Opioid Use and Storage Patterns by Patients after Hospital Discharge following Surgery

Evidence-based prescribing of opioids after laparotomy: A quality-improvement initiative in gynecologic oncology

Introduction

Across specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy.

Methods

In 2021, open surgical gynecologic oncology patients were called 2-4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2-4 weeks after surgery to again assess their opioid use at home.

Results

Data from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p < 0.01) and self-reported use of opioids at home decreased from 22.5 to 7.5 OME (p = 0.05). The refill rate did not differ (12.6 % pre- and 11.6 % post-intervention, p = 0.82). The surplus of opioids our patients reported having at home decreased from 1264 doses of 5 mg oxycodone tabs in the pre-intervention cohort, to 490 doses in the post-intervention cohort, a 61 % reduction.

Conclusions

An evidence-based approach for prescribing opioids to patients after laparotomy decreased the surplus of opioids we introduced into our patients' communities without impacting refill rates.

Evaluating the Efficacy of Methocarbamol and Nefopam in Orthopedic Surgical Pain

Introduction Pain after orthopedic surgeries represents a special concern in patients with fractures. The use of multimodal analgesia significantly reduced the opioid need and reduced the risk of their side effects. Objectives This study compared the effectiveness and safety of methocarbamol and nefopam in the reduction of post-operative pain for patients undergoing orthopedic surgeries. Method This prospective, double-blind, randomized controlled trial took place at Al-Sader Teaching Hospital in Basrah, Iraq, from the first of February 2022 to the end of October 2023. The study aimed to assess the post-operative pain relief efficacy and safety of intramuscular nefopam (20 mg) and intravenous methocarbamol (1 g) in 110 adults (aged 18-65) undergoing elective orthopedic surgeries. Exclusions were made for allergies to the drugs, substance abuse history, and severe hepatic or renal impairment. Participants were randomized into two groups, with pain intensity measured at one hour, six hours, and 12 hours post-operation using the visual analog scale (VAS). Side effects were also evaluated. Statistical analysis was done using SPSS 27, with a significance level set at p<0.05 and a 95% confidence interval (CI). Results  In this study, we conducted a rigorous comparison between two groups, methocarbamol and nefopam, to evaluate their efficacy and safety in post-operative pain management. We started by ensuring that the groups were well-matched in terms of age, gender distribution, and body mass index (BMI). The results showed remarkable similarities in mean age, gender distribution, and BMI, supported by robust p-values, affirming the effective matching of the two groups. Moving to pain management, we observed a significant advantage in favor of methocarbamol. At all-time intervals (one hour, six hours, and 12 hours post-operation), methocarbamol consistently demonstrated lower mean VAS scores compared to nefopam. These differences were highly statistically significant, underscoring the superior pain relief efficacy of methocarbamol. Exploring side effects, we found no statistically significant disparities in the occurrence of nausea and vomiting between the two groups. However, there was a noticeable trend toward higher tachycardia incidence in the nefopam group, though it did not reach statistical significance. Conclusion The present study showed a higher efficacy of methocarbamol in post-operative pain reduction in comparison to nefopam. No serious side effects were observed with both drugs.

Lower Opioid Prescription Quantity Does Not Negatively Impact Pain Control or Patient Satisfaction After ACL Reconstruction: A Randomized, Prospective Trial

BACKGROUND

The purpose of this study was to evaluate the effects of different quantities of prescribed opioid tablets on patient opioid utilization, postoperative pain and function, and satisfaction after anterior cruciate ligament reconstruction (ACLR).

METHODS

This was a prospective, randomized trial enrolling patients undergoing primary ACLR. Patients were assigned to 1 of 3 prescription groups: 15, 25, or 35 tablets containing 5-mg oxycodone. Patients completed visual analog scale (VAS) pain and medication logs, opioid medication satisfaction surveys, and International Knee Documentation Committee (IKDC) questionnaires postoperatively.

RESULTS

Among the 180 patients included in the analysis, there was no significant difference in VAS pain scores (p > 0.05), IKDC scores (p > 0.05), morphine milligram equivalents (MMEs) (p = 0.510) consumed, or patient satisfaction with regard to pain control (p = 0.376) between treatment groups. Seventy-two percent of opioids were consumed in the first 3 days postoperatively, and 83% of patients in the 15-tablet cohort felt that they received the "right amount" of or even "too many" opioids.

CONCLUSIONS

The prescription of 15 opioid tablets resulted in equivalent pain control, patient satisfaction, and short-term functional outcomes as prescriptions of 25 or 35 opioid tablets after ACLR. Lower prescription quantities of opioid medication may provide equivalent postoperative pain and help to minimize the number of unused opioid doses at risk for possible diversion after ACLR.

LEVEL OF EVIDENCE

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

Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter

BACKGROUND

The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic.

STUDY DESIGN

Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs.

RESULTS

Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs.

CONCLUSIONS

Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.

Opioid use and disposal at 2 weeks post-surgery: Brief communication regarding excess opioids and disposal habits

OBJECTIVE

To measure the number of unused prescription opioids and disposal habits of patients following orthopedic shoulder surgery.

DESIGN

A prospective observational study.

SETTING

Academic orthopedic sports medicine department.

PATIENTS

Sixty-seven patients undergoing shoulder surgery.

INTERVENTIONS

Nine-question opioid use questionnaire.

MAIN OUTCOME MEASURES

Responses to an opioid use questionnaire were collected at 2 weeks post-surgery. Outcomes of interest included the amount of initial opioid prescription used and the disposal of excess opioids.

RESULTS

Sixty-seven patients completed the opioid use questionnaire. Forty-six (68.7 percent) patients reported having excess opioids at 2 weeks. Of the 46 patients with excess opioids, 57 percent disposed of the excess, and 43 percent planned to keep their opioids.

CONCLUSION

Two-thirds of the patients reported having excess opioids, highlighting the issue of an overabundance of unused prescription opioids in America. Utilization of opioid-free pain management strategies and drug disposal kits should be explored to reduce the number of unused and improperly disposed opioids.

Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial

BACKGROUND

Opioids are routinely prescribed for postoperative pain control after gynecologic surgery with growing evidence showing that most prescribed opioids go unused. Restrictive opioid prescribing has been implemented in other surgical specialties to combat the risk for opioid misuse and diversion. The impact of this practice in the urogynecologic patient population is unknown.

OBJECTIVE

This study aimed to determine if a restrictive opioid prescription protocol is noninferior to routine opioid prescribing in terms of patient satisfaction with pain control after minor and major surgeries for prolapse and incontinence.

STUDY DESIGN

This was a single-center, randomized, noninferiority trial of opioid-naïve patients who underwent minor (eg, colporrhaphy or mid-urethral sling) or major (eg, vaginal or minimally invasive abdominal prolapse repair) urogynecologic surgery. Patients were excluded if they had contraindications to all multimodal analgesia and if they scored ≥30 on the Pain Catastrophizing Scale. Subjects were randomized on the day of surgery to the standard opioid prescription protocol (wherein patients routinely received an opioid prescription upon discharge [ie, 3-10 tablets of 5 mg oxycodone]) or to the restrictive protocol (no opioid prescription unless the patient requested one). All patients received multimodal pain medications. Participants and caregivers were not blinded. Subjects were asked to record their pain medication use and pain levels for 7 days. The primary outcome was satisfaction with pain control reported at the 6-week postoperative visit. We hypothesized that patient satisfaction with the restrictive protocol would be noninferior to those randomized to the standard protocol. The noninferiority margin was 15 percentage points. Pain level scores, opioid usage, opioid prescription refills, and healthcare use were secondary outcomes assessed for superiority.

RESULTS

A total of 133 patients were randomized, and 127 (64 in the standard arm and 63 in the restrictive arm) completed the primary outcome evaluation and were included in the analysis. There were no statistically significant differences between the study groups, and this remained after adjusting for the surgery type. Major urogynecologic surgery was performed in 73.6% of the study population, and minor surgery was performed in 26.4% of the population. Same-day discharge occurred for 87.6% of all subjects. Patient satisfaction was 92.2% in the standard protocol arm and 92.1% in the restrictive protocol arm (difference, -0.1%; P=.004), which met the criterion for noninferiority. No opioid usage in the first 7 days after hospital discharge was reported by 48.4% of the patients in the standard protocol arm and by 70.8% in the restrictive protocol arm (P=.009). Opioid prescription refills occurred in 8.5% of patients with no difference between the study groups (9.4% in the standard arm vs 6.7% in the restrictive arm; P=.661). No difference was seen in the rate of telephone calls and urgent visits for pain control between the study arms.

CONCLUSION

Among women who underwent minor and major surgery for prolapse and incontinence, patient satisfaction rates were noninferior after restrictive opioid prescribing when compared with routine opioid prescribing.

Effect of Best Practice Alert (BPA) on Post-Discharge Opioid Prescribing After Minimally Invasive Hysterectomy: A Quality Improvement Study

Purpose

The aim of this study was to describe the effectiveness of an electronic health record best practice alert (BPA) in decreasing gynecologic post-discharge opioid prescribing following benign minimally invasive hysterectomy.

Patients and Methods

The BPA triggered for opioid orders >15 tablets. Prescribers' options included (1) decrease to 15 ≤ tablets; (2) remove the order/utilize a defaulted order set; or (3) override the alert.

Results

332 patients were included. The BPA triggered 29 times. The following actions were taken among 16 patients for whom the BPA triggered: "override the alert" (n=13); "cancel the alert" (n=2); and 'remove the opioid order set' (n=1). 12/16 patients had discharge prescriptions: one patient received 20 tablets; two received 10 tablets; and nine received 15 tablets. Top reasons for over prescribing included concerns for pain control and lack of alternatives.

Conclusion

Implementing a post-discharge opioid prescribing BPA aligned opioid prescribing following benign minimally invasive hysterectomy with guideline recommendations.

Efficacy of Supplemental Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined with Lateral Femoral Cutaneous Nerve Block in Patients Receiving Local Infiltration Analgesia after Hip Fracture Surgery: A Prospective Randomized Controlled Trial

Background and Objectives: Local infiltration analgesia (LIA) represents a potential approach to reducing pain in patients undergoing total hip arthroplasty (THA). The pericapsular nerve group (PENG) block also provides adequate analgesia for fractures and THA. As most hip surgeries use a lateral incision, affecting the cutaneous supply by branches of the lateral femoral cutaneous nerve (LFCN), the LFCN block can contribute to postoperative analgesia. However, no studies have investigated the effectiveness of supplemental PENG block combined with LFCN block in patients undergoing LIA after hip fracture surgery. Our study aimed to assess the effectiveness of PENG combined with LFCN block following hip fracture surgery in patients who underwent LIA. Materials and Methods: Forty-six patients were randomly assigned to LIA or PENG + LFCN + LIA groups. The primary outcome was the pain score at rest and during movement at 2, 6, 12, 24, and 48 h postoperatively. The total opioid dose for postoperative analgesia was also measured at the same time points. Secondary outcomes included postoperative cognitive function assessment. Results: The median pain scores at rest and during movement were lower in the PENG + LFCN + LIA group throughout the study periods compared to the LIA group, except at 2 h (at rest) and 48 h (during movement) after surgery. The total fentanyl dose was lower in the PENG + LFCN + LIA group at all time points after surgery when compared to the LIA group. Postoperative delirium incidence and the median abbreviated mental test scores were not significantly different between the two groups. Conclusions: The combination of PENG and LFCN blocks may contribute to enhanced recovery for patients undergoing LIA after hip fracture surgery. However, further well-controlled research is necessary to determine the effectiveness of supplemental PENG combined with LFCN block in addressing cognitive deficits in these patients.

A Prescribing Guideline Decreases Postoperative Opioid Prescribing in Emergency General Surgery

INTRODUCTION

Patients prescribed higher opioid dosages have a higher risk of persistent opioid use, overdose, and death. There is a lack of standardization for opioid prescribing for acute surgical pain in emergency general surgery (EGS) patients. We hypothesized that implementing a guideline to standardize opioid prescribing would be associated with a decrease in prescribing at hospital discharge for EGS patients without increasing additional postdischarge refills.

METHODS

This was a quasi-experimental study evaluating opioid prescribing by EGS providers before and after the implementation of a prescribing guideline. Patients were assigned to preguideline and postguideline groups based on admission date surrounding the implementation of the guideline. The primary outcome was the proportion of patients receiving an opioid prescription for ≥50 Morphine Milligram Equivalents (MME) per day on hospital discharge.

RESULTS

There were 227 patients in the preguideline group and 226 patients in the postguideline group. After guideline implementation, median total MME prescribed decreased from 113 (interquartile range = 75) to 75 (interquartile range = 75, P = 0.03). The proportion of patients receiving a prescription for daily MME ≥50 also decreased from 75% to 25% (P ≤0.01). There were no increases in requested refills (17% versus 16%, P = 0.72) or received refills (14% versus 14%, P = 0.98). Guideline compliance ranged from 75% in ventral hernia repair patients to 94% in laparoscopic cholecystectomy patients.

CONCLUSIONS

A departmental guideline to standardize postoperative opioid prescriptions was associated with a decrease in the amount of MMEs prescribed to EGS patients without an increase in requested or received refills.

Drug disposal deserts: An assessment of receptacle availability in Kentucky community pharmacies

PURPOSE

The purpose of this study was to describe the county-level availability of drug disposal receptacles in Kentucky community pharmacies and show the relationship between installed receptacles and opioid analgesic (OA)/controlled substance dispensing rates, stratifying where possible by urban-rural classification.

METHODS

Using 2020 data from the Kentucky All Schedule Prescription Electronic Reporting program and disposal receptacle data from the US Drug Enforcement Agency, county-level comparisons were made between number of receptacles and OA/controlled substance dispensing rates. Logistic and negative binomial regression models were used to assess for differences between rural/urban county designation and odds of ≥1 disposal receptacle and compare the rates of receptacles per dispensed OA dose in rural/urban counties.

FINDINGS

While rural counties saw higher OA and controlled substance dispensing rates, the majority (55.6%) of disposal receptacles were in urban locations. The odds of having at least 1 receptacle were higher in urban counties (OR 2.60, 95% CI: 1.15, 5.92) compared to rural. The estimated rate of disposal receptacles per million dispensed OA doses was found to be 0.47 (95% CI: 0.36, 0.61) in urban counties compared to 0.32 (95% CI: 0.25, 0.42) in rural counties, with an estimated rate ratio of 1.45 (95% CI: 1.01, 2.10).

CONCLUSIONS

A mismatch between the availability of county-level disposal receptacles in community pharmacies and the volume of dispensed OAs/controlled substances exists, resulting in fewer receptacles per dispensed OA in rural counties compared to urban counties. Future efforts are necessary to increase access to convenient disposal receptacles located in community pharmacies, particularly in rural communities.

Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags

OBJECTIVE

To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids.

DATA SOURCES AND STUDY SETTING

We collected patient surveys and electronic medical record data at an academic health system.

STUDY DESIGN

We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias.

DATA COLLECTION/EXTRACTION METHODS

From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy.

PRINCIPAL FINDINGS

We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up.

CONCLUSIONS

A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.

Reducing opioid prescribing after ambulatory breast reconstruction surgery

BACKGROUND

The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse.

METHODS

Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker.

RESULTS

Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively).

CONCLUSION

Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data.

Naloxone co-prescriptions for surgery patients prescribed opioids: A retrospective cohort study

Background

Surgeon-prescribed opioids contribute to 11% of prescription drug overdoses in the United States (US). With prescription opioids involved in 24% of all opioid-related overdose deaths in 2020, the US Centers for Disease Control and Prevention (CDC) recommends naloxone co-prescribing to patients at high-risk of overdose and death as a harm reduction strategy. We sought to 1) examine naloxone co-prescribing rates to surgical patients (using common post-surgical prescribing amounts) and those with potential risk factors for opioid-related overdoses or adverse events, and 2) identify the factors associated with patients receiving naloxone co-prescriptions.

Methods

We conducted a single-institution, retrospective study using the electronic medical records of all patients undergoing surgery at an academic institution between August 2020 and May 2021. We included post-surgical adults prescribed opioids that were sent to a pharmacy in our health system. The primary outcome was the percentage of co-prescribed naloxone in patients prescribed opioids.

Results

The overall naloxone co-prescription rate was low (1.7%). Only 14.6% of patients prescribed ≥350 morphine milligram equivalents (MME, equivalent to 46.7 oxycodone 5 mg tablets) and 8.6% of patients using illicit drugs were co-prescribed naloxone. On multivariable analysis, patients who were prescribed >350 MME, used illicit drugs or tobacco, underwent an elective or emergent general surgery procedure, self-identified as Hispanic, or had ASA scores of 2-4 were more likely to receive a naloxone co-prescription.

Conclusions

Naloxone co-prescribing after surgery remains low, even for high-risk patients. Harm reduction strategies such as naloxone, safe storage, and disposal of leftover opioids could reduce surgeons' iatrogenic contributions to the worsening US opioid crisis.

More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health

Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.

Opioid Use and Disposal Patterns of Emergency Department Patients

Introduction

To date, there is limited literature to guide emergency providers (EPs) on the proper dosing of prescription opioids. Our study aims to assess the self-reported opioid use, storage, and disposal practices of patients presenting to the emergency department (ED) with acute pain.

Methods

This prospective cohort study employed a validated, cross-sectional survey of subjects identified using electronic medical records. The survey link was e-mailed to a continuous sample of eligible participants 3-4 weeks following ED discharge. Nonrespondents were surveyed through telephone after 1 week. We used descriptive and nonparametric statistics to report survey results.

Results

Of 500 eligible subjects, 97 completed the questionnaire. Only 28% of respondents reported that they took all of the prescribed pills. Of the remaining responses, 20% stated that they did not take any pills, 33% took about one-fourth, 7.2% took about half, and 12.4% took about three-fourths of the pills. Among those who did not take any pills, 42% filled the prescription. Most (71.2%) reported storing their leftover pills; among those who stored their pills, less than one-fourth (23.8%) used a locked storage location.

Conclusions

Our findings suggest that less than one-third of patients who receive prescriptions in the ED for acute pain use all of their prescribed pills, suggesting that many patients are unnecessarily prescribed opioids for acute conditions. The findings of this study also suggest that many patients with unused prescription opioids do not practice safe storage or proper disposal of leftover pills. This represents a potential opportunity for EPs to improve medication safety by educating patients on proper storage and disposal practices. Limitations include low response rate and the use of self-reporting.

Opioid utilization after lower extremity amputation for peripheral vascular disease and discharge prescribing recommendations

OBJECTIVES

Opioids are commonly used for pain control after lower extremity amputations (LEA)-below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge.

METHODS

Patients undergoing LEA (2008-2016) with identified peripheral vascular disease were selected from Cerner's Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate.

RESULTS

2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6.

CONCLUSIONS

This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325 mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.

Pain Management and Opioid Use with Long-Acting Peripheral Nerve Blocks for Hand Surgery: A Descriptive Study

Background

Peripheral nerve blocks (PNBs) are used in multiple surgical fields to provide a high level of regional pain relief with a favorable adverse effect profile. Peripheral nerve blocks aim to decrease overall perioperative pain and lower systemic analgesic requirements. Short-acting anesthetic agents are commonly given as single-injection PNBs for pain relief, typically lasting less than 24 hours. Liposomal bupivacaine is a newer anesthetic formulation lasting up to 72 hours as a single-injection PNB and may allow patients to recover postoperatively with a lower need for opioid analgesics.

Objectives

This study investigates peri- and postoperative pain and opioid use in patients receiving a long-acting brachial plexus PNB for hand surgery.

Methods

A retrospective review of patients who underwent a long-acting PNB using liposomal bupivacaine in the brachial plexus for minor hand operations was performed between July 2020 and May 2023 in Florida, USA. Patients were administered a ten-question survey regarding perioperative pain levels, post-operative symptoms, patient satisfaction, postoperative opioid use, and postoperative non-opioid analgesics.

Results

One hundred three patients, including 21 males and 82 females with an average age of 68.3 ± 15.8 years, completed a survey (34.2% response rate). Patients reported a considerable reduction in pain from 7.9 ± 2.2 out of ten before the PNB to 1.6 ± 1.8 in the perioperative period, 4.3 ± 2.7 in postoperative days zero to three, and 3.8 ± 2.4 in postoperative days four and five. Nerve block effects lasted a mean of 2.2 ± 2.0 days and patients reported a high level of satisfaction regarding their pain management plan with a score of 9.4 ± 1.4 out of ten. 20.4% of patients were prescribed opioids and 41.7% used NSAIDs postoperatively.

Conclusions

Liposomal bupivacaine PNBs effectively reduced peri- and postoperative pain with pain relief lasting 2.2 ± 2.0 days. Patients were highly satisfied with their pain management and there was a low rate of postoperative opioid prescription. Given these results, long-acting PNBs have the potential to significantly improve patient satisfaction, reduce anesthesia use, and reduce postoperative opioid prescription.

Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers

Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

The development of a safe opioid use agreement for surgical care using a modified Delphi method

BACKGROUND

Opioids prescribed to treat postsurgical pain have contributed to the ongoing opioid epidemic. While opioid prescribing practices have improved, most patients do not use all their pills and do not safely dispose of leftovers, which creates a risk for unsafe use and diversion. We aimed to generate consensus on the content of a "safe opioid use agreement" for the perioperative settings to improve patients' safe use, storage, and disposal of opioids.

METHODS

We conducted a modified three-round Delphi study with clinicians across surgical specialties, quality improvement (QI) experts, and patients. In Round 1, participants completed a survey rating the importance and comprehensibility of 10 items on a 5-point Likert scale and provided comments. In Round 2, a sub-sample of participants attended a focus group to discuss items with the lowest agreement. In Round 3, the survey was repeated with the updated items. Quantitative values from the Likert scale and qualitative responses were summarized.

RESULTS

Thirty-six experts (26 clinicians, seven patients/patient advocates, and three QI experts) participated in the study. In Round 1, >75% of respondents rated at least four out of five on the importance of nine items and on the comprehensibility of six items. In Round 2, participants provided feedback on the comprehensibility, formatting, importance, and purpose of the agreement, including a desire for more specificity and patient education. In Round 3, >75% of respondents rated at least four out of five for comprehensibility and importance of all 10 updated item. The final agreement included seven items on safe use, two items on safe storage, and one item on safe disposal.

CONCLUSION

The expert panel reached consensus on the importance and comprehensibility of the content for an opioid use agreement and identified additional patient education needs. The agreement should be used as a tool to supplement rather than replace existing, tailored education.

Preoperative pain sensitivity predicts postoperative pain severity and analgesics requirement in lumbar fusion surgery - a prospective observational study

BACKGROUND CONTENT

The goal of postoperative pain management is to facilitate the patient's return to normal activity and decrease the detrimental effects of acute postsurgical pain. In order to provide more tailored and successful pain treatment, it is necessary to identify individuals who are at a high risk of experiencing severe postoperative pain. The most precise way to assess pain sensitivity is by determining the pressure pain threshold and heat pain threshold by objective methods using a digital algometer and neurotouch respectively.

PURPOSE

The primary aim of the study is to assess the preoperative pain threshold and its influence on postoperative pain severity and analgesics requirements in patients undergoing lumbar fusion surgeries.

STUDY DESIGN

Prospective, observational study.

PATIENT SAMPLE

Sixty patients requiring a single-level lumbar fusion surgery.

OUTCOME MEASURES

Postoperative pain intensity and the amount of postoperative analgesics consumption.

METHODS

In our patients, preoperative pain sensitivity was assessed by pressure pain threshold measurements with the help of a digital algometer, and heat pain threshold using a neurotouch instrument. In addition, pain sensitivity questionnaires (PSQ) were used in all our patients to determine pain sensitivity. Preoperative psychosocial and functional assessments were performed by Hospital anxiety-depression scores (HADS), and Oswestry disability index (ODI) respectively. Preoperative visual analog scale (VAS) score was determined at three instances of needle prick (phlebotomy, glucometer blood sugar, and intradermal antibiotic test dose) and during the range of movements of the lumbar spine region. Postoperative VAS score and postoperative breakthrough analgesic requirements were recorded in all of these patients from day 0 to day 3.

RESULTS

The average age of the patients was 51.11±13.467 years and 70% were females. Females had lower mean algometry values (72.14±7.56) compared to males (77.34±6.33). Patients with higher HADS (p<.0016), higher PSQ (p<.001), higher ODI scores(p<.001), and female gender significantly correlated with a lower algometer average indicating high pain sensitivity. Patients with lower preoperative VAS scores and with higher neurotouch scores showed lower postoperative VAS scores at different time periods. Preoperative VAS scores, algometer average scores, neurotouch scores, and HADS scores were considered as independent variables (predictors) for postoperative VAS at 6 hours period. By the multivariate analysis, factors like preoperative VAS scores, algometer average scores, and HADS scores were statistically significant (p<.05). There was a significant correlation between algometer average scores (p<.001) with the breakthrough analgesics.

CONCLUSION

Preoperative assessment of pain sensitivity can predict postoperative analgesic requirements and aid in recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively.

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

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

Opioid versus non-opioid postoperative pain management in otolaryngology

BACKGROUND

The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC).

METHODS

A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups.

RESULTS

The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel.

CONCLUSIONS

HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Implementation of a Pharmacy Follow-Up Program for Dispensed Opioid Medications

BACKGROUND

There have been multiple reported pharmacy initiatives to reduce opioid misuse and accidental overdose to address our nation's public health crisis. To date, there has not been a description in the literature of a community pharmacy follow-up initiative for dispensed opioids.

METHODS

A follow-up program was designed and implemented in community pharmacies as part of a previously developed opioid overdose and misuse prevention program (ONE Program). Five to twelve days after the dispensing of an opioid, pharmacy technicians called the patient to follow up on opioid safety topics. Pharmacy technicians used a questionnaire to inquire about medication disposal plans, if the patient was taking the medication more than prescribed, medication side effects, and if the patient needed a pharmacist consultation. The results from that questionnaire were documented.

RESULTS

During the first 18 months of the follow-up program, 1789 phone calls were completed. Of those contacted, 40% were still using their opioid medication, and over 10% were experiencing side effects which triggered a pharmacist consult. Patients were reminded of proper medication disposal methods, and most patients (78%) desired to dispose of unused medication at the pharmacy medication disposal box.

CONCLUSIONS

Follow-up phone calls post-opioid medication dispensing were shown to add value to a previously established opioid misuse and accidental overdose prevention program and allowed for the fulfillment of the Pharmacist Patient Care Process.

Virtual transitional pain service delivered via telehealth is effective in preventing new and persistent opioid use amongst post-surgical spine patients

Opioid dependence is a national crisis, with 30 million patients annually at risk of becoming persistent opioid users after receiving opioids for post-surgical pain management. Translational Pain Services (TPS) demonstrate effectiveness for behavioral health improvements but its effectiveness in preventing persistent opioid use is less established, especially amongst opioid exposed patients. Prohibitive costs and accessibility challenges have hindered TPS program adoption. To address these limitations, we designed and implemented a remote telehealth TPS protocol focusing on preventing continued opioid use while improving behavioral health. Licensed therapists trained in the opioid-tapering CBT protocol delivered sessions reimbursed through standard payer reimbursement. Our prospective study evaluated the protocol's effectiveness on preventing persistent opioid use and behavioral health outcomes amongst both opioid naïve and exposed patients. In an opioid-naive patient cohort (n=67), 100% completely tapered off opioids, while in an opioid-exposed cohort (n =19) 52% completely tapered off opioids, demonstrating promising results. In both cohorts, we observed significant improvements in behavioral health scores, including pain. This opioid-tapering digital TPS is effective, adoptable, and incurs no out-of-pocket cost for healthcare systems. We provide the opioid-tapering CBT protocol in the supplement to facilitate adoption. Trial Registration Impact of Daily, Digital and Behavioral Tele-health Tapering Program for Perioperative Surgical Patients Exposed to Opioids and Benzodiazepines registered at clinicaltrials.gov, NCT04787692. https://clinicaltrials.gov/ct2/show/NCT04787692?term=NCT04787692&draw=2&rank=1.

Best Practice Alerts Informed by Inpatient Opioid Intake to Reduce Opioid Prescribing after Surgery (PRIOR): A Cluster Randomized Multiple Crossover Trial

BACKGROUND

Overprescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. This study therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery.

METHODS

This study included 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating 8-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on previous inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid and nonopioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial.

RESULTS

The total postdischarge opioid prescription was a median [quartile 1, quartile 3] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI, 0.80 to 1.13; P = 0.586). The alert was displayed in 28% (3,074 of 11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid and nonopioid combination medications or additional opioid prescriptions written after discharge.

CONCLUSIONS

A decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.(Anesthesiology 2023; 139:186-96).

EDITOR’S PERSPECTIVE

Opioid use following pelvic reconstructive surgery: a predictive calculator

INTRODUCTION AND HYPOTHESIS

Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median.

METHODS

This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery.

RESULTS

One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review.

CONCLUSIONS

Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.

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

Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.

Evidence-based opioid prescribing guidelines after lung resection: a prospective, multicenter analysis

Background

Opioid prescribing guidelines have significantly decreased overprescribing and post-discharge use after cardiac surgery; however, limited recommendations exist for general thoracic surgery patients, a similarly high-risk population. We examined opioid prescribing and patient-reported use to develop evidence-based, opioid prescribing guidelines after lung cancer resection.

Methods

This prospective, statewide, quality improvement study was conducted between January 2020 to March 2021 and included patients undergoing surgical resection of a primary lung cancer across 11 institutions. Patient-reported outcomes at 1-month follow-up were linked with clinical data and Society of Thoracic Surgery (STS) database records to characterize prescribing patterns and post-discharge use. The primary outcome was quantity of opioid used after discharge; secondary outcomes included quantity of opioid prescribed at discharge and patient-reported pain scores. Opioid quantities are reported in number of 5-mg oxycodone tablets (mean ± standard deviation).

Results

Of the 602 patients identified, 429 met inclusion criteria. Questionnaire response rate was 65.0%. At discharge, 83.4% of patients were provided a prescription for opioids of mean size 20.5±13.1 pills, while patients reported using 8.2±13.0 pills after discharge (P<0.001), including 43.7% who used none. Those not taking opioids on the calendar day prior to discharge (32.4%) used fewer pills (4.4±8.1 vs. 11.7±14.9, P<0.001). Refill rate was 21.5% for patients provided a prescription at discharge, while 12.5% of patients not prescribed opioids at discharge required a new prescription before follow-up. Pain scores were 2.4±2.5 for incision site and 3.0±2.8 for overall pain (scale 0-10).

Conclusions

Patient-reported post-discharge opioid use, surgical approach, and in-hospital opioid use before discharge should be used to inform prescribing recommendations after lung resection.

Association Between Surgical Opioid Prescriptions and Opioid Initiation by Opioid-naïve Spouses

OBJECTIVE

To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses.

SUMMARY OF BACKGROUND DATA

Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown.

METHODS

This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from January 1, 2011 to June 30, 2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months after surgery was assessed. Secondary analyses assessed how this association varied with postoperative time.

RESULTS

There were 318,022 patients (mean ± standard deviation age 48.8 ±9.3 years; 49.5% women). Among the 50,833 (16.0%) patients that did not fill a surgical opioid prescription, 2152 (4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189 (84.0%) patients who filled a surgical opioid prescription, 15,026 (5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery [unadjusted P < 0.001; adjusted odds ratio (aOR) 1.37, 95% confidence interval (CI) 1.31-1.43, P < 0.001]. Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95% CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57,95% CI 1.391.76, P < 0.001).

CONCLUSIONS

Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.

The role of preoperative opioid use in shoulder surgery-A systematic review

Background

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids.

Methods

EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies.

Results

Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively.

Conclusion

Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients.

Level of evidence

Level IV, Systematic review.

Safety and Efficacy of Liposomal Bupivacaine Supraclavicular Nerve Blocks in Open Treatment of Distal Radius Fractures: A Perioperative Pain Management Protocol

INTRODUCTION

Distal radius fractures (DRFs) are common fractures requiring surgical fixation. The literature varies regarding opioid prescribing habits, opioid consumption, and postoperative pain scores. We hypothesized that the preoperative administration of a liposomal bupivacaine (LB) supraclavicular nerve block would be safe and effective in controlling postoperative pain.

METHODS

A standardized pain management protocol was implemented at a single institution from July 2021 to March 2022 for patients undergoing open reduction internal fixation of DRF. Protocol elements included a preoperative LB supraclavicular nerve block and a multimodal postoperative pain regimen. Primary clinical outcomes included postoperative pain scores and number of opioid tablets consumed.

RESULTS

Twenty patients underwent a newly implemented protocol. The average age was 56 years. Mean number of oxycodone 5-mg tablets consumed was 4.1 (median, 2.5), and mean visual analog scale pain score at first postoperative appointment was 2.8. There were no incidences of missed acute carpal tunnel postoperatively. When compared with an institutional historical control (n = 189), number of opioid pills prescribed was reduced by 60% (21.4 vs 8.6 tablets, P < 0.0001), and no patients had unscheduled health care contact because of uncontrolled pain (22% vs 0%, P < 0.016).

CONCLUSIONS

Liposomal bupivacaine supraclavicular nerve blocks are safe and effective in the treatment of postoperative pain after open reduction internal fixation of DRF. Patients consumed <5 oxycodone tablets on average, which is less than many recommend prescribed quantities (>20-30 tablets). Patients had low pain scores (2.8/10) at the first postoperative follow-up. To our knowledge, this is the first study demonstrating the utility of LB in this clinical setting.

Implementation and Effectiveness of Opioid Prescribing Guidelines After Hiatal Hernia Repair

INTRODUCTION

We defined institutional opioid prescribing patterns, established prescribing guidelines, and evaluated the adherence to and effectiveness of these guidelines in association with opioid prescribing after hiatal hernia repair (HHR).

METHODS

A retrospective chart review was completed for patients who underwent transthoracic (open) or laparoscopic HHR between January and December 2016. Patient-reported opioid use after surgery was used to establish prescribing recommendations. Guideline efficacy was then evaluated among patients undergoing HHR after implementation (August 2018 to June 2019). Data are reported in oral morphine equivalents (OMEs).

RESULTS

The initial cohort included n = 87 patients (35 open; 52 laparoscopic) with a 68% survey response rate. For open repair, median prescription size was 338 mg OME (interquartile range [IQR] 250-420) with patient-reported use of 215 mg OME (IQR 78-308) (P = 0.002). Similarly, median prescription size was 270 mg OME (IQR 200-319) with patient-reported use of 100 mg OME (IQR 4-239) (P < 0.001) for laparoscopic repair. Opioid prescribing guidelines were defined as the 66th percentile of patient-reported opioid use. Postguideline implementation cohort included n = 108 patients (36 open; 72 laparoscopic). Median prescription amount decreased by 54% for open and 43% laparoscopic repair, with no detectable change in the overall refill rate after guideline implementation. Patient education, opioid storage, and disposal practices were also characterized.

CONCLUSIONS

Evidence-based opioid prescribing guidelines can be successfully implemented for open and laparoscopic HHR with a high rate of compliance and without an associated increase in opioid refills.

Efficacy of Wound Instillation With Bupivacaine Through a Wound Catheter for Postoperative Analgesia in Laparotomy Wounds in Comparison With Conventional Intravenous Analgesics

Introduction A laparotomy can cause severe postoperative pain, which, if treated adequately, can result in reduced incidence of lung atelectasis and ileus promoting early mobilization and faster recovery and in turn reducing the duration of hospital stays. Hence, effective postoperative analgesia is important to reduce postoperative stress and improve early surgical outcomes. Therefore, the hypothesis is based on the fact that following a midline laparotomy, instillation of local anaesthetic agent 0.25% bupivacaine through a wound catheter placed in the subcutaneous plane may provide better analgesia compared to the conventional intravenous analgesics and improve the early surgical outcomes. Methodology A prospective, comparative, quasi-experimental study was conducted on 80 patients planned for emergency or elective midline laparotomy procedures over a period of 18 months, who were randomly distributed into two groups of 40 each. The bupivacaine group consisted of 40 patients who received 10ml of 0.25% bupivacaine instilled through a wound catheter placed in the subcutaneous plane following a midline laparotomy. This was repeated every six hours for the first 24 hours followed by every 12 hours for the next 24 hours. The conventional intravenous (IV) analgesics group involved 40 patients who received conventional IV analgesics routinely used. Pain scores were recorded every four hours for 60 hours using the visual analogue scale (VAS) and dynamic visual analogue scale (DVAS). The parameters assessed were mean VAS and DVAS scores, number of rescue analgesic demands, cumulative rescue analgesic requirement, and early surgical outcomes. Wound complications were also assessed. Results Both groups shared similar demographic characteristics in terms of age, gender, comorbidities, and duration of operation. In comparison to patients who got standard IV analgesics, those who received 0.25% bupivacaine had improved postoperative analgesia. Between the two groups, there were statistically significant results in the number of rescue analgesic demands in the first 24 hours, but in the next 24 hours, it was statistically insignificant. The study also showed that bupivacaine instillation led to a significant decrease in postoperative lung complications and the length of hospital stays; however as hypothesised, it did not improve early surgical outcomes. Conclusion This modality, the instillation of bupivacaine through a wound catheter, is an efficient and technically simple method to provide optimal postoperative analgesia. It substantially reduces the need for systemic analgesics and can potentially avoid their related side effects. Hence, the armamentarium of multimodal analgesia can therefore include this method of delivering postoperative analgesia.

Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study

BACKGROUND

Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids.

AIMS

Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region.

METHODS

We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM).

RESULTS

We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient-provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden.

CONCLUSIONS

We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

A multi-disciplinary program for opioid sparse arthroplasty results in reduced long-term opioid consumption: a four year prospective study

INTRODUCTION

The current opioid epidemic poses patient safety and economic burdens to healthcare systems worldwide. Postoperative prescriptions of opioids contribute, with reported opioid prescription rates following arthroplasty as high as 89%. In this multi-centre prospective study, an opioid sparing protocol was implemented for patients undergoing knee or hip arthroplasty. The primary outcome is to report our patient outcomes in the context of this protocol, and to examine the rate of opioid prescription on discharge from our hospitals following joint arthroplasty surgery. This is possibly associated with the efficacy of the newly implemented Arthroplasty Patient Care Protocol.

METHODS

Over three years, patients underwent perioperative education with the expectation to be opioid-free after surgery. Intraoperative regional analgesia, early postoperative mobilisation and multimodal analgesia were mandatory. Long-term opioid medication use was monitored and PROMs (Oxford Knee/Hip Score (OKS/OHS), EQ-5D-5 L) were evaluated pre-operatively, and at 6 weeks, 6 months and 1 year postoperatively. Primary and secondary outcomes were opiate use and PROMs at different time points.

RESULTS

A total of 1,444 patients participated. Two (0.2%) knee patients used opioids to one year. Zero hip patients used opioids postoperatively at any time point after six weeks (p < 0.0001). The OKS and EQ-5D-5 L both improved for knee patients from 16 (12-22) pre-operatively to 35 (27-43) at 1 year postoperatively, and 70 (60-80) preoperatively to 80 (70-90) at 1 year postoperatively (p < 0.0001). The OHS and EQ-5D-5 L both improved for hip patients from 12 (8-19) preoperatively to 44 (36-47) at 1 year postoperatively, and 65 (50-75) preoperatively to 85 (75-90) at 1 year postoperatively (p < 0.0001). Satisfaction improved between all pre- and postoperative time points for both knee and hip patients (p < 0.0001).

CONCLUSIONS

Knee and hip arthroplasty patients receiving a peri-operative education program can effectively and satisfactorily be managed without long-term opioids when coupled with multimodal perioperative management, making this a valuable approach to reduce chronic opioid use.

Higher Pain Catastrophizing and Preoperative Pain is Associated with Increased Risk for Prolonged Postoperative Opioid Use

BACKGROUND

Prolonged postoperative opioid use (PPOU) is considered an unfavorable post-surgical outcome. Demographic, clinical, and psychosocial factors have been associated with PPOU, but methods to prospectively identify patients at increased risk are lacking.

OBJECTIVES

Our objective was to determine whether an individual or a combination of several psychological factors could identify a subset of patients at increased risk for PPOU.

STUDY DESIGN

Observational cohort study with prospective baseline data collection and passive outcomes data collection.

SETTING

A single VA medical center in the United States.

METHODS

Patients were recruited from a preoperative anesthesia clinic where they were undergoing evaluation prior to elective surgery, and they completed a survey before surgery. The primary outcome was PPOU, defined as outpatient receipt of a prescribed opioid 31 to 90 days after surgery as determined from pharmacy records. Primary covariates of interest were pain catastrophizing, self-efficacy, and optimism. Additional covariates included social and demographic factors, pain severity, medication use, depression, anxiety, and surgical fear.

RESULTS

Of 123 patients included in the final analyses, 30 (24.4%) had PPOU. In bivariate analyses, preoperative opioid use and preoperative nonsteroidal anti-inflammatory drug use were significantly associated with PPOU. The combination of high pain catastrophizing and high preoperative pain (OR 3.32, 95% CI 1.41 - 7.79) was associated with higher odds of PPOU than either alone, and the association remained significant after adjusting for preoperative opioid use (OR 2.56, 95% CI 1.04 - 6.29).

LIMITATIONS

Patients were recruited from a single site, and the sample was not large enough to include potentially important variables such as procedure type.

CONCLUSIONS

A combination of high pain catastrophizing and high preoperative pain has the potential to be a clinically useful means of identifying patients at elevated risk of PPOU.

Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio

OBJECTIVE

Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels.

METHODS

We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level.

RESULTS

There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01).

CONCLUSION

Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.

Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use

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.

Tapered Dose Postoperative Opioid Prescriptions Following Inpatient Total Hip and Knee Arthroplasty: Quality Improvement Study and Retrospective Review

BACKGROUND

Overprescription of pain medications directly fuels the opioid epidemic. Veterans are profoundly impacted. Tapered dose protocols may reduce excessive prescribing.

METHODS

A retrospective study of adult veterans who presented to our institution for primary total knee arthroplasty or total hip arthroplasty (THA) was performed. Postdischarge opioid use was reviewed before and after an opioid taper prescription protocol. The preprotocol and postprotocol groups had 299 and 89 veterans, respectively. Total Morphine Milligram Equivalent (MME) prescribed postdischarge, number of tablets prescribed, number of refills issued, 30-day emergency department visits, and 30-day readmissions were compared. Opioid naïve and chronic opioid users were both included.

RESULTS

Preprotocol and postprotocol implementation group, in combination with surgery type (total knee arthroplasty versus THA) and opioid naïve status, predicted MME. On average, the postprotocol group received 224 MME less, THA patients received 177 MME less, and nonopioid naïve patients received 152 MME more.

CONCLUSION

The opioid taper protocol led to less opioid administration after discharge. Taper protocols should be considered for postoperative pain management.

LEVEL OF EVIDENCE

III, retrospective comparison study.

Enhanced Recovery After Surgery Patients Are Prescribed Fewer Opioids at Discharge: A Propensity-score Matched Analysis

OBJECTIVE

We aimed to compare discharge opioid prescriptions pre- and post-ERAS implementation.

SUMMARY OF BACKGROUND DATA

ERAS programs decrease inpatient opioid use, but their relationship with postdischarge opioids remains unclear.

METHODS

All patients undergoing hysterectomy between October 2016 and November 2020 and pancreatectomy or hepatectomy between April 2017 and November 2020 at 1 tertiary care center were included. For each procedure, ERAS was implemented during the study period. PSM was performed to compare pre - versus post-ERAS patients on discharge opioids (number of pills and oral morphine equivalents). Patients were matched on age, sex, race, payor, American Society of Anesthesiologists score, prior opioid use, and procedure. Sensitivity analyses in open versus minimally invasive surgery cohorts were performed.

RESULTS

A total of 3983 patients were included (1929 pre-ERAS; 2054 post-ERAS). Post-ERAS patients were younger (56.0 vs 58.4 years; P < 0.001), more often female (95.8% vs 78.1%; P < 0.001), less often white (77.2% vs 82.0%; P < 0.001), less often had prior opioid use (20.1% vs 28.1%; P < 0.001), and more often underwent hysterectomy (91.1% vs 55.7%; P < 0.001). After PSM, there were no significant differences between cohorts in baseline characteristics. Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs 22.0 pills; P < 0.001) and lower oral morphine equivalents (129.4 mg vs 167.6 mg; P < 0.001) than pre-ERAS patients. Sensitivity analyses confirmed these findings [open (18.8 pills vs 25.4 pills; P < 0.001 \ 138.9 mg vs 198.7 mg; P < 0.001); minimally invasive surgery (17.2 pills vs 21.1 pills; P < 0.001 \ 127.1 mg vs 160.1 mg; P < 0.001).

CONCLUSIONS

Post-ERAS patients were prescribed significantly fewer opioids at discharge compared to matched pre-ERAS patients.

Reducing Opioid Overprescribing through Procedure-specific Prescribing Guidelines

Despite advances in opioid-sparing pain management, postdischarge opioid overprescribing in plastic surgery remains an issue. Procedure-specific prescribing protocols have been implemented successfully in other surgical specialties but not broadly in plastic surgery. This study examined the efficacy of procedure-specific prescribing guidelines for reducing postdischarge opioid overprescribing.

Methods

A total of 561 plastic surgery patients were evaluated retrospectively after a prescribing guideline, which recommended postdischarge prescription amounts based on the type of operation, was introduced in July 2020. Prescription and postdischarge opioid consumption amounts before (n = 428) and after (n = 133) guideline implementation were compared. Patient satisfaction and prescription frequency of nonopioid analgesia were also compared.

Results

The average number of opioid pills per prescription decreased by 25% from 19.3 (27.4 OME) to 15.0 (22.7 OME; P = 0.001) after guideline implementation, with no corresponding decrease in the average number of postdischarge opioid pills consumed [10.6 (15.1 OME) to 8.2 (12.4 OME); P = 0.147]. Neither patient satisfaction with pain management (9.6-9.6; P > 0.99) nor communication (9.6-9.5; P > 0.99) changed. The rate of opioid-only prescription regimens decreased from 17.9% to 7.6% (P = 0.01), and more patients were prescribed at least two nonopioid analgesics (27.5% to 42.9%; P = 0.003). The rate of scheduled acetaminophen prescription, in particular, increased (54.7% to 71.4%; P = 0.002).

Conclusions

A procedure-specific prescribing model is a straight-forward intervention to promote safer opioid-prescribing practices in plastic surgery. Its usage in clinical practice may lead to more appropriate opioid prescribing.

Predictors of opioid-free discharge after laparoscopic cholecystectomy

BACKGROUND

Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare.

STUDY DESIGN

Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge.

RESULTS

Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge.

CONCLUSION

Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.

Opioid prescribing practices and patient-requested refill patterns following laparoscopic inguinal hernia repair

PURPOSE

Excessive post-operative opioid prescribing has led to efforts to match prescriptions with patient need after surgery. We investigated opioid prescribing practices, rate of patient-requested opioid refills, and associated factors after laparoscopic inguinal hernia repair (LIHR).

METHODS

LIHRs at a single institution from 3/2019 to 3/2021 were queried from the Abdominal Core Health Quality Collaborative for demographics, perioperative details, and patient-reported opioid usage. Opioid prescriptions at discharge and opioid refills were extracted from the medical record. Univariate and multivariable regression were used to identify factors associated with opioid refills within 30-days of surgery.

RESULTS

Four hundred and ninety LIHR patients were analyzed. The median number of opioid tablets prescribed was 12 [interquartile range (IQR) 10-15], and 4% requested a refill. On univariate analysis, patients who requested refills were younger [55 years (IQR 37-61) vs. 62 years (IQR 36.8-61), p = 0.012], more likely to have undergone transabdominal preperitoneal repair (75% vs. 26.4%, p < 0.001), have a scrotal component (30% vs. 11%, p = 0.022), and have permanent tacks used (80% vs. 49.4%, p = 0.014). There was a 12% increase in the odds of opioid refill for every 1 tablet of oxycodone prescribed at discharge (95% CI for OR 1.04-1.21, p = 0.003) after controlling for age and surgery type. Patient-reported opioid use was available for 289 (59%) patients. Post-operatively, 67% of patients used ≤ 4 opioid tablets, and 87% used no more than 10 opioid tablets.

CONCLUSION

Most patients use fewer opioid tablets than prescribed. Requests for opioid refills are rare following LIHR (4%) and associated with higher opioid prescribing.

Factors that influence discharge opioid prescribing among bariatric surgeons across Michigan

BACKGROUND

Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices.

METHODS

We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis.

RESULTS

At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery.

CONCLUSION

Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.

Cross-Country Analysis of the Association of Cultural Dimensions with Prescription Opioid Consumption and Implications for Health Education

Background and Purpose: Over 247,000 people died in the U.S. from overdoses related to prescription opioids in 1999-2019, leading the WHO to deem the situation an epidemic. The purpose of this study is to examine whether culture is related to perceptions and behaviors around opioid consumption because culture has been shown, for example, to influence decision-making strategies, risk-taking, and responses to self-congruent communications. Methods: Scores for country-wide dimensions of culture from Hofstede and opioid consumption data from the International Narcotics Control Board were used to study a possible relationship. The relationship was tested by including a set of economic and socio-economic indicators from the World Bank, the United Nations, and PROSPERED. Results: The scores for the cultural dimension of individualism are correlated with opioid consumption on a country level, with higher levels of individualism connected to higher consumption. This correlation is robust to the inclusion of economic and socio-economic variables (GDP per capita, inflation, income inequality, unemployment, education, life expectancy, median age, and sick leave coverage). Conclusions and Importance: Because messages that reinforce a group's cultural value are more meaningful and effective in motivating action, educational health messages about opioid consumption in the U.S. need to be designed with culture in mind to disrupt decisions to take opioid analgesics unless medically justified or to limit their use. More research is needed on how to design self-congruent individualistic versus collectivistic persuasive appeals.

Patient Willingness to Dispose of Leftover Opioids After Surgery: A Mixed Methods Study

We examined how convenience and financial incentives influence patient willingness to dispose of leftover prescription opioids after surgery. We also identified additional barriers and facilitators to disposal.

Background

In the United States, up to 70% of surgical patients are prescribed opioids and up to 92% will have leftover tablets. Most do not dispose of leftover opioids, increasing the risk for opioid-related harm. Current interventions promoting opioid disposal have shown mixed success.

Methods

We conducted a mixed methods study using a standard gamble survey and semi-structured interviews. Participants estimated willingness to dispose in 16 scenarios with varying convenience (time requirements of <5, 15, 30, and 60 minutes) and financial incentives ($0, $5, $25, $50). We estimated the likelihood of disposal using a multivariable mixed effects modified Poisson regression model. Semi-structured interviews explored how convenience, financial incentives, and other barriers and facilitators influenced decisions to dispose.

Results

Fifty-five participants were surveyed and 42 were interviewed. Most were willing to dispose when the time required was <15 minutes. Few were willing to dispose if the process required 60 minutes, although a $50 financial incentive increased rates from 9% to 36%. Anxiety about future pain, opioid scarcity, recreational use, family safety, moral beliefs, addiction, theft, and environmental harm also influenced decision-making.

Conclusions

Interventions promoting opioid disposal should focus on convenience, but the selective use of financial incentives can be effective. Tailoring interventions to individual barriers and facilitators could also increase disposal rates.

Use and misuse of opioid after gynecologic surgery

Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.

A Web-based Educational Intervention to Increase Perianesthesia Nurses' Knowledge, Attitude, and Intention to Promote Safe Use, Storage, and Disposal of Opioids

PURPOSE

The purpose of this study was to determine if a web-based educational intervention increased knowledge, attitudes, and intention of perianesthesia nurses regarding opioid discharge education (including safe use, storage, and disposal of opioids). Secondary outcomes were to determine Perceived Behavioral Control, subjective norms, and familiarity with American Society of PeriAnesthesia Nurses (ASPAN) guidance on opioid education.

DESIGN

A pre-test, post-test longitudinal design.

METHODS

An email described the study and had a link for those choosing to participate. The intervention was a web-based voiceover module with patient education scenarios focused on information required for patients before discharge home. Responses to the evidence-based pre-survey, post-survey one, and post-survey two were collected. The survey was developed using components of the Theory of Planned Behavior. Data analysis included descriptive summary and evaluation of changes in knowledge and domains of Theory of Planned Behavior using repeated measures mixed modeling.

FINDINGS

The participants were invited to complete a pre-test survey (n = 672), the immediate post-test (n = 245), and the 4-week post-test (n = 172). The analysis presented is limited to 245 who completed at least the first post-survey. Most were staff nurses (82%), and the majority had a BSN (62%); participants most typically worked in a hospital-based PACU (73%). For all outcomes, there was an immediate increase in the measure following the intervention; this pairwise difference (between pretest and the immediate post-test) was significant in all but one of the models. The immediate and 4-week post-test scores exceeded the corresponding pre-test score, though for Perceived Behavioral Control, attitude, and intention, the degree of increase between baseline and week 4 was not significant.

CONCLUSIONS

In all cases, both the immediate and 4-week post-test scores exceeded the corresponding pre-test score, though, for three of the TPB constructs, the difference between baseline and week 4 was not significant, while nearly all of the increases between baseline and immediately following the intervention were significant. These findings suggest a more intensive intervention, possibly with the inclusion of booster sessions, may be needed.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

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.