brings the weaning into the physician's focus.
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Affiliation(s)
- Julia-Marie Tourneur
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Carsten Weissbrich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany.
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Abstract
STUDY DESIGN Longitudinal Cohort Study. OBJECTIVE Determine 1-year patient-reported outcomes associated with preoperative chronic opioid therapy and high-preoperative opioid dosages in patients undergoing elective spine surgery. SUMMARY OF BACKGROUND DATA Back pain is the most disabling condition worldwide and over half of patients presenting for spine surgery report using opioids. Preoperative dosage has been correlated with poor outcomes, but published studies have not assessed the relationship of both preoperative chronic opioids and opioid dosage with patient-reported outcomes. METHODS For patients undergoing elective spine surgery between 2010 and 2017, our prospective institutional spine registry data was linked to opioid prescription data collected from our state's Prescription Drug Monitoring Program to analyze outcomes associated with preoperative chronic opioid therapy and high-preoperative opioid dosage, while adjusting for confounders through multivariable regression analyses. Outcomes included 1-year meaningful improvements in pain, function, and quality of life. Additional outcomes included 1-year satisfaction, return to work, 90-day complications, and postoperative chronic opioid use. RESULTS Of 2128 patients included, preoperative chronic opioid therapy was identified in 21% and was associated with significantly higher odds (adjusted odds ratio [95% confidence interval]) of not achieving meaningful improvements at 1-year in extremity pain (aOR:1.5 [1.2-2]), axial pain (aOR:1.7 [1.4-2.2]), function (aOR:1.7 [1.4-2.2]), and quality of life (aOR:1.4 [1.2-1.9]); dissatisfaction (aOR:1.7 [1.3-2.2]); 90-day complications (aOR:2.9 [1.7-4.9]); and postoperative chronic opioid use (aOR:15 [11.4-19.7]). High-preoperative opioid dosage was only associated with postoperative chronic opioid use (aOR:4.9 [3-7.9]). CONCLUSION Patients treated with chronic opioids prior to spine surgery are significantly less likely to achieve meaningful improvements at 1-year in pain, function, and quality of life; and less likely to be satisfied at 1-year with higher odds of 90-day complications, regardless of dosage. Both preoperative chronic opioid therapy and high-preoperative dosage are independently associated with postoperative chronic opioid use. LEVEL OF EVIDENCE 2.
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