Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015

Oxycodone and Morphine Use in Hospitals and Primary Care in Norway 2010-2021: A Nationwide Study

BACKGROUND

Increasing oxycodone prescribing and its association with opioid-related harms have raised concerns. In Norway, nearly 90% of opioids are prescribed in primary care, making primary care decisions important to overall opioid exposure. In-hospital use may influence primary care practices through several mechanisms. This study analyses oxycodone and morphine use in Norwegian hospitals and its association with primary care prescribing from 2010 to 2021, alongside a review of tender agreements for these medications.

METHODS

Morphine and oxycodone, available in all relevant formulations, served as opioid proxies to compare covariation between hospitals and their catchment areas. We analyzed 2010-2021 procurement data from hospital pharmacies and primary care dispensing data from the Norwegian Prescription Database for all hospital trusts. Correlations between hospital and primary care morphine-to-oxycodone prescribing ratios were assessed using Pearson's r. Annual tender agreements were obtained from the national Hospital Procurement Organization.

RESULTS

Hospital oxycodone use increased by 67.0% and primary care prescribing rose by 86.5%. Morphine use increased by 12.6% in hospitals but decreased by 23.2% in primary care. A moderate covariation (Pearson's r = 0.48) between hospital use and primary care prescribing was observed. Hospital tender agreements for morphine declined by 80%, while those for oxycodone remained stable.

CONCLUSIONS

Oxycodone use substantially increased relative to morphine in Norwegian hospitals and primary care. Prescription patterns show moderate covariation, suggesting a potential link between hospital and primary care prescribing, though causality remains uncertain. Tender agreements may contribute to prescribing trends in hospitals, with possible associations in primary care.

SIGNIFICANCE

This study is the first to provide quantitative evidence of covariation between in-hospital use and primary care opioid prescribing across a national healthcare system. Despite recommendations favoring morphine, oxycodone prescribing continues to rise in Norway, with marked geographical variation. By linking procurement data, prescription patterns and tender agreements, our findings highlight the need to consider hospital practices and structural factors when addressing opioid prescribing. These results offer new insights into potential levers for opioid stewardship across care levels.

Trends of opioid use following anterior cervical discectomy and fusion: A 10-year longitudinal study of the Veterans Health Administration

Background

The United States Veteran Health Administration (VHA) cares for a substantial group of patients who are at higher risk of substance abuse in comparison to the general population. The purpose of this study was to (1) examine opioid consumption in the veteran population both pre- and postoperatively to anterior cervical discectomy and fusion (ACDF) and (2) understand the risk factors that are associated with sustained postoperative opioid use.

Methods

A retrospective database study was conducted using the Veterans Affairs Informatics and Computing Infrastructure database. Patients who underwent ACDF between 2010 and 2020 were identified and stratified into 3 groups based on their preoperative opioid usage prior to the procedure: opioid naïve, low preoperative opioid use (1-3 preoperative claims), and high preoperative opioid use (≥4 preoperative claims). Cumulative pre- and postoperative opioid usage for each patient was calculated in Morphine Milligram Equivalents (MME).

Results

A total of 7,894 patients were identified with 3,929 (49.7%) opioid naïve, 1,813 (23.0%) low preoperative opioid use, and 2,152 (27.3%) high opioid usage. The proportion of patients in the opioid-naïve cohort, low preoperative usage cohort, and high preoperative opioid usage cohort, that remained on opioids 1 year postoperatively was 13.1%, 31.3%, and 77.8%, respectively. At 1 year postoperatively, the median opioid MME significantly decreased pre- to postoperatively (25.0 vs. 0, p<.006). High preoperative opioid consumption was found to be the greatest risk factor for continued chronic opioid use (OR 17.1, p<.001).

Conclusions

Following ACDF procedures, opioid consumption significantly decreased; however, at 1 year, over one-third of patients remained on opioid therapy. A disproportionate number of patients who remained on chronic opioid therapy had high preoperative opioid consumption. Notably, increased scrutiny and policy changes regarding opioids, which began around 2017, resulted in a significant reduction in preoperative opioid use by 2020 compared to a decade earlier.

Implementation of a Patient-Specific Opioid Taper Calculator for Total Hip and Knee Arthroplasty: A Pre- and Post-Implementation Study

BACKGROUND

Given the association between high opioid use and postoperative complications after total joint arthroplasty, it is important to prescribe opioids responsibly in the postoperative period. While many pain regimen protocols exist to try and limit opioid use, an optimal approach to narcotic prescription for arthroplasty patients is yet to be established. This study evaluated the effects of using an individualized opioid taper calculator for patients undergoing elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that using the calculator would lead to a decrease in the amount and variability of opioids prescribed postoperatively.

METHODS

All primary THAs (117 precalculator and 105 postcalculator) and TKAs (172 precalculator and 139 postcalculator) meeting study inclusion and exclusion criteria were reviewed at a single academic hospital from January 2016 to December 2018 (precalculator) and January 2020 to December 2022 (postcalculator). The primary outcome measure was the quantity of opioids prescribed at discharge in morphine milligram equivalents between the two groups. Secondary measures included opioid refills, visual analog scale pain scores, and emergency department presentations or clinic calls due to pain. Statistical significance was defined as P <0.05.

RESULTS

Implementation of the opioid taper calculator resulted in a 40% decrease in the median morphine milligram equivalent prescribed at discharge for both THA (450 versus 270; P < 0.0001) and TKA (450 versus 270; P < 0.0001) patients, respectively. There was no significant difference within the THA or TKA cohorts when comparing visual analog scale pain scores (THA, 3 versus 4; P = 0.47; TKA; 5 versus 6, P = 0.26), and no increase in percentage of patients who had emergency department visits (THA, 5.98 versus 0.95%; P = 0.069; TKA, 6.40 versus 11.5%; P = 0.155) or calls to the clinic for pain (THA, 17.1 versus 24.8%; P = 0.186; TKA, 36.6 versus 37.4%; P = 0.906) between the precalculator and postcalculator groups.

CONCLUSIONS

Our findings support the use of a patient-specific opioid taper calculator to decrease the volume and variability of narcotics prescribed postoperatively for THA and TKA pain management. Our findings confirmed the general applicability and effectiveness of the opioid taper calculator outside of its institution of origin.

Multimorbidity and analgesic-related harms: a systematic review

BACKGROUND

Multimorbidity is the presence of two or more long-term medical conditions. Chronic pain affects more than half of people with multimorbidity, and optimal treatment strategies are unknown. We aimed to quantify the risk of adverse outcomes from the following analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids in adults with multimorbidity.

METHOD

The review was registered on PROSPERO (CRD42023462592). We searched Medline, CINAHL, Web of Science, Embase, and CENTRAL for studies reporting analgesic-related harms in people with multimorbidity or the impact of multimorbidity on harms in adults exposed to analgesics. Two researchers independently screened titles/abstracts, completed full-text reviews, extracted data, and assessed risk of bias using the Newcastle-Ottawa scale. Studies were synthesised narratively, grouping by analgesic class and direction of effect.

RESULTS

We screened 6690 records and 344 full texts, with 27 studies included (n=2 671 958 patients). Studies were heterogenous, with variable quality (high risk of bias, n=11). Most studies on opioids reported adverse outcomes (12/16). Opioid use compared with non-use was associated with increased mortality in adults with multimorbidity. Multimorbidity was associated with opioid overdose and death among adults prescribed opioids for pain. Half of studies of NSAIDs reported adverse outcomes (6/11) including gastrointestinal bleeding. Only one study assessed gabapentinoids which found an association with delirium and pneumonia, but not mortality in people with multimorbidity.

CONCLUSIONS

There is evidence of harms associated with opioids in adults with multimorbidity, including overdose and increased mortality. There is a lack of evidence on gabapentinoids. Further research is required to understand optimal analgesic management in people with multimorbidity.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023462592).

Concurrent Prescribing of Opioids and Sedative-Hypnotic Drugs for Long-Term Use in Australian General Practice: A Cross-Sectional Analysis Using MedicineInsight

The number of unintentional deaths involving opioid and/or benzodiazepine use continues to increase in Australia. This study examined patterns of concurrent prescribing of opioids and benzodiazepines/Z-drugs (BZDs) for long-term use in Australian general practice. A cross-sectional analysis was undertaken using MedicineInsight, a national database of de-identified general practice electronic health records. We estimated the proportion of patients (per 1000, ‰) in 2017 receiving concurrent prescriptions for opioid and BZD medications for long-term use (≥ 3 prescriptions within 90 days). Poisson regression models were used to estimate the marginal adjusted prevalence (adjP) and adjusted prevalence ratios (adjPR) were used to compare concurrent long-term prescribing according to sociodemographic characteristics, rurality, smoking status, and diagnosis of mental health or musculoskeletal conditions. The sample included 1,207,671 individuals (41.3% males; mean age 50.6 ± 18.6 years) regularly attending 544 general practices. The prevalence of concurrent long-term opioid and BZD prescribing was 7.0‰, and the median duration of prescribing overlap was 611 days (p25-p75 348-952). The prevalence was higher for patients aged over 65 years (adjPR = 3.62 95% CI 3.30, 3.98), females (adjPR = 1.33 95% CI 1.27, 1.39), those living in more disadvantaged (adjPR = 1.70 95% CI 1.49, 1.93) or rural/remote areas (adjPR = 1.13 95% CI 1.00, 1.28), smokers (adjPR = 4.10 95% CI 3.87, 4.35), and those with mental health (adjPR = 3.23; 95% CI 2.83, 3.69) or musculoskeletal conditions (adjPR = 2.74; 95% CI 2.47, 3.04). In patients with both mental health and musculoskeletal conditions, the prevalence was 32.1‰. Interventions to reduce concurrent long-term prescribing could be targeted to the identified vulnerable groups.

Identifying spatiotemporal patterns in opioid vulnerability: investigating the links between disability, prescription opioids and opioid-related mortality

BACKGROUND

The opioid crisis remains one of the most daunting and complex public health problems in the United States. This study investigates the national epidemic by analyzing vulnerability profiles of three key factors: opioid-related mortality rates, opioid prescription dispensing rates, and disability rank ordered rates.

METHODS

This study utilizes county level data, spanning the years 2014 through 2020, on the rates of opioid-related mortality, opioid prescription dispensing, and disability. To successfully estimate and predict trends in these opioid-related factors, we augment the Kalman Filter with a novel spatial component. To define opioid vulnerability profiles, we create heat maps of our filter's predicted rates across the nation's counties and identify the hotspots. In this context, hotspots are defined on a year-by-year basis as counties with rates in the top 5% nationally.

RESULTS

Our spatial Kalman filter demonstrates strong predictive performance. From 2014 to 2018, these predictions highlight consistent spatiotemporal patterns across all three factors, with Appalachia distinguished as the nation's most vulnerable region. Starting in 2019 however, the dispensing rate profiles undergo a dramatic and chaotic shift.

CONCLUSIONS

The initial primary drivers of opioid abuse in the Appalachian region were likely prescription opioids; however, it now appears that abuse is sustained by illegal drugs. Additionally, we find that the disabled subpopulation may be more at risk of opioid-related mortality than the general population. Public health initiatives must extend beyond controlling prescription practices to address the transition to and impact of illicit drug use.

Opioid Analgesic Prescribing Practice in a Predoctoral Dental School Over a Decade

BACKGROUND

Dental schools play an influential role in shaping education and training of future dental professionals. This study investigated the prevalence and evolving trend of opioid analgesic prescription across dental surgical and endodontic procedures between 2013-2023 within a predoctoral dental school.

METHODS

Electronic health records (axiUm database) of our predoctoral dental school were retrospectively searched for dental surgical and endodontic procedure codes dated between July 2013-May 2023. Differences in frequency of opioid prescriptions across study period and procedure types were compared using Chi-square tests. Logistic regression was used to determine whether COVID-19 pandemic, tooth involved, patient's age, or multiple-procedure were associated with the prescription of opioid analgesics.

RESULTS

A total of 1,145 opioid prescriptions were dispensed after 54,652 dental surgical and endodontic procedures completed over 41,343 dental visits. The prevalence of opioid-prescribing practice was 3.3% after dental surgical procedures and 0.7% after endodontic procedures, with a statistically significant difference across procedure types (p < 0.00001). 42.4% of all opioid prescriptions were dispensed after surgical removal of erupted teeth. Opioid-analgesic prescribing practice was influenced by multiple procedures conducted during the same dental visit (odds ratio, OR = 9,047,709), tooth number (OR = 1.04), and COVID-19 period (OR = 6,101,435). The 10-year period revealed a -58.3% percentage change in opioid-prescribing practices (from 1.2% in 2013 to 0.5% in 2023), after a peak in 2016 (∼6.1%).

CONCLUSIONS

There was a low combined 2.8% prevalence of opioid-analgesic prescriptions following dental surgical (3.3% prevalence) and endodontic (0.7% prevalence) procedures at a predoctoral dental school, with a steady decline after 2016.

Purposeful Shared Decision-Making in Caring for and with Patients with Chronic Pain Receiving Opioid Therapy

CDC guidelines for prescribing opioids for chronic pain recommend that patients and clinicians engage in shared decision-making (SDM), a practice often described as clinicians working with patients to find treatment options that match patient preferences. Some experts have argued otherwise given limited efficacy of opioid use for chronic pain, the potential effects of long-term opioid therapy on patient's decision-making capacity, and the societal consequences of opioid diversion. Chronic pain care involves reaching a shared understanding of how the patient's pain affects living and how to change this situation. The conversation to achieve this shared understanding and to change the problematic situation of the patient is called Purposeful SDM. Purposeful SDM as a method of collaborative care is a useful and usable framework for patient-centered chronic pain care with or without prescription opioids. Chronic pain or long-term opioid therapy do not render patients unable to participate in Purposeful SDM. And yet, some regulatory tools intended to make opioid prescribing safer, when used punitively, may undermine both the trust that sustains the patient-clinician relationship and the possibility of SDM. There is considerable nuance in chronic pain management and opioid prescribing decisions. The Purposeful SDM framework is based on and contributes to a collaborative, non-punitive relationship between patient and clinician to make chronic pain care fit while avoiding unintended harm from unilateral treatment decisions.

Reducing Chronic Opioid Use: Long-term Impacts of Enhanced Recovery After Mastectomy Protocols

OBJECTIVE

This study investigates Enhanced Recovery After Surgery (ERAS) protocols' impact on long-term opioid and sedative use following mastectomy with or without implant-based breast reconstruction (IBBR).

BACKGROUND

ERAS protocols for patients undergoing mastectomy with or without IBBR are associated with decreased length of stay, increased rate of same-day discharge, decreased postoperative pain, and decreased postoperative opioid requirements. However, less is known about their effect on opioid and sedative use beyond 90 days after surgery.

METHODS

A retrospective review of all patients undergoing mastectomy with or without IBBR at a single institution between January 2013 and December 2019. Mastectomy ERAS protocols were implemented in February 2017, creating 2 groups: pre-ERAS and ERAS. Baseline characteristics and prevalence of chronic opioid and sedative use were compared. Univariable and multivariable logistic regression predicted factors associated with increased odds of chronic opioid and sedative use.

RESULTS

A total of 756 patients were evaluated: 405 pre-ERAS and 351 ERAS. Post-ERAS, chronic opioid use decreased in opioid-naive (40% vs 30%, P =0.024) and opioid-tolerant patients (58% vs 37%, P =0.002), with no increase in chronic sedative use. There were decreased odds of chronic opioid use for all ERAS patients (OR=0.57, 95% CI: 0.42-0.76), and of IBBR patients, those receiving subcutaneous implants (OR=0.31, 95% CI: 0.20-0.48). There was increased chronic opioid-use odds if undergoing bilateral surgery (OR=1.54, 95% CI: 1.14-2.08), 2-stage reconstruction (OR=9.78, 95% CI: 5.94-16.09), and for patients with higher PACU pain scores (OR=1.09, 95% CI: 1.03-1.14) or >150 discharge OMEs (OR=2.63, 95% CI: 1.48-4.68).

CONCLUSION

ERAS protocols for mastectomy patients with or without IBR are associated with decreases in chronic opioid use, without concomitant increases in chronic sedative use.

How Is Preoperative Opioid Use Associated With Readmissions and Outcomes in Lower Extremity Trauma?

BACKGROUND

Opioid use disorder (OUD) has been implicated as a potential risk factor for adverse outcomes and readmissions in various surgical procedures. Patients admitted with an open fracture of the lower extremity often have multifarious pain needs, require surgical procedures, and have prolonged rehabilitation; previous OUD complicates this process. Our goal was to describe at a national level how OUD is associated with readmission, complications, and healthcare expenditure for patients admitted with open lower extremity fractures.

QUESTIONS/PURPOSES

(1) Do patients with OUD who were treated for open lower extremity fractures have higher odds of readmission compared with patients without OUD? (2) Do patients with OUD who were treated for open lower extremity fractures have higher healthcare utilization (specifically, length of stay and hospitalization charges and costs)?

METHODS

This was a retrospective, comparative study using the Nationwide Readmissions Database, which is the largest nationally representative readmissions database in the United States. Patients were included if they had an ICD-10-CM principal diagnosis of open lower extremity fracture. Between January 1, 2019, and September 30, 2019, a total of 17,811 patients were admitted for open lower extremity fractures and entered in the National Readmissions Database. Of the 17,811 patients, 2.3% (410) had a secondary diagnosis of OUD and 97.7% (17,401) did not. The mean age was 46 years for both groups. The most common operative procedure was debridement, and 1.5% of patients received a flap for reconstruction. Opioid disorders were identified using ICD-10-CM codes. Ninety-day complications and readmissions were characterized for the calendar year. Patients undergoing flap-based reconstructions were identified with ICD-10-PR codes. Confounders (patient demographic and hospital characteristics) were adjusted for using multivariable regression analysis models.

RESULTS

After controlling for potentially confounding variables such as primary payer, Charlson comorbidity index, Gustillo type, and bone density, we found that patients with OUD had greater odds of readmission after open lower extremity fractures (adjusted OR 1.45 [95% confidence interval (CI) 1.0 to 2.0]; p = 0.03). The 90-day infection occurrence was higher in patients with OUD (adjusted OR 1.96 [95% CI 1.0 to 3.8]; p = 0.049) and was the primary reason for readmission in both groups. Moreover, 11% (11 of 103) of patients with OUD were readmitted with opioid-induced complications, which was exclusively observed in this cohort. Patients with OUD also had longer hospital stays (adjusted mean difference 2.2 days [95% CI 0.5 to 3.8]; p = 0.01) and higher hospitalization charges (adjusted mean difference in USD 34,000 [95% CI 1000 to 66,000]; p = 0.04) and costs (adjusted mean difference in USD 7000 [95% CI 2000 to 13,000]; p = 0.007) than those without OUD.

CONCLUSION

These findings suggest that mitigating infection and opioid overdose, addiction, and constipation in patients with OUD could reduce readmissions in lower extremity fracture patients. Future research should focus on antibiotic and wound care compliance and the early and frequent engagement of postoperative opioid addiction support services.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Quality of recovery (QoR-15) following opioid-free versus opioid anaesthesia for elective endoscopic nasal surgeries: A randomised, open-label comparative trial

Background and Aims

Newer modalities like opioid-free analgesia overcome the opioid-related side effect profile and are equally efficacious. This study aims to compare the clinical outcomes between opioid-free anaesthesia (OFA) and opioid-based anaesthesia (OA) in elective nasal endoscopic surgeries.

Methods

A randomised, open-label trial was conducted to evaluate the quality of recovery (QoR). The study included 64 patients with American Society of Anesthesiologists physical status I and II, of either gender, aged between 18 and 60 years, scheduled for elective endoscopic nasal surgery at a tertiary care centre. The patients were randomised into two groups: Group OA (patients receiving opioid anaesthesia) and Group OFA (patients receiving opioid-free anaesthesia). The primary outcome was the effects of OFA versus OA on the QoR-15 in patients undergoing endoscopic nasal surgeries under general anaesthesia. Secondary outcomes included intraoperative haemodynamics, respiratory depression, nausea/vomiting, pruritus, postoperative analgesia, and length of stay in the post-anaesthesia care unit. An independent sample t-test and Chi-squared test were employed for between-group comparisons.

Results

Patients undergoing OFA showed higher postoperative QoR-15 scores compared to the opioid group. Intraoperatively, the OFA group demonstrated a better haemodynamic profile at 15, 30, 60, 90, and 120 min, with lower mean arterial pressure values compared to the opioid group. Notably, the OFA group experienced reduced nausea/vomiting and pruritus. Postoperative analgesia requirements and length of stay in recovery were also lower in the OFA group.

Conclusion

OFA in elective nasal endoscopic surgeries results in higher QoR-15 scores, better postoperative analgesia and fewer adverse effects associated with opioids.

De-prescribing opioids among Medicaid patients with long-term opioid use

BACKGROUND

Guidelines encourage deprescribing opioids for long-term opioid patients, especially those using opioids and benzodiazepines, z-drugs, or muscle relaxants ("other respiratory depressants").

OBJECTIVE

Were long-term opioid patients who were prescribed other respiratory depressants more likely to have deprescribing opioid trajectories?

DESIGN

Cross-sectional retrospective study using pharmacy and professional claims from 2015 to 2019. Adjusted logistic regression models were stratified on low (<50 morphine milligram equivalents; MME) and high (>50 MME) starting opioid doses. We reported predicted probabilities with 95 % confidence intervals.

SUBJECTS

Nevada and Colorado Medicaid beneficiaries 18-64 years old without cancer diagnoses with long-term (120 days' supply/6 months) opioid use (117,400 person-windows).

MEASURES

We used group-based trajectory modeling in Stata to identify characteristic 12-month dosing trajectories. Using the resulting trajectories, we assigned the outcome = 1 if the observation had a deprescribing trajectory (versus a constant trajectory). Binary exposure variables indicated that the patient had an opioid prescription overlapping with 1, 2, or 3 types of other respiratory depressants.

RESULTS

Among patients with a low starting opioid dose, the predicted probabilities of a deprescribing trajectory were lower when the patient had overlapping other respiratory depressants compared to when they did not (0 respiratory depressants: 0.33, [0.32, 0.33]; vs. 1 respiratory depressant: 0.22, [0.20, 0.23]; 2 respiratory depressants: 0.18 [0.16, 0.20]; 3 respiratory depressants:0.20 [0.13, 0.27]). Among patients with a high starting opioid dose, we observed similar results.

CONCLUSIONS AND RELEVANCE

Targeted provider-level interventions to support deprescribing for long-term opioid patients using opioids and other respiratory depressants may provide particularly high-value care.

Decreasing Incident Opioid Use Disorder, Especially Adolescent and Young Adult

INTRODUCTION

Opioid prescription policies may reduce availability of prescription opioids and decrease initiation of opioid analgesic misuse and possible opioid use disorder. Opioid use disorder prevalence may have decreased in recent years, but there are few studies on trends of opioid use disorder incidence. The objective of this study was to examine opioid use disorder incidence rates to detect population changes overall and within demographic subgroups over time.

METHODS

In 2023, a longitudinal analysis of incident opioid use disorder diagnoses was conducted after implementation of Vermont's July 2017 policy limiting opioid analgesic prescriptions for acute pain. Included were individuals ≥16 years with medical claims in Vermont's all-payer claims database between July 1, 2017, and December 31, 2021. Multiple Poisson regression models assessed changes in opioid use disorder incidence rates per month overall, controlling for age, sex, rurality, and insurance type, and separately, testing age, rurality, and insurance as moderators.

RESULTS

Among 537,707 individuals, there was a 0.8% decrease per month in the opioid use disorder incidence rate (95% CI=0.991, 0.993) from July 2017 through December 2021. Age moderated the association between opioid use disorder incidence and time, with the largest decrease per month (1.6%) among those aged 16-29 years (95% CI=0.981, 0.986). There were smaller decreases in opioid use disorder incidence rate per month among those aged 30-44 years (0.6%), 45-59 years (0.5%), and ≥60+ years (0.6%).

CONCLUSIONS

This study found that the opioid use disorder incidence rate in Vermont decreased overall between July 2017 (policy start limiting opioid analgesic prescriptions) and December 2021, including during the COVID-19 pandemic, with the most pronounced decrease among adolescents and young adults.

Impact of Prospective, System-Wide Intervention to Influence Opioid Prescribing Practices Among Patients with Back Pain

BACKGROUND

In response to the opioid epidemic, our multidisciplinary team designed and integrated an alert-based, clinical-decision support intervention which identifies patients at risk of opioid misuse based on five evidence-based risk factors (early refill of opioids/benzodiazepines; >2 ED/Urgent Care visits with onsite opioids; >3 prescriptions of opioids/benzodiazepines; prior overdose; and positive toxicology screen).

OBJECTIVE

To evaluate the impact of the intervention on prescribing decisions for back pain by measuring the percent of opioid prescriptions modified in response to the alert.

METHODS

A total of 93,192 adult patients presenting to the emergency department with complaints of back pain from 2017-2021 were included in this prospective, observational study. We calculated rates of "decision influenced" (modifying or canceling prescriptions) in response to the PRIMUM intervention and characterized patients, encounters, and prescriptions in this population.

RESULTS

The 30.2% of back pain patients received an opioid prescription. Among patients prescribed opioids, 18.6% had a risk factor. An alert fired in 6,501 (19.8%) encounters, and positive toxicology was the most common risk factor (52.1%). The prescriber decision was influenced in 430 of these encounters overall (6.6%) and was highest for three or more prescriptions in the past month (11.8%) and early refill (9.1%). Chronic patients were more likely to receive opioids.

CONCLUSIONS

Roughly 1 in 3 patients presenting to the emergency department for back pain received an opioid. A clinical decision support intervention to identify patients at risk of opioid use disorder had a minimal influence on opioid prescribing decisions in this population.

Mindful Jazz and Preferred Music Interventions Reduce Pain Among Patients With Chronic Pain and Anxiety: A Pilot Randomized Controlled Trial

BACKGROUND

A mindfulness-based intervention (MBI) focused on listening to music might reduce chronic pain and provide a new approach to overcoming challenges from traditional MBIs (e.g., breathing). Due to the potential unpredictability and unfamiliarity of jazz, an MBI focused on listening to improvisational jazz music might be a particularly efficacious pain reduction intervention. This pilot study explores whether mindfully listening to music, including jazz, can reduce pain-related outcomes.

METHODS

Chronic musculoskeletal pain (CMP) participants (n=30 per group, N = 120 total) were enrolled online between 12/7/2023 and 2/8/2024. Participants were randomly assigned to one of four groups in a 2 (Mindful Music Listening/Intervention vs. Music Education/Control) X 2 (Preferred Music (choose their own music genre) vs Jazz (assigned to listen to improvisational jazz)) experiment, for a total of four groups (Mindful Jazz, Mindful Music, Jazz Education, and Music Education). Patients in each group were provided with training in either mindful listening to music (Intervention groups) or music education (Control groups) and given four sets of weekly recordings related to their group for daily listening/practice. Patients completed online surveys on pain-related outcomes (e.g., pain catastrophizing, pain intensity, and anxiety) pre- and post-training (immediate outcomes), and throughout a four-week period (longer-term outcomes). The main outcomes analyses compared the intervention and control groups, with secondary sub-analyses among participants who listened to at least 2/3 of their recordings (10 minutes), and among those who experienced a clinically meaningful (20%) reduction in pain.

RESULTS

Mindful Jazz and Mindful Music (Intervention) participants reported significantly less pain intensity (p < 0.001) and pain unpleasantness (p < 0.001) immediately after the training relative to the Jazz Education and Music Education (Control) participants. Mindful Jazz participants also reported a significant reduction in anxiety compared to the Jazz and Music Education groups (p < 0.05). Throughout the four-week period, Mindful Jazz participants reported less pain intensity relative to both control groups (Jazz and Music Education); Mindful Music participants reported significantly less pain intensity relative to only the Jazz Education participants. Mindful Jazz participants reported a >20% decrease in pain intensity more frequently than Jazz Education (Χ2=48.71, p<0.001), Music Education (Χ2=65.13, p<0.001), and Mindful Music (Χ2=8.74, p=0.003) participants. Similarly, among the instances when a participant listened to at least 10 minutes of their audio recording, the proportion who achieved a >20% decrease in pain intensity differed significantly ((Χ2=84.03, p<0.001): Jazz Education, 29%; Music Education, 26%, Mindful Jazz, 50%; Mindful Music 41%).

CONCLUSION

Mindfully listening to music can help to reduce pain-related outcomes. Both music education (i.e., music listening without mindfulness training) and mindfully listening to music (i.e., listening with mindfulness training) helped to decrease pain and anxiety from baseline to follow-up. However, mindful listening reduced pain to a greater amount compared to music education, suggesting that mindfully listening to music is a more impactful pain reduction intervention compared to listening without mindfulness training. Future research is warranted with a larger sample.

The effect of preoperative interventions on postoperative outcomes following elective hand surgery: A systematic review

Background

Hand surgery is commonly required for conditions like Dupuytren's disease, carpal tunnel syndrome, and carpometacarpal osteoarthritis. Hand experts agree that patient education and managing expectations can optimise surgical outcomes. With an aging population, and rising rates of diabetes and obesity, a significant increase in elective hand surgeries is anticipated over the next decade.

Objective

To assess the effectiveness of preoperative therapy interventions on improving postoperative outcomes following elective hand surgery.

Method

A systematic search of six databases accessed journals from January 2011 to April 2024. Included studies assessed postoperative outcomes following preoperative therapy intervention.

Results

Seven articles met the inclusion criteria: six randomised controlled trials (RCTs) and one retrospective cohort study. Five RCTs explored effects of opioid education on postoperative consumption, all reporting statistically significant differences in favour of the intervention, with one showing a decrease of 49.7 morphine equivalent units (95% CI: 11.9 to 87.5), representing a 34.7% decrease between intervention and control. All RCTs scored poorly for risk of bias with the exception of one which assessed the effects of a neuroscience pain education on postoperative pain, reporting a non-significant decrease of 7.7% favouring the control.

Conclusion

There is a lack of quality research assessing preoperative interventions and outcomes for hand surgery. There was some indication of favourable outcomes following preoperative opioid education; however, number of studies were small, the evidence quality was poor, and data were limited. Further research is required to address these gaps and identify the most effective preoperative interventions.

Disparities in Postoperative Pain Management: A Scoping Review of Prescription Practices and Social Determinants of Health

Background: Opioid analgesic therapy has been traditionally used for pain management; however, the variability in patient characteristics, complexity in evaluating pain, availability of treatment within facilities, and U.S. physicians overprescribing opioids have contributed to the current opioid epidemic. Despite large research efforts investigating the patterns of postsurgical pain management and influencing factors, it remains unclear how these overall trends vary across the varying sizes and available resources of academic hospitals, community hospitals, and outpatient surgery centers. The primary aim of this scoping review was to examine the patterns of contemporary postoperative pain management across healthcare settings, including academic medical centers, community hospitals, and outpatient surgery centers. Specifically, this study investigates how prescription practices for opioids, NSAIDs, and acetaminophen are influenced by patient demographics, including sex, race, gender, insurance status, and other social determinants of health (SDoH), to inform equitable and patient-centered pain management strategies. Methods: This study utilized The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and was used as a reference checklist. The Arksey and O'Malley methodological framework was used to guide the review process. To ensure comprehensive coverage, searches were conducted across three major databases: PubMed, Embase, and Cochrane Library. Results: A total of 43 eligible studies were retained for analysis. The highest reported Healthy People 2030 category was Social and community context (n = 39), while the highest reported category of SDoH was age (n = 36). A total of 34 articles listed sex and age as SDoH. Additional SDoH examined were race/ethnicity (n = 17), insurance (n = 7), employment (n = 1), education (n = 4), and income (n = 1). This review suggests that there are significant gaps in the implementation of institution-specific, patient-centered, and equitable pain management strategies, particularly in academic hospitals, which our findings show have the highest rates of opioid and NSAID prescriptions (n = 26) compared to outpatient surgical centers (n = 8). Findings from our review of the literature demonstrated that while academic hospitals often adopt enhanced recovery protocols aimed at reducing opioid dependence, these protocols can fail to address the diverse needs of at-risk populations, such as those with chronic substance use, low socioeconomic status, or racial and ethnic minorities. Conclusions: Findings from this review are expected to have implications for informing both organizational-specific and nationwide policy recommendations, potentially leading to more personalized and equitable pain management strategies across different healthcare settings. These include guidelines for clinicians on addressing various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care.

Predictors of new persistent opioid use after surgery in adults

Purpose

Persistent opioid use is one of the most common post-operative complications. Identification of at-risk patients pre-operatively is key to reducing post-operative opioid use. We sought to develop a predictive model for persistent post-operative opioid used and to determine if geographic factors from community databases improve model prediction based solely on electronic health records (EHRs) and claims data.

Methods

EHR and claims data for 4,116 opioid-naïve surgical patients older than 18 in North Carolina were linked with census tract-level unemployment data from the American Community Survey and Centers for Disease Control and Prevention data on opioid prescriptions and deaths attributed to drug poisoning. Primary outcome was new persistent opioid use and covariates included patient factors from EHR, claims data, and geographic factors. Multivariable logistic regression models of potential risk factors were evaluated.

Results

6.0% of patients developed new persistent opioid use. Associated risk factors based on multivariable logistic regressions include age (adjusted odds ratio [AOR] 1.08; 95% confidence interval [CI] 1.00, 1.16), back and neck pain (1.82; 1.39, 2.39), joint disorders (1.58; 1.18, 2.11), mood disorders (1.71; 1.28, 2.28), opioid retail prescription (1.04; 1.00, 1.07) and drug poisoning rates (1.33; 1.09, 1.62). On Monte-Carlo cross-validation, the addition of geographic factors to EHRs and claims may modestly improve prediction performance (area under the curve, AUC) of logistic regression models compared to those based on EHRs and claims data (AUC 0.667 (95% CI 0.619, 0.717) vs AUC 0.653 (0.600, 0.706)).

Conclusions

Co-morbidities and area-based factors are predictive of new persistent post-operative opioid use. As the addition of geographic-based factors did not significantly improve performance of multivariable logistic regression, larger samples are needed to fully differentiate models.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44254-024-00083-1.

Transdermal Fentanyl Patch Effectiveness in Postoperative PainManagement in Orthopedic Patients: Literature Review

Controlling pain after major orthopedic surgery may be challenging, and it is related to delayed recovery, the development of chronic pain, and analgesic dependence. It is well known that effective postoperative pain control can reduce hospital stays by ensuring a more rapid rehabilitation,thereby decreasing the overall costs. Despite the development of analgesics, the use of opioids and their derivates remains the cornerstone of treatment for patients with acute moderate-to-severe pain in association with general or regional anesthesia. To reduce the risk of side effects and opioid addiction, considering the alarming epidemiological reports in relation to opioid abuse, combined analgesic methods are used, in addition to lower dosages or different forms of administration, such as transdermal administration. Fentanyl transdermal patches appear to be effective in controlling postoperative pain as part of multimodal analgesic regimens in knee and hip surgery, shoulder arthroplasty, traumatic fractures, and one-day surgery; this treatment has fewer associated side effects and can be safely used even in patients with renal impairment. It is also recommended for postoperative pain management in combination with a femoral-sciatic nerve block during foot and ankle surgery.

Oxymorphone and Oxycodone Pharmacy Purchases in US Counties: Prelude to the Largest Rural Human Immunodeficiency Virus Outbreak in US History

PURPOSE

The largest rural outbreak of human immunodeficiency virus (HIV) in the US was centered in Scott County, Indiana, and linked to injection practices involving the opioid Opana ER (oxymorphone extended release [ER] reformulated). We examined supply trends using pharmacy transactions of Opana ER in Scott and all US counties from January 2007 to December 2019.

METHODS

We calculated the monthly morphine milligram equivalents (MME) of Opana ER (and its competitor OxyContin) in pharmacies using the Automation of Reports and Consolidated Orders System (ARCOS) database from the Washington Post. We modeled the MME rate per capita in Scott County and five geographic comparators in seven distinct time periods including the market introduction of abuse deterrent formulations of both drugs and the HIV outbreak period (circa 2014).

RESULTS

After Opana ER introduction, transaction rates surged in Scott County, where annual OxyContin MMEs were already seven-fold higher than Indiana overall (CY2009: 46.8 vs. 6.8 MME/pop., respectively). Immediately after OxyContin's reformulation, the Opana ER growth rate in Scott County surpassed all geographic comparators modeled (~27 times faster than the US, 1.28 vs. 0.047 MME/pop/month, respectively). By 2012, prior to the outbreak, MMEs from Opana ER almost perfectly replaced the diminishing OxyContin supply. When Opana ER with INTAC was subsequently introduced, pharmacy transactions declined precipitously by nearly 50%, persisting through the HIV outbreak period and market withdrawal.

CONCLUSIONS

Opana ER rapidly supplanted OxyContin in a vulnerable population that was at heightened risk for HIV who subsequently faced an immediate supply shock after its reformulation. Pharmacy transactions are critical for suspicious order monitoring and pharmacovigilance by US and international agencies especially during deleterious supply shocks in legal and illicit drug markets.

Suicide deaths involving opioid poisoning in the United States, by sex, 1999-2021

Suicide remains a leading cause of death in the United States, and recent data suggest suicide deaths involving opioids are increasing. Given unprecedented increases in drug-poisoning deaths, suicidality, and suicide deaths in recent years, an updated examination of the trends in suicide deaths involving opioids is warranted. In this descriptive epidemiologic analysis, we leverage final and provisional mortality data from the US Centers for Disease Control and Prevention's WONDER database to examine trends in suicide deaths involving opioid poisoning from 1999 to 2021 by biological sex. Results reveal complex changes over time: the number and age-adjusted rate of suicide deaths involving opioid poisoning among male and female residents tended to track together, and both increased through 2010, but then diverged, with the number and rate of suicide deaths involving opioid poisoning among female residents outpacing that of male residents. However, the number and rate of suicide deaths involving opioid poisoning among male residents then began to stabilize, while that of female residents declined, closing the sex-based gap. Across all years of data, the proportion of suicide deaths that involved opioid poisoning was consistently higher among female decedents (5.8%-11.0%) compared with male decedents (1.4%-2.8%). Findings have implications for improved suicide prevention and harm reduction efforts. This article is part of a Special Collection on Mental Health.

Chronic Opioid Prescribing After Common Otolaryngology Procedures in Adults

OBJECTIVE

(1) Describe short and long-term opioid prescribing patterns and variation after common otolaryngologic procedures and (2) assess risk factors for chronic opioid use in this cohort.

STUDY DESIGN

Retrospective cohort.

SETTING

Optum's deidentified Integrated Claims-Clinical data set.

METHODS

An adult cohort of patients undergoing common otolaryngology procedures from 2010 to 2017 was identified. Associations between procedure and other covariates with any initial opioid prescription and continuous opioid prescriptions were assessed with multivariable modeling. Opioid use was defined as continuous if a new prescription was filled within 30 days of the previous prescription. A time-to-event analysis assessed continuous prescriptions from the index procedure to end of the last continuous opioid prescription.

RESULTS

Among a cohort of 19,819 patients undergoing predominately laryngoscopy procedures (12,721, 64.2%), 2585 (13.0%) received an opioid prescription with variation in receiving a prescription, daily dose, and total initially prescribed dose varying by procedure, patient demographics, provider characteristics, and facility type. Opioids were prescribed most frequently after tonsillectomy (45.4%) and least frequently after laryngoscopy with interventions (3.9%), which persisted in the multivariable models. Overall rates of continuous use at 180 and 360 days were 0.48% and 0.27%, respectively. Among patients receiving an initial opioid prescription, maintaining continuous prescriptions was associated with tonsillectomy procedures, age (adjusted hazard ratio [aHR]: 0.997 per year, 95% confidence interval [CI]: 0.993-0.999), opioid prescriptions 6 months preprocedure (aHR: 0.42, 95% CI: 0.37-0.47), and nonotolaryngology initial prescribers (aHRs: <1, P < .05).

CONCLUSION

There is substantial variation in initial prescribing practices and continuous opioid prescriptions after common Otolaryngology procedures, but the overall rate of maintaining a continuous prescription starting after these procedures is very low.

LEVEL OF EVIDENCE

Level 3.

Medicaid expansion and opioid prescriptions: Evidence from the Medical Expenditure Panel Survey

Evidence is mixed on whether increased access to insurance, specifically through the ACA's Medicaid expansion, exacerbated the opioid public health crisis through increased opioid prescribing. Using survey data on retail prescription drug fills from 2008 to 2019, we did not find a significant relationship between Medicaid expansion and opioid prescribing in the newly eligible Medicaid population. It may be that the dangers of opioids were known well enough by the time of the Medicaid expansion that lack of access to care was no longer a binding constraint on opioid prescription receipt.

Opioid-Prescribing Trends in Dermatology From 2014 to 2020 in the United States

Introduction The opioid epidemic is a critical public health crisis, with opioid overdose deaths being a leading cause of injury-related deaths in the United States. Dermatology, though a small contributor to overall opioid prescriptions, still accounts for over 700,000 opioid pills annually. Reducing opioid prescribing in this specialty has been challenging due to limited comprehensive research. This study aimed to investigate opioid-prescribing trends in dermatology across all nine US regions over seven years. Methods Data on opioid prescriptions by dermatologists from 2014 to 2020 were collected retrospectively from the Medicare Part D Prescribers by Provider database, available through the United States Centers for Medicare and Medicaid Services (CMS). The data were analyzed nationally and by geographic division, using US census population estimates for the respective states to calculate rates per population. Over the years studied, opioid prescription claims, the number of dermatologists, and the proportion of dermatologists prescribing opioids gradually decreased both by average and by population. Results Over the years evaluated, there were a total of 618,714 claims for short-acting opioids throughout the United States. Prescription claims, the number of dermatologists, and the proportion of dermatologists prescribing opioids all saw a gradual decrease in numbers by average and by population. Claims per year decreased from 2,023 in 2014 to 1,124 in 2020. Dermatologists per 10,000 people decreased from 0.35 in 2014 and 2015 to 0.32 in 2020. The percentage of dermatologists prescribing opioids decreased from 16.5% (0.06 per 10,000 people) in 2014 to 9.14% (0.03 per 10,000 people) in 2020. Over the seven-year period, the geographic state divisions that make up the south region had the most claims by population with 3330 claims in division 5 (3.9 per 10,000 people), 2531 claims in division 6 (5.2 per 10,000 people), and 3287 claims in division 7 (2.97 claims per 10,000 people). Division 1 had the least amount, with 0.6 claims per 10,000 people. Conclusion The findings show a gradual decline in opioid prescriptions by dermatologists, consistent with the national trend. Moreover, there are significant regional variations in opioid prescribing, with the southern states having the highest prescribing rates. The study highlights the need for targeted education policies to address regional variations and promote standardized opioid protocols in dermatology practice.

Demographic, Social, Behavioral, and Clinical Characteristics Associated with Long-Term Opioid Therapy and Any Opioid Prescription in High-Risk VA Patients

BACKGROUND

Social risks (individual social and economic conditions) have been implicated as playing a major role in the opioid epidemic and may be more prevalent in the most medically vulnerable patients. However, the extent to which specific social risks and other patient factors are associated with opioid use among high-risk patients has not been comprehensively assessed.

OBJECTIVE

To identify patient-reported and electronic health record (EHR)-derived demographic, social, behavioral/psychological, and clinical characteristics associated with opioid use in Veterans Affairs (VA) patients at high risk for hospitalization or death.

DESIGN

We used generalized estimating equations to calculate the probability of long-term opioid therapy (LTOT) and the probability of filling any opioid prescription (regardless of duration) over five intervals during a 4-year period (12/2016-12/2020).

PARTICIPANTS

Prospective cohort of 4121 medically high-risk VA patients not receiving palliative or end-of-life care, and who responded to a survey mailed to a nationally representative sample of 10,000 high-risk VA patients.

MAIN MEASURES

Patient-reported demographic, social risk, behavioral/psychological, and clinical measures, and linked EHR-derived data.

KEY RESULTS

The average age was 69.8 years, 6.7% were female, and 17.5% were Non-Hispanic Black race/ethnicity. The majority had diagnosed chronic pain (76.1%). LTOT and any opioid prescription were positively associated with the following: younger age, non-Hispanic White race/ethnicity (compared to non-Hispanic Black race/ethnicity), male sex assigned at birth (LTOT only), not being currently employed, current tobacco use, no alcohol use, higher grit (any opioid prescription only), functional limitations, diagnosed chronic pain, lower comorbidity burden (LTOT only), obesity class I or class II/III (any opioid prescription only), undergoing surgery (any opioid prescription only), and diagnosed cancer (any opioid prescription only).

CONCLUSIONS

Multifactor screening could help identify individuals at elevated risk for adverse opioid-related outcomes and augment current multifaceted initiatives, as several social risks and patient characteristics were predictors of LTOT and any opioid prescription.

Opioid and Nonopioid Analgesic Prescribing Patterns of Hepatologists for Medicare Beneficiaries

INTRODUCTION

Opioids are commonly prescribed to patients with chronic liver disease, but little is known regarding medication prescribing patterns of hepatologists. Opioid use increased until national guidelines limited opioid prescriptions in early 2016. We aimed to describe rates of opioid and nonopioid analgesics to Medicare beneficiaries by hepatologists from 2013 to 2017 and identify demographic characteristics associated with higher prescribing.

METHODS

Prescription data from 2013 to 2017 by 761 hepatologists identified in the Centers for Medicare and Medicaid Services Part D Public Use File were analyzed. Annual prescription volumes were compared for providers with >10 annual prescriptions of a given drug type. Provider characteristics associated with opioid prescriptions were identified through multivariate logistic regression analyses.

RESULTS

The proportion of hepatologists prescribing >10 annual opioid prescriptions decreased from 29% to 20.6%. Median annual opioid prescriptions per hepatologist significantly decreased from 24 to 20. Tramadol remained the most prescribed analgesic. Nonopioid analgesic prescription volume did not increase significantly. Provider characteristics associated with increased opioid prescriptions included male sex, practice location in the South and Midwest (vs West), more years in practice, and a greater proportion of beneficiaries who are white or with low-income subsidy claims. Characteristics associated with fewer prescriptions included non-university-based practice, having a greater proportion of female beneficiaries, and later prescription year.

DISCUSSION

Hepatologists are prescribing less opioids. However, the prevalence of tramadol use and the lack of increase in nonopioid analgesic use highlights the need for advancing the science and training of pain management in chronic liver disease and targeted implementation of nonopioid treatment programs.

Opioids and Cannabinoids in Neurology Practice

OBJECTIVE

Opioid and cannabinoid therapies for chronic pain conditions including neuropathic pain are controversial. Understanding patient and prescribing factors contributing to risks and implementing risk mitigation strategies optimizes outcomes.

LATEST DEVELOPMENTS

The ongoing transformation from a biomedical model of pain care toward a biopsychosocial model has been accompanied by a shift away from opioid therapy for pain, in particular for chronic pain. Opioid overdose deaths and opioid use disorder have greatly increased in the last several decades, initially because of increases in opioid prescribing and more recently associated with illicit drug use, in particular fentanyl derivatives. Opioid risk mitigation strategies may reduce risks related to opioid prescribing and tapering or discontinuation. Opioid therapy guidelines from the Centers for Disease Control and Prevention have become the consensus best practice for opioid therapy. Regulatory agencies and licensing medical boards have implemented restrictions and other mandates regarding opioid therapy. Meanwhile, interest in and use of cannabinoids for chronic pain has grown in the United States.

ESSENTIAL POINTS

Opioid therapy is generally not recommended for the chronic treatment of neuropathic pain conditions. Opioids may be considered for temporary use in patients with severe pain related to selected neuropathic pain conditions (such as postherpetic neuralgia), and only as part of a multimodal treatment regimen. Opioid risk mitigation strategies include careful patient selection and evaluation, patient education and informed consent, querying the state prescription drug monitoring programs, urine drug testing, and issuance of naloxone as potential rescue medication. Close follow-up when initiating or adjusting opioid therapy and frequent reevaluation during long-term opioid therapy is required. There is evidence for the efficacy of cannabinoids for neuropathic pain, with meaningful response rates in select patient populations.

Pain Medication Data from the 2021 and 2022 National Football League Prescription Drug Monitoring Program

ABSTRACT

We report 2021 and 2022 prescription drug monitoring program data that include pain medication prescriptions, including over-the-counter medications, issued to NFL players by either club physicians or external medical providers and entered in the NFL electronic medical record. Of 3142 players who signed a contract with at least one NFL Club during the 2021 season, there were 14,903 prescriptions for pain medications issued to 2207 players. During the 2022 season, there were 14,880 prescription pain medications issued to 2189 players (out of a population of 3152). Notably, most pain medication prescriptions across the two seasons were for nonsteroidal anti-inflammatory agents (NSAIDs; 85.1%), whereas only 2.9% were for opioids. Despite the demanding physical nature of professional football and the need for pain management during a season, the prevalence of opioid prescriptions among NFL players appears to be similar to and, in some cases, potentially lower than previous U.S. population-based data.

The Polyanalgesic Consensus Conference (PACC)®: Intrathecal Drug Delivery Guidance on Safety and Therapy Optimization When Treating Chronic Noncancer Pain

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant.

RESULTS

The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

High-risk use of prescription opioids among patients treated for alcohol problems in New York State. A repeated cross-sectional study, 2005-2018

Background

Patients with alcohol use disorder (AUD) and high-risk opioid use are at risk of serious complications. The purpose of this study was to estimate the prevalence of and factors associated with high-risk opioid use in patients with an alcohol use problem from 2005 to 2018.

Methods

This repeated cross-sectional study analyzed data from first admissions for alcohol treatment (2005-2018) to the NYS Office of Addiction Services and Supports merged with Medicaid Claims Data. High-risk opioid use was defined as opioid dose ≥50 morphine mg equivalents (MME) per day; opioid prescriptions overlapping ≥7 days; opioids for chronic pain >90 days or opioids for acute pain >7 days.

Results

Patients receiving ≥50 MME increased from 690 to 3226 from 2005 to 2010; then decreased to 2330 in 2018. From 2005-2011, patients with opioid prescriptions overlapping ≥7 days increased from 226 to 1594 then decreased to 892 in 2018. From 2005-2010, opioid use >7 days for acute pain increased from 133 to 970 and plateaued after 2010. From 2005-2018, patients who received opioids >90 days for chronic pain trended from 186 to 1655. White patients, females, age 36-55, patients with chronic and acute pain diagnoses had the highest rates of high-risk use.

Conclusions

The prevalence of high-risk opioid use in patients with alcohol use problems increased from 2005 to 2011, and generally decreased after 2010. However, prevalence of opioids >90 days for chronic pain trended up from 2005 to 2018. High-risk opioid use among patients with AUD emphasizes the need to develop interventional strategies to improve patient care.

Patterns of gabapentinoid use among long-term opioid users

OBJECTIVE

Understanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide future research to optimize effectiveness and safety of gabapentinoids for pain management. We used a national sample of Medicare beneficiaries to examine trends, patterns, and patient-level predictors of gabapentinoid use among long-term opioid users.

METHODS

Using a national Medicare sample between 2014 and 2020, we examined factors associated with gabapentinoid use among long-term opioid users. We included Medicare eligible long-term opioid users with no prior gabapentinoid use. The primary outcome was gabapentinoid use after the long-term opioid use episode. Logistic regression was used to test the association with gabapentinoid use for year, age, sex, race/ethnicity, region, Medicare entitlement, low-income status, frailty, pain locations, anxiety, depression, opioid use disorder, and opioid morphine milligrams equivalent.

RESULTS

Gabapentinoid use among long-term opioid users increased from 12.6% in 2014 to 16.8% in 2019 (p < .0001). Factors associated with increased gabapentinoid use were Hispanic ethnicity, back pain, nerve pain, and moderate or high opioid usage. Factors associated with decreased gabapentinoid use were older age and Medicare entitlement due to old age.

CONCLUSIONS

Variation of gabapentinoid use by socio-demographics and insurance status indicates opportunities to improve pain management and a need for shared therapeutic decision making informed by discussion between pain patients and providers regarding safety and effectiveness of pain therapies. Our findings underscore the need for future research into the comparative effectiveness and safety of gabapentinoids for non-cancer chronic pain in various subpopulations.

Preoperative opioid use is associated with worse two-year patient-reported outcomes after hand surgery: A retrospective cohort study

Introduction

Opioid overprescribing has caused a substantial increase in opioid related deaths and billions of dollars in additional healthcare costs. Orthopaedic surgeons commonly prescribe opioids in the perioperative period; however, research has shown preoperative opioid use may be associated with worse postoperative outcomes. Despite this body of evidence, there are few studies investigating the association between preoperative opioid use and two-year outcomes after hand surgery.

Materials and methods

This study evaluated two-year postoperative patient-reported outcomes in patients who used opioids prior to hand surgery, and those who did not. Patients completed pre and postoperative questionnaires including Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Brief Michigan Hand Questionnaire (BMHQ), and other questionnaires related to pain, function, and satisfaction. 342 patients undergoing upper-extremity surgery were enrolled into a prospective orthopaedic surgery outcome registry, and 69.9% completed the follow-up surveys. Preoperative opioid use and its association to patient outcome scores was analyzed through bivariate analysis. Significant associations were further tested by multivariable analysis to determine independent predictors.

Results

Preoperative opioid use was associated with worse two-year PROMIS Fatigue (p ​< ​.01), PROMIS Anxiety (p ​< ​.01), PROMIS Depression (p ​< ​.01), SSQ-8 (p ​= ​.01), BMHQ (p ​= ​.01), NPS Hand (p ​< ​.01) and MODEMS met expectations (p ​= ​.03). No significant differences were observed in patient-reported outcome change scores. Multivariable analysis demonstrated that preoperative opioid use was predictive of worse two-year PROMIS Fatigue (p ​< ​.01), PROMIS Anxiety (p ​< ​.01), PROMIS Depression (p ​= ​.02), BMHQ (p ​= ​.01), SSQ-8 (p ​< ​.01), NPS Hand (p ​= ​.02) and MODEMS met expectations (p ​< ​.01).

Conclusion

Preoperative opioid use was associated with worse patient-reported outcomes two years after elective hand surgery. There was no significant difference in the improvement from baseline between the two groups. Clinically significant differences were observed in follow-up PROMIS Anxiety, BMHQ and NPS - Hand scores. Clinically significant change scores were noted in both groups for PROMIS PF, PROMIS PI, PROMIS SS, BMHQ, and NPS - Hand.

Patient Perspectives on Mental Health and Pain Management Support Needed Versus Received During Opioid Deprescribing

Prescription opioid tapering has increased significantly over the last decade. Evidence suggests that tapering too quickly or without appropriate support may unintentionally harm patients. The aim of this analysis was to understand patients' experiences with opioid tapering, including support received or not received for pain control or mental health. Patients with evidence of opioid tapering from 6 health care systems participated in semi-structured, in-depth interviews; family members of suicide decedents with evidence of opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. Participants included 176 patients and 16 family members. Results showed that 24% of the participants felt their clinicians checked in with them about their taper experiences while 41% reported their clinicians did not. A majority (68%) of individuals who experienced suicide behavior during tapering reported that clinicians did check in about mood and mental health changes specifically; however, 27% of that group reported no such check-in. More individuals reported negative experiences (than positive) with pain management clinics-where patients are often referred for tapering and pain management support. Patients reporting successful tapering experiences named shared decision-making and ability to adjust taper speed or pause tapering as helpful components of care. Fifty-six percent of patients reported needing more support during tapering, including more empathy and compassion (48%) and an individualized approach to tapering (41%). Patient-centered approaches to tapering include reaching out to monitor how patients are doing, involving patients in decision-making, supporting mental health changes, and allowing for flexibility in the tapering pace. PERSPECTIVE: Patients tapering prescription opioids desire more provider-initiated communication including checking in about pain, setting expectations for withdrawal and mental health-related changes, and providing support for mental health. Patients preferred opportunities to share decisions about taper speed and to have flexibility with pausing the taper as needed.

The geography of arthritis-attributable pain outcomes: a county-level spatial analysis

ABSTRACT

Research on the geographic distribution of pain and arthritis outcomes, especially at the county level, is limited. This is a high-priority topic, however, given the heterogeneity of subnational and substate regions and the importance of county-level governments in shaping population health. Our study provides the most fine-grained picture to date of the geography of pain in the United States. Combining 2011 Behavioral Risk Factor Surveillance System data with county-level data from the Census and other sources, we examined arthritis and arthritis-attributable joint pain, severe joint pain, and activity limitations in US counties. We used small area estimation to estimate county-level prevalences and spatial analyses to visualize and model these outcomes. Models considering spatial structures show superiority over nonspatial models. Counties with higher prevalences of arthritis and arthritis-related outcomes are mostly clustered in the Deep South and Appalachia, while severe consequences of arthritis are particularly common in counties in the Southwest, Pacific Northwest, Georgia, Florida, and Maine. Net of arthritis, county-level percentages of racial/ethnic minority groups are negatively associated with joint pain prevalence, but positively associated with severe joint pain prevalence. Severe joint pain is also more common in counties with more female individuals, separated or divorced residents, more high school noncompleters, fewer chiropractors, and higher opioid prescribing rates. Activity limitations are more common in counties with higher percentages of uninsured people. Our findings show that different spatial processes shape the distribution of different arthritis-related pain outcomes, which may inform local policies and programs to reduce the risk of arthritis and its consequences.

Prescription opioids following herpes zoster: An observational study among insured adults, United States, 2007-2021

BACKGROUND

The opioid overdose epidemic has resulted in hundreds of thousands of overdose deaths in the United States (US). One indication for opioids is herpes zoster (HZ)-a common painful condition with an estimated 1 million cases occurring annually in the US.

OBJECTIVE

We aimed to characterize prescription opioid claims and trends among patients with HZ who were previously opioid naive.

DESIGN

We used a cohort study involving three insurance claims databases in the US. We included all beneficiaries 18-64 years (commercial and Medicaid) and beneficiaries 65 years and older (Medicare) who were diagnosed with incident HZ during 2007-2021. We determined the proportion of opioid-naive patients with HZ who filled an opioid prescription within 30 days and 180 days following HZ diagnosis. We also examined trends over the study period, proportion receiving moderate, high dosages (50-89 morphine milligram equivalent [MME], and ≥90 MME per day), and long-term receipt.

RESULTS

Among all three insurance databases, 2,595,837 patients had an incident episode of HZ and were opioid naive during the prior 6 months. Within 30 days following HZ, 623,515 (24 percent) filled a prescription for an opioid. The percentage with an opioid claim declined during 2007-2021 for all groups; 65 percent for commercially insured patients, 51 percent for Medicaid-insured patients, and 60 percent for Medicare-insured patients. Approximately 8-15 percent of all beneficiaries received moderate and 2-6 percent received high dosage opioids. Long-term prescription opioid use of at least 6 months was found in 7-12 percent of the patients.

CONCLUSIONS

Continuing trends in judicious opioid prescribing as well as use of recommended HZ vaccines may decrease opioid prescriptions for HZ.

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships

PURPOSE

To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States.

METHODS

We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317).

RESULTS

We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state).

CONCLUSIONS

This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

The persistent benefits of decreasing default pill counts for postoperative narcotic prescriptions

BACKGROUND

In 2017, a university-based academic healthcare system changed the opioid default pill count from 30 to 12 pills. Modifying the electronic default pill count influences short-term clinician prescribing practices. We sought to understand the long-term impact on postoperative opioid prescribing habits after an opioid default pill count reduction.

MATERIALS AND METHODS

A retrospective electronic medical record system (EMRS) review was conducted in a healthcare system comprised of seven affiliated hospitals. Patients who underwent a surgical procedure and were prescribed an opioid on discharge between 2017-2021 were evaluated. All prescriptions were converted into morphine equivalents (MME). Analyses were performed with the chi-square test and Bonferonni adjusted t-test.

RESULTS

191,379 surgical procedures were studied. The average quantity of opioids prescribed decreased from 32 oxycodone 5 mg tablets in 2017 to 21 oxycodone 5 mg tablets in 2021 (236 MME to 154 MME, p<0.001). The percentage of patients obtaining a refill within 90 days of surgery varied between 18.3% and 19.9% (p<0.001). Patients with a pre-existing opioid prescription and opioid-naïve patients both had significant reductions in prescription quantities above the default MME (79.7% to 60.6% vs. 65.3% to 36.9%, p<0.001). There was no significant change in refills for both groups (pre-existing 36.7% to 38.3% (p = 0.1) vs naïve 15.0% to 15.3% (p = 0.29)).

CONCLUSIONS

The benefits of decreasing the default opioid pill count continue to accumulate long after the original change. Physician uptake of small changes to default EMRS practices represents a sustainable and effective intervention to reduce the quantities of postoperative opioids prescribed without deleterious effects on outpatient opiate requirements.

Epidemiology of Opioid Prescribing After Discharge From Surgical Procedures Among Adults

Importance

Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs.

Objective

To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States.

Design, Setting, and Participants

This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023.

Main Outcomes and Measures

The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years.

Results

Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]).

Conclusions and Relevance

In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.

Drug-related physician continuing medical education requirements, 2010-2020

INTRODUCTION

The crisis of drug-related harm in the United States continues to worsen. While prescription-related overdoses have fallen dramatically, they are still far above pre-2010 levels. Physicians can reduce the risk of overdose and other drug-related harms by improving opioid prescribing practices and ensuring that patients are able to easily access medications for substance use disorder treatment. Most physicians received little or no training in those subjects in medical school. It is possible that continuing medical education can improve physician knowledge of appropriate prescribing and substance use disorder treatment and patient outcomes.

METHODS

Descriptive legal review. Laws in all 50 states and the District of Columbia were searched for provisions that require all or most physicians to receive either one-time or continuing medical education regarding controlled substance prescribing, pain management, or substance use disorder treatment.

RESULTS

There has been a rapid increase in the number of states with relevant requirements, from three states at the end of 2010 to 42 at the end of 2020. The frequency and duration of required education varied substantially across states. In all states, the number of hours required in relevant topics is a small fraction of overall required continuing education, an average of 1 h per year. Despite recent shifts in the substances driving overdose, most requirements remain focused on opioids.

CONCLUSION

While most states have now adopted continuing education requirements regarding controlled substance prescribing, pain management, or substance use disorder treatment, these requirements comprise a small component of the required post-training education requirements. Research is needed to determine whether this training translates into reductions in drug-related harm.

Assessing Risk Factors and Comorbidities in the Treatment of Chronic Pain: A Narrative Review

PURPOSE OF REVIEW

Chronic pain affects a significant portion of the population globally, making it a leading cause of disability. Understanding the multifaceted nature of chronic pain, its various types, and the intricate relationship it shares with risk factors, comorbidities, and mental health issues like depression and anxiety is critical for comprehensive patient care. Factors such as socioeconomic status (SES), age, gender, and obesity collectively add layers of complexity to chronic pain experiences and pose management challenges.

RECENT FINDINGS

Low SES presents barriers to effective pain care, while gender differences and the prevalence of chronic pain in aging adults emphasize the need for tailored approaches. The association between chronic pain and physical comorbidities like cardiovascular disease, chronic obstructive pulmonary disease (COPD), and diabetes mellitus reveals shared risk factors and further highlights the importance of integrated treatment strategies. Chronic pain and mental health are intricately linked through biochemical mechanisms, profoundly affecting overall quality of life. This review explores pharmacologic treatment for chronic pain, particularly opioid analgesia, with attention to the risk of substance misuse and the ongoing opioid epidemic. We discuss the potential role of medical cannabis as an alternative treatment with a nuanced perspective on its impact on opioid use. Addressing the totality and complexity of pain states is crucial to individualizing chronic pain management. With different types of pain having different underlying mechanisms, considerations should be made when approaching their treatment. Moreover, the synergistic relationship that pain states can have with other comorbidities further complicates chronic pain conditions.

Predictors of postoperative opioid use in ventral and incisional hernia repair

BACKGROUND

One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription.

METHODS

VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison.

RESULTS

205 patients were included in the study (average age 53.5 years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45 days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001).

CONCLUSION

Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.

Efficacy of Postoperative Opioid-Sparing Regimens for Hand Surgery: A Systematic Review of Randomized Controlled Trials

PURPOSE

Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia.

METHODS

We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics.

RESULTS

Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens.

CONCLUSIONS

Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Oral opioid prescribing to active duty US military personnel: a cross-sectional population

INTRODUCTION

While civilian opioid prescriptions have seen a dramatic decline in recent years, there are few studies investigating trends in opioid prescription in the active duty military population. We evaluated oral opioid prescribing patterns to active duty military personnel in the Military Health System (MHS) from 2017 to 2020 to determine the incidence of opioid prescriptions as well as demographic and military-specific risk factors for receiving an oral opioid prescription.

METHODS

The MHS Data Repository was queried from 2017 to 2020 to identify all outpatient oral opioid prescriptions to active duty military personnel in August of each year as well as demographic information on the study population. Data were evaluated in a logistic regression model, and ORs of receiving an oral opioid prescription were calculated for each factor.

RESULTS

The proportion of active duty military personnel receiving an oral opioid prescription declined from 2.71% to 1.26% (53% relative reduction) over the study period. Within the logistic regression model, female military personnel were significantly more likely to receive opioid prescriptions compared with men, and there was a stepwise increase in likelihood of an opioid prescription with increasing age. Army and Marine personnel, personnel without a history of military deployment and those stationed within the continental USA were significantly more likely to receive an opioid prescription.

DISCUSSION

The substantial decrease in oral opioid prescriptions to active duty military personnel mirrors data published in the civilian community. The identified risk factors for receiving an opioid prescription may be potential targets for future interventions to further decrease prescribing.

Changes in opioid prescribing and prescription drug monitoring program utilization following electronic health record integration-Massachusetts, 2018

OBJECTIVE

In this study, we explored key prescription drug monitoring program-related outcomes among clinicians from a broad cohort of Massachusetts healthcare facilities following prescription drug monitoring program (PDMP) and electronic health record (EHR) data integration.

METHODS

Outcomes included seven-day rolling averages of opioids prescribed, morphine milligram equivalents (MMEs) prescribed, and PDMP queries. We employed a longitudinal study design to analyze PDMP data over a 15-month study period which allowed for six and a half months of pre- and post-integration observations surrounding a two-month integration period. We used longitudinal mixed effects models to examine the effect of EHR integration on each of the key outcomes.

RESULTS

Following EHR integration, PDMP queries increased both through the web-based portal and in total (0.037, [95% CI = 0.017, 0.057] and 0.056, [95% CI = 0.035, 0.077]). Both measures of clinician opioid prescribing declined throughout the study period; however, no significant effect following EHR integration was observed. These results were consistent when our analysis was applied to a subset consisting only of continuous PDMP users.

CONCLUSIONS

Our results support EHR integration contributing to PDMP utilization by clinicians but do not support changes in opioid prescribing behavior.

Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey

BACKGROUND

Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting.

METHODS

Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription.

RESULTS

There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06).

CONCLUSION

Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.

Severe Neonatal Opioid Withdrawal Requiring Pharmacotherapy: Impact of Region of Residence

OBJECTIVES

Our objective was to evaluate the trend and to assess the impact of maternal region of residence in Western New York (WNY), on severe neonatal opioid withdrawal syndrome (NOWS).

STUDY DESIGN

Term infants' born at gestational age greater than or equal to 37 weeks with severe NOWS, defined as withdrawal resulting in the receipt of pharmacologic therapy from WNY admitted to our neonatal intensive care unit (NICU) from January 1, 2008 to December 31, 2016, were included. Severe NOWS admissions to our NICU from the following five regions were controlled with birth and insurance data: (1) Urban North, (2) Erie Coastal, (3) Niagara Frontier, (4) Southern Tier, and (5) Urban South.

RESULTS

"Urban South" residence was associated with an increased risk of severe NOWS (adjusted odds ratio = 1.8, 97.5% confidence interval: 1.1-2.9). The trend in admission for severe NOWS doubled between 2008 to 2010 and 2014 to 2016 (p = 0.01). More infants born to maternal nonprescribed opioid users were placed in foster care at discharge (36.5 vs. 1.9%, p < 0.001).

CONCLUSION

In WNY, neonates born to mothers from the "Urban South" were twice at risk of being admitted for severe NOWS. One-third of infants with severe NOWS after nonprescribed opioid use were placed in foster care. Implementing targeted strategies at the community level may help improve outcomes in NOWS.

KEY POINTS

· Maternal region of residence is a risk factor for severe neonatal opioid withdrawal.. · Admissions for severe neonatal opioid withdrawal trended up from 2008 to 2010 to 2014 to 2016.. · One-third of the infants born to mothers on nonprescribed opioids were discharged to foster care..

Unraveling the Tapestry of Pain: A Comprehensive Review of Ethnic Variations, Cultural Influences, and Physiological Mechanisms in Pain Management and Perception

The medical management of pain is a nuanced challenge influenced by sociocultural, demographic, and ethical factors. This review explores the intricate interplay of these dimensions in shaping pain perception and treatment outcomes. Sociocultural elements, encompassing cultural beliefs, language, societal norms, and healing practices, significantly impact individuals' pain experiences across societies. Gender expectations further shape these experiences, influencing reporting and responses. Patient implications highlight age-related and socioeconomic disparities in pain experiences, particularly among the elderly, with challenges in managing chronic pain and socioeconomic factors affecting access to care. Healthcare provider attitudes and biases contribute to disparities in pain management across racial and ethnic groups. Ethical considerations, especially in opioid use, raise concerns about subjective judgments and potential misuse. The evolving landscape of placebo trials adds complexity, emphasizing the importance of understanding psychological and cultural factors. In conclusion, evidence-based guidelines, multidisciplinary approaches, and tailored interventions are crucial for effective pain management. By acknowledging diverse influences on pain experiences, clinicians can provide personalized care, dismantle systemic barriers, and contribute to closing knowledge gaps, impacting individual and public health, well-being, and overall quality of life.

Minimal differences in acute postoperative pain after anterior cruciate ligament reconstruction with quadriceps versus hamstring autograft

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon ( n  = 31) or hamstring ( n  = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups ( P  > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups ( P  > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P  = 0.89). Maximum pain scores on POD 1-3 were similar between groups ( P  > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 ( P  > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period.

Program of All-Inclusive Care for the Elderly: an untapped setting for research to advance pain care in older persons

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based care model in the United States that provides comprehensive health and social services to frail, nursing home-eligible adults aged 55 years and older. PACE organizations aim to support adequate pain control in their participants, yet few evidence-based pain interventions have been adopted or integrated into this setting. This article provides a roadmap for researchers who are interested in collaborating with PACE organizations to embed and evaluate evidence-based pain tools and interventions. We situate our discussion within the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework that considers multi-level influences to implementation and evaluation of evidence-based programs. Within each CFIR domain, we identify key factors informed by our own work that merit consideration by research teams and PACE collaborators. Inner setting components pertain to the organizational culture of each PACE organization, the type and quality of electronic health record data, and availability of staff to assist with data abstraction. Outer setting components include external policies and regulations by the National PACE Association and audits conducted by the Centers for Medicare and Medicaid Services, which have implications for research participant recruitment and enrollment. Individual-level characteristics of PACE organization leaders include their receptivity toward new innovations and perceived ability to implement them. Forming and sustaining research-PACE partnerships to deliver evidence-based pain interventions pain will require attention to multi-level factors that may influence future uptake and provides a way to improve the health and well-being of patients served by these programs.

Receipt of prescription opioid medication is associated with increased mortality in an Israeli population

BACKGROUND

Despite Israel's increased use of prescription opioids, reported deaths resulting or associated with opioids have decreased, in fact dramatically, since 2005. This contrast is unique and difficult to explain. We sought to examine whether higher prescribed opioid dosages among adults without oncologic diagnoses were associated with higher all-cause mortality rates.

METHODS

A historical cohort study in Clalit Health Services, using a data repository including all adult patients prescribed opiates between 2010 and 2020, excluding patients with oncologic diagnoses. Patients were classified into three groups according to opioid use: below 50 Morphine milligram equivalents (MME) per day, 50 to 90 MME per day, and above 90 MME per day. Sex, Charlson comorbidity score, age and socioeconomic status were recorded. Mortality rates were compared between the dosage groups and compared to age-standardized mortality rates in the general population.

RESULTS

On multivariate analysis, patients receiving 90 or more MME per day were 2.37 (95%CI 2.1 to 2.68) more likely to have died compared to patients receiving below 50 MME per day. The respective hazard ratio among patients receiving between 50 and 90 MME per day was 2.23 (2.01 to 2.46). Among patients aged 18 to 50, standardized mortality ratios (SMRs) compared to the general population ranged between 5.4 to 8.6 among women, receiving between 50 and 90 MME per day, and between 8.07 and 10.7 among women receiving 90 or more MME per day. The respective SMRs among men were 1.2 to 3.8 and 2.7 to 5.4.

CONCLUSION

Increased opioid use is independently associated with increased all-cause mortality among non-oncological patients. This result is most notable among young adults with little or no known comorbidities. These findings are consistent with results in other countries and seem more credible than previous Israeli reports. Healthcare regulators and providers should, therefore, act to curtail the increasing opioid prescriptions and devise and enhance controls in the healthcare system, which, until 2020, had very limited mechanisms in place.