Implementing a Postoperative Opioid-Prescribing Protocol Significantly Reduces the Total Morphine Milligram Equivalents Prescribed

Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion

BACKGROUND CONTEXT

Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated.

PURPOSE

The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF.

OUTCOME MEASURES

Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day.

METHODS

A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use.

RESULTS

A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs. 0.65, p=.023) and take more morphine milligram equivalents (MME) per day (0.60 vs. 0.04, p=.014) within 1 year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs. 10.4%, p=.040) and take more MMEs per day (0.70 vs. 0.05, p=.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs. 52.1%, p<.001) and took more MMEs per day (3.73 vs. 1.71, p<.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate: -1.63 p=.022).

CONCLUSION

Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

Evaluating Prescriber Adherence to a Standardized Postoperative Opioid Prescription Protocol for Cubital Tunnel Surgery

Purpose

Concerns regarding the ongoing opioid epidemic have led to the implementation of standardized postoperative opioid-prescribing protocols for many common hand surgical procedures. This study investigated patient- and procedure-specific factors affecting adherence to a standardized postoperative opioid-prescribing protocol after cubital tunnel surgery.

Methods

A retrospective review of patients who underwent primary cubital tunnel surgery within one academic medical system between October 1, 2016 (after the implementation of a standardized postoperative opioid-prescribing protocol) and March 1, 2020 was performed. Patients aged <18 years or with a history of revision surgery, prior traumatic ulnar nerve injury, additional concurrent surgical procedures, or a surgeon not participating in the protocol were excluded. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was adherence to the standardized postoperative opioid-prescribing protocol. A bivariate statistical analysis was performed.

Results

Ninety-eight patients were included. The median initial postoperative prescription amount was 75 morphine equivalent units (100% of protocol target) for 78 patients (80% of cohort) who underwent in situ decompression and 75 morphine equivalent units (50% of protocol target) for 20 patients (20% of cohort) who underwent decompression with ulnar nerve transposition. Forty-nine percent of initial opioid prescriptions adhered to protocol, compared with 26% below target and 26% above target. In the bivariate analysis, recent opioid prescriptions within 3 months preoperatively were associated with improved prescriber protocol adherence; longer tourniquet time and anterior transposition were associated with prescriptions below target, and in situ decompression was associated with prescriptions above target.

Conclusions

Variation in postoperative opioid-prescribing patterns persists despite the implementation of a standardized postoperative opioid-prescribing protocol. Recent opioid prescriptions were associated with protocol adherence, possibly reflecting increased provider vigilance in this patient population. Differing target prescription amounts for in situ decompression versus decompression with anterior transposition may be unnecessary.

Type of study/level of evidence

Therapeutic IV.

Postsurgical opioid prescribing among veterans using community care for orthopedic surgery at non-VA hospitals compared to a VA hospital with a transitional pain service: a retrospective cohort study

BACKGROUND

The USA provides medical services to its military veterans through Veterans Health Administration (VHA) medical centers. Passage of recent legislation has increased the number of veterans having VHA-paid orthopedic surgery at non-VHA facilities.

METHODS

We conducted a retrospective cohort study among veterans who underwent orthopedic joint surgery paid for by the VHA either at the Salt Lake City VHA Medical Center (VAMC) or at non-VHA hospitals between January 2018 and December 2021. 562 patients were included in the study, of which 323 used a non-VHA hospital and 239 patients the VAMC. The number of opioid tablets prescribed at discharge, the total number prescribed by postdischarge day 90, and the number of patients still filling opioid prescriptions between 90 and 120 days after surgery were compared between groups.

RESULTS

Veterans who underwent orthopedic surgery at a non-VHA hospital were prescribed more opioid tablets at discharge (median (IQR)); (40 (30-60) non-VHA vs 30 (20-47.5) VAMC, p<0.001) and in the first 90 days after surgery than patients who had surgery at the Salt Lake City VAMC (60 (40-120) vs 35 (20-60), p<0.001). Patients who had surgery at Salt Lake City VAMC were also significantly less likely to fill opioid prescriptions past 90 days after hospital discharge (OR (95% CI) 0.06 (0.01 to 0.48), p=0.007).

CONCLUSION

These results suggest that veterans who have surgery at a veterans affairs hospital with a transitional pain service are at lower risk for larger opioid prescriptions both at discharge and within 90 days after surgery as well as persistent opioid use beyond 90 days after discharge than if they have surgery at a community hospital.

Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery

BACKGROUND

Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery.

METHODS

A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed.

RESULTS

Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions.

CONCLUSIONS

While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.

Variations in opioid prescribing after total joint arthroplasty: An Observational study

Background

This study aimed to analyze the prescribing patterns of opioids by different categories of providers for postoperative pain after primary total hip and knee arthroplasty (THA, TKA) at a single institution.

Methods

A retrospective review was conducted on 1774 patients who underwent primary THA or TKA between 2014 and 2019 at a single, level one academic trauma center. Patients were excluded for additional procedures within 90 days of the index surgery. Patient demographics, operative variables, and opioid prescriptions were collected and analyzed. Generalized linear models accounting for within-person correlations were used to model the association between patient age, prescriber, etiology, opioid category, and mean morphine milligram equivalent (MME) prescribed.

Results

The mean MME prescribed per patient up to 90 days postoperatively was 1591. Significant variations were observed in prescribing habits based on patient gender, age, prescriber category, and drug type. Females were prescribed more MMEs than males (CI 8.58, 667.16; p = 0.0443) and patients 65 years or younger received higher MMEs compared to those above 65 (CI 231.11, 926.48; p = 0.0011). Non-orthopedic physicians prescribed higher MMEs than orthopedic surgeons (CI 402.76, 1219.48; p < 0.0001). Hydrocodone and oxycodone prescriptions had significantly higher MMEs than tramadol prescriptions (CI 446.33, 719.52; p < 0.0001 and CI 681.09, 1065.26; p < 0.0001, respectively).

Conclusion

These findings suggest the need for standardized guidelines and interventions to address variations in opioid prescribing practices for postoperative pain control. Understanding baseline prescription habits can help guide efforts to optimize pain management and reduce opioid overprescribing in the surgical setting.

A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial

BACKGROUND

Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption.

METHODS

In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey.

RESULTS

Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455).

CONCLUSIONS

This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of evidence

Level IV, Systematic review.

Treatment of First Carpometacarpal Osteoarthritis with Arthroscopy: A Systematic Review

Background First carpometacarpal (CMC) osteoarthritis or trapeziometacarpal osteoarthritis is a common debilitating hand condition. No one surgical technique has demonstrated superiority in managing this disease. Purpose This study performed a systematic review of arthroscopic techniques for treating first CMC arthritis to assess the effectiveness of different arthroscopic techniques. Methods Grip strength, pinch strength, visual analog scale, the Disability of Arm, Shoulder, and Hand (DASH) score, range of motion (ROM), and complications were recorded. Two subgroup analyses were performed, comparing outcomes of (1) trapeziectomy of any type versus debridement alone and (2) trapeziectomy alone versus interposition versus suspension techniques. Results Preoperative and postoperative scores significantly improved for DASH scores and pain at rest and with activity with variable improvements in ROM. Complications occurred in 13% of cases in publications that reported complications. When comparing studies that utilized techniques with any type of trapeziectomy to debridement alone, only the trapeziectomy subgroup showed significant improvements in pain. When comparing trapeziectomy alone to interposition and suspension techniques, mean DASH scores and pain levels significantly improved in interposition and suspension subgroups. Conclusions The existing literature describes a predominantly female population with Eaton-Littler stage II and III disease. In the subgroup analysis, arthroscopic techniques involving a trapeziectomy seem to be more effective at lowering pain scores compared to techniques involving debridement alone. Likewise, interposition and suspension techniques may show improved outcomes compared to techniques involving trapeziectomy alone. Level of evidence This is a Level III study.

Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?

BACKGROUND

The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use.

METHODS

A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods.

RESULTS

A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use.

CONCLUSIONS

In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.

Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System

PURPOSE

We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons.

METHODS

A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation.

RESULTS

The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup.

CONCLUSIONS

The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions.

CLINICAL RELEVANCE

An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.

Regional anesthesia and analgesia for trauma: an updated review

PURPOSE OF REVIEW

This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain.

RECENT FINDINGS

In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes.

SUMMARY

Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.

Complete Abolition of Opioid Prescribing in an Upper Extremity Surgical Practice

BACKGROUND

Prescription opioids threaten potential addiction, diversion, and death. Nonopioid regimens have demonstrated similar efficacy for select upper extremity postoperative patients.

METHODS

After adopting a practice policy completely abolishing opioid prescriptions, data were collected on all consecutive surgical cases for the next 6 months, without exclusion. There were 800 cases, 61% male and 39% female, with a mean age of 45. Seventy patients (9%) reported already using prescription medications employed in multimodality regimens; no instruction was given to alter consumption. Patients were divided into 5 groups based on the type of surgery: elective soft tissue (24%), trauma wound management (19%), soft tissue structural repairs (9%), hand fracture/bone procedures (34%), and wrist to elbow fracture/bone procedures (14%). Each group was compared directly to each other group with a 2-tailed t-test, P < .05.

RESULTS

Patients reported achieving pain control without the need for further medication assistance by a mean of postoperative day 2.7. Times to pain control by group were as follows: 1.5, 3.1, 2.7, 2.9, and 3.6 days respectively. Mean postoperative daily pain scores (using a 10-point visual analog scale) for days 1 to 5 were as follows: 2.8, 2.1, 1.5, 1.0, and 0.6, respectively, with a sum of 8.0. During the 6-month tracking period, the practice only received 4 calls from patients with questions about pain control (0.5% of cases).

CONCLUSIONS

Patients achieved good immediate pain control without opioids and reported rapidly declining pain levels over the next several days to the point of no longer requiring medication.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prospective cohort case series, therapeutic; Level IV.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures

PURPOSE

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.

METHODS

This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.

RESULTS

Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.

CONCLUSIONS

There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

BACKGROUND

Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines.

AIM

To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.

METHODS

We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively.

RESULTS

There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15.

CONCLUSION

All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

The Effect of Standardized Perioperative Patient Education on Opioid Use After Minor Soft Tissue Procedures Distal to the Wrist

PURPOSE

Several studies have explored opioid consumption and opioid prescriber education for upper extremity procedures; however, less literature has focused on patient-centered interventions and their impact on opioid consumption after surgery. The purpose of this study was to create a standardized perioperative patient education program regarding postoperative pain management after hand surgery and to determine if it could reduce opioid use after hand surgery.

METHODS

Patients scheduled to undergo elective outpatient hand surgery comprising minor soft tissue procedures at and distal to the wrist were randomized to receive pain management education or standard care. Before the surgery, all patients viewed a webinar with instructions for participation, whereas the education group received an additional 10 minutes of education on postoperative pain management and a pain management reference card for review after the surgery. All patients completed a postoperative daily log documenting the number of opioids consumed, other pain management modalities used, and pain scores. The primary outcome of the number of opioid pills consumed by the patients was compared between the groups. We constructed a linear regression model to determine the risk factors for postoperative opioid use after surgery.

RESULTS

One hundred seventy-four patients completed the study (n = 90 education group; n = 84 standard care group). Patients in the education group took significantly fewer opioid pills (median = 0, range 0-13) than those in the standard care group (median = 0.5, range 0-40). A linear regression model showed that average week-1 pain (B = 0.93; 95% confidence interval, 0.56-1.3) and the number of pills prescribed (B = 0.12; 95% confidence interval, 0.017-0.22) were predictive of greater opioid use.

CONCLUSIONS

Perioperative patient education significantly reduced postoperative opioid use following a minor soft tissue hand surgery, with greater than 70% of the patients taking no opioids.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Opioid Prescribing Patterns Among Orthopedic Hand Surgeons After Implementation of a Divisional Protocol

INTRODUCTION

Overprescribing contributes to the misuse and overuse of narcotics. We hypothesized that implementation of postoperative prescribing guidelines would consistently reduce the amount of opioids prescribed after ambulatory hand surgery.

METHODS

A divisional protocol was instituted in November 2018. A retrospective cohort study was designed to examine the policy's effects on postoperative prescribing. Postoperative opioid prescriptions for patients undergoing ambulatory hand surgery were evaluated 1 year before and 1 year after policy initiation. All prescriptions were converted into the total oral morphine equivalent (OME) prescribed.

RESULTS

A total of 1,672 surgeries were included. Six hundred sixty-one cases were in preimplementation group, and 1,011 cases were in the postimplementation group. The median of total OME decreased significantly after distribution of prescribing guidelines from 75 in the preimplementation group to 45 in the postimplementation group (p < .001) with significant reductions seen for carpal tunnel release (p < .001), trigger finger release (p < .001), distal radius open reduction internal fixation (p < .001), and finger closed reduction and pinning (p < .001). When categorized by procedure type, the median of total OME decreased from 75 to 30 for soft tissue procedures (p < .001) and from 120 to 100 for bony procedures (p < .001).

CONCLUSION

Divisional prescribing guidelines lead to consistent short-term to mid-term reductions in the amount of opioid medication prescribed postoperatively.

Opioid2MME: Standardizing opioid prescriptions to morphine milligram equivalents from electronic health records

BACKGROUND

The national increase in opioid use and misuse has become a public health crisis in the U.S. To tackle this crisis, the systematic evaluation and monitoring of opioid prescribing patterns is necessary. Thus, opioid prescriptions from electronic health records (EHRs) must be standardized to morphine milligram equivalent (MME) to facilitate monitoring and surveillance. While most studies report MMEs to describe opioid prescribing patterns, there is a lack of transparency regarding their data pre-processing and conversion processes for replication or comparison purposes.

METHODS

In this work, we developed Opioid2MME, a SQL-based open-source framework, to convert opioid prescriptions to MMEs using EHR prescription data. The MME conversions were validated internally using F-measures through manual chart review; were compared with two existing tools, as MedEx and MedXN; and the framework was tested in an external academic EHR system.

RESULTS

We identified 232,913 prescriptions for 49,060 unique patients in the EHRs, 2008-2019. We manually annotated a sample of prescriptions to assess the performance of the framework. The internal evaluation for medication information extraction achieved F-measures from 0.98 to 1.00 for each piece of the extracted information, outperforming MedEx and MedXN (F-Scores 0.98 and 0.94, respectively). MME values in the internal EHR system obtained a F-measure of 0.97 and identified 3% of the data as outliers and 7% missing values. The MME conversion in the external EHR system obtained 78.3% agreement between the MME values obtained with the development site.

CONCLUSIONS

The results demonstrated that the framework is replicable and capable of converting opioid prescriptions to MMEs across different medical institutions. In summary, this work sets the groundwork for the systematic evaluation and monitoring of opioid prescribing patterns across healthcare systems.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Occupational health care personnel tackling alcohol overuse - an observational study of work processes and patient characteristics

Background

Overuse of alcohol is a significant risk factor for early retirement. This observational study investigated patient characteristics and work processes in occupational health care (OHC) affecting practices in tackling alcohol overuse.

Methods

The data were from 3089 patient contacts gathered for quality improvement purposes in fifteen OHC units during the years 2013–2019 in Finland. A two-proportion z-test was performed to find associations between reason for contact, and 17 other factors, and the probability of alcohol use being checked and overuse tackled.

Results

OHC personnel checked alcohol use twice as often with male patients as with female patients. Employees at risk of needing sick leave were checked for alcohol use more often (55.4, 95% confidence interval 49.2–61.6%) than those on > 30-day sick leave or working with permanent work disability (p < 0.01). Alcohol use was checked in 64.1% (59.5–68.7%) of patients while making an individual health promotion plan compared to 36.9% of those without a plan (33.1–40.6%, p < 0.0001). Patients with depression were actively checked for alcohol use, especially in cases of major depression (72.7%, 64.0–81.0%). Work processes in which OHC should have been more active in checking and tackling alcohol use included assessing the need for rehabilitation (36.5%, 32.0–41.0%) and health check-ups (HCUs) for mental reasons (43.8%, 38.1–49.4%). HCUs where alcohol overuse was detected led to brief interventions to tackle the overuse in 58.1% (43.4–72.9%) of cases.

Conclusions

The study showed factors that increased OHC personnel’s practices in checking and tackling alcohol use and work processes where the activity should be improved. Discussions about alcohol use took place more often with working-aged men than women, the younger the more. OHC personnel checked actively alcohol use with patients in danger of sick leave, patients treated for depression, while making an individual health promotion plan, and in planned HCUs with a confirmed protocol. More improvement is needed to conduct brief interventions in disability prevention processes, and especially when overuse is detected.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12473-2.

The Effect of an Electronic Prescribing Policy for Opioids on Physician Prescribing Patterns Following Common Upper Extremity Procedures

Purpose

We evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed.

Methods

We retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed.

Results

A total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60], P = .03) and CMC arthroplasty (283 [SD, 147] vs 217 [SD, 92], P < .01). There was also a significant decrease in the total number of tablets prescribed for ganglion excision (11 [SD, 5.7] vs 6.8 [SD, 8.0], P < .01), CMC arthroplasty (36 [SD, 13] vs 29 [SD, 12], P < .01), and DRF ORIF (31 [SD, 8.6] vs 28 [SD, 8.5], P = .04). The number of patients receiving any opioid prescription also significantly decreased following CTR (30% vs 51%, P = .03) and ganglion excision (11% vs 53%, P < .01).

Conclusions

The initiation of state-mandated ePrescribing was associated with a decreased number of opioids—both MMEs and tablets—prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions.

Type of study/level of evidence

Therapeutic III.

The Association of Preoperative Opioid Use With Revision Surgery and Complications Following Carpometacarpal Arthroplasty

PURPOSE

Preoperative opioid use has been shown to be associated with poor outcomes following different upper-extremity surgeries. We aimed to examine the relationship between preoperative opioid use and outcomes following carpometacarpal (CMC) arthroplasty. We hypothesized that patients prescribed higher daily average numbers of preoperative oral morphine equivalents (OMEs) would show higher rates of complications and revision surgery.

METHODS

In the Truven Health MarketScan Database, we identified all patients who underwent CMC arthroplasty from 2009 to 2018. We separated them into cohorts based on average daily OMEs prescribed in the 6 months prior to the surgery: opioid naïve, <2.5, 2.5 to 5, 5 to 10, and >10 OMEs per day. We retrieved 90-day complications and 3-year revision surgery data, and we compared these outcomes by opioid-use groups.

RESULTS

We identified 40,141 patients. The majority (55.9%) were opioid naïve, with the next most common group receiving a daily average of <2.5 OMEs (19.2%). Complications increased with increased preoperative OMEs. Multivariable analysis revealed that patients taking >10 OMEs per day had a 1.45% increase in 3-year revision surgery compared with opioid-naïve patients, which equated to 2.12 (confidence interval [CI]: 1.33-3.36) times increased odds. Additionally, patients taking >10 OMEs had increased odds of an emergency department visit (odds ratio [OR]: 1.60, CI: 1.43-1.78), a 90-day hospital admission (OR: 2.34, CI: 1.97-2.79), and surgical site infection (OR, 2.02, CI: 1.59-2.54) compared with opioid-naïve patients, with absolute differences of 4.53%, 2.78%, and 1.22% compared with opioid-naïve patients, respectively. Additionally, preoperative opioid use predicted both number of prescriptions filled in the short term and long term continued opioid use.

CONCLUSIONS

Preoperative opioid use of >10 OMEs per day is associated with a higher risk for complications and revision surgery following CMC arthroplasty. Our findings demonstrate a dose-dependent relationship between opioid use and postoperative complications. Further study is necessary to determine if reducing opioid use prior to CMC arthroplasty may reduce the likelihood of these negative outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Fracture location impacts opioid demand in upper extremity fracture surgery

INTRODUCTION

Opioid sparing protocols should be formulated with appropriate demand. Specific fracture location has been hypothesized as an important predictor of post-operative pain. The purpose of this study is to evaluate the impact of fracture location on perioperative opioid demand after surgery with the hypothesis that this factor would be significantly associated with perioperative opioid demand in upper extremity fracture surgery.

METHODS

A national database was used to identify1-month pre-operative to 1-year postdischarge opioid demand in oxycodone 5-mg equivalents in 336,493 patients undergoing fracture fixation of the clavicle through distal radius between 2010 and 2020. Three timeframes were evaluated: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year postdischarge. Multivariable main effects linear and logistic regression models were constructed to evaluate the changes in opioids filled, opioid prescriptions, and odds of two or more opioid prescriptions in these timeframes based on fracture location with adjustment for age, sex, obesity, pre-operative opioid usage, and polytrauma.

RESULTS

Compared to distal radius fracture fixation, fixation of elbow, distal humerus, humeral shaft, and proximal humerus fractures were associated with large, significant increases in 1-month pre-op to 1-year post-discharge opioid filling (33.5 - 63.4 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.33 - 0.92 additional prescriptions, all p<0.05) compared to patients with other operatively treated upper extremity injuries.

DISCUSSION

Fracture location was a significant predictor of perioperative opioid demand. Elbow, distal humerus, humeral shaft, and proximal humerus fracture fixation was associated with the largest increases in opioid demand after upper extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption.

LEVEL OF EVIDENCE

Level III, retrospective, observational cohort study.

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (p = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.

Collaborative Creation of Regional Opioid-Prescribing Guidelines in Orthopaedics: Description of a Process, Measurement of Its Effectiveness, and Impact on Patient Satisfaction at a Participating Institution

Background:

Interventions designed to decrease opioid prescribing in orthopaedics have been effective when employed by specific institutions, subspecialties, and procedures. The objectives of this study were to examine the effectiveness of developing regional guidelines on opioid-prescribing practices after common orthopaedic surgical procedures, to determine whether compliance with the guidelines varied by procedure, and to measure the effect of the guidelines on patient satisfaction. All objectives were assessed at 1 participating institution.

Methods:

In February 2018, 53 orthopaedic surgeons representing 8 practices in Western New York attended a summit meeting to collaboratively create regional opioid-prescribing guidelines for 70 common orthopaedic procedures; these guidelines were later distributed electronically to all orthopaedists in Western New York. We retrospectively examined opioid-prescribing practices for adults undergoing an orthopaedic surgical procedure performed by 1 large practice in October 2017, 4 months before the summit meeting (776 patients), and in July 2018, 5 months after the summit meeting (653 patients). The number of opioid pills prescribed postoperatively and patient satisfaction were compared before and after the summit meeting using t tests.

Results:

The overall mean number of opioid pills (and standard deviation) prescribed postoperatively decreased from 69.5 ± 45.5 pills before the summit to 43.3 ± 28.0 pills after the summit (p < 0.0001). Sports medicine surgeons reduced the number of pills prescribed for anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair, knee arthroscopy with meniscectomy, and shoulder arthroscopy with decompression; and adult reconstruction surgeons reduced the number of pills prescribed for total hip and knee arthroplasty. There was no change in the number of pills prescribed for lumbar spine fusion or implant removal. Satisfaction with the provider did not differ from before to after the summit; 75% of patients in the pre-summit group and 76% of patients in the post-summit group reported receiving excellent service (p = 0.62).

Conclusions:

The creation of regional opioid-prescribing guidelines in a collaborative fashion was assessed at 1 participating institution and was found to be effective at reducing the number of opioid pills prescribed by the orthopaedic surgeons participating in the project without affecting patient satisfaction, but adherence to the guidelines varied by procedure.

Factors associated with perioperative opioid demand in lower extremity fractures: Does consumption vary by anatomic location?

INTRODUCTION

Perioperative opioid pain management protocols should reflect anticipated patient need. Fracture location and external fixation may be related to post-operative pain. The purpose of this study is to evaluate the impact of fracture location, articular injury, and pre-operative external fixation, and articular injury on perioperative opioid demand following definitive fixation.

METHODS

1-month pre-operative to 1-year post-discharge opioid demand in oxycodone 5-mg equivalents in 23,441 patients undergoing fracture fixation of the femoral shaft through ankle between 2007 and 2017 was evaluated using a national database. Opioid demand was compiled over several timeframes: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year post-discharge. Multivariable main effects linear and logistic regression models were constructed to evaluate the increased opioids filled, increased opioid prescriptions, and odds of refills in these timeframes with adjustment for fracture location, external fixator placement, and baseline patient and injury characteristics.

RESULTS

Lower extremity anatomic location and pre-operative external fixation were significantly associated with increased 1-month pre-op to 1-year post-discharge opioid filling (17.6-54.7 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.28-0.54 additional prescriptions, all p<0.05). Pilon fractures and pre-operative external fixation, specifically, were associated with increased odds of two or more opioid prescriptions within the 1-month pre-op to 1-year post-discharge time frame (1.25-1.32 odds ratio, all p<0.05).

DISCUSSION

Fracture location and pre-operative external fixator placement predicted perioperative opioid demand. Articular zone (pilon, plateau, and distal femur) fracture fixation was associated with the largest increases in opioid demand after lower extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption.

A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims

INTRODUCTION

As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees.

METHODS

The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age.

RESULTS

We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05).

CONCLUSION

Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes.

Opioid Use following Open versus Endoscopic Carpal Tunnel Release: A Population Study

Open (OCTR) and endoscopic carpal tunnel release (ECTR) are both effective treatments for carpal tunnel syndrome, with similar outcomes and complication rates. Given the opioid epidemic, it is important to consider how surgical modality impacts narcotic use. We compared narcotic use after OCTR and ECTR to identify trends and risk factors for prolonged postoperative use.

The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review

BACKGROUND

Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing.

METHODS

This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan-Jun 2018) versus postintervention (Jan-Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service.

RESULTS

A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5-36.5). There was no significant difference in 2019 (-8 morphine milligram equivalents, 95% confidence interval -20.5 to 4.6).

CONCLUSION

Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical Trial

BACKGROUND

An effective strategy to manage acute pain and minimize opioid exposure is needed for injured patients. In this trial, we aimed to compare 2 multimodal pain regimens (MMPRs) for minimizing opioid exposure and relieving acute pain in a busy, urban trauma center.

METHODS

This was an unblinded, pragmatic, randomized, comparative effectiveness trial of all adult trauma admissions except vulnerable patient populations and readmissions. The original MMPR (IV administration, followed by oral, acetaminophen, 48 hours of celecoxib and pregabalin, followed by naproxen and gabapentin, scheduled tramadol, and as-needed oxycodone) was compared with an MMPR of generic medications, termed the Multi-Modal Analgesic Strategies for Trauma (MAST) MMPR (ie oral acetaminophen, naproxen, gabapentin, lidocaine patches, and as-needed opioids). The primary endpoint was oral morphine milligram equivalents (MMEs) per day and secondary outcomes included total MMEs during hospitalization, opioid prescribing at discharge, and pain scores.

RESULTS

During the trial, 1,561 patients were randomized, 787 to receive the original MMPR and 774 to receive the MAST MMPR. There were no differences in demographic characteristics, injury characteristics, or operations performed. Patients randomized to receive the MAST MMPR had lower MMEs per day (34 MMEs/d; interquartile range 15 to 61 MMEs/d vs 48 MMEs/d; interquartile range 22 to 74 MMEs/d; p < 0.001) and fewer were prescribed opioids at discharge (62% vs 67%; p = 0.029; relative risk 0.92; 95% credible interval, 0.86 to 0.99; posterior probability relative risk <1 = 0.99). No clinically significant difference in pain scores were seen.

CONCLUSIONS

The MAST MMPR was a generalizable and widely available approach that reduced opioid exposure after trauma and achieved adequate acute pain control.

Variation in Postoperative Opioid Prescribing Among Upper-Extremity Surgery Providers

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical relevance

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

Opioid Prescribing Patterns in Orthopaedic Surgery Patients: the Effect of New York State Regulations and Institutional Initiatives

BACKGROUND

The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period.

METHODS

We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization.

RESULTS

A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001).

CONCLUSIONS

The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased.

LEVEL OF EVIDENCE

Level III.

Endogenous Opiates and Behavior: 2018

This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).

Perioperative Opioid Use Predicts Postoperative Opioid Use and Inferior Outcomes After Shoulder Arthroscopy

PURPOSE

The purpose of this study is to define the impact of preoperative opioid use on postoperative opioid use, patient-reported outcomes, and revision rates in a cohort of patients receiving arthroscopic shoulder surgery.

METHODS

Patients who underwent shoulder arthroscopy were identified from an institutional database. Inclusion criteria were completion of preoperative and postoperative patient-reported outcome measures (PROMs) at 1-year follow-up and completion of a questionnaire on use of opioids and number of pills per day. Outcomes assessed included postoperative PROM scores, postoperative opioid use, persistent pain, and achievement of the patient acceptable symptomatic state. A matched cohort analysis was performed to evaluate the impact of opioid use on achievement of postoperative outcomes, whereas a multivariate regression was performed to determine additional risk factors. Receiver operating characteristic curves were used to establish threshold values in oral morphine equivalents (OMEs) that predicted each outcome.

RESULTS

A total of 184 (16.3%) patients were included in the opioid use (OU) group and 1,058 in the no opioid use (NOU) group. The OU and NOU groups showed statistically significant differences in both preoperative and postoperative scores across all PROMs (P < .001). Multivariate logistic regression identified preoperative opioid use as a significant predictor of reduced achievement of the patient acceptable symptomatic state (odds ratio [OR], 0.69, 95% confidence interval [CI], 0.29-0.83, P = .008), increased likelihood of endorsing persistent pain (OR, 1.73, 95% CI, 1.17-2.56, P = .006), and increased opioid use at 1 year (OR, 21.3, 95% CI, 12.2-37.2, P < .001). Consuming a high dosage during the perioperative period increased risk of revision surgery (OR, 8.59, 95% CI, 2.12-34.78, P < .003). Results were confirmed by matched cohort analysis. Receiver operating characteristic analysis found that total OME >1430 mg/d in the perioperative period (area under the curve, 0.76) and perioperative daily OME >32.5 predicted postoperative opioid consumption (area under the curve, 0.79).

CONCLUSIONS

Patients with a history of preoperative opioid use can achieve significant improvements in patient-reported outcomes after arthroscopic shoulder surgery. However, preoperative opioid use negatively impacts patients' level of satisfaction and is a significant predictor of pain and continued opioid usage.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Opioid Stewardship in Orthopaedic Surgery: Principles and Practice

The abuse of prescription opioid pain medication has contributed to the U.S. opioid crisis. Opioid stewardship programs ensure that our patients receive the safest and most effective opioid regimens. Opioid stewardship programs involve a multidisciplinary team, including pharmacists, orthopaedic surgeons, nurses, pain management personnel, and anesthesiologists. All of these stakeholders work together to formulate the best evidence-based use of these medications.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study

BACKGROUND

Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery.

MATERIALS AND METHODS

We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis.

RESULTS

One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription.

CONCLUSIONS

Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.

Quality Measures to Reduce Opioid Use After Common Soft Tissue Hand and Wrist Procedures

PURPOSE

To develop quality measures that are clinically important, feasible, usable, and scientifically acceptable for reducing opioid use after soft tissue procedures of the hand and wrist, and which can be used to evaluate quality in hand surgery.

METHODS

A consortium of 9 fellowship-trained hand/upper-limb surgeons with expertise in quality measure development used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the validity of 2 quality measures for reducing opioid use, based on 4 quality indicators (clinical importance, feasibility, usability, and scientific acceptability). Panelists rated each measure on a scale of 1 (definitely not important/feasible/usable/supported) to 9 (definitely important/feasible/usable/supported) in 2 voting rounds with an intervening face-to-face discussion. Agreement was assessed using predetermined criteria. A measure was considered a valid quality measure if it received a median score of 7 or higher for all 4 indicators with no more than 2 panelists rating outside the range of 7 to 9.

RESULTS

Panelists achieved agreement on the 4 quality indicators for measuring the proportion of patients undergoing carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision who received structured counseling on opioid use. Panelists also achieved agreement on the 4 quality indicators for measuring the proportion of patients without recent opioid use who did not fill an opioid prescription within 30 days after these procedures. Both candidate quality measures were considered valid.

CONCLUSIONS

Using a validated consensus-building approach, we developed process and outcome quality measures for reducing opioid use after soft tissue hand surgery that were demonstrated to be valid according to 4 quality indicators.

CLINICAL RELEVANCE

In the era of value-based health care, hand surgeons are assuming increasing responsibility in the prevention of excess opioid prescribing. Quality measures for reducing opioid overprescription can help promote the delivery of evidence-based, high-quality care in hand surgery.

Patient Satisfaction and Opioid Use With a Postoperative Opioid Protocol After Common Hand Procedures

Purpose

Given the state of the opioid crisis and national pressure to minimize prescriptions, pain management after common hand procedures can pose a challenge for patients and providers. Despite the volume of recent literature on prescribing protocols and over-the-counter (OTC) medications, patient satisfaction has not been adequately assessed. The purposes of this study were (1) to investigate patient satisfaction with pain management using an opioid prescribing protocol after common hand procedures, and (2) to evaluate medication use in the postoperative period using this opioid prescribing protocol.

Methods

A prospective survey was administered to 100 consecutive patients undergoing common soft tissue hand procedures at a Level I academic institution over a 5-month period. The medical record was reviewed for demographics and the number or dosage of opioid pills prescribed. The survey was conducted at 2 time points within 2 weeks after the procedure and assessed the number of opioid pills taken, use of OTC medications, visual analog scale (VAS) pain score, and satisfaction with pain management and surgery.

Results

Mean number of opioid pills consumed at 2 weeks after the procedure was 1.5; 19 patients consumed all of their prescribed opioid pills. Acetaminophen was the most commonly used OTC medication and 84 patients reported using OTC medication in the postoperative period. The average VAS score at the end of the study period was 1.7. Nearly all patients were satisfied with the pain management and surgery; no patients received a second opioid prescription.

Conclusions

We found that patients consumed far fewer opioid pills than were prescribed to them. We also found that patients who took more opioid pills had higher VAS pain scores, with lower satisfaction in both categories. The cohort demonstrated effective control of pain with high satisfaction, indicating that an opioid protocol is a successful and patient-accepted tool for managing postoperative pain.

Type of study/level of evidence

Therapeutic IV.

Upper-Extremity Nerve Decompression Under Local Anesthesia: A Systematic Review of Methods for Reduction of Postoperative Pain and Opioid Consumption

Background: Opioid abuse is a major health concern in North America. Data have shown an alarming increase in opioid-related deaths and complications, which has shed light on current prescription practices across many specialties, including hand surgery. To that end, we sought to conduct a focused literature review to determine the available modalities to decrease postoperative pain and opioid consumption following upper-extremity nerve decompression procedures, taking advantage of the homogeneity and inherent pain pathways of this specific patient cohort. Methods: A systematic review of the literature was conducted. Primary studies evaluating perioperative and intraoperative modalities for postoperative pain reduction and analgesic consumption following upper-extremity nerve decompression procedures under local anesthesia were included. Studies implementing modalities requiring non-hand surgeon expertise (ie, intravenous sedation), as well as studies that include non-nerve decompression procedures, were excluded. Results: A total of 1478 studies were identified, and 9 studies were included after full-text review. Six studies evaluated intraoperative and 3 studies evaluated preoperative and postoperative modalities. Successful interventions included buffered anesthetic, the use of hyaluronidase, and varying techniques and mixtures for anesthetic administration. No successful preoperative or postoperative modalities were identified. Conclusion: Despite data reporting on the dangers associated with current opioid prescription practices, evidence-based modalities to decrease postoperative pain and opioid consumption are limited in general. Several intraoperative modalities do exist, and nonopioid oral analgesics, standardized opioid protocols, and reduced postoperative prescriptions can be used. Large randomized controlled trials evaluating perioperative modalities for pain reduction are needed to further address this issue.

Evaluation of Quality Improvement Methods for Altering Opioid Prescribing Behavior in Hand Surgery

BACKGROUND

The opioid epidemic in the United States continues to be problematic as morbidity and mortality rates increase yearly. Orthopaedic surgeons are the third highest prescribing group among physicians. Studies show that orthopaedic surgeons tend to overprescribe opioids, but published data on patient opioid utilization, pain management satisfaction, and national clinical practice guidelines on opioid prescribing are scarce or lacking. Furthermore, little information is available on influences on physician prescribing behavior and whether changes in prescribing habits are lasting.

METHODS

Using recently published opioid utilization and prescribing guidelines for hand surgery, we created an opioid prescribing quality improvement program with the aim of reducing postoperative opioid prescribing without negatively impacting patient pain satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education-executed in 2 intervention steps-about how their prescribing behavior compared with that of their peers. Three phases of data representing 3 months each were collected prior to, between, and after the interventions.

RESULTS

Two thousand and sixty-seven hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51% reduction) to 61.3 in Phase 3 (57% reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96).

CONCLUSIONS

Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. Similar studies on quality improvement methods and prescribing behavior, patient opioid utilization, and patient satisfaction with pain management are needed in other orthopaedic subspecialties.

CLINICAL RELEVANCE

Evidence-based guidelines, a quality improvement process, and unblinded information on prescribing behavior compared with that of peers may result in long-lasting reductions in surgeons' opioid prescribing practices.

Evaluation of communication to general practitioners when opioid-naïve post-surgical patients are discharged from hospital on opioids

BACKGROUND

To address the opioid crisis, much work has focused on minimizing opioid supply to surgical patients upon hospital discharge. Research is limited regarding handover to primary care providers. The aim of this study was to evaluate the communication of post-operative opioid prescribing information provided by hospitals to general practitioners (GPs).

METHODS

This study comprised two components. First, a retrospective audit of discharge summaries for opioid-naïve surgical patients supplied with an opioid on discharge was conducted to evaluate accuracy of opioid documentation and presence of an opioid management plan. Second, a survey was distributed to GPs to seek their opinions regarding adequacy of communication about hospital-initiated opioids in discharge summaries, challenges experienced in opioid management and suggestions for improvement.

RESULTS

Discharge summaries for 285 patients were audited. Twenty-seven (9.5%) patients had no discharge summary completed. Of the remaining 258, 63 (24.4%) summaries had at least one discrepancy between the opioid(s) listed and the opioid(s) dispensed. Only 33 (12.8%) summaries contained an opioid management plan. From 57 GP-completed surveys, 41 (71.9%) GPs rarely or never received an opioid management plan from hospital surgical units and 34 (59.7%) were dissatisfied/very dissatisfied with information provided about opioid supply and management. Qualitative responses highlighted difficulties GPs experience managing opioid treatment for post-surgical patients after discharge, differing patient expectations and the need to improve communication at times of transition.

CONCLUSION

When opioid-naive patients are discharged from hospital on opioids, communication from hospitals to GPs is poor. Future interventions should focus on strategies to improve this.

Proper Disposal of Prescription Opioids in Southwest Virginia: Assessment of Patient, Physician, and Medical Student Beliefs and Practices

CONTEXT

Southwestern Virginia demonstrates the highest regional mortality rate from prescription opioid overdoses. Nationally, 65% of patients misusing opioid medications received them from friends and family, underscoring the need for effective disposal of unused narcotics.

OBJECTIVES

(1) To understand patient, provider, and medical student beliefs and misconceptions regarding proper methods of opioid disposal; (2) to characterize discrepancies that exist between patient self-reported habits and medical student/provider perceptions of opioid usage, disposal, and diversion.

DESIGN

Descriptive, cross-sectional, observational study.

SETTING

Large, nonprofit health care organization and allopathic medical school in Southwestern Virginia.

PARTICIPANTS

All ambulatory patients 18 years or older presenting for elective consultation at health system orthopedics department; all institutionally employed physicians with active system e-mail addresses; and all current students at the associated medical school.

MAIN OUTCOMES/MEASURES

Patients: The number who had received information regarding proper methods of opioid disposal, intended disposal method, methods of disposal considered appropriate, comfort level with opioid disposal, and demographic data. Physicians and Medical Students: The number who had received instruction regarding proper methods of opioid disposal, acceptable means of opioid disposal, most appropriate disposal method, disposal method most likely to be employed by patients, practice profile/prescribing data, and medical school year.

RESULTS

In total, 64% of patients (n = 255/750) had never received instruction from a physician regarding opioid disposal; 56% of physicians (n = 212/732) and 78% (n = 80/171) of medical students indicated that they never received formal instruction regarding methods of disposal. The majority of physicians believed that their patients are most likely to use in-home methods of disposal or store prescription medications for future use; 61% of patients indicated a preference for accessible disposal facilities.

CONCLUSIONS

The discrepancy between patient and physician responses highlights a lack of communication regarding disposal of unused opioid medications and is a target for future intervention.

Factors associated with discharge opioid prescription after hip fracture fixation

OBJECTIVE

Opioid prescribing after hip fracture fixation is variable, but the factors that drive this prescribing variation are not well-described. The purpose of this study was to determine independent factors associated with increased opioid prescription upon discharge after hip fracture fixation.

METHODS

A retrospective cohort study of 296 adult patients who underwent hip fracture fixation between January 2016 and December 2017 at two Level I trauma centers were included in our study. The primary outcome measurement was opioid prescription at discharge in morphine milligram equivalents (MME). Bivariate analysis was used to screen for factors, and multivariable regression analysis was used to identify independent factors associated with opioid prescription upon discharge from the hospital.

RESULTS

Discharge opioid prescription amounts were available for 280 out of 296 patients (95%). The mean (±standard deviation) discharge opioid prescription was 212 (±319) MME. Multivariable regression analysis showed that younger age (p = 0.004), diabetes mellitus (p = 0.02), smoking (p < 0.001), treatment at hospital #2 (p < 0.001), and weekend discharge (p = 0.03) were associated with increased opioid prescription at discharge.

CONCLUSIONS

Increased opioid prescribing after hip fracture fixation is associated with patient- and system-related factors. Prescriber education programs, prescription guidelines, and safe handoff practices that focus on these factors may help to decrease prescription variability and opioid overprescription across institutions.