1
|
Crawford AM, Striano BM, Gong J, Koehlmoos TP, Simpson AK, Schoenfeld AJ. Validation of the Stopping Opioids After Surgery (SOS) Score for the Sustained Use of Prescription Opioids Following Orthopaedic Surgery. J Bone Joint Surg Am 2023; 105:1403-1409. [PMID: 37410854 DOI: 10.2106/jbjs.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND The Stopping Opioids after Surgery (SOS) score was developed to identify patients at risk for sustained opioid use following surgery. The SOS score has not been specifically validated for patients in a general orthopaedic context. Our primary objective was to validate the SOS score within this context. METHODS In this retrospective cohort study, we considered a broad array of representative orthopaedic procedures performed between January 1, 2018, and March 31, 2022. These procedures included rotator cuff repair, lumbar discectomy, lumbar fusion, total knee and total hip arthroplasty, open reduction and internal fixation (ORIF) of ankle fracture, ORIF of distal radial fracture, and anterior cruciate ligament reconstruction. The performance of the SOS score was evaluated by calculating the c-statistic, receiver operating characteristic curve, and the observed rates of sustained prescription opioid use (defined as uninterrupted prescriptions of opioids for ≥90 days) following surgery. For our sensitivity analysis, we compared these metrics among various time epochs related to the COVID-19 pandemic. RESULTS A total of 26,114 patients were included, of whom 51.6% were female and 78.1% were White. The median age was 63 years. The observed prevalence of sustained opioid use was 1.3% (95% confidence interval [CI], 1.2% to 1.5%) in the low-risk group (SOS score of <30), 7.4% (95% CI, 6.9% to 8.0%) in the medium-risk group (SOS score of 30 to 60), and 20.8% (95% CI, 17.7% to 24.2%) in the high-risk group (SOS score of >60). The performance of the SOS score in the overall group was strong, with a c-statistic of 0.82. The performance of the SOS score showed no evidence of worsening over time. The c-statistic was 0.79 before the COVID-19 pandemic and ranged from 0.77 to 0.80 throughout the waves of the pandemic. CONCLUSIONS We validated the use of the SOS score for sustained prescription opioid use following a diverse array of orthopaedic procedures across subspecialties. This tool is easy to implement for the purpose of prospectively identifying patients in musculoskeletal service lines who are at higher risk for sustained opioid use, thereby enabling the future implementation of upstream interventions and modifications to avert opioid abuse and to combat the opioid epidemic. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Gardner WT, Pitts SE, Patterson CT, Richards J, Neilly D, Smitham P, Stevenson I, Aitken SA. Geographic variation in the frequency and potency of postoperative opioid prescriptions for extremity fracture surgery. A retrospective cohort study. J Clin Orthop Trauma 2022; 30:101921. [PMID: 35755931 PMCID: PMC9218827 DOI: 10.1016/j.jcot.2022.101921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION There is increasing evidence that the prescription opioid crisis is spreading internationally. However, there is scarce literature comparing contemporary prescribing practices between units in different countries, particularly in the context of this evolving international problem. We sought to determine the patterns of postoperative opioid prescribing in three hospitals from geographically distinct regions. METHODS This is a retrospective cohort study involving patients from three hospitals: XXX, Maine, USA; XXX, Scotland; and XXX, Australia. The health records, surgical details, and frequency and potency of discharge prescriptions were analyzed for 350 patients receiving surgery for isolated wrist or ankle fractures. Regression analysis was used to identify independent predictors of prescription opioid provision. RESULTS Following ankle fracture surgery, Aberdeen patients (OR 6.0, 95% CI 3.0-11.5) and Adelaide patients (11.8, 95% CI 4.1-39.6) were significantly more likely to receive a prescription for opioids than those in Augusta (p < 0.001). For distal radius fractures, this was also the case (Aberdeen OR 21.2, 95% CI 7.2-79.3, Adelaide OR 21.6, 95% CI 7.3-81.3). For both fracture groups, the potency of prescription provided (measured in morphine milligram equivalents) was not significantly different. When opioids were included in the discharge prescription, Adelaide prescribers favored strong opioids, Aberdeen prescribers selected weak opioids, and prescribers in Augusta chose an even distribution of both types (p < 0.001). Multivariate analysis demonstrated that the odds of receiving prescription opioids were significantly influenced by geographic location and decreased by advancing patient age. CONCLUSIONS Geographic location is a key factor influencing the provision of postoperative opioids. We found no association with fracture type, patient demographic factors or intra-operative practices. Prescriber culture is likely an influential determinant of postoperative opioid provision. Emphasis on patient and prescriber education regarding the risks of prescription opioids and their potential long-term sequelae is key if we wish to change modifiable prescriber behavior.
Collapse
Affiliation(s)
| | | | | | | | - David Neilly
- Aberdeen Royal Infirmary, Aberdeen, Scotland, UK,Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Stuart A. Aitken
- MaineGeneral Orthopedics, Augusta, ME, USA,Corresponding author. MaineGeneral Orthopedics, 15 Enterprise Drive, Augusta, ME, 04330, United States.
| |
Collapse
|
3
|
Sieberg CB, Karunakaran KD, Kussman B, Borsook D. Preventing pediatric chronic postsurgical pain: Time for increased rigor. Can J Pain 2022; 6:73-84. [PMID: 35528039 PMCID: PMC9067470 DOI: 10.1080/24740527.2021.2019576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/12/2021] [Accepted: 12/13/2021] [Indexed: 11/15/2022]
Abstract
Chronic postsurgical pain (CPSP) results from a cascade of events in the peripheral and central nervous systems following surgery. Several clinical predictors, including the prior pain state, premorbid psychological state (e.g., anxiety, catastrophizing), intraoperative surgical load (establishment of peripheral and central sensitization), and acute postoperative pain management, may contribute to the patient's risk of developing CPSP. However, research on the neurobiological and biobehavioral mechanisms contributing to pediatric CPSP and effective preemptive/treatment strategies are still lacking. Here we evaluate the perisurgical process by identifying key problems and propose potential solutions for the pre-, intra-, and postoperative pain states to both prevent and manage the transition of acute to chronic pain. We propose an eight-step process involving preemptive and preventative analgesia, behavioral interventions, and the use of biomarkers (brain-based, inflammatory, or genetic) to facilitate timely evaluation and treatment of premorbid psychological factors, ongoing surgical pain, and postoperative pain to provide an overall improved outcome. By achieving this, we can begin to establish personalized precision medicine for children and adolescents presenting to surgery and subsequent treatment selection.
Collapse
Affiliation(s)
- Christine B. Sieberg
- Biobehavioral Pediatric Pain Lab, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, Massachusetts, United States
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Keerthana Deepti Karunakaran
- Biobehavioral Pediatric Pain Lab, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, Massachusetts, United States
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States
| | - Barry Kussman
- Department of Anesthesiology, Critical Care, & Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States
- Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts, United States
| | - David Borsook
- Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts, United States
- Department of Psychiatry and Radiology, Massachusetts General Hospital, Hospital, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
4
|
Discharge Opioid Prescribing Patterns in an Academic Orthopaedic Setting: Level of Training and Subspecialty Patterns. J Am Acad Orthop Surg 2022; 30:e361-e370. [PMID: 34844260 DOI: 10.5435/jaaos-d-21-00895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/22/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Despite increased research on opioids in the orthopaedic literature, little is known of the prescribing practices of orthopaedic providers based on their level of training. The purpose of this study was to describe the discharge opioid prescribing patterns of orthopaedic providers, stratifying by level of training and orthopaedic subspecialty, within a single medical system. METHODS A retrospective review of orthopaedic surgical encounters was performed over a 1-year period for adults who received a discharge opioid prescription. Patient demographics and prescriber characteristics were collected, including the provider's level of training (attending, fellow, resident, physician assistant [PA], and nurse practitioner [NP]) and surgical subspecialty. Junior residents were postgraduate year 1 to 3, whereas senior residents/fellows were postgraduate year 4 to 6. Discharge opioids were converted to milligram morphine equivalents (MMEs). Overprescribing was defined as a prescribing more than a seven-day supply or >45 MMEs per day. Multivariable linear regression analysis determined the factors associated with discharge MMEs, whereas logistic regression determined the factors associated with overprescribing opioids. RESULTS Of the 3,786 patients reviewed, 1,500 met the criteria for inclusion in the study. The greatest proportion of opioid prescriptions was written by junior residents (33.9%), followed by NPs (30.1%), PAs (24.1%), senior residents/fellows (10.6%), and attendings (1.2%). Compared with junior residents, senior residents prescribed -59.4 MMEs, NPs prescribed +104 MMEs, and attendings prescribed +168 MMEs (P < 0.05), whereas PAs prescribed similar amounts (P > 0.05). Orthopaedic subspecialty was also predictive of discharge MMEs (P < 0.05). Senior residents and attendings were more likely to prescribe more than seven days of opioids (P < 0.05), whereas NPs and PAs were more likely to prescribe >45 MMEs per day (P < 0.05). DISCUSSION This study demonstrates significant variability in opioid prescribing practices according to provider level of training and subspecialty. National guidelines for opioid prescribing practices and educational programs may help reduce such variability. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
|
5
|
Lans J, Westenberg RF, Gottlieb RE, Valerio IL, Chen NC, Eberlin KR. Long-Term Opioid Use Following Surgery for Symptomatic Neuroma. J Reconstr Microsurg 2022; 38:137-143. [PMID: 35100646 DOI: 10.1055/s-0041-1731640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery. METHODS After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments. RESULTS Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3, p = 0.013). CONCLUSION Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.
Collapse
Affiliation(s)
- Jonathan Lans
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ritsaart F Westenberg
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Rachel E Gottlieb
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ian L Valerio
- Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Neal C Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kyle R Eberlin
- Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
6
|
Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails. J Clin Med 2022; 11:jcm11020468. [PMID: 35054162 PMCID: PMC8781195 DOI: 10.3390/jcm11020468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 12/10/2022] Open
Abstract
The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.
Collapse
|
7
|
Lv H, Yang N. Clinical effect of application of nursing concept of rehabilitation surgery for improvement of quality of postoperative recovery in orthopedics. J Orthop Surg Res 2021; 16:471. [PMID: 34330306 PMCID: PMC8323299 DOI: 10.1186/s13018-021-02610-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
Objective To analyze the application of concept nursing of accelerated rehabilitation surgery in orthopedic postoperative recovery. Methods A total of 120 patients who received orthopedic surgery were divided into the control group undergoing routine orthopedic nursing and the observation group undergoing the concept of accelerated rehabilitation surgery nursing. Results Patients in the observation group had shorter in-bed activity time and out-of-bed activity time, average time of hospital stay, and lower total treatment costs. The incidence of incision infection, respiratory system infection, digestive tract infection, urinary tract infection, deep vein thrombosis, and other complications in the observation group was much lower. The recovery scores of joint function in the observation group at 1, 3, 6, and 12 months after the operation were all better, and the recovery rate of joint function within 1 year after the operation was higher. Conclusion Following the concept of accelerated rehabilitation surgery nursing during the perioperative period can improve the quality of postoperative orthopedic recovery.
Collapse
Affiliation(s)
- Hong Lv
- Inner Mongolia Sports Hospital, No.2 South Tongdao Road, Huimin District, Hohhot, 010030, Inner Mongolia Autonomous Region, China.
| | - Ning Yang
- Inner Mongolia Sports Hospital, No.2 South Tongdao Road, Huimin District, Hohhot, 010030, Inner Mongolia Autonomous Region, China
| |
Collapse
|
8
|
Patient and surgical factors affect postoperative opioid prescription for orthopaedic trauma patients undergoing single-admission, single-surgery fracture fixation: a retrospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Dahm V, Lui JT, Liepins R, Chen JM, Le TN, Arnoldner C, Lin VYW. Is otologic surgery contributing to the opioid epidemic? J Otolaryngol Head Neck Surg 2021; 50:38. [PMID: 34158125 PMCID: PMC8220669 DOI: 10.1186/s40463-021-00521-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background The opioid epidemic is a significant public health crisis challenging the lives of North Americans. Interestingly, this problem does not exist to the same extent in Europe. Surgeons play a significant role in prescribing opioids, especially in the context of post-operative pain management. The aim of this study was to compare the post-surgical prescribing patterns of otologists comparing Canada and Austria. Methods An online questionnaire was sent to 33 Canadian and 32 Austrian surgeons, who perform otologic surgery on a regular basis. Surgeons were asked to answer some questions about their background as well as typical prescribing patterns for postoperative pain medication for different ear surgeries (cochlear implant, stapedotomy, tympanoplasty). In addition, surgeons were asked about the typical use of local anesthetics for pain control at the end of a procedure. Otologists gave an estimate how confident they were that their therapy and prescriptions provide sufficient pain control to their patients. Results Analysis of the returned questionnaires showed that opioids are more commonly prescribed in Canada than in Austria. Nonsteroidal anti-inflammatory drugs are used for postoperative pain more regularly after ear surgery in Austria, as opposed to Canada. Some of the prescribed drugs by European otologists are not available in North America. The use of local anesthetics at the end of surgery is not common in Austria. Surgeons´ confidence that the prescribed pain medication was sufficient to control postoperative symptoms was higher in the group not prescribing opioids than in the group that did routinely prescribe opioids. Conclusion Prescribing patterns differ substantially between the two evaluated countries. This data suggests an opportunity to reduce opioid prescriptions after otologic surgeries. Studies to evaluate pain after these operations as well as efficacy of analgesics following ear surgery are an important next step. Graphical abstract ![]()
Collapse
Affiliation(s)
- Valerie Dahm
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Justin T Lui
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Rudolfs Liepins
- Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Joseph M Chen
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Trung N Le
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Vincent Y W Lin
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| |
Collapse
|
10
|
Tighe P, Modave F, Horodyski M, Marsik M, Lipori G, Fillingim R, Hu H, Hagen J. Geospatial Analyses of Pain Intensity and Opioid Unit Doses Prescribed on the Day of Discharge Following Orthopedic Surgery. PAIN MEDICINE 2020; 21:1644-1662. [PMID: 31800063 DOI: 10.1093/pm/pnz311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Inappropriate opioid prescribing after surgery contributes to opioid use disorder and risk of opioid overdose. In this cross-sectional analysis of orthopedic surgical patients, we examined the role of patient location on postoperative pain intensity and opioids prescribed on hospital discharge. METHODS We used geospatial analyses to characterize spatial patterns of mean pain intensity on the day of discharge (PiDoD) and opioid units prescribed on the day of discharge (OuPoD), as well as the effect of regional social deprivation on these outcomes. RESULTS At a 500-km radius from the surgery site, the Global Moran's I for PiDoD (2.71 × 10-3, variance = 1.67 × 10-6, P = 0.012) and OuPoD (2.19 × 10-3, SD = 1.87, variance = 1.66 × 10-6, P = 0.03) suggested significant spatial autocorrelation within each outcome. Local indicators of spatial autocorrelation, including local Moran's I, Local Indicator of Spatial Autocorrelation cluster maps, and Getis-Ord Gi* statistics, further demonstrated significant, specific regions of clustering both OuPoD and PiDoD. These spatial patterns were associated with spatial regions of area deprivation. CONCLUSIONS Our results suggest that the outcomes of pain intensity and opioid doses prescribed exhibit varying degrees of clustering of patient locations of residence, at both global and local levels. This indicates that a given patient's pain intensity on discharge is related to the pain intensity of nearby individuals. Similar interpretations exist for OuPoD, although the relative locations of hot spots of opioids dispensed in a geographic area appear to differ from those of hot spots of pain intensity on discharge.
Collapse
Affiliation(s)
| | | | - MaryBeth Horodyski
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida
| | - Matthew Marsik
- Data Science and Planning, University of Florida Health, Gainesville, Florida
| | - G Lipori
- Data Science and Planning, University of Florida Health, Gainesville, Florida
| | - Roger Fillingim
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Hui Hu
- Department of Epidemiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer Hagen
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida
| |
Collapse
|
11
|
Affiliation(s)
- Niloofar Dehghan
- The CORE Institute, Phoenix, Arizona
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
- Banner University Medical Center-Phoenix, Phoenix, Arizona
| | - Michael D McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
- Banner University Medical Center-Phoenix, Phoenix, Arizona
| |
Collapse
|
12
|
Zhao J, Peters L, Gelzinnis S, Carroll R, Nolan J, Di Sano S, Pockney P, Smith S. Post-discharge opioid prescribing after laparoscopic appendicectomy and cholecystectomy. ANZ J Surg 2020; 90:1014-1018. [PMID: 32395916 DOI: 10.1111/ans.15882] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/27/2020] [Accepted: 03/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Opioid over-prescription following surgery is a significant public health issue in most developed countries. Multiple studies have been conducted in the USA demonstrating and investigating the issue; however, there is a lack of literature addressing this topic in the Australian setting. The aim of this study is to review prescribing practices at an Australian tertiary referral hospital on discharge in patients having undergone laparoscopic cholecystectomy (LC) or laparoscopic appendicetomy (LA). Additionally, to identify potential factors which influence medical officer prescribing practices. METHODS A retrospective observational study on opioid prescribing practice on all patients who underwent LC or LA over a 12-month period at an Australian tertiary referral hospital. RESULTS A total of 435 patients (223 LC, 214 LA) were prescribed a mean opioid dose on discharge of 25 oral morphine milli-equivalents (range 0-180 morphine milli-equivalents). Less opioids were prescribed following elective procedures (42% versus 10%, P < 0.001). There is a downward trend of opioid prescribing on discharge as the Junior Medical Officer clinical year progresses (P < 0.001). CONCLUSIONS This study demonstrates a lower rate of opiate prescription on discharge for LC and LA in an Australian setting when compared to the US data. There is a wide diversity of prescribing demonstrated. This indicates the need for better training of opioid prescribers to reduce over-prescribing.
Collapse
Affiliation(s)
- Jie Zhao
- Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Luke Peters
- Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Scott Gelzinnis
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Rosemary Carroll
- Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jennifer Nolan
- Pharmacy, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Suzanne Di Sano
- Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Peter Pockney
- Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,GI Research, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Stephen Smith
- Hunter Surgical Clinical Research Unit, John Hunter Hospital, Newcastle, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| |
Collapse
|
13
|
Young JD, Bhashyam AR, Parisien RL, Van der Vliet Q, Qudsi RA, Fils J, Dyer GSM. Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000051. [PMID: 33970576 PMCID: PMC7434039 DOI: 10.5435/jaaosglobal-d-20-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND After musculoskeletal injury, US providers prescribe opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti; however, the extent of variation in nonopioid analgesic prescribing is unknown. The aim of our study was to evaluate how nonopioid prescribing by orthopaedic residents varies by geographic context. METHODS Orthopaedic residents in three countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the United States) responded to surveys using vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for postdischarge analgesia. We quantified the likelihood and dose of acetaminophen or a nonsteroidal anti-inflammatory drug prescription. We constructed multivariable regressions with generalized estimating equations to describe differences in nonopiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS Compared with residents from the United States, residents from Haiti were more likely to prescribe nonopioids (odds ratio, 3.22 [confidence interval, 1.94 to 5.34], P < 0.0001) and residents from the Netherlands nearly always prescribed nonopioids. Of those cases where one or more opioid was prescribed, providers also prescribed a nonopioid (acetaminophen or nonsteroidal anti-inflammatory drug) in 345/603 (57.2%) of US, 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher exact test P value <0.0001). Finally, providers prescribed only nonopioids for pain control in 3/348 (0.86%) of US, 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher exact test P < 0.0001). CONCLUSIONS When comparing multimodal analgesic patterns, US prescribers prescribed nonopioid analgesics less frequently than prescribers in two other countries, one low income and one high income, either in isolation or in conjunction with opioids.
Collapse
Affiliation(s)
- Jason D Young
- From the Harvard Medical School (Mr. Young, Dr. Bhashyam, Dr. Dyer); the Harvard Combined Orthopaedic Residency Program (Dr. Bhashyam, Dr. Dyer); Boston, MA; the Department of Orthopaedic Surgery (Dr. Parisien), University of Pennsylvania; Philadelphia, PA; the Department of Trauma Surgery (Dr. Van der Vliet), University Medical Center Utrecht; Utrecht, the Netherlands; the Department of Orthopaedics, Nemours (Dr. Qudsi)/A.I. duPont Hospital for Children; Wilmington, DE; and the Department of Orthopaedic Surgery (Dr. Fils, Dr. Dyer), Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | |
Collapse
|