Prescription Opioid Use and Satisfaction With Care Among Adults With Musculoskeletal Conditions

Emotional barriers and facilitators of deprescribing for older adults with cancer and polypharmacy: a qualitative study

PURPOSE

To describe emotional barriers and facilitators to deprescribing (the planned reduction or discontinuation of medications) in older adults with cancer and polypharmacy.

METHODS

Virtual focus groups were conducted over Zoom with 5 key informant groups: oncologists, oncology nurses, primary care physicians, pharmacists, and patients. All groups were video- and audio-recorded and transcribed verbatim. Focus group transcripts were analyzed using inductive content analysis, and open coding was performed by two coders. A codebook was generated based on the initial round of open coding and updated throughout the analytic process. Codes and themes were discussed for each transcript until consensus was reached. Emotion coding (identifying text segments expressing emotion, naming the emotion, and assigning a label of positive or negative) was performed by both coders to validate the open coding findings.

RESULTS

All groups agreed that polypharmacy is a significant problem. For clinicians, emotional barriers to deprescribing include fear of moral judgment from patients and colleagues, frustration toward patients, and feelings of incompetence. Oncologists and patients expressed ambivalence about deprescribing due to role expectations that physicians "heal with med[ication]s." Emotional facilitators of deprescribing included the involvement of pharmacists, who were perceived to be neutral, discerning experts. Pharmacists described emotionally aware communication strategies when discussing deprescribing with other clinicians and expressed increased awareness of patient context.

CONCLUSION

Deprescribing can elicit strong and predominantly negative emotions among clinicians and patients which could inhibit deprescribing interventions. The involvement of pharmacists in deprescribing interventions could mitigate these emotional barriers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05046171 . Date of registration: September 16, 2021.

The Association of Postoperative Opioid Prescriptions with Patient Outcomes

OBJECTIVE

To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids.

SUMMARY OF BACKGROUND DATA

Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks.

METHODS

We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups.

RESULTS

In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids ( P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%- 85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)].

CONCLUSIONS

Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.

"Can we have a little humanity here?": Patient perspectives on the impact of a standardized care process for patients who use opioids for the management of chronic pain

OBJECTIVE

Standardized processes have evolved in response to the opioid epidemic. The impact of standardized processes on patients has not been adequately described.

METHODS

Five focus groups were held at four affiliated academic family medicine clinics. All participants experienced a transition to a standardized process for their ongoing opioid use for chronic, non-cancer pain. Data was analyzed and coded using a grounded theory approach with NVivo12 (QSR International).

RESULTS

Thirty patients participated. Five main themes emerged: experience of pain; view of opioid medications; view of opioid prescribing process changes; "good patients" and trust; and experience with medical clinicians and clinics.

CONCLUSIONS

Standardized processes created to improve the safety of opioid prescribing have burdened patients and resulted in a loss of trust and autonomy. Patients perceived greater risks for other patients prescribed opioids and processes are a result of their actions.

PRACTICE IMPLICATIONS

Healthcare systems must acknowledge patients' burden, shift away from interventions that are limited in supporting data, reinforce patient agency and shift the conversation to unsafe medications rather than supervision of "bad actors".

Patient satisfaction with clinical pharmacy services and the affecting factors: a literature review

Service quality is measured to assess the consistency of medical services provided to fulfill patient expectations. This article provides an overview of patient satisfaction with clinical pharmacy services and the influencing factors. A literature search from MEDLINE and EBSCO databases was performed with the keywords “patient satisfaction”, “pharmacy service”, “hospital pharmacy service”, and “clinical pharmacy service”. The inclusion criteria for articles are original articles, full papers, articles in English, and published in 2011–2021. A total of 25 articles from 1,118 articles discussed patient satisfaction with clinical pharmacy services such as counseling, drug therapy monitoring, patient support programs, and pharmaceutical care. Generally, patients are satisfied with clinical pharmacy services such as counseling, drug therapy monitoring, patient support programs, and pharmaceutical care. The most influencing factors with clinical pharmacy services are the quality, convenience, ease of information, and confidence in pharmacist competence. Pharmacists should equip themselves with the appropriate knowledge and competencies in clinical pharmacy services for benefits their patients.

The effect of patient satisfaction scores on physician clinical decision making: A possible factor driving utilization of opioid prescriptions, magnetic resonance imaging, and interventional spine procedures

Objective

To survey the effect of patient satisfaction scores on pain physicians' medical decision making, with an emphasis on resource utilization.

Design

Email-based Survey.

Methods

Setting & Subjects: A 23-question survey was approved for dissemination to membership of a medical society and emailed to all members. The survey was also available online and via a promoted QR code.

Results

An email with link to the survey was viewed 1,116 times, and clicked on 223 times, with 75 members completing the survey online once the link was clicked. Thirty-three additional physicians directly accessed the survey online and completed it. Seventy-seven percent of physicians reported that patient satisfaction scores were tracked by their institution and were used as a consideration in financial compensation (22%) or performance review (36%). Over half of the physicians surveyed reported feeling that satisfaction scores would decline if they did not order MRI imaging, prescribe opioids or provide work restrictions/disability. Thirty percent reported to have performed a spine injection due to concern about patient satisfaction scores. Twenty-one reported that they had prescribed an opioid medication because of this concern. Lastly 25% and 24% have filled out disability paperwork or provided a disability parking placard respectively.

Conclusions

Over half of physicians surveyed reported having ordered physical therapy, MRIs, opioid medications, spine injections, or provided disability documentation over concern about how providing or not providing such things impacts patient satisfaction scores. This may be an unintended consequence of the current emphasis placed on patient satisfaction scores.

Association of Primary Care Physician Compensation Incentives and Quality of Care in the United States, 2012-2016

BACKGROUND

Physician compensation incentives may have positive or negative effects on clinical quality.

OBJECTIVE

To assess the association between various physician compensation incentives on technical indicators of primary care quality.

DESIGN

Cross-sectional, nationally representative retrospective analysis.

PARTICIPANTS

Visits by adults to primary care physicians in the National Ambulatory Medical Care Survey from 2012-2016. We analyzed 49,580 sampled visits, representing 1.45 billion primary care visits.

MAIN MEASURES

We assessed the association between 5 compensation incentives - quality measure performance, patient experience scores, individual productivity, practice financial performance, or practice efficiency - and 10 high-value and 7 low-value care measures as well as high-value and low-value care composites.

KEY RESULTS

Quality measure performance was an incentive in 22% of visits; patient experience scores, 17%; individual productivity, 57%; practice financial performance, 63%; and practice efficiency, 12%. In adjusted models, none of the compensation incentives were consistently associated with individual high- and low-value measures. None of the compensation incentives were associated with high- or low-value care composites. For example, quality measure performance compensation was not significantly associated with high-value care (visits with quality incentive, 47% of eligible measures met; without quality incentive, 43%; adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI], 0.91 to 1.15) or low-value care (aOR, 0.99; 95% CI, 0.82-1.19). Physician compensation incentives that might be expected to increase low-value care did not: patient experience (aOR for low-value care composite, 0.83; 95% CI, 0.65-1.05), individual productivity (aOR, 1.03; 95% CI, 0.88-1.22), and practice financial performance (aOR, 1.05; 95% CI, 0.81-1.36).

CONCLUSION

In this retrospective, cross-sectional, nationally representative analysis of care in the United States, physician compensation incentives were not generally associated with more or less high- or low-value care.

Prescription opioids are commonly unused after ambulatory head and neck surgeries: Opioids prescription presence and size has no effect on patient satisfaction with pain control

PURPOSE

To explore the opioid prescribing practices after common ambulatory head and neck surgeries in a large academic institution; and to examine the association between opioid prescription and the patient's satisfaction with pain control.

METHODS

This retrospective cohort study conducted in a tertiary academic medical center. Phone interviews of patients who underwent ambulatory head and neck surgeries one month after their procedures were conducted. The interview included, among several questions, the amount of opioid prescribed and consumed, the use of non-opioid pain medications, and the patient's satisfaction with pain control. Logistic regression models were used to investigate the significant factors affecting the patient's satisfaction with pain control.

RESULTS

Most patients were prescribed opioids at discharge (84%). Of those, 17% did not use their prescriptions. The median of leftover opioid was 76.50 morphine milligram equivalents (MMEs) with IQR (45-130.95). Patient satisfaction with pain control is not associated with opioid prescription at discharge (OR 0.195 [95% CL, 0.036-1.036], p = 0.059) or the amount of the prescribed opioid (OR 1.001 [95% CL, 0.997-1.004], p = 0.717) after controlling for other patient and procedural factors.

CONCLUSION

A significant portion of ambulatory head and neck surgery patients were discharged with opioid prescriptions they may not use. Patient satisfaction with pain control is not associated with the presence or the amount of opioid prescribed.

The Relationship Between Patient Satisfaction and Healthcare Expenditures in Adults with Spine Related Disorders: An Analysis of the 2008 to 2015 Medical Expenditures Panel Survey (MEPS)

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The aim of this study was to investigate the relationship between patient satisfaction (PS) and healthcare expenditures (HCE) in adults with spine related disorders (SRDs).

SUMMARY OF BACKGROUND DATA

SRDs are widespread and pose a high cost to society. PS and HCE have yet to be studied in this population.

METHODS

Fifteen thousand eight hundred fifty adults with SRDs from the Medical Expenditures Panel Survey (MEPS) (2008-2015) were analyzed. The MEPS medical conditions files were used to identify SRDs based on International Classification of Diseases-9 codes. Frequencies and percentages of sample demographics were calculated. HCE was measured as total direct payments for care provided during the survey year. A composite PS score was constructed using a 0 to 10 rating of their healthcare providers combined with the frequency in which patients felt they were listened to, were given understandable explanations, were respected, and were given enough time. Mean unadjusted HCE were calculated for each year and by quartile of PS. A two-part model consisting of a probit model and subsequent generalized linear model with gamma distribution was performed, adjusting for relevant covariates. Margins command was used to calculate incremental estimates of HCE.

RESULTS

Mean unadjusted HCE increased annually from $7057 (95% confidence interval [CI], $6516, $7597) in 2008 to $9820 (95% CI, $8811, $10,830) in 2015 for adults with SRDs. Adjusting for predisposing factors, individuals in second, third, and fourth quartiles of PS were significantly different from the first quartile. Adjusting for predisposing and enabling factors, only fourth quartile was significantly different from first quartile. After adjusting for predisposing, enabling and need factors, second, third, and fourth quartiles were no longer significantly different from the first quartile.

CONCLUSION

Expenditures have increased over time in adults with SRDs. PS is significantly associated with expenditures after controlling for predisposing and enabling factors, but not significant after controlling for need factors. Need factors appear to explain the relationship between lower levels of PS and higher HCE in adults with SRDs.Level of Evidence: 2.

Direct-to-Consumer Drug Advertisement and Prescribing Practices: Evidence Review and Practical Guidance for Clinicians

Direct to consumer advertising (DTCA) of prescription drugs has increased dramatically in the past two decades. The effect of this increase in advertising on the frequency of inappropriate prescribing is poorly understood, as are the factors that may underly inappropriate prescribing. A review of existing observational and experimental studies that address advertising-related prescription requests and contain some measure of prescription appropriateness demonstrate that DTCA increases prescription requests, increases the likelihood of prescription, and increases both appropriate and inappropriate prescribing. Patient expectations, insufficient information sharing, and patient satisfaction surveys are proposed contributors to potentially inappropriate prescribing in response to DTCA.

Factors associated with persistent opioid use after an upper extremity fracture

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.

Methods

A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support.

Results

A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001).

Conclusion

This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health.

Cite this article: Bone Jt Open 2021;2(2):119–124.

Narcotic Refills and Patient Satisfaction With Pain Control After Total Joint Arthroplasty

BACKGROUND

Patient satisfaction has become an important metric for total joint arthroplasty (TJA) used to reimburse hospitals. Despite ubiquitous narcotic use for post-TJA pain control, there is little understanding regarding patient factors associated with obtaining opioid refills and associations with patient satisfaction.

METHODS

Using our state's mandatory opioid prescription monitoring program, we reviewed preoperative and postoperative narcotic prescriptions filled for 438 consecutive TJA patients. Subjects were divided into 3 groups based on the number of post-TJA narcotic refills obtained (0, 1, or >1), and logistic regression analysis was conducted comparing demographics, surgical factors, and satisfaction with pain control.

RESULTS

One hundred twenty-five patients (25.8%) did not consume preoperative opioids and received no postoperative refills. Total hip arthroplasty (THA) patients (P = .0004), subjects ≥65 years (P = .0057), and Medicare patients (P = .0058) had significantly higher rates of 0 postdischarge refills. THA recipients had 268% increased odds of not receiving a refill narcotic (adjusted odds ratio = 0.373; 95% confidence interval, 0.224- 0.622). Every 100-morphine milligram equivalent (MME) increase in presurgery use led to a 16% increase in odds of needing >1 opioid refill (adjusted odds ratio = 1.161; 95% confidence interval, 1.085-1.242). Subjects who noted higher satisfaction consumed less overall opioids when receiving a refill (436 vs 1119 MMEs, P = .021).

CONCLUSION

Subjects who received fewer narcotic prescriptions and overall MMEs demonstrated higher rates of satisfaction with early pain control. Our results are consistent with other studies in showing that increased preoperative narcotic use portends higher rates of postoperative refills. There appears to be a subset of THA patients >65 years of age who may be candidates for opioid-sparing analgesia.

Opioids and Kidney Stones

In recent years, the use of opioids in medical practice has come under significant scrutiny. This, in part, is owing to evidence of overprescription and overuse of opioid medications, as well as the unintended consequences and side effects for patients who take these medications. Here, we review the role of opioids and the responsible use of these medications with respect to kidney stone disease and surgical interventions for kidney stones.

Predictors of long-term opioid use and opioid use disorder among construction workers: Analysis of claims data

BACKGROUND

Construction workers have high rates of work-related musculoskeletal disorders, which lead to frequent opioid use and opioid use disorder (OUD). This paper quantified the incidence of opioid use and OUD among construction workers with and without musculoskeletal disorders.

METHODS

We conducted a retrospective study using union health claims from January 2015 to June 2018 from 19,909 construction workers. Claims for diagnoses of chronic musculoskeletal disorders, acute musculoskeletal injuries, musculoskeletal surgery, and other conditions were linked to new opioid prescriptions. We examined the effects of high doses (≥50 morphine mg equivalents per day), large supply (more than 7 days per fill), long-term opioid use (60 or more days supplied within a calendar quarter), and musculoskeletal disorders, on the odds of a future OUD.

RESULTS

There were high rates (42.8% per year) of chronic musculoskeletal disorders among workers, of whom 24.1% received new opioid prescriptions and 6.3% received long-term opioid prescriptions per year. Workers receiving opioids for chronic musculoskeletal disorders had the highest odds of future OUD: 4.71 (95% confidence interval 3.09-7.37); workers prescribed long-term opioids in any calendar quarter had a nearly 10-fold odds of developing an OUD.

CONCLUSIONS

Among construction workers, opioids initiated for musculoskeletal pain were strongly associated with incident long-term opioid use and OUD. Musculoskeletal pain from physically demanding work is likely one driver of the opioid epidemic in occupations like construction. Prevention of work injuries and alternative pain management are needed for workers at risk for musculoskeletal injuries.

Variation in Postoperative Opioid Prescribing Among Upper-Extremity Surgery Providers

Purpose

To identify targets for corrective interventions and guide improved opioid stewardship, we studied opioid prescribing patterns of attending surgeons compared with surgical trainees for 2 upper-extremity surgeries: open reduction internal fixation (ORIF) of distal radius fractures (DRF), and carpal tunnel release (CTR).

Methods

We retrospectively reviewed records for all patients who underwent CTR or DRF ORIF at 6 hospitals across a large health system from 2016 to 2018. We collected prescriber training level (attending vs trainee), analgesic prescribed, and amount initially prescribed after surgery converted to oral morphine equivalents (OMEs). Regression models evaluated OMEs by prescriber and surgery type. Our final models included an interaction term between prescriber training level and year of surgery to assess group changes over time. No prescription guidelines or formal training was provided during the study period.

Results

We included 707 CTR and 383 DRF ORIF patients. Opioids prescribed by trainees ranged from 90 to 300 OMEs (median, 180 OMEs). Opioids prescribed by attendings ranged from 100 to 225 OMEs (median, 150 OMEs). Early in the analyses, trainees prescribed significantly more than attendings (320 versus 180). Over time, trainees reduced overprescribing significantly more, by an additional 40 OME/y. By the end of the analysis period, trainees were prescribing less OME than were attendings (112.5 vs 150). Both groups continued to prescribe more than recently suggested amounts for both procedures.

Conclusions

Our study found that both attendings and trainees overprescribed opioids after surgery. Trainees prescribed more than attendings over the study period; however, when analyzing for improvement over time and with no formal intervention or training, trainees showed greater improvement, eventually dropping to levels at or below that of attendings. Considering that most change was seen at the trainee level, education for established providers may be an area in which more improvement can be made.

Clinical relevance

Understanding which providers are more likely to overprescribe opioids can help guide interventions that improve opioid stewardship.

Patient Satisfaction in Academic Pain Management Centers: How Do We Compare?

PURPOSE OF REVIEW

The aim of the study was to investigate patient satisfaction amongst academic pain management centers and associated factors.

RECENT FINDINGS

Approximately 25% of pain management centers perform better than other practices on Press Ganey surveys. The majority of respondents (96%) indicated that pain management practices were uniquely positioned to receive poorer scores on patient satisfaction surveys. The majority of respondents (20/26), who reported a reason, indicated that limiting opioid prescribing led to poor patient satisfaction scores. Eighty-three percent of respondents indicated that they received pressure from administrators to improve patient satisfaction scores. The opioid epidemic in the USA must be addressed in order to diminish the senseless loss of life that is occurring in staggering numbers. The quality of care physicians provide has increasingly been assessed via patient satisfaction surveys. The results of these surveys often are utilized to provide financial incentives to physicians to obtain higher satisfaction scores. In the field of pain management, physicians may experience pressure to prescribe opioids in order to obtain higher patient satisfaction scores.

Prevalence of Therapeutic use of Opioids in Chronic non-Cancer Pain Patients and Associated Factors: A Systematic Review and Meta-Analysis

Objectives: To determine the prevalence and factors associated with the use of opioids among patients with chronic non-cancer pain (CNCP).

Methods: A systematic review and meta-analysis. Comprehensive literature searches in Medline-PubMed, Embase and SCOPUS databases. Original studies published between 2009 and 2019 with a cross-sectional design were included. The quality of the studies was assessed with Critical Appraisal Checklist for Studies Reporting Prevalence Data from the Joanna Briggs Institute. Protocol registered in the International Prospective Register of Systematic Reviews with reference number: CRD42019137990.

Results: Out of the 1,310 potential studies found, 25 studies fulfilled the inclusion criteria. Most of the studies were of high quality. High levels of heterogeneity were found in the studies included. In the general population, the prevalence of long-term opioid use was 2.3% (95% CI: 1.5–3.6%), the prevalence of short-term opioid use was 8.1% (95% CI: 5.6–11.6%), and among people with chronic low back pain it was 5.8% (95% CI: 0.5–45.5%). The prevalence of opioid use among patients from the health records or medical surveys was 41% (95% CI: 23.3–61.3%). Finally, in patients with musculoskeletal pain, the prevalence was 20.5% (95% CI: 12.9–30.9%) and in patients with fibromyalgia, 24.5% (95% CI: 22.9–26.2%). A higher prevalence of opioid use was observed among men, younger people, patients receiving prescriptions of different types of drugs, smokers and patients without insurance or with noncommercial insurance. In addition, non-white and Asian patients were less likely to receive opioids than non-Hispanic white patients.

Conclusions: The prevalence of opioid use among patients with CNCP was higher in subjects with short or occasional use compared to those with long-term use. Men, younger people, more chronic pain conditions, and patients without insurance or with noncommercial insurance were most related to opioid use. However, non-white and Asian patients, and those treated by a physician trained in complementary medicine were less likely to use opioids.

The effect of patient satisfaction scores on physician job satisfaction and burnout

Physician burnout is recognized as reversible with the potential to negatively influence quality of care and patient outcomes. The study objective was to evaluate associations between patient satisfaction scores (PSS) and physicians' perceptions of job satisfaction and burnout via a physician survey. Eighty two out of 107 report PSS are institutionally tracked, with 23/107 and 39/107 reporting PSS utilization in financial compensation or performance review, respectively. Fifty four out of 107, report pressure to emphasize PSS; 63/107, report PSS having negative effect on job satisfaction; 31/107 considered leaving their job or career due to PSS and 84/107 report PSS contribute to burnout. In the cohort of physicians treating patients with spine pain who responded to this survey, PSS are associated with decreased job satisfaction and increased burnout.

Association of Decreased Postsurgical Opioid Prescribing With Patients' Satisfaction With Surgeons

Importance

Opioid overdose is the leading cause of injury-related death in the United States. Several studies have shown that surgeons overprescribe opioids, and guidelines for appropriate opioid prescribing are available. Concern about patient-reported satisfaction scores may be a barrier to surgeons adopting guideline-directed prescribing.

Objective

To determine whether decreased opioid prescribing is associated with a decrease in patient-reported satisfaction with their surgeon.

Design, Setting, and Participants

Retrospective analysis of clinician satisfaction scores at Dartmouth-Hitchcock Medical Center obtained in 2 periods: 1 before (period A) and 1 after (period B) an educational intervention that resulted in decreased opioid prescribing. The analysis included 11 surgeons who performed 5 common outpatient general surgical operations on 996 patients. Data were analyzed between March and August 2018.

Main Outcomes and Measures

Patient-reported overall satisfaction rating of the surgeon (scale, 0-10). This was collected by a nonstudy-related, routine general institutional survey of approximately 40% of all outpatient encounters.

Results

Of the total number of patients, 67% were women (667 of 996), and the mean patient age was 58 years. Comparing period A with B, the proportion of patients prescribed opioids decreased from 90.2% (n = 367 of 407) to 72.8% (n = 429 of 589) (P < .001). The mean number of opioid pills per prescription decreased from 28.3 to 13.3 (P < .001) and significantly decreased for each of the 11 surgeons. One hundred five of 996 patients (10.5%) undergoing index operations responded to the survey. There was no difference in the mean clinician satisfaction ratings from period A vs B (9.70 vs 9.65; P = .69). During the study periods, 640 total surveys were collected referencing these surgeons (including outpatient encounters associated with operations other than the 5 index cases). There was no difference in the mean satisfaction ratings from period A vs period B (9.55 vs 9.59; P = .62). When individual clinicians were analyzed, none had a significant difference in overall satisfaction rating from period A vs period B.

Conclusions and Relevance

Despite a marked decrease in the proportion of patients receiving opioids and in the number of pills prescribed, there was no significant change in clinician satisfaction ratings.

Confronting challenges to opioid risk mitigation in the U.S. health system: Recommendations from a panel of national experts

BACKGROUND

Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors.

OBJECTIVE

We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S.

DESIGN

We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems.

PARTICIPANTS

Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated.

APPROACH

Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation.

KEY RESULTS

Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery.

CONCLUSIONS

Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.

Obesity and Incident Prescription Opioid Use in the U.S., 2000-2015

INTRODUCTION

Prior studies have identified associations between obesity and numerous conditions that increase risks for chronic pain. However, the impact of obesity on prescription opioid use is not well known. This study investigates the association between obesity and incidence of long-term prescription opioid use.

METHODS

Fifteen panels of the Medical Expenditure Panel Survey from 2000 to 2015 were pooled to generate a sample of civilian non-institutionalized adults aged 30-84 years who were prescription opioid-naïve for approximately 9 months. Incident long-term prescription opioid use was defined as reporting use at 2 of 3 interviews during a 15-month follow-up. BMI was reported at baseline. Analyses were completed in 2019.

RESULTS

Among opioid-naïve adults (n=89,629), obesity was strongly associated with incident long-term prescription opioid use. The association increased at progressively higher BMI values, with 24% elevated odds (95% CI=7%, 44%) in adults with overweight (25-29.9 kg/m²) and 158% increased odds (95% CI=106%, 224%) among adults with Class III obesity (40-49.9 kg/m²). These associations grew with higher-dosage opioids. Of the reasons for opioid use, joint pain, back pain, injury, and muscle/nerve pain contributed the most to the excess use observed among adults with obesity. At the population level, 27.0% of incident long-term prescription opioid use (95% CI=19.0%, 34.8%) was attributable to adults having a BMI above normal weight (25-49.9 kg/m²).

CONCLUSIONS

These findings suggest that obesity has contributed to prescription opioid use in the U.S. Future investments in chronic pain reduction may benefit from increased integration with obesity prevention and treatment.

Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US

IMPORTANCE

Prior studies have identified an association between obesity and prescription opioid use in the US. However, the pain conditions that are factors in this association remain unestablished.

OBJECTIVE

To investigate the association between obesity and pain diagnoses recorded by primary care clinicians as reasons for prescription of opioids.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study including 565 930 patients aged 35 to 64 years with a body mass index (BMI) measurement recorded in 2016 was conducted. Electronic health records of patients seen by primary care clinicians in the US in the multipayer athenahealth network from January 1, 2015, to December 31, 2017, were reviewed, and data were analyzed from March 1 to September 15, 2019.

MAIN OUTCOMES AND MEASURES

Any prescription of opioids in the 365 days before or after the first BMI measurement in 2016 were identified. All International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, claims within 7 days before each opioid prescription were captured and classified using a pain diagnosis typologic system. Weight was categorized as underweight (BMI, 18.5-19.9), normal weight (BMI, 20.0-24.9), overweight (BMI, 25.0-29.9), obese I (BMI, 30-34.9), obese II (BMI, 35.0-39.9), obese III (BMI, 40.0-49.9), and obese IV (BMI, 50.0-80.0).

RESULTS

Among 565 930 patients, 329 083 (58.1%) were women. A total of 125 093 patients (22.1%) were aged 35 to 44 years, 199 384 patients (35.2%) were 45 to 54 years, and 241 453 patients (42.7%) were 55 to 64 years. A total of 177 631 patients (31.4%) were overweight and 273 135 patients (48.2%) were obese at baseline. Over 2 years, 93 954 patients (16.6%) were prescribed opioids. The risk of receiving prescription opioids increased progressively with BMI (adjusted relative risk for overweight: 1.08; 95% CI, 1.06-1.10; obese I: 1.24; 95% CI, 1.22-1.26; obese II: 1.33; 95% CI, 1.30-1.36; obese III: 1.48; 95% CI, 1.45-1.51; and obese IV, 1.71; 95% CI, 1.65-1.77). The percentage of patients with opioid prescriptions attributable to an overweight or obese BMI was 16.2% (95% CI, 15.0%-17.4%). Prescription opioids for management of osteoarthritis (relative risk for obese vs normal weight, 1.90; 95% CI, 1.77-2.05) and other joint disorders (relative risk, 1.63; 95% CI, 1.55-1.72) both had stronger associations with obesity than the mean for any pain diagnosis (relative risk, 1.33; 95% CI, 1.31-1.36). Osteoarthritis, other joint disorders, and other back disorders comprised a combined 53.4% of the absolute difference in prescription of opioids by obesity.

CONCLUSIONS AND RELEVANCE

Joint and back disorders appear to be the most important diagnoses in explaining the increased receipt of opioid prescriptions among patients with obesity. Addressing the opioid crisis will require attention to underlying sources of demand for prescription opioids, including obesity, through its associations with pain.

Pain management and prescribing practices in otolaryngology residency programs

PURPOSE

To understand the knowledge, competency and influencing factors regarding postoperative opioid prescribing practices among Otolaryngology Residents. To understand the educational background and resources regarding pain management and opioid prescribing among Otolaryngology Residency Programs.

MATERIALS AND METHODS

An anonymous electronic survey was distributed to Otolaryngology residents in the greater New York City area. Subjects reported their preferred pain management prescription for eight common otolaryngology surgeries. Questions addressed opioid and non-opioid prescribing influences, use/knowledge of pain management resources, and prior opioid prescribing education (OPE). An anonymous survey was distributed to US Otolaryngology Program Directors addressing resident prescribing influences and OPE in residency training programs.

RESULTS

Thirty-Five residents and fifteen PDs participated. Resident opioid prescribing was widely variable with averages ranging from 3.8 to 21.1 narcotic pills among eight standard otolaryngology surgeries. Attending/senior preference was believed to largely influence resident prescribing habits among residents (3.66, ±6.68), and PDs (4.73, ±0.46). Only 20% of programs had formal OPE in place, consistent with the 65.71% of residents who reported no prior OPE.

CONCLUSIONS AND RELEVANCE

A large inconsistency in Otolaryngology resident postoperative pain management exists, despite their responsibility to provide analgesic therapy. The lack of formal OPE programs in US Otolaryngology residency programs may lead to outside factors unrelated to surgery influencing these prescribing practices. This brings light to the need of Otolaryngology Resident OPE to assist in standardizing prescribing practices, provide meaningful patient education on opioid use and disposal and educate residents on the risk assessment tools offered to provide the most appropriate and safe analgesic therapy to patients.

Cancer Screening Among Women Prescribed Opioids: A National Study

PURPOSE

Prior work suggests that there are competing demands between addressing pain and other issues in primary care, potentially lessening delivery of evidence-based cancer screening. We assessed the association between opioid therapy and cancer screening among women in a nationally representative US sample.

METHODS

We conducted an observational analysis of the 2005-2015 Medical Expenditure Panel Surveys. We included all women aged ≥18 years without cancer and with opioid prescription and preventive care services data. Logistic regression analyses examined associations between receipt of opioid prescription (any vs none) and receipt of breast, cervical, and colorectal cancer screenings. Analyses were adjusted for sociodemographic characteristics, health status, health conditions, and usual source of care, as well as health care utilization.

RESULTS

Of 53,982 participants, 15.8% reported ≥1 opioid prescription. Compared with women not prescribed opioids, those prescribed opioids were more likely to visit their doctor (median number of visits per year = 5, vs 1). Without adjustment for number of visits, women prescribed opioids were more likely to receive all 3 cancer screenings; the adjusted odds ratio for breast cancer screening was 1.26 (95% CI, 1.16-1.38), that for cervical cancer screening was 1.22 (95% CI, 1.13-1.33), and that for colorectal cancer screening was 1.22 (95% CI, 1.12-1.33). With adjustment for number of visits, adjusted odds ratios decreased (breast 1.07 [95% CI, 0.98-1.18]; cervical 1.01 [95% CI, 0.93-1.09]; colorectal 1.04 [95% CI, 0.95-1.14]).

CONCLUSIONS

In a nationally representative sample, receipt of opioid prescriptions was not associated with less recommended cancer screenings. Rather, women receiving opioids had greater adjusted odds of receiving breast, cervical, and colorectal cancer screening, although the associations were attenuated by adjusting for their more frequent office visits relative to women not receiving opioids.

Ethics of Opioid Prescriber Regulations: Physicians, Patients, and Pain

BACKGROUND

Opioid addiction affects patients of every race, sex, and socioeconomic status. Overprescribing is a known cause of the opioid crisis. Various agencies have implemented requirements and programs to combat practitioner overprescribing; however, there can be adverse ethical consequences when regulations are used to influence physician behavior. We aimed to explore the ethical aspects of some of these interventions.

METHODS

We reviewed various interventions for opioid prescribing through the lens of ethical inquiry. Specifically, we evaluated (1) requirements for educational programs for prescribers and patients, (2) prescription monitoring programs, (3) prescription limits, (4) development of condition-specific pain management guidelines, (5) increased utilization of naloxone, and (6) opioid disposal programs. We also evaluated patient satisfaction survey questions relating to pain.

RESULTS

The present analysis demonstrated that the following regulatory interventions are ethically sound: requirements for educational programs for prescribers and patients, robust prescription monitoring programs that cross state lines, increased prescribing of naloxone for at-risk patients, development of condition-specific pain management guidelines, improvement of opioid disposal programs, and elimination of pain-control questions from patient satisfaction surveys. However, implementation of strict prescribing limits without accommodation for procedure and patient characteristics may have negative ethical consequences.

CONCLUSIONS

Although the importance of addressing the current opioid crisis cannot be understated, as surgeons, we must examine ethical implications of any new regulations that affect musculoskeletal patient care.

Descriptive Analysis of an Interdisciplinary Musculoskeletal Program

BACKGROUND

Interdisciplinary musculoskeletal programs address comorbidities confounding musculoskeletal conditions and serve as an alternative to the single provider model.

OBJECTIVE

Descriptive analysis of an interdisciplinary musculoskeletal program.

DESIGN

Retrospective descriptive analysis of patients enrolled in an interdisciplinary musculoskeletal program. Retrospective subanalysis: cohort of patients enrolled in interdisciplinary program with low back pain compared to historical cohort of patients in a single provider clinic.

SETTING

Academic interdisciplinary musculoskeletal health program.

PATIENTS

Patients referred to program with at least one follow-up visit over a 2-year period.

INTERVENTIONS

Interdisciplinary musculoskeletal program involving physiatry, pain anesthesia, nutrition, psychology, rheumatology, sleep medicine, nursing, and physical therapy.

MAIN OUTCOME MEASUREMENTS

Patient Specific Functional Scale (PSFS), Oswestry Low Back Disability Index (ODI), number of magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, opioid prescriptions; Press Ganey scores.

RESULTS

One hundred and seventy-three patients were enrolled and had at least one follow-up visit. Twenty-four percent of patients with any musculoskeletal complaint demonstrated clinically significant improvements in total PSFS. Mean improvement in PSFS was + 0.864 (SD 1.94), which was a statistically significant improvement (P = .0005), but not clinically significant. Magnetic resonance imaging was ordered for 5% of patients, and no computed tomography scans were ordered. Six percent of patients received opioid prescriptions. Press Ganey scores: 96% responded favorably in regard to physician communication quality, 86% of patients responded favorably for access to care, and 78% responded favorably for care coordination. 27.8% of patients with low back pain in the interdisciplinary program achieved a significant decrease in their ODI, compared to 26.6% in the single provider clinic (P = .87).

CONCLUSIONS

Interdisciplinary musculoskeletal programs are a promising model to improve the functioning of patients with musculoskeletal pain and decrease downstream utilization. These programs may be more appropriate for patients at higher risk of developing chronic pain.

Association of Depression Risk with Patient Experience, Healthcare Expenditure, and Health Resource Utilization Among Adults with Atherosclerotic Cardiovascular Disease

BACKGROUND

Approximately 20% of patients with atherosclerotic cardiovascular disease (ASCVD) suffer from depression.

OBJECTIVE

To compare healthcare expenditures and utilization, healthcare-related quality of life, and patient-centered outcomes among ASCVD patients, based on their risk for depression (among those without depression), and those with depression (vs. risk-stratified non-depressed).

DESIGN AND SETTING

The 2004-2015 Medical Expenditure Panel Survey (MEPS) was used for this study.

PARTICIPANTS

Adults ≥ 18 years with a diagnosis of ASCVD, ascertained by ICD-9 codes and/or self-reported data. Individuals with a diagnosis of depression were identified by ICD-9 code 311. Participants were stratified by depression risk, based on the Patient Health Questionnaire-2.

RESULTS

A total of 19,840 participants were included, translating into 18.3 million US adults, of which 8.6% (≈ 1.3 million US adults) had a high risk for depression and 18% had a clinical diagnosis of depression. Among ASCVD patients without depression, those with a high risk (compared with low risk) had increased overall and out-of-pocket expenditures (marginal differences of $2880 and $287, respectively, both p < 0.001), higher odds for resource utilization, and worse patient experience and healthcare quality of life (HQoL). Furthermore, compared with individuals who had depression, participants at high risk also reported worse HQoL and had higher odds of poor perception of their health status (OR 1.83, 95% CI [1.50, 2.23]) and poor patient-provider communication (OR 1.29 [1.18, 1.42]).

LIMITATION

The sample population includes self-reported diagnosis of ASCVD; therefore, the risk of underestimation of the cohort size cannot be ruled out.

CONCLUSION

Almost 1 in 10 individuals with ASCVD without diagnosis of depression is at high risk for it and has worse health outcomes compared with those who already have a diagnosis of depression. Early recognition and treatment of depression may increase healthcare efficiency, positive patient experience, and HQoL among this vulnerable population.

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse

Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.

'I just need an opiate refill to get me through the weekend'

In this article, we discuss the ethical dimensions for the prescribing behaviours of opioids for a chronic pain patient, a scenario commonly witnessed by many physicians. The opioid epidemic in the USA and Canada is well known, existing since the late 1990s, and individuals are suffering and dying as a result of the easy availability of prescription opioids. More recently, this problem has been seen outside of North America affecting individuals at similar rates in Australia and Europe. We argue that physicians are also confronted with an ethical crisis where a capitalist-consumerist society is contributing to this opioid crisis in which societal, legal and business interests push physicians to overprescribe opioids. Individual physicians often find themselves unequipped and unsupported in attempts to curb the prescribing of opioid medications and balance competing goals of alleviating pain against the judicious use of pain medications. Physicians, individually and as a community, must reclaim the ethical mantle of our profession, through a more nuanced understanding of autonomy and beneficence. Furthermore, physicians and the medical community at large have a fiduciary duty to patients and society to play a more active role in curbing the widespread distribution of opioids in our communities.

Factors associated with opioid use after endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Responsible prescribing of postoperative pain medications is necessary in combatting the current opioid epidemic in the United States. The goal of this study was to determine which clinical factors affect opioid usage following functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Retrospective medical records study.

METHODS

This is a single-institution retrospective study of subjects undergoing FESS by the senior author between September 2016 and December 2017. Opioid usage was assessed for each patient at the first postoperative visit. Univariate and multivariable analyses were performed to investigate factors associated with pain medication usage. Patients using opioids prior to surgery were excluded.

RESULTS

A total of 136 patients were stratified into three groups based on number of opioid tablets taken during the first week after surgery: 31 patients (23%) took no opioids, 61 patients (45%) took one to five tablets, and 44 patients (32%) took more than five tablets. Gender, extent of surgery, revision surgery, polyp status, and cystic fibrosis did not significantly vary between the three groups. Multinomial logistic regression analysis with backward stepwise variable selection method revealed that those who had septoplasty (odds ratio [OR]: 4.84, 95% confidence interval [CI]: 1.68-13.98; P < .01) or were of younger age (OR 0.96, 95% CI: 0.93-0.99; P = .01) had significantly higher odds of taking >5 tablets.

CONCLUSIONS

The majority of patients undergoing FESS did not take more than 5 opioid tablets after surgery. Concurrent septoplasty and younger age were associated with increased opioid usage. Knowledge of such factors can help surgeons to assess opioid prescribing patterns and to counsel their patients on postoperative pain. Laryngoscope, 129:1751-1755, 2019.

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

Background

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

Methods

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

Results

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

Conclusion

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