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Khalil M, Woldesenbet S, Munir MM, Khan MMM, Rashid Z, Altaf A, Katayama E, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery. Ann Surg Oncol 2024; 31:5283-5292. [PMID: 38762641 PMCID: PMC11236845 DOI: 10.1245/s10434-024-15435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/24/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery. METHODS Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms. RESULTS Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66). CONCLUSION Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Gong J, Jones P, Chan AHY. Incidence and risk factors of new persistent opioid use after surgery and trauma: A systematic review. BMC Surg 2024; 24:210. [PMID: 39014357 PMCID: PMC11251237 DOI: 10.1186/s12893-024-02494-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 07/01/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Persistent opioid use (POU) can occur with opioid use after surgery or trauma. Current systematic reviews include patients with previous exposure to opioids, meaning their findings may not be relevant to patients who are opioid naïve (i.e. Most recent exposure was from surgery or trauma). The aim of this review was to synthesise narratively the evidence relating to the incidence of, and risk factors for POU in opioid-naïve surgical or trauma patients. METHOD Structured searches of Embase, Medline, CINAHL, Web of Science, and Scopus were conducted, with final search performed on the 17th of July 2023. Searches were limited to human participants to identify studies that assessed POU following hospital admission due to surgery or trauma. Search terms relating to 'opioid', 'analgesics', 'surgery', 'injury', 'trauma' and 'opioid-related disorder' were combined. The Newcastle-Ottawa Scale for cohort studies was used to assess the risk of bias for studies. RESULTS In total, 22 studies (20 surgical and two trauma) were included in the analysis. Of these, 20 studies were conducted in the United States (US). The incidence of POU for surgical patients 18 and over ranged between 3.9% to 14.0%, and for those under 18, the incidence was 2.0%. In trauma studies, the incidence was 8.1% to 10.5% among patients 18 and over. Significant risk factors identified across surgical and trauma studies in opioid-naïve patients were: higher comorbidity burden, having pre-existing mental health or chronic pain disorders, increased length of hospital stay during the surgery/trauma event, or increased doses of opioid exposure after the surgical or trauma event. Significant heterogeneity of study design precluded meta-analysis. CONCLUSION The quality of the studies was generally of good quality; however, most studies were of US origin and used medico-administrative data. Several risk factors for POU were consistently and independently associated with increased odds of POU, primarily for surgical patients. Awareness of these risk factors may help prescribers recognise the risk of POU after surgery or trauma, when considering continuing opioids after hospitalisation. The review found gaps in the literature on trauma patients, which represents an opportunity for future research. TRIAL REGISTRATION PROSPERO registration: CRD42023397186.
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Affiliation(s)
- Jiayi Gong
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
| | - Peter Jones
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Amy Hai Yan Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Ikoma N. What defines the "value" of robotic surgery for patients with gastrointestinal cancers? Perspectives from a U.S. Cancer Center. Ann Gastroenterol Surg 2024; 8:566-579. [PMID: 38957558 PMCID: PMC11216793 DOI: 10.1002/ags3.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 07/04/2024] Open
Abstract
The use of robotic surgery has experienced rapid growth across diverse medical conditions, with a notable emphasis on gastrointestinal cancers. The advanced technologies incorporated into robotic surgery platforms have played a pivotal role in enabling the safe performance of complex procedures, including gastrectomy and pancreatectomy, through a minimally invasive approach. However, there exists a noteworthy gap in high-level evidence demonstrating that robotic surgery for gastric and pancreatic cancers has substantial benefits compared to traditional open or laparoscopic methods. The primary impediment hindering the broader implementation of robotic surgery is its cost. The escalating healthcare expenses in the United States have prompted healthcare providers and payors to explore patient-centered, value-based healthcare models and reimbursement systems that embrace cost-effectiveness. Thus, it is important to determine what defines the value of robotic surgery. It must either maintain or enhance oncological quality and improve complication rates compared to open procedures. Moreover, its true value should be apparent in patients' expedited recovery and improved quality of life. Another essential aspect of robotic surgery's value lies in minimizing or even eliminating opioid use, even after major operations, offering considerable benefits to the broader public health landscape. A quicker return to oncological therapy has the potential to improve overall oncological outcomes, while a speedier return to work not only alleviates individual financial distress but also positively impacts societal productivity. In this article, we comprehensively review and summarize the current landscape of health economics and value-based care, with a focus on robotic surgery for gastrointestinal cancers.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Diaz S, Brockhaus KK, Bobel MC, Colom SM, Ramm C, Cleary RK. Pain and opioid use after colorectal resection for benign versus malignant disease: A single institution analysis. Am J Surg 2024; 232:131-137. [PMID: 38365550 DOI: 10.1016/j.amjsurg.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Studies comparing opioid needs between benign and malignant colorectal diseases are inconclusive. METHODS Single institution analysis of prospectively maintained colorectal surgery database. Multiple regression analyses done on perioperative numeric pain scores (NPS) and opioids prescribed at discharge. RESULTS 641 patients in Benign and 276 patients in the Malignant group. Unadjusted comparison revealed significantly higher NPS for the Benign than the Malignant group preoperative and postoperative day 0 (after surgery), 1, 2, and 3 (all p ≤ 0.001). Opioids prescribed at discharge were significantly higher in the Benign group (60.0% vs 51.1%, p = 0.018). After regression analysis, there was no longer a significant difference in NPS (B = 0.703, p = 0.095) and opioids prescribed between groups [OR = 0.803 (95%CI 0.586, 1.1), p = 0.173]. CONCLUSIONS Pain and opioids prescribed at discharge are not significantly different between benign and malignant diseases in an enhanced recovery pain management pathway that maximizes non-opioid multimodal analgesic strategies.
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Affiliation(s)
- Sarah Diaz
- Department of Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | - Kara K Brockhaus
- Department of Pharmacy, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | - Matthew C Bobel
- Department of Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | | | - Carole Ramm
- Department of Academic Research, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA.
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Chang P, Amaral LJ, Asher A, Clauw D, Jones B, Thompson P, Warner AS. A perspective on a precision approach to pain in cancer; moving beyond opioid therapy. Disabil Rehabil 2024; 46:2174-2183. [PMID: 37194659 DOI: 10.1080/09638288.2023.2212916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 05/07/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE Cancer-related pain is primarily treated with opioids which while effective can add significant patient burden due to side effects, associated stigma, and timely access. The purpose of this perspective discussion is to argue for a precision approach to pain in cancer based on a biopsychosocial and spiritual model which we argue can offer a higher quality of life while limiting opioid use. CONCLUSIONS Pain in cancer represents a heterogenous process with multiple contributing and modulating factors. Specific characterization of pain as either nociceptive, neuropathic, nociplastic, or mixed can allow for targeted treatments. Additional assessment of biopsychosocial and spiritual issues can elucidate further points of targeted intervention which can lead to overall greater pain control.
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Affiliation(s)
- Philip Chang
- Philip Chang - Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Arash Asher
- Arash Asher - Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Bronwen Jones
- Bronwen Jones - Cedars Sinai Medical Center, Los Angeles, CA
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Chelly JE, Goel SK, Kearns J, Kopac O, Sadhasivam S. Nanotechnology for Pain Management. J Clin Med 2024; 13:2611. [PMID: 38731140 PMCID: PMC11084313 DOI: 10.3390/jcm13092611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.
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Affiliation(s)
- Jacques E. Chelly
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA
| | - Shiv K. Goel
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Jeremy Kearns
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Orkun Kopac
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
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Bello RJ, Palleiko BA, Kennedy K, Cournoyer L, Larkin AC, Dinh KH, LaFemina J. Interpectoral nerve blocks may lower postoperative narcotic use after mastectomy. Surg Oncol 2024; 53:102055. [PMID: 38394843 DOI: 10.1016/j.suronc.2024.102055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Pain management following mastectomy is a significant challenge often requiring opioids. Nonopioid pain management utilizing nerve blocks has been shown in other fields to reduce postoperative opioid use and may be effective for postoperative pain in mastectomy patients. The primary purpose of this study was to compare postoperative opioid use, measured in morphine milligram equivalents (MME), between mastectomy patients who underwent interpectoral nerve block (IPNB) and a historical control group. Secondary outcomes included length of stay (LOS) and postoperative pain scores. METHODS This is a single-center, retrospective cohort study. The charts of women who underwent mastectomy for cancer without immediate reconstruction from 10/2017-12/2019 were reviewed. Wilcoxon rank sum test was used for unadjusted analysis and multiple linear regression for adjusted analysis. RESULTS There were 105 patients included in this study, of which 37 (35%) underwent IPNB. In unadjusted analysis, median MME use was significantly lower in patients that received IPNB compared to the control group (IPNB = 5, controls = 17, p = 0.03). Patients that received IPNB had an observed reduction in LOS and postoperative pain, though these results failed to reach statistical significance. There were no IPNB-related complications. CONCLUSIONS IPNB may be an effective strategy to decrease postoperative opioid use in mastectomy patients. Larger, prospective studies are needed to further investigate the effectiveness of IPNB.
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Affiliation(s)
- Ricardo J Bello
- UMass Chan Medical School, Department of Surgery, Worcester, MA, USA
| | | | - Kara Kennedy
- UMass Chan Medical School, Department of Surgery, Worcester, MA, USA
| | - Lauren Cournoyer
- UMass Chan Medical School, Department of Surgery, Worcester, MA, USA
| | - Anne C Larkin
- UMass Chan Medical School, Department of Surgery, Worcester, MA, USA
| | - Kate H Dinh
- UMass Chan Medical School, Department of Surgery, Worcester, MA, USA
| | - Jennifer LaFemina
- UMass Chan Medical School, Department of Surgery, Worcester, MA, USA
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Chang CY, Jones BL, Hincapie-Castillo JM, Park H, Heldermon CD, Diaby V, Wilson DL, Lo-Ciganic WH. Association between trajectories of prescription opioid use and risk of opioid use disorder and overdose among US nonmetastatic breast cancer survivors. Breast Cancer Res Treat 2024; 204:561-577. [PMID: 38191684 DOI: 10.1007/s10549-023-07205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE To examine the association between prescription opioid use trajectories and risk of opioid use disorder (OUD) or overdose among nonmetastatic breast cancer survivors by treatment type. METHODS This retrospective cohort study included female nonmetastatic breast cancer survivors with at least 1 opioid prescription fill in 2010-2019 Surveillance, Epidemiology and End Results linked Medicare data. Opioid mean daily morphine milligram equivalents (MME) calculated within 1.5 years after initiating active breast cancer therapy. Group-based trajectory models identified distinct opioid use trajectory patterns. Risk of time to first OUD/overdose event within 1 year after the trajectory period was calculated for distinct trajectory groups using Cox proportional hazards models. Analyses were stratified by treatment type. RESULTS Four opioid use trajectories were identified for each treatment group. For 38,030 survivors with systemic endocrine therapy, 3 trajectories were associated with increased OUD/overdose risk compared with early discontinuation: minimal dose (< 5 MME; adjusted hazard ratio [aHR] = 1.73 [95% CI 1.43-2.09]), very low dose (5-25 MME; 2.67 [2.05-3.48]), and moderate dose (51-90 MME; 6.20 [4.69-8.19]). For 9477 survivors with adjuvant chemotherapy, low-dose opioid use was associated with higher OUD/overdose risk (aHR = 7.33 [95% CI 2.52-21.31]) compared with early discontinuation. For 3513 survivors with neoadjuvant chemotherapy, the differences in OUD/OD risks across the 4 trajectories were not significant. CONCLUSIONS Among Medicare nonmetastatic breast cancer survivors receiving systemic endocrine therapy or adjuvant chemotherapy, compared with early discontinuation, low-dose or moderate-dose opioid use were associated with six- to sevenfold higher OUD/overdose risk. Breast cancer survivors at high-risk of OUD/overdose may benefit from targeted interventions (e.g., pain clinic referral).
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Affiliation(s)
- Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Bobby L Jones
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | | | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Coy D Heldermon
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Debbie L Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Wei-Hsuan Lo-Ciganic
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, USA.
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, USA.
- Geriatric Research Education and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, USA.
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9
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Di Lena É, Barone N, Hopkins B, Do U, Kaneva P, Fiore JF, Meterissian S. Opioid prescribing practices in breast oncologic surgery-A retrospective cohort study. World J Surg 2024; 48:642-649. [PMID: 38312060 DOI: 10.1002/wjs.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/01/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND In breast oncologic surgery, 75% of patients receive a postoperative opioid prescription at discharge, and 10%-20% will develop persistent opioid use. To inform future institutional guidelines, the objective of this study was to determine baseline opioid prescribing patterns in a single high-volume, referral-based breast center. We hypothesized that opioid prescribing practices varied between procedures and operating surgeons. METHODS A retrospective analysis of all women undergoing breast cancer surgery between January and December 2019. Opioid prescriptions at discharge were converted to morphine milligram equivalents (MME). The primary outcome of interest was MME prescribed at discharge. Multiple linear regression was used to identify factors independently associated with MME prescribed. RESULTS 392 patients met inclusion criteria; 68.3% underwent partial mastectomy. Median age was 61 (interquartile range [IQR] 51-70). Median MME prescribed at discharge was 112.5 (IQR 75-150); 83.9% of patients were prescribed co-analgesia. The prescriber was a trainee in 37.7% of cases. 15 patients (3.8%) required opioid renewal. On multivariate analysis, axillary procedure was associated with increased MME (ß = 17, 95% CI 5.5-28 and ß = 32, 95% CI 17-47, for sentinel node and axillary dissection, respectively). However, the factor with the greatest impact on MME was operating surgeon (ß = 72, 95% CI 58-87). Residents prescribed less MME compared to attending surgeons (ß = 11, 95% CI -22; -0.06). CONCLUSION In a tertiary care center, the operating surgeon had the greatest influence on opioid prescribing practices, and trainees tended to prescribe less MME. These findings support the need for a standardized approach to optimize prescribing and reduce opioid-related harms after oncologic breast surgery.
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Affiliation(s)
- Élise Di Lena
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Brent Hopkins
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Uyen Do
- Centre de recherche de l'Université de Montréal, Montreal, Quebec, Canada
| | - Pepa Kaneva
- The Steinberg-Bernstein Center for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Julio F Fiore
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- The Steinberg-Bernstein Center for Minimally Invasive Surgery, McGill University, Montreal, Quebec, Canada
| | - Sarkis Meterissian
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Breast Center, McGill University Health Center, Montreal, Quebec, Canada
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Casamento A, Ghosh A, Hui V, Neto AS. Hospital and long-term opioid use according to analgosedation with fentanyl vs. morphine: Findings from the ANALGESIC trial. CRIT CARE RESUSC 2024; 26:24-31. [PMID: 38690190 PMCID: PMC11056422 DOI: 10.1016/j.ccrj.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 05/02/2024]
Abstract
Objectives Opioid use disorder is extremely common. Many long-term opioid users will have their first exposure to opioids in hospitals. We aimed to compare long-term opioid use in patients who received fentanyl vs. morphine analgosedation and assess ICU related risk factors for long-term opioid use. Design We performed a post-hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation in mechanically ventilated patients. Setting Two mixed, adult, university affiliated intensive care units in Melbourne, Australia. Participants Adult patients who were mechanically ventilated and received fentanyl or morphine for analgosedation in the ANALGESIC trial. Main outcome measures We assessed discharge and long-term (90-365 days) opioid use in opioid-naïve patients at hospital admission according to the agent used for analgosedation. Results We studied 477 patients (242 fentanyl and 235 morphine). There were no differences between discharge (16.5% vs. 14.0%, p = 0.45), 90-180 day post-discharge use (3.7% vs 2.1%, p = 0.30) or 180-365 day post-discharge use (3.4% vs 1.3%, p = 0.22) of opioids when comparing those patients who received fentanyl vs. those who received morphine. Surgical diagnosis and one chronic condition were associated with increased hospital discharge prescription of opioids, whereas increasing APACHE II score was associated with decreased discharge prescription. No ICU-related factors were associated with long-term opioid use. Conclusions Approximately one in seven opioid-naïve patients who receive analgosedation for mechanical ventilation in ICU will be prescribed opioid medications at hospital discharge. There was no difference in discharge prescription or long-term use of opioids depending on whether fentanyl or morphine was used for analgosedation.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Victor Hui
- Department of Anaesthesia, Austin Hospital, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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11
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Li L, Chang Y, Smith NA, Losina E, Costenbader KH, Laidlaw TM. Nonsteroidal anti-inflammatory drug "allergy" labeling is associated with increased postpartum opioid utilization. J Allergy Clin Immunol 2024; 153:772-779.e4. [PMID: 38040042 PMCID: PMC10939859 DOI: 10.1016/j.jaci.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Current guidelines recommend a stepwise approach to postpartum pain management, beginning with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with opioids added only if needed. Report of a prior NSAID-induced adverse drug reaction (ADR) may preclude use of first-line analgesics, despite evidence that many patients with this allergy label may safely tolerate NSAIDs. OBJECTIVE We assessed the association between reported NSAID ADRs and postpartum opioid utilization. METHODS We performed a retrospective cohort study of birthing people who delivered within an integrated health system (January 1, 2017, to December 31, 2020). Study outcomes were postpartum inpatient opioid administrations and opioid prescriptions at discharge. Statistical analysis was performed on a propensity score-matched sample, which was generated with the goal of matching to the covariate distributions from individuals with NSAID ADRs. RESULTS Of 38,927 eligible participants, there were 883 (2.3%) with an NSAID ADR. Among individuals with reported NSAID ADRs, 49.5% received inpatient opioids in the postpartum period, compared to 34.5% of those with no NSAID ADRs (difference = 15.0%, 95% confidence interval 11.4-18.6%). For patients who received postpartum inpatient opioids, those with NSAID ADRs received a higher total cumulative dose between delivery and hospital discharge (median 30.0 vs 22.5 morphine milligram equivalents [MME] for vaginal deliveries; median 104.4 vs 75.0 MME for cesarean deliveries). The overall proportion of patients receiving an opioid prescription at the time of hospital discharge was higher for patients with NSAID ADRs compared to patients with no NSAID ADRs (39.3% vs 27.2%; difference = 12.1%, 95% confidence interval 8.6-15.6%). CONCLUSION Patients with reported NSAID ADRs had higher postpartum inpatient opioid utilization and more frequently received opioid prescriptions at hospital discharge compared to those without NSAID ADRs, regardless of mode of delivery.
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Affiliation(s)
- Lily Li
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Yuchiao Chang
- Harvard Medical School, Boston, Mass; Division of General Internal Medicine, Massachusetts General Hospital, Boston, Mass
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Elena Losina
- Harvard Medical School, Boston, Mass; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Karen H Costenbader
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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12
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Baum LVM, Kc M, Soulos PR, Jeffery MM, Ruddy KJ, Lerro CC, Lee H, Graham DJ, Rivera DR, Leapman MS, Jairam V, Dinan MA, Gross CP, Park HS. Trends in new and persistent opioid use in older adults with and without cancer. J Natl Cancer Inst 2024; 116:316-323. [PMID: 37802882 DOI: 10.1093/jnci/djad206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND The impact of ongoing efforts to decrease opioid use on patients with cancer remains undefined. Our objective was to determine trends in new and additional opioid use in patients with and without cancer. METHODS This retrospective cohort study used data from Surveillance, Epidemiology, and End Results program-Medicare for opioid-naive patients with solid tumor malignancies diagnosed from 2012 through 2017 and a random sample of patients without cancer. We identified 238 470 eligible patients with cancer and further focused on 4 clinical strata: patients without cancer, patients with metastatic cancer, patients with nonmetastatic cancer treated with surgery alone ("surgery alone"), and patients with nonmetastatic cancer treated with surgery plus chemotherapy or radiation therapy ("surgery+"). We identified new, early additional, and long-term additional opioid use and calculated the change in predicted probability of these outcomes from 2012 to 2017. RESULTS New opioid use was higher in patients with cancer (46.4%) than in those without (6.9%) (P < .001). From 2012 to 2017, the predicted probability of new opioid use was more stable in the cancer strata (relative declines: 0.1% surgery alone; 2.4% surgery+; 8.8% metastatic cancer), than in the noncancer stratum (20.0%) (P < .001 for each cancer to noncancer comparison). Early additional use declined among surgery patients (‒14.9% and ‒17.5% for surgery alone and surgery+, respectively) but was stable among patients with metastatic disease (‒2.8%, P = .50). CONCLUSIONS Opioid prescribing declined over time at a slower rate in patients with cancer than in patients without cancer. Our study suggests important but tempered effects of the changing opioid climate on patients with cancer.
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Affiliation(s)
- Laura Van Metre Baum
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Madhav Kc
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | | | - Catherine C Lerro
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
| | - Hana Lee
- Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Donna R Rivera
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
| | - Michael S Leapman
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Vikram Jairam
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Cary P Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
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13
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Kurteva S, Pook M, Fiore JF, Tamblyn R. Rates and risk factors for persistent opioid use after cardiothoracic surgery: A cohort study. Surgery 2024; 175:271-279. [PMID: 38008605 DOI: 10.1016/j.surg.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/25/2023] [Accepted: 10/25/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND This study's aim was to estimate potential risk factors for persistent opioid use after cardiothoracic surgery. METHODS This study included participants in the McGill University Health Centre clinical trial (2014 to 2016). Provincial medical services, prescription claims, and medical charts data were linked. Persistent opioid use was defined as an initial peri-operative opioid dispensation followed by an opioid dispensation between 91 and 180 days postdischarge. Multivariable Cox Proportional Hazards models were used to assess factors associated with persistent opioid use. RESULTS A cohort of 815 patients (mean age: 68.9 [standard deviation = 8.9]) was assembled, of which 8.2% became persistent opioid users. Factors such as higher Charlson Comorbidity Index (adjusted hazard ratio: 3.4, 95% confidence interval: 1.1-10.6), history of diabetes (adjusted hazard ratio: 2.1, 95% confidence interval: 1.3-3.4), substance and alcohol abuse (adjusted hazard ratio: 16.3, 95% confidence interval: 5.3-49.5), and radiotherapy (adjusted hazard ratio: 2.4, 95% confidence interval: 1.5-4.1) were associated with a higher hazard of persistent opioid use. Previous opioid use (adjusted hazard ratio: 1.7, 95% CI: 1.0-2.8), daily peri-operative opioid dose (adjusted hazard ratio: 2.3, 95% confidence interval: 1.5-3.7), having an opioid dispensation 30 days pre-admission (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), and pre-admission analgesic use (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), were also associated with an increased hazard of persistent use. Being prescribed multimodal analgesia at discharge (adjusted hazard ratio: 0.54, 95% confidence interval: 0.32-0.92) was associated with a 46% decreased hazard of developing persistent opioid use. CONCLUSION Multiple patient- and medication-related characteristics were associated with an increased hazard of persistent opioid use.
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Affiliation(s)
- Siyana Kurteva
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.
| | - Makena Pook
- Division of Experimental Surgery, McGill University, Montreal, Canada
| | - Julio Flavio Fiore
- Division of Experimental Surgery, McGill University, Montreal, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada; Department of Medicine, McGill University Health Center, Montreal, Canada
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14
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Basabe MS, Suki TS, Munsell MF, Iniesta MD, Garcia Lopez JE, Hillman RT, Cain K, Huepenbecker S, Mena G, Taylor JS, Ramirez PT, Meyer LA. Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement. Int J Gynecol Cancer 2023; 34:ijgc-2023-004948. [PMID: 38123191 PMCID: PMC11186977 DOI: 10.1136/ijgc-2023-004948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription. OBJECTIVE To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education. METHODS We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis. RESULTS The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99). CONCLUSION Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.
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Affiliation(s)
- M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina S Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Department of Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Zipursky JS, Everett K, Calzavara A, Gomes T, Juurlink DN. New Persistent Opioid Use After Childbirth. Obstet Gynecol 2023; 142:1440-1449. [PMID: 37917933 DOI: 10.1097/aog.0000000000005432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To examine factors associated with new persistent opioid use after childbirth. METHODS We conducted a population-based cohort study of individuals who initiated opioid therapy within 7 days of discharge from hospital after delivery between September 1, 2013, and September 30, 2021. The primary outcome was new persistent opioid use , which was defined as one or more prescriptions for an opioid within 90 days of the first postpartum prescription and one or more subsequent opioid prescriptions in the 91-365 days afterward. We used multivariable logistic regression to assess patient-, pregnancy-, and prescription-related factors associated with new persistent opioid use after delivery. RESULTS We identified 118,694 unique deliveries after which opioids were initiated, including 99,399 cesarean (83.7%) and 19,295 vaginal (16.3%) deliveries. Among mothers who initiated an opioid after delivery, 1,282 (10.8/1,000 deliveries) met our definition of new persistent opioid use in the subsequent year. Rates of new persistent opioid use were appreciably higher after vaginal (16.0/1,000) compared with cesarean (9.8/1,000) deliveries. Each additional 30 morphine milligram equivalents in the initial opioid prescription was associated with an increased risk of new persistent use after cesarean (adjusted odds ratio [aOR] 1.06, 95% CI 1.04-1.08) and vaginal (aOR 1.05, 95% CI 1.02-1.08) delivery. A concomitant benzodiazepine prescription after cesarean delivery was associated with a markedly increased risk of persistent opioid use (aOR 2.69, 95% CI 1.60-4.52). CONCLUSION Among people who filled an opioid prescription after delivery, about 1% displayed evidence of persistent opioid use in the subsequent year. Initial prescriptions for large quantities of opioids and a concurrent benzodiazepine prescription may be important modifiable risk factors to prevent new persistent opioid use after delivery.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, ICES, the Sunnybrook Research Institute, the Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, and the Leslie Dan Faculty of Pharmacy and the Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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16
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Black KA, Nelson G, Goucher N, Foley J, Pin S, Chong M, Ghosh S, Bisch SP. Effect of transversus abdominis plane block on postoperative outcomes in gynecologic oncology patients managed on an Enhanced Recovery After Surgery pathway. Gynecol Oncol 2023; 178:1-7. [PMID: 37729808 DOI: 10.1016/j.ygyno.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES To characterize the effect of transversus abdominis plane (TAP) blocks on post-operative outcomes in patients undergoing laparotomy for gynecologic malignancy. METHODS This retrospective cohort study assessed patients undergoing laparotomy in 2016-2017 and 2020 in Alberta, Canada. The primary outcome was opioid consumption in oral morphine milligram equivalent (MME). Secondary outcomes included maximum pain scores, length of stay, and patient-controlled analgesia (PCA) use. Outcomes were compared using t-test with subgroup analysis by NSAID use. Multivariate regression modelling was performed for potential confounders. RESULTS Data was collected on 956 patients; 828 received a TAP block, 128 did not. Opioid use in the first 24 h was lower in the TAP block group (35.9 mg MME vs 44.5 mg MME, p = 0.0294), without any increase in pain scores, this did not remain significant after regression analysis. Patients with TAP blocks had significant reduced mean length of stay (3.2 days vs. 5.0 days, p < 0.0001), and PCA use (19.9% vs. 56.25%, p < 0.0001). On subgroup analysis of patients that did not receive NSAIDs (n = 160), mean opioid use was decreased in those patients with TAP blocks compared to those without TAP blocks in the first 24 h (36.1 mg vs. 61.2 mg, p = 0.0017), and at 24 to 48 h (16.3 mg vs. 51.0 mg, p < 0.0001). CONCLUSIONS Surgeon-administered TAP blocks were associated with decreased length of stay and post-operative opioid use in patients not receiving scheduled NSAIDs. This decrease in opioid use was not associated with any increase in average or maximum pain scores.
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Affiliation(s)
- Kristin A Black
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Natalie Goucher
- Department of Anesthesia, Memorial University, St. John's, Newfoundland, Canada
| | - Joshua Foley
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Division of Gynecologic Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Chong
- Department of Anesthesia, University of Calgary, Calgary, Alberta, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Steven P Bisch
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Boyev A, Jain AJ, Newhook TE, Prakash LR, Chiang YJ, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm. JAMA Surg 2023; 158:e234154. [PMID: 37672236 PMCID: PMC10483385 DOI: 10.1001/jamasurg.2023.4154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/16/2023] [Indexed: 09/07/2023]
Abstract
Importance Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anish J Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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18
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Phatak UR, Raji M, Chen L, Baillargeon JG, Yong-Fang K. Opioid Prescribing Patterns After Colorectal Resections in the United States of America. Cureus 2023; 15:e48890. [PMID: 38106740 PMCID: PMC10725122 DOI: 10.7759/cureus.48890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
Background The opioid epidemic is a significant source of morbidity and mortality in the United States of America. Minimizing opioid prescribing after operations has become an important component of post-operative care pathways. We hypothesized that opioid prescribing has decreased over time after colorectal resections. Methods This is a retrospective study from 2012 to 2019 using the Optum Clinformatics database (Eden Prairie, MN). We included patients aged 18 years or older who had an elective colorectal resection. Our primary outcome was the rate of opioid prescription at post-operative discharge. Secondary outcomes included the rates of gabapentinoid (GABA) prescribing post-operatively. Results Of 17,900 patients, the most common procedure was sigmoid colectomy (35%). Most procedures were open (N=10,626, 59.4%). The most common indication was benign disease (N=12,439, 69.5%). Post-operative opioid prescribing decreased from 64.4% in 2012 to 46.7% in 2019. In the adjusted model, the odds of post-operative opioid prescription were 37% lower in 2019 than in 2012 (OR, 0.63; 95% CI, 0.56-0.72; p<0.0001). At 60 days and one year post surgery, opioid prescribing decreased from 11.6% and 5.9% in 2012 to 7.2% and 5.2% in 2019 (p<0.0001). At 60 days, gabapentinoid prescribing increased from 2.3% in 2012 to 4.0% in 2019 (p=0.0016). Conclusions Our data show that opioid prescribing is common after colorectal surgery with an overall post-operative prescription rate of 55.8%. The modification of post-operative pathways to include guidance on opioid prescribing and non-opioid alternatives may curb opioid prescribing, decrease the number of new persistent opioid users, and decrease the number of opioids available for diversion.
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Affiliation(s)
- Uma R Phatak
- Department of Surgery, University of Texas Medical Branch, Galveston, USA
| | - Mukaila Raji
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
| | - Lu Chen
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
| | - Jacques G Baillargeon
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
| | - Kuo Yong-Fang
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA
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19
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Sudduth JD, Moss WD, Clinker C, Marquez JL, Anderson E, Eddington D, Agarwal J, Kwok AC. Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction. J Reconstr Microsurg 2023; 39:751-757. [PMID: 37068512 DOI: 10.1055/s-0043-1768220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. METHODS A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). RESULTS One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. CONCLUSION In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.
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Affiliation(s)
- Jack D Sudduth
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Whitney D Moss
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Christopher Clinker
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Jessica L Marquez
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Eric Anderson
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Devin Eddington
- Division of Epidemiology, Department of Internal Medicine, The University of Utah Hospital, Salt Lake City, Utah
| | - Jayant Agarwal
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Alvin C Kwok
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
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20
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Zhou N, Niu J, Nelson D, Feldman HA, Antonoff MB, Hofstetter WL, Mehran RJ, Rice DC, Sepesi B, Swisher SG, Walsh GL, Giordano SH, Rajaram R. Surgical Approach and Persistent Opioid Use in Medicare Patients Undergoing Lung Cancer Resection. Ann Thorac Surg 2023; 116:1020-1027. [PMID: 36801207 DOI: 10.1016/j.athoracsur.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 12/27/2022] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Robotic and video-assisted thoracoscopic surgery (VATS) approaches for lung resection are associated with decreased inpatient opioid use compared with open surgery. Whether these approaches affect outpatient persistent opioid use remains unknown. METHODS Non-small cell lung cancer patients aged 66 years or more who underwent lung resection between 2008 and 2017 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Persistent opioid use was defined as filling an opioid prescription 3 to 6 months after lung resection. Adjusted analyses were performed to evaluate surgical approach and persistent opioid use. RESULTS We identified 19,673 patients: 7479 (38%) underwent open surgery, 10,388 (52.8%) VATS, and 1806 (9.2%) robotic surgery. Persistent opioid use was 38% in the entire cohort, including 27% of opioid naïve patients, and highest after open surgery (42.5%), followed by VATS (35.3%) and robotic (33.1%, P < .001). In multivariable analyses, robotic (odds ratio 0.84; 95% CI, 0.72-0.98; P = .028) and VATS (odds ratio 0.87; 95% CI, 0.79-0.95; P = .003) approaches were both associated with decreased persistent opioid use compared with open surgery in opioid naïve patients. At 12 months, patients resected using a robotic approach had the lowest oral morphine equivalent per month compared with VATS (133 vs 160, P < .001) and open surgery (133 vs 200, P < .001). Among chronic opioid patients, surgical approach was not associated with postoperative opioid use. CONCLUSIONS Persistent opioid use after lung resection is common. Both robotic and VATS approaches were associated with decreased persistent opioid use compared with open surgery among opioid naïve patients. Whether a robotic approach yields additional long-term advantages over VATS warrants further investigation.
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Affiliation(s)
- Nicolas Zhou
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jiangong Niu
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Nelson
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hope A Feldman
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Garret L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Jain S, Lapointe-Gagner M, Alali N, Elhaj H, Poirier AS, Kaneva P, Alhashemi M, Lee L, Agnihotram RV, Feldman LS, Gagner M, Andalib A, Fiore JF. Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study. Surg Endosc 2023; 37:8006-8018. [PMID: 37460817 DOI: 10.1007/s00464-023-10265-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/27/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. METHODS This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. RESULTS We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). CONCLUSION This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.
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Affiliation(s)
- Shrieda Jain
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Maxime Lapointe-Gagner
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Naser Alali
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Anne-Sophie Poirier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ramanakumar V Agnihotram
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Michel Gagner
- Clinique Michel Gagner (Westmount Square Surgical Center), Westmount, QC, Canada
| | - Amin Andalib
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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22
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Zanolli NC, Lim S, Knechtle W, Feng K, Truong T, Havrileskey LJ, Davidson BA. Implementation of a validated post-operative opioid nomogram into clinical gynecologic surgery practice: A quality improvement initiative. Gynecol Oncol Rep 2023; 49:101260. [PMID: 37655046 PMCID: PMC10465856 DOI: 10.1016/j.gore.2023.101260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/09/2023] [Accepted: 08/12/2023] [Indexed: 09/02/2023] Open
Abstract
Objectives The Gynecologic Oncology Postoperative Opioid use Predictive (GO-POP) calculator is a validated tool to provide evidence-based guidance on post-operative opioid prescribing. The objective of this study was to evaluate the impact of the implementation of GO-POP within an academic Gynecologic Oncology division. Methods Two cohorts of patients (pre-implementation and post-implementation) who underwent surgery were compared with reference to GO-POP calculator implementation. All patients were included in the post-implementation group, regardless of GO-POP calculator use. An additional expanded-implementation cohort was used to compare pain control between GO-POP users and non-GO-POP users prospectively. Wilcoxon rank sum tests or ANOVA for continuous variables and Chi-square or Fisher's exact tests were used to categorical variables. Results The median number of pills prescribed post-operatively decreased from 15 pills (Q1: 10, Q3: 20) to 10 pills (Q1: 8, Q3: 14.8) after implementation (p < 0.001). In the expanded-implementation cohort (293 patients), 41% patients were prescribed opioids using the GO-POP calculator. An overall median of 10 pills were prescribed with no difference by GO-POP calculator use (p = 0.26). Within the expanded-implementation cohort, refill requests (5% vs 9.2%; p = 0.26), clinician visits (0.8% vs 0.6%, p = 1), ED or urgent care visits (0% vs 2.3%, p = 0.15) and readmissions (0% vs 1.7%, p = 0.27) for pain did not differ between those prescribed opioids with and without the GO-POP calculator. Conclusions A 33% reduction in post-operative opioid pills prescribed was seen following implementation of the GO-POP calculator into the Gynecologic Oncology division without increasing post-operative pain metrics or encounters for refill requests.
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Affiliation(s)
- Nicole C. Zanolli
- Duke University School of Medicine, Duke University, Durham, NC, United States
| | - Stephanie Lim
- Department of Obstetrics & Gynecology, Duke University, Durham, NC, United States
| | - William Knechtle
- Duke Institute for Health Innovation, Duke University, Durham, NC, United States
| | - Kelvin Feng
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
| | - Tracy Truong
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
| | - Laura J. Havrileskey
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University, Durham, NC, United States
| | - Brittany A. Davidson
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University, Durham, NC, United States
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23
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Vijayakumar G, Vance D, Colman MW, Gitelis S, Sweeney K, Blank AT. Opiate use after total hip arthroplasty for metastatic bone disease. J Opioid Manag 2023; 19:395-402. [PMID: 37968973 DOI: 10.5055/jom.0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days. BACKGROUND MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD. METHODS This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate. RESULTS Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks. CONCLUSION To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.
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Affiliation(s)
- Gayathri Vijayakumar
- Department of Orthopedic Surgery, Section of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois. ORCID: https://orcid.org/0000-0001-7324-4864
| | - Dylan Vance
- University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew W Colman
- Department of Orthopedic Surgery, Section of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois
| | - Steven Gitelis
- Department of Orthopedic Surgery, Section of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois
| | - Kyle Sweeney
- University of Kansas Medical Center, Kansas City, Kansas
| | - Alan T Blank
- Department of Orthopedic Surgery, Section of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois
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Mastrolonardo EV, Mann DS, Sethi HK, Yun BH, Sina EM, Armache M, Worster B, Fundakowski CE, Mady LJ. Perioperative opioids and survival outcomes in resectable head and neck cancer: A systematic review. Cancer Med 2023; 12:18882-18888. [PMID: 37706634 PMCID: PMC10557889 DOI: 10.1002/cam4.6524] [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: 07/25/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Opioids are a mainstay in pain control for oncologic surgery. The objective of this systematic review is to evaluate the associations of perioperative opioid use with overall survival (OS) and disease-free survival (DFS) in patients with resectable head and neck cancer (HNC). METHODS A systematic review of PubMed, SCOPUS, and CINAHL between 2000 and 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating perioperative opioid use for patients with HNC undergoing surgical resection and its association with OS and DFS were included. RESULTS Three thousand three hundred seventy-eight studies met initial inclusion criteria, and three studies representing 562 patients (intraoperative opioids, n = 463; postoperative opioids, n = 99) met final exclusion criteria. One study identified that high intraoperative opioid requirement in oral cancer surgery was associated with decreased OS (HR = 1.77, 95% CI 0.995-3.149) but was not an independent predictor of decreased DFS. Another study found that increased intraoperative opioid requirements in treating laryngeal cancer was demonstrated to have a weak but statistically significant inverse relationship with DFS (HR = 1.001, p = 0.02) and OS (HR = 1.001, p = 0.02). The last study identified that patients with chronic opioid after resection of oral cavity cancer had decreased DFS (HR = 2.7, 95% CI 1.1-6.6) compared to those who were not chronically using opioids postoperatively. CONCLUSION An association may exist between perioperative opioid use and OS and DFS in patients with resectable HNC. Additional investigation is required to further delineate this relationship and promote appropriate stewardship of opioid use with adjunctive nonopioid analgesic regimens.
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Affiliation(s)
- Eric V. Mastrolonardo
- Department of Otolaryngology – Head and Neck SurgeryThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Derek S. Mann
- Department of Otolaryngology – Head and Neck SurgeryThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Harleen K. Sethi
- Department of Otolaryngology – Head and Neck SurgeryPhiladelphia College of Osteopathic MedicinePhiladelphiaPennsylvaniaUSA
| | - Bo H. Yun
- Department of Otolaryngology – Head and Neck SurgeryThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Elliott M. Sina
- Department of Otolaryngology – Head and Neck SurgeryThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Maria Armache
- Department of Otolaryngology – Head and Neck SurgeryThe Johns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Brooke Worster
- Department of Hospice and Palliative CareThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Christopher E. Fundakowski
- Department of Otolaryngology – Head and Neck SurgeryThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Leila J. Mady
- Department of Otolaryngology – Head and Neck SurgeryThe Johns Hopkins School of MedicineBaltimoreMarylandUSA
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25
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Gross DJ, Alnajar A, Villamizar NR, Nguyen DM. Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience. JTCVS OPEN 2023; 15:508-519. [PMID: 37808010 PMCID: PMC10556950 DOI: 10.1016/j.xjon.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 10/10/2023]
Abstract
Objectives Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid-free discharge. Methods We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent), and opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid-free discharge; our secondary objective was to determine the incidence of new persistent opioid users. Results In total, 466 patients from our optimized ERATS protocol were included; 309 (66%) were discharged without opioids. However, 34 (11%) of patients discharged without opioids required a prescription postdischarge. Conversely, 7 of 157 patients (11%), never filled their opioid prescriptions given at discharge. Factors associated with opioid-free discharges were nonanatomic resections, mediastinal procedures, minimal pain, and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges (P = .0013). Finally, only 2.3% of opioid-naive patients of the entire cohort became chronic opioid users; there was no difference in the incidence of chronic use by opioid discharge status. Conclusions Optimized opioid-sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic.
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Affiliation(s)
- Daniel J. Gross
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Ahmed Alnajar
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Nestor R. Villamizar
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
| | - Dao M. Nguyen
- Division of Thoracic Surgery, The DeWitt Daughtry Department of Surgery, The University of Miami, Miami, Fla
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26
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Kiamanesh CS, Fuller MC, Lu M, Nordin EJ, Ma JX, Dugan SM, Cummings CE, Sherman K, Ebert TJ. New Opioid Persistence in Veterans Following Major and Minor Surgery. Mil Med 2023; 188:e1813-e1820. [PMID: 36317545 PMCID: PMC10362993 DOI: 10.1093/milmed/usac322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/14/2022] [Accepted: 10/07/2022] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION Opioids are often a mainstay of managing postsurgical pain. Persistent use of opioids for more than 90 days after surgery is problematic, and the incidence of this adverse outcome has been reported in the civilian population ranging from 0.4% to 7%. Veterans compose a special population exposed to trauma and stressful situations and consequently face increased risk for habit-forming behavior and drug overdose. This evaluation determined the prevalence of opioid persistence after surgery and its relationship to patient characteristics in a military veteran population. METHODS A retrospective chart review was completed on 1,257 veterans who were opioid naive and had undergone a surgical procedure between January 2017 and May 2018. Patient characteristics, health conditions, and discharge opioid medications were recorded, and the incidence of persistent opioid use beyond 90 days was determined. RESULTS The incidence of opioid persistence following major (3.3%) and minor (3.4%) procedures was similar. The incidence in patients younger than 45 years (3.3%), between 45 and 64 years (4.3%), and 65 years and older (2.2%) was also determined to be similar. Univariate patient factors associated with an increased risk for persistent opioid use include cancer (odds ratio [OR], 2.13; 95% CI, 1.11-4.09), mental health disorders (OR, 2.32; 95% CI, 1.17-4.60), and substance use disorders (OR, 2.09; 95% CI, 1.09-4.00). CONCLUSIONS Among a cohort of over 1,200 opioid-naïve veterans undergoing surgery at a VA Medical Center, just over 3% went on to develop persistent opioid use beyond 3 months following their procedure. Persistent use was not found to be related to the type of procedure (major or minor) or patient age. Significant patient-level risk factors for opioid persistence were cancer and a history of mental health and substance use disorders.
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Affiliation(s)
| | | | - Marvin Lu
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | - Jessie X Ma
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Shannon M Dugan
- Department of Anesthesiology, 112A, Zablocki VA Medical Center, Milwaukee, WI 53295, USA
| | - Craig E Cummings
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Anesthesiology, 112A, Zablocki VA Medical Center, Milwaukee, WI 53295, USA
| | - Katherine Sherman
- Research Service, Zablocki VA Medical Center, Milwaukee, WI 53295, USA
| | - Thomas J Ebert
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Anesthesiology, 112A, Zablocki VA Medical Center, Milwaukee, WI 53295, USA
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Thomas C, Ayres M, Pye K, Yassin D, Howell SJ, Alderson S. Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review. Perioper Med (Lond) 2023; 12:34. [PMID: 37430326 DOI: 10.1186/s13741-023-00312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 05/19/2023] [Indexed: 07/12/2023] Open
Abstract
Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.
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Affiliation(s)
- C Thomas
- Department of Anaesthesia, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK.
| | - M Ayres
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Pye
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Yassin
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Institute of Health Research, University of Leeds, Leeds, UK
| | - S Alderson
- Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Ameta N, Ramkiran S, Vivekanand D, Honwad M, Jaiswal A, Gupta MK. Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study. J Anaesthesiol Clin Pharmacol 2023; 39:488-496. [PMID: 38025564 PMCID: PMC10661648 DOI: 10.4103/joacp.joacp_411_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 08/15/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery. Material and Methods This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block. Results The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable. Conclusion Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.
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Affiliation(s)
- Nihar Ameta
- Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Seshadri Ramkiran
- Department of Onco-Anesthesiology, HCG Cancer Centre, Kalinga Rao Road, Sampangiram Nagar, Bengaluru, India
| | | | - Manish Honwad
- Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Alok Jaiswal
- Department of Anaesthesia, 150 General Hospital, C/O 99 APO, Meerut, Uttar Pradesh, India
| | - Manoj Kumar Gupta
- Station Health Organisation, Meerut Cantt, Meerut, Uttar Pradesh, India
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Harsanyi H, Cuthbert C, Schulte F. The Stigma Surrounding Opioid Use as a Barrier to Cancer-Pain Management: An Overview of Experiences with Fear, Shame, and Poorly Controlled Pain in the Context of Advanced Cancer. Curr Oncol 2023; 30:5835-5848. [PMID: 37366920 DOI: 10.3390/curroncol30060437] [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: 04/26/2023] [Revised: 06/10/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Cancer-related pain affects a majority of patients with advanced cancer and is often undertreated. The treatment of this pain is largely reliant on the use of opioids, which are essential medicines for symptom management and the maintenance of quality of life (QoL) for patients with advanced cancer. While there are cancer-specific guidelines for the treatment of pain, widespread publication and policy changes in response to the opioid epidemic have drastically impacted perceptions of opioid use. This overview therefore aims to investigate how manifestations of opioid stigma impact pain management in cancer settings, with an emphasis on the experiences of patients with advanced cancer. Opioid use has been widely stigmatized in multiple domains, including public, healthcare, and patient populations. Physician hesitancy in prescribing and pharmacist vigilance in dispensing were identified as barriers to optimal pain management, and may contribute to stigma in the context of advanced cancer. Evidence in the literature suggests that opioid stigma may result in patient deviations from prescription instructions, which generally leads to pain undertreatment. Patients reflected on experiencing shame and fear surrounding their prescription opioid use and feeling uncomfortable communicating with their healthcare providers on these topics. Our findings indicate that future work is required to educate patients and providers in order to de-stigmatize opioid use. Through alleviating stigma, patients may be better able to make decisions regarding their pain management which lead to freedom from cancer-related pain and improved QoL.
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Affiliation(s)
- Hannah Harsanyi
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Colleen Cuthbert
- Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Fiona Schulte
- Division of Psychosocial Oncology, Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
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Fender Z, Bleicher J, Johnson JE, Phan K, Powers D, Stoddard G, Brooke BS, Huang LC. Improving pain management and safe opioid use after surgery: A DMAIC-based quality intervention. Surg Open Sci 2023; 13:27-34. [PMID: 37351188 PMCID: PMC10282558 DOI: 10.1016/j.sopen.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/16/2023] [Accepted: 04/10/2023] [Indexed: 06/24/2023] Open
Abstract
Background Multimodal perioperative patient education and expectation-setting can reduce post-operative opioid use while maintaining pain control and satisfaction. As part of a quality-improvement project, we developed a standardized model for perioperative education built upon the American College of Surgeons (ACS) Safe and Effective Pain Control After Surgery (SEPCAS) brochure to improve perioperative education regarding opioid use and pain control. Material and methods Our study was designed within the Define, Measure, Analyze, Improve, Control (DMAIC) quality-improvement framework. Patients were surveyed about the adequacy of their perioperative education regarding pain control and use of prescription opioid medication. After gathering baseline data, a multimodal educational intervention based on the SEPCAS brochure was implemented. Survey responses were then compared between groups. Results Twenty-seven subjects were included from the pre-intervention period, and thirty-nine were included from the post-intervention period (n = 66). Those in the post-intervention period were more likely to report receiving the appropriate amount of education regarding recognizing the signs of opioid overdose and how to safely store and dispose of opioid medications. The majority of patients who received the SEPCAS brochure reported that it was useful in their post-operative recovery and that it should be given to every patient undergoing surgery. Conclusions The ACS SEPCAS brochure is an effective tool for improving patient preparation to safely store and dispose of their opioid medication and recognize the signs of opioid overdose. The brochure was also well received by patients and perceived as an effective educational material.
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Affiliation(s)
- Zachary Fender
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Josh Bleicher
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Kathy Phan
- Division of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Damien Powers
- Division of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Gregory Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Lyen C. Huang
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
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Howard R, Brown CS, Lai YL, Gunaseelan V, Brummett CM, Englesbe M, Waljee J, Bicket MC. Postoperative Opioid Prescribing and New Persistent Opioid Use: The Risk of Excessive Prescribing. Ann Surg 2023; 277:e1225-e1231. [PMID: 35129474 PMCID: PMC10537242 DOI: 10.1097/sla.0000000000005392] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate the association between postoperative opioid prescribing and new persistent opioid use. SUMMARY BACKGROUND DATA Opioid-nave patients who develop new persistent opioid use after surgery are at increased risk of opioid-related morbidity and mortality. However, the extent to which postoperative opioid prescribing is associated with persistent postoperative opioid use is unclear. METHODS Retrospective study of opioid-naïve adults undergoing surgery in Michigan from 1/1/2017 to 10/31/2019. Postoperative opioid prescriptions were identified using a statewide clinical registry and prescription fills were identified using Michigan's prescription drug monitoring program. The primary outcome was new persistent opioid use, defined as filling at least 1 opioid prescription between post-discharge days 4 to 90 and filling at least 1 opioid prescription between post-discharge days 91 to 180. RESULTS A total of 37,654 patients underwent surgery with a mean age of 52.2 (16.7) years and 20,923 (55.6%) female patients. A total of 31,920 (84.8%) patients were prescribed opioids at discharge. Six hundred twenty-two (1.7%) patients developed new persistent opioid use after surgery. Being prescribed an opioid at discharge was not associated with new persistent opioid use [adjusted odds ratio (aOR) 0.88 (95% confidence interval (CI) 0.71-1.09)]. However, among patients prescribed an opioid, patients prescribed the second largest [12 (interquartile range (IQR) 3) pills] and largest [20 (IQR 7) pills] quartiles of prescription size had higher odds of new persistent opioid use compared to patients prescribed the smallest quartile [7 (IQR 1) pills] of prescription size [aOR 1.39 (95% CI 1.04-1.86) andaOR 1.97 (95% CI 1.442.70), respectively]. CONCLUSIONS In a cohort of opioid-naïve patients undergoing common surgical procedures, the risk of new persistent opioid use increased with the size of the prescription. This suggests that while opioid prescriptions in and of themselves may not place patients at risk of long-term opioid use, excessive prescribing does. Consequently, these findings support ongoing efforts to mitigate excessive opioid prescribing after surgery to reduce opioid-related harms.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Mark C Bicket
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
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Li L, Chang Y, Losina E, Costenbader KH, Chen AF, Laidlaw TM. Association of Reported Nonsteroidal Anti-Inflammatory Drug (NSAID) Adverse Drug Reactions With Opioid Prescribing After Total Joint Arthroplasty. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1891-1898.e3. [PMID: 36948493 PMCID: PMC10272084 DOI: 10.1016/j.jaip.2023.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/24/2023] [Accepted: 03/08/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for postoperative pain management, but use may be precluded by the report of adverse drug reactions (ADRs). The effect of NSAID ADR labeling on opioid prescribing after total joint arthroplasty (TJA) is unknown. OBJECTIVE To assess the association between NSAID ADRs and postoperative opioid prescribing after TJA, a common surgical procedure. METHODS We performed a retrospective cohort study of adults who underwent total joint (knee or hip) replacement in a single hospital network between April, 1, 2016, and December 31, 2019. Demographic information, clinical and surgical characteristics, and prescription data were obtained from the electronic health record. We studied the association between reported NSAID ADRs and postoperative opioid prescribing in a propensity score-matched sample over 1 year of follow-up. RESULTS NSAID ADRs were reported by 9.6% of the entire cohort (n = 584/6091). NSAID ADR was associated with 41% higher odds of receipt of opioid prescriptions at 181 to 365 days after hospital discharge (95% confidence interval: 13%-75%) in a propensity score-matched sample. Over 98% of individuals received an opioid prescription at the time of hospital discharge, with no difference in overall median opioid dose prescribed by NSAID ADR status. However, more patients with NSAID ADRs (7.6% vs 4.7%) received cumulative opioid doses ≥ 750 morphine milligram equivalents (MME) at discharge (P = .004). CONCLUSION Reported NSAID ADR was associated with increased risk for prolonged receipt of opioids at 181 to 365 days postoperatively. Patients with NSAID ADRs more frequently received cumulative opioid doses ≥ 750 MME at discharge after TJA. Clarification and evaluation of reported NSAID ADRs may be particularly beneficial for surgical patients at high risk for prolonged receipt of opioids.
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Affiliation(s)
- Lily Li
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Yuchiao Chang
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Orthopedic Surgery, Harvard Medical School, Boston, Mass
| | - Karen H Costenbader
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Orthopedic Surgery, Harvard Medical School, Boston, Mass
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
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Lin N, Dabas E, Quan ML, Cheung WY, Cuthbert C, Feng Y, Kong S, Sauro KM, Brenner DR, Yang L, Lu M, Xu Y. Outcomes and Healthcare Utilization Among New Persistent Opioid Users and Nonopioid Users After Curative-intent Surgery for Cancer. Ann Surg 2023; 277:e752-e758. [PMID: 34334636 DOI: 10.1097/sla.0000000000005109] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare the health outcomes and resource use of cancer patients who were new persistent opioid users with those who were not, after undergoing curative intent surgery for cancer. BACKGROUND Little is known about long-term health outcomes (overdose, mortality) and resource utilization of new persistent opioid users among cancer patients undergoing curative-intent surgery. METHODS This retrospective cohort study included all adults with a diagnosis of solid cancers who underwent curative-intent surgery during the study period (2011-2015) in Alberta, Canada and were opioid-naïve before surgery, with a follow-up period until December 31, 2019. The key exposure, "new persistent opioid user," was defined as a patient who was opioid-naive before surgery and subsequently filled at least 1 opioid prescription between 60 and 180 days after surgery. The primary outcome was opioid overdose that occurred within 3 years of surgery. All-cause death, noncancer caused death, and department visit (yes vs. no), and hospitalization (yes vs. no) in the follow-up periods were also included as outcomes. RESULTS In total, 19,219 patients underwent curative intent surgery with a median follow-up of 47 months, of whom 1530 (8.0%) were identified as postoperative new persistent opioid users. In total, 101 (0.5%) patients experienced opioid overdose within 3 years of surgery. Compared with nonopioid users, new persistent opioid users experienced a higher rate of opioid overdose (OR = 2.37, 95% CI: 1.44-3.9) within 3 years of surgery. New persistent opioid use was also associated with a greater likelihood of being hospitalized (OR = 2.03, 95% CI: 1.76-2.33) and visiting an emergency room (OR = 1.83, 95% CI: 1.62-2.06) in the first year after surgery, and a higher overall (HR = 1.28, 95% CI: 1.1-1.49) and noncancer caused mortality (HR = 1.33, 95% CI: 1.12-1.58), when compared with nonopioid users. CONCLUSION Postoperative new persistent opioid use among cancer patients undergoing curative-intent surgery is associated with subsequent opioid overdose, worse survival, and more health resource utilization.
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Affiliation(s)
- Na Lin
- The Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eashita Dabas
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - May Lynn Quan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Winson Y Cheung
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Colleen Cuthbert
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Yuanchao Feng
- The Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shiying Kong
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Khara M Sauro
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Lin Yang
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Mingshan Lu
- Department of Economics, Faculty of Arts, University of Calgary, Calgary, Alberta, Canada
| | - Yuan Xu
- The Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Johnson E, Yoshida M, Hallway A, Byrnes M, Waljee J, Englesbe M, Howard R. "I Prefer to Stay Away": A Qualitative Study of Patients in an Opioid-Sparing Pain Management Protocol. Ann Surg 2023; 277:596-602. [PMID: 34787984 DOI: 10.1097/sla.0000000000005087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to explore beliefs and behaviors of opioid pain medications among patients undergoing elective surgery. BACKGROUND Opioid dependence after surgery is a major contributor to the ongoing opioid epidemic. Recent efforts by surgeons and health systems have sought to improve the education patients receive regarding safe opioid use after surgery; however, little is known about patients' pre-existing beliefs surrounding opioids. METHODS Semistructured interviews were conducted with patients who underwent 1 of 4 common elective surgical procedures at 1 institution. Patients were specifically asked about their knowledge and beliefs about opioids before surgery and their opinions of opioid-sparing recovery after surgery. Coding was conducted through iterative steps, beginning with an initial cycle of rapid analysis, followed by focused coding, and thematic analysis. RESULTS Twenty-one patients were interviewed. Three major themes emerged regarding patient opinions about using opioids after surgery. First, there was widespread awareness among patients about opioid medications, and preoperatively, patients had specific intentions about using opioids, often informed by this awareness. Second, patients described a spectrum of opioid related behavior which both aligned and conflicted with preoperative intentions. Third, there was tension among patients about opioid-free postoperative recovery, with patients expressing support, opposition, and emphasis on tailoring recovery to patient needs. CONCLUSIONS Patients undergoing common surgical procedures often arrive at their surgical encounter with strong, pre-formed opinions about opioids. Eliciting these preexisting opinions may help surgeons better counsel patients about safe opioid use after surgery.
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Affiliation(s)
- Emily Johnson
- University of Michigan Medical School, Ann Arbor, MI
| | - Maxwell Yoshida
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
| | | | - Mary Byrnes
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, Mi
| | - Jennifer Waljee
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Section of Transplant Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Ryan Howard
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, Mi
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La J, Alqaydi A, Wei X, Shellenberger J, Digby GC, Brogly SB, Merchant SJ. Variation in opioid filling after same-day breast surgery in Ontario, Canada: a population-based cohort study. CMAJ Open 2023; 11:E208-E218. [PMID: 36882209 PMCID: PMC10000904 DOI: 10.9778/cmajo.20220055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Postoperative pain management practices in breast surgery are variable, with recent evidence that approaches for minimizing or sparing opioids can be successfully implemented. We describe opioid filling and predictors of higher doses in patients undergoing same-day breast surgery in Ontario, Canada. METHODS In this retrospective population-based cohort study, we used linked administrative health data to identify patients aged 18 years or older who underwent same-day breast surgery from 2012 to 2020. We categorized procedure types by increasing invasiveness of surgery: partial, with or without axillary intervention (P ± axilla); total, with or without axillary intervention (T ± axilla); radical, with or without axillary intervention (R ± axilla); and bilateral. The primary outcome was filling an opioid prescription within 7 or fewer days after surgery. Secondary outcomes were total oral morphine equivalents (OMEs) filled (mg, median and interquartile range [IQR]) and filling more than 1 prescription within 7 or fewer days after surgery. We estimated associations (adjusted risk ratios [RRs] and 95% confidence intervals [CIs]) between study variables and outcomes in multivariable models. We used a random intercept for each unique prescriber to account for provider-level clustering. RESULTS Of the 84 369 patients who underwent same-day breast surgery, 72% (n = 60 620) filled an opioid prescription. Median OMEs filled increased with invasiveness (P ± axilla = 135 [IQR 90-180] mg; T ± axilla = 135 [IQR 100-200] mg; R ± axilla = 150 [IQR 113-225] mg, bilateral surgery = 150 [IQR 113-225] mg; p < 0.0001). Factors associated with filling more than 1 opioid prescription were age 30-59 years (v. age 18-29 yr), increased invasiveness (RR 1.98, 95% CI 1.70-2.30 bilateral v. P ± axilla), Charlson Comorbidity Index ≥ 2 versus 0-1 (RR 1.50, 95% CI 1.34-1.69) and malignancy (RR 1.39, 95% CI 1.26-1.53). INTERPRETATION Most patients undergoing same-day breast surgery fill an opioid prescription within 7 days. Efforts are needed to identify patient groups where opioids may be successfully minimized or eliminated.
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Affiliation(s)
- Julie La
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Anood Alqaydi
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Xuejiao Wei
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Jonas Shellenberger
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Geneviève C Digby
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Susan B Brogly
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont
| | - Shaila J Merchant
- Division of General Surgery and Surgical Oncology (La, Alqaydi, Merchant), Queen's University; ICES Queen's (Wei, Shellenberger, Brogly); Departments of Medicine (Digby) and Surgery (Brogly, Merchant), Queen's University, Kingston, Ont.
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Boudrias C, Migneault B, Plante F, Carrier FM. Postoperative opioid consumption and prescription in major abdominal surgery. Can J Anaesth 2023; 70:451-452. [PMID: 36536156 DOI: 10.1007/s12630-022-02383-1] [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: 11/02/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Catherine Boudrias
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
| | - Brigitte Migneault
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - François Plante
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - François M Carrier
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada.
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
- Carrefour de l'innovation et santé des populations, Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.
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Levy BE, Castle JT, Ebbitt LM, Kennon C, McAtee E, Davenport DL, Evers BM, Bhakta A. Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use. J Surg Res 2023; 283:296-304. [PMID: 36423479 DOI: 10.1016/j.jss.2022.10.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.
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Affiliation(s)
- Brittany E Levy
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Jennifer T Castle
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Laura M Ebbitt
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Caleb Kennon
- Department of Anesthesiology Residency Program, University of Kentucky, Lexington, Kentucky
| | - Erin McAtee
- Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - Daniel L Davenport
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - B Mark Evers
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Avinash Bhakta
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of Colon and Rectal Surgery, University of Kentucky, Lexington, Kentucky.
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Preoperative transversus abdominis plane block decreases intraoperative opiate consumption during minimally invasive cholecystectomy. Surg Endosc 2023; 37:2209-2214. [PMID: 35864354 DOI: 10.1007/s00464-022-09445-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as multimodal drug regimens and regional anesthetic blocks (like transversus abdominis plane (TAP) block), have been introduced to the perioperative period in hopes of decreasing postoperative opiate use. However, the effect of these interventions on intraoperative opiate use has not been examined. We hypothesized that preoperative TAP block would be associated with decreased intraoperative opiate use during minimally invasive cholecystectomy. METHODS This was a retrospective review of patients undergoing minimally invasive cholecystectomy between June 2018 and January 2021. Perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements. RESULTS 261 patients were included in this study, of which 62 (23.8%) received preoperative TAP block and 199 (76.2%) did not. Preoperative TAP block was associated with decreased intraoperative opiate use (0.199 vs 0.312, p < 0.001), while there were no statistically significant differences associated with other analgesic adjuncts including preoperative acetaminophen (p = 0.485), celecoxib (p = 0.112), gabapentin (p = 0.165), or intraoperative ketorolac (p = 0.200). On multivariate analysis, preoperative TAP block was independently associated with decreased intraoperative opiate use (< 0.001), while chronic cholecystitis on final pathology was associated with increased intraoperative opiate use (p = 0.002). CONCLUSION The use of preoperative TAP block was associated with decreased intraoperative opiate use during minimally invasive cholecystectomy and should be considered for routine use. Future research should investigate whether preoperative TAP blocks and a subsequent decrease of intraoperative opiates, also result in a decrease in postoperative opiate use and improvements in postoperative outcomes.
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Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy. Surgery 2023; 173:864-869. [PMID: 36336504 DOI: 10.1016/j.surg.2022.07.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/03/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy. METHODS In a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts. RESULTS There were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001). CONCLUSION Performing a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.
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Hamed MA, Fargaly OS, Abdelghaffar RA, Moussa MA, Algyar MF. The role of dexmedetomidine as an adjuvant for high-thoracic erector spinae plane block for analgesia in shoulder arthroscopy; a randomized controlled study. BMC Anesthesiol 2023; 23:53. [PMID: 36793000 PMCID: PMC9930274 DOI: 10.1186/s12871-023-02014-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Management of postoperative pain after shoulder arthroscopy is an important issue. Dexmedetomidine, as an adjuvant, improves nerve block efficacy and decreases postoperative consumption of opioids. As a result, we designed this study to determine if adding dexmedetomidine to an erector spinae plane block (ESPB) that is guided by ultrasound (US) is beneficial for treating immediate postoperative pain following shoulder arthroscopy. METHODS This randomized controlled double-blind trial recruited 60 cases 18-65 years old of both sexes, American Society of Anesthesiologists (ASA) physical status I-II, scheduled for elective shoulder arthroscopy. Random allocation of 60 cases was done equally into two groups according to the solution injected in US-guided ESPB at T2 before general anesthetic induction. Group (ESPB): 20 ml 0.25% bupivacaine. Group (ESPB + DEX): 19 ml bupivacaine 0.25% + 1 mL dexmedetomidine 0.5 µg/kg. The primary outcome was The total rescue morphine consumption in the first 24 postoperative hours. RESULTS The mean intraoperative fentanyl consumption was significantly lower in the group (ESPB + DEX) compared to the group (ESPB) (82.86 ± 13.57 versus 100.74 ± 35.07, respectively, P = 0.015). The median (IQR) time of the 1st rescue analgesic request was significantly delayed in the group (ESPB + DEX) compared to group (ESPB) [18.5 (18.25-18.75) versus 12 (12-15.75), P = 0.044]. The number of cases that required morphine was significantly lower in the group (ESPB + DEX) than in the group (ESPB) (P = 0.012). The median (IQR) of total postoperative morphine consumption in 1st 24 h was significantly lower in the group (ESPB + DEX) compared to the group (ESPB) [0 (0-0) versus 0 (0-3), P = 0.021]. CONCLUSION The dexmedetomidine as an adjuvant to bupivacaine in ESPB produced adequate analgesia by reducing the intraoperative and postoperative opioid requirements in shoulder arthroscopy. TRIAL REGISTRATION This study is registered on ClinicalTrials.gov (NCT05165836; principal investigator: Mohammad Fouad Algyar; registration date: 21/12/ 2021).
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Affiliation(s)
- Mohamed Ahmed Hamed
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, 63511, Egypt.
| | - Omar Sayed Fargaly
- grid.411170.20000 0004 0412 4537Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, 63511 Egypt
| | - Rana Ahmed Abdelghaffar
- grid.411170.20000 0004 0412 4537Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, 63511 Egypt
| | - Mohammed Ahmed Moussa
- grid.411170.20000 0004 0412 4537Department of Orthopedics, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Mohammad Fouad Algyar
- grid.411978.20000 0004 0578 3577Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Kafrelsheikh University, Kafr el-Sheikh, Egypt
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Zhang KK, Blum K, Chu JJ, Zewdu A, Janse S, Skoracki R, Janis JE, Barker JC. A Personalized Opioid Prescription Model for Predicting Postoperative Discharge Opioid Needs. Plast Reconstr Surg 2023; 151:450-460. [PMID: 36696335 PMCID: PMC10449368 DOI: 10.1097/prs.0000000000009865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Opioid overprescribing after surgery is common. There is currently no universal predictive tool available to accurately anticipate postdischarge opioid need in a patient-specific manner. This study examined the efficacy of a patient-specific opioid prescribing framework for estimating postdischarge opioid consumption. METHODS A total of 149 patients were evaluated for a single-center retrospective cohort study of plastic and reconstructive surgery patients. Patients with length of stay of 2 to 8 days and quantifiable inpatient opioid consumption (n = 116) were included. Each patient's daily postoperative inpatient opioid consumption was used to generate a personalized logarithmic regression model to estimate postdischarge opioid need. The validity of the personalized opioid prescription (POP) model was tested through comparison with actual postdischarge opioid consumption reported by patients 4 weeks after surgery. The accuracy of the POP model was compared with two other opioid prescribing models. RESULTS The POP model had the strongest association (R2 = 0.899; P < 0.0001) between model output and postdischarge opioid consumption when compared to a procedure-based (R2 = 0.226; P = 0.025) or a 24-hour (R2 = 0.152; P = 0.007) model. Accuracy of the POP model was unaffected by age, gender identity, procedure type, or length of stay. Odds of persistent use at 4 weeks increased, with a postdischarge estimated opioid need at a rate of 1.16 per 37.5 oral morphine equivalents (P = 0.010; 95% CI, 1.04 to 1.30). CONCLUSIONS The POP model accurately estimates postdischarge opioid consumption and risk of developing persistent use in plastic surgery patients. Use of the POP model in clinical practice may lead to more appropriate and personalized opioid prescribing.
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Affiliation(s)
- Kevin K. Zhang
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Kevin Blum
- Center for Regenerative Medicine, Nationwide Children’s Hospital, Columbus, OH
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH
| | - Jacqueline J. Chu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abeba Zewdu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Sarah Janse
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Medical Center, Columbus, OH
| | - Roman Skoracki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Jenny C. Barker
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
- Center for Regenerative Medicine, Nationwide Children’s Hospital, Columbus, OH
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Owens SM, Voigt P, Ponzini MD, Wilson MD, Chen HA. Perioperative Education and Postoperative Discharge Medications in Gynecologic Oncology Patients: Prescribing Practices, Clinical Encounters, and Patient Satisfaction. J Gynecol Surg 2023. [DOI: 10.1089/gyn.2022.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Steffanie M. Owens
- University of California Davis Medical Center, Sacramento, California, USA
| | - Petra Voigt
- University of California Davis Medical Center, Sacramento, California, USA
| | - Matthew D. Ponzini
- University of California Davis Medical Center, Sacramento, California, USA
| | - Machelle D. Wilson
- University of California Davis Medical Center, Sacramento, California, USA
| | - H. Amy Chen
- University of California Davis Medical Center, Sacramento, California, USA
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Reasons for Long-term Opioid Prescriptions After Guideline-directed Opioid Prescribing and Excess Opioid Pill Disposal. Ann Surg 2023; 277:173-178. [PMID: 36827492 DOI: 10.1097/sla.0000000000004967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal. BACKGROUND Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed. METHODS We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply. RESULTS 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess. CONCLUSIONS In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.
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Nam CS, Lai YL, Hu HM, George AK, Linsell S, Ferrante S, Brummett CM, Waljee JF, Dupree JM. Less is More: Fulfillment of Opioid Prescriptions Before and After Implementation of a Modifier 22 Based Quality Incentive for Opioid-Free Vasectomies. Urology 2023; 171:103-108. [PMID: 36243141 DOI: 10.1016/j.urology.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/03/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To examine the percentage of patients who filled peri-procedural opioid prescriptions before and after Blue Cross Blue Shield of Michigan (BCBSM) launched a modifier 22 payment incentive for opioid-sparing vasectomies in Michigan on July 1, 2019. METHODS We evaluated BCBSM administrative claims data from February 1, 2018 - November 16, 2020 for men 20 - 64 years old who underwent vasectomy or a control office-based urologic procedure (cystourethroscopy, prostate biopsy, circumcision, and transurethral destruction of prostate tissue.) The primary outcome was the percentage of patients who filled opioid prescriptions 30 days before to 3 days after their procedure. We performed an interrupted time series analysis to estimate changes in the percentage of patients who filled opioid prescriptions in the vasectomy and control group before and after July 1, 1019. RESULTS Our cohort included 4,559 men who had a vasectomy and 4,679 men who had a control procedure. Within each group, demographics and clinical factors were similar before and after July 1, 2019. Before implementation of the modifier 22 policy, 32.5% of men who had a vasectomy filled an opioid prescription whereas only 12.6% of men filled an opioid prescription after July 1, 2019 -a 19.9% absolute reduction and 61.0% relative reduction (P < .001). In the control group, there was no significant change in the percentage of patients who filled opioid prescriptions before and after July 1, 2019 (0.8% absolute increase, P = .671). CONCLUSION Implementation of modifier 22 based financial incentive for opioid-sparing vasectomies was associated with decrease in the percentage of men who filled opioid prescriptions after vasectomy.
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Affiliation(s)
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Hsou Mei Hu
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Arvin K George
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Susan Linsell
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Stephanie Ferrante
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI; Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Jennifer F Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - James M Dupree
- Department of Urology, Michigan Medicine, Ann Arbor, MI.
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Turner KM, Delman AM, Griffith A, Wima K, Wallen TE, Starnes SL, Budde BM, Van Haren RM. The Impact of Enhanced Recovery After Surgery on Persistent Opioid Use Following Pulmonary Resection. Ann Thorac Surg 2023; 115:249-255. [PMID: 35779597 DOI: 10.1016/j.athoracsur.2022.05.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/15/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been associated with improved perioperative outcomes after thoracic surgery; however, the impact on long-term opioid use remains unknown. The aim of our study was to evaluate the effects of ERAS on long-term opioid use. METHODS Patients who underwent pulmonary resection were identified from a prospectively maintained database and linked to the regional prescription drug monitoring program. Outcomes were compared between pre-ERAS (February 2016 to November 2018) and ERAS (December 2018 to June 2020) cohorts. Our ERAS protocol included regional anesthetic, multimodal pain control, and protocolized rehabilitation. RESULTS We analyzed 240 pulmonary resections, 64.6% (n = 155) in the pre-ERAS era and 35.4% (n = 85) in the ERAS era. Baseline characteristics were similar; however, more patients in the ERAS cohort underwent minimally invasive surgery (67.7% vs 87.9%; P = .002). Median length of stay was reduced (5 days vs 4 days; P = .03) upon implementation of ERAS, with no change in perioperative complications or readmission rate. On multivariate analysis, ERAS was associated with decreased total inpatient morphine milligram equivalent and discharge morphine milligram equivalent. However, both long-term opioid use up to 1 year postoperatively and new persistent opioid use remained similar despite implementation of ERAS. On multivariate analysis, implementation of ERAS was not associated with a reduction in opioid use 14 to 90 days postoperatively or persistent opioid use 90 to 180 days postoperatively. CONCLUSIONS Despite short-term opioid reduction, long-term opioid use persisted after implementation of ERAS. Additional strategies to monitor for and avoid opioid dependence are urgently needed to prevent chronic opioid use after pulmonary resection.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Azante Griffith
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sandra L Starnes
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bradley M Budde
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Cogan JC, Raghunathan RR, Beauchemin MP, Accordino MK, Huang Y, Elkin EB, Melamed A, Wright JD, Hershman DL. New and Persistent Sedative-Hypnotic Use After Adjuvant Chemotherapy for Breast Cancer. J Natl Cancer Inst 2022; 114:1698-1705. [PMID: 36130058 PMCID: PMC9745429 DOI: 10.1093/jnci/djac170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/19/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Sedative-hypnotic medications are used to treat chemotherapy-related nausea, anxiety, and insomnia. However, prolonged sedative-hypnotic use can lead to dependence, misuse, and increased health-care use. We aimed to estimate the rates at which patients who receive adjuvant chemotherapy for breast cancer become new persistent users of sedative-hypnotic medications, specifically benzodiazepines and nonbenzodiazepine sedative-hypnotics (Z-drugs). METHODS Using the MarketScan health-care claims database, we identified sedative-hypnotic-naïve patients who received adjuvant chemotherapy for breast cancer. Patients who filled 1 and more prescriptions during chemotherapy and 2 and more prescriptions up to 1 year after chemotherapy were classified as new persistent users. Univariate and multivariable logistic regression analyses were used to estimate odds of new persistent use and associated characteristics. RESULTS We identified 22 039 benzodiazepine-naïve patients and 23 816 Z-drug-naïve patients who received adjuvant chemotherapy from 2008 to 2017. Among benzodiazepine-naïve patients, 6159 (27.9%) filled 1 and more benzodiazepine prescriptions during chemotherapy, and 963 of those (15.6%) went on to become new persistent users. Among Z-drug-naïve patients, 1769 (7.4%) filled 1 and more prescriptions during chemotherapy, and 483 (27.3%) became new persistent users. In both groups, shorter durations of chemotherapy and receipt of opioid prescriptions were associated with new persistent use. Medicaid insurance was associated with new persistent benzodiazepine use (odds ratio = 1.88, 95% confidence interval = 1.43 to 2.47) compared with commercial or Medicare insurance. CONCLUSIONS Patients who receive sedative-hypnotic medications during adjuvant chemotherapy for breast cancer are at risk of becoming new persistent users of these medications after chemotherapy. Providers should ensure appropriate sedative-hypnotic use through tapering dosages and encouraging nonpharmacologic strategies when appropriate.
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Affiliation(s)
- Jacob C Cogan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Rohit R Raghunathan
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Melissa P Beauchemin
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Melissa K Accordino
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Yongmei Huang
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Elena B Elkin
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
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Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1-95. [PMID: 36327391 PMCID: PMC9639433 DOI: 10.15585/mmwr.rr7103a1] [Citation(s) in RCA: 426] [Impact Index Per Article: 213.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.
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Haskins IN, Duchesneau ED, Agala CB, Lumpkin ST, Strassle PD, Farrell TM. Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database. Surg Endosc 2022; 36:8430-8440. [PMID: 35229211 PMCID: PMC9733437 DOI: 10.1007/s00464-022-09123-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use. METHODS Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression. RESULTS A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively. CONCLUSIONS Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.
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Affiliation(s)
- Ivy N Haskins
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
| | - Emilie D Duchesneau
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Chris B Agala
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | | | - Paula D Strassle
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Oh TK, Kim HG, Song IA. New, long-term opioid use after lung cancer surgery is associated with reduced 2-year survival: a retrospective population-based cohort study in South Korea. Reg Anesth Pain Med 2022; 47:rapm-2022-103769. [PMID: 36096683 DOI: 10.1136/rapm-2022-103769] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/29/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION We aimed to investigate the proportion and associated factors for new long-term opioid use and its long-term effects after lung cancer surgery. METHODS The South Korean National Health Insurance Database was used as a nationwide registration data source. All patients undergoing lung cancer surgery between 2011 and 2018 were included, and patients who were preoperative opioid users were excluded from the analysis. New long-term opioid use was defined as an active opioid prescription at 6 months postoperatively. RESULTS In total, 54 509 patients were included in the final analysis. At 6 months postoperatively, 3325 (6.1%) patients who were newly prescribed opioids comprised the new long-term opioid user group. Older age, male sex, wider surgical extent, open thoracotomy, increased Charlson Comorbidity Index score, neoadjuvant or adjuvant chemotherapy, preoperative anxiety disorder and insomnia disorder were associated with a higher rate of new long-term opioid use. The new long-term opioid user group showed a 40% (HR, 1.40; 95% CI 1.29 to 1.53; p<0.001) higher risk of 2-year all-cause mortality. Moreover, the new long-term potent opioid user and less potent opioid user groups showed a 92% (HR, 1.92; 95% CI 1.67 to 2.21; p<0.001) and 22% (HR, 1.22; 95% CI 1.10 to 1.36; p<0.001) higher risk of 2-year all-cause mortality, respectively. CONCLUSIONS Among preoperative opioid-naive patients in South Korea, 6.1% became new long-term opioid users after lung cancer surgery. Certain factors are potential risk factors for new long-term opioid use, which could be associated with poorer long-term survival outcomes.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyeong Geun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Isokääntä S, Ruohoaho UM, Anttila M, Kokki H, Sintonen H, Toroi P, Kokki M. Resilience, pain, and health-related quality of life in gynecological patients undergoing surgery for benign and malignant conditions: a 12-month follow-up study. BMC Womens Health 2022; 22:345. [PMID: 35974326 PMCID: PMC9382813 DOI: 10.1186/s12905-022-01923-7] [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] [Received: 01/07/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Gynecological surgery has many impacts on women’s physical and mental health, and efforts to improve recovery from surgery are constantly under evaluation. Resilience is an ability to overcome stressors and adversities, such as traumas and surgeries. This study aimed to explore patients’ resilience and psychological symptoms in relation to recovery, health-related quality of life (HRQoL), and pain one year after gynecological surgery. Methods In a prospective cohort study, we enrolled consecutive elective gynecologic surgery patients who completed questionnaires before and at one year after surgery: the Resilience Scale-25, the 15D instrument of HRQoL (15D), the Life Satisfaction Scale-4, and the Hospital Anxiety and Depression Scale. Their mean 15D scores were compared to those of an age-matched sample of women from the general Finnish population (n = 2743). Results We enrolled 271 women who underwent gynecological surgery due to benign (n = 190) and malignant (n = 81) diagnoses. Resilience was equally high in women with benign and malignant diagnoses at both time points. Higher resilience associated with less pain, analgesic use, and better pain relief from the use of pain medication at 12 months after surgery. Pain intensity was similar in the two groups, but patients with benign diseases had less pain at 12 months than before surgery. Before surgery, patients’ HRQoL was worse than that of the general population, but at 12 months the mean HRQoL of patients with benign diseases had improved to the same level as that in the general population but had decreased further in patients with malignant diseases. Anxiety was higher and life satisfaction was lower in patients with malignant diseases before surgery. At 12 months, anxiety had decreased in both groups, and life satisfaction had increased in patients with malignant diseases. Depression was similarly low in both groups and time points. Conclusions Resilience correlated with less pain one year after surgery. After surgery, HRQoL improved in patients with benign diseases but deteriorated in patients with malignant diseases. Patients with low resilience should be identified during preoperative evaluation, and health care professionals should give these patients psychological support to enhance their resilience. Trial Registration ClinicalTrials.gov; registered October 29, 2019; identifier: NCT04142203; retrospectively registered.
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