The Association of Cannabis Use After Discharge From Surgery With Opioid Consumption and Patient-reported Outcomes

OBJECTIVE

To compare outcomes of patients using versus not using cannabis as a treatment for pain after discharge from surgery.

BACKGROUND

Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes.

METHODS

Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing 16 procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included postdischarge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life, and regret to undergo surgery (secondary).

RESULTS

Of 11,314 included patients (58% females, mean age: 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI: 0.4-1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (adjusted odds ratio: 1.7, 95% CIL 1.4-2.1) and 1 month (adjusted odds ratio: 2.1, 95% CI: 1.7-2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs 82.6%), best quality of life (46.7% vs 63.0%), and no regret (87.6% vs 92.7%) (all P < 0.001).

CONCLUSIONS

Patient-reported cannabis use, to treat postoperative pain, was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes.

Cohort study of new off-label gabapentin prescribing in chronic opioid users

INTRODUCTION

Gabapentin is commonly prescribed as an off-label adjunct to opioids because of its safer risk profile. Recent evidence has shown an increased risk of mortality when coprescribed with opioids. Therefore, we aimed to evaluate whether the addition of off-label gabapentin in patients with chronic opioid use is associated with a reduction in opioid dosage.

METHODS

We performed a retrospective cohort study of patients with chronic opioid use with a new off-label gabapentin prescription (2010-2019). Our primary outcome of interest was a reduction in opioid dosage measured via oral morphine equivalents (OME) per day after the addition of a new off-label gabapentin prescription.

RESULTS

In our cohort of 172,607 patients, a new off-label gabapentin prescription was associated with a decrease in opioid dosage in 67,016 patients (38.8%) (median OME/day reduction:13.8), with no change in opioid dosage in 24,468 patients (14.2%), and an increase in opioid dosage in 81,123 patients (47.0%) (median OME/day increase: 14.3). A history of substance/alcohol use disorders was associated with a decrease in opioid dosage after the addition of a new off-label gabapentin (aOR 1.20, 95% CI 1.16 to 1.23). A history of pain disorders was associated with a decrease in opioid dosage after the initiation of a new gabapentin prescription including arthritis (aOR 1.12, 95% CI 1.09 to 1.15), back pain (aOR 1.10, 95% CI 1.07 to 1.12), and other pain conditions (aOR 1.08, 95% CI 1.06 to 1.10).

CONCLUSIONS

In this study of patients with chronic opioid use, an off-label gabapentin prescription did not reduce opioid dosage in the majority of patients. The coprescribing of these medications should be critically evaluated to ensure optimal patient safety.

Perioperative Opioid-Related Harms: Opportunities to Minimize Risk

Although substantial attention has been given to opioid prescribing in the United States, opioid-related mortality continues to climb due to the rising incidence and prevalence of opioid use disorder. Perioperative care has an important role in the consideration of opioid prescribing and the care of individuals at risk for poor postoperative pain- and opioid-related outcomes. Opioids are effective for acute pain management and commonly prescribed for postoperative pain. However, failure to align prescribing with patient need can result in overprescribing and exacerbate the flow of unused opioids into communities. Conversely, underprescribing can result in the undertreatment of pain, complicating recovery and impairing well-being after surgery. Optimizing pain management can be particularly challenging for individuals who are previously exposed to opioids or have critical risk factors, including opioid use disorder. In this review, we will explore the role of perioperative care in the broader context of the opioid epidemic in the United States, and provide considerations for a multidisciplinary, comprehensive approach to perioperative pain management and optimal opioid stewardship.

Comparison of methods to identify individuals prescribed opioid analgesics for pain

INTRODUCTION

While identifying opioid prescriptions in claims data has been instrumental in informing best practises, studies have not evaluated whether certain methods of identifying opioid prescriptions yield better results. We compared three common approaches to identify opioid prescriptions in large, nationally representative databases.

METHODS

We performed a retrospective cohort study, analyzing MarketScan, Optum, and Medicare claims to compare three methods of opioid classification: claims database-specific classifications, National Drug Codes (NDC) from the Centers for Disease Control and Prevention (CDC), or NDC from Overdose Prevention Engagement Network (OPEN). The primary outcome was discrimination by area under the curve (AUC), with secondary outcomes including the number of opioid prescriptions identified by experts but not identified by each method.

RESULTS

All methods had high discrimination (AUC>0.99). For MarketScan (n=70,162,157), prescriptions that were not identified totalled 42,068 (0.06%) for the CDC list, 2,067,613 (2.9%) for database-specific categories, and 0 (0%) for the OPEN list. For Optum (n=61,554,852), opioid prescriptions not identified totalled 9,774 (0.02%) for the CDC list, 83,700 (0.14%) for database-specific categories, and 0 (0%) for the OPEN list. In Medicare claims (n=92,781,299), the number of opioid prescriptions not identified totalled 8,694 (0.01%) for the CDC file and 0 (0%) for the OPEN list.

DISCUSSION

This analysis found that identifying opioid prescriptions using methods from CDC and OPEN were similar and superior to prespecified database-specific categories. Overall, this study shows the importance of carefully selecting the approach to identify opioid prescriptions when investigating claims data.

What evidence is needed to inform postoperative opioid consumption guidelines? A cohort study of the Michigan Surgical Quality Collaborative

INTRODUCTION

To balance adequate pain management while minimizing opioid-related harms after surgery, opioid prescribing guidelines rely on patient-reported use after surgery. However, it is unclear how many patients are required to develop precise guidelines. We aimed to compare patterns of use, required sample size, and the precision for patient-reported opioid consumption after common surgical procedures.

METHODS

We analyzed procedure-specific 30-day opioid consumption data reported after discharge from 15 common surgical procedures between January 2018 and May 2019 across 65 hospitals in the Michigan Surgical Quality Collaborative. We calculated proportions of patients using no pills and the estimated number of pills meeting most patients' needs, defined as the 75th percentile of consumption. We compared several methods to model consumption patterns. Using the best method (Tweedie), we calculated sample sizes required to identify opioid consumption within a 5-pill interval and estimates of pills to meet most patients' needs by calculating the width of 95% CIs.

RESULTS

In a cohort of 10,688 patients, many patients did not consume any opioids after all types of procedures (range 20%-40%). Most patients' needs were met with 4 pills (thyroidectomy) to 13 pills (abdominal hysterectomy). Sample sizes required to estimate opioid consumption within a 5-pill wide 95% CI ranged from 48 for laparoscopic appendectomy to 188 for open colectomy. The 95% CI width for estimates ranged from 0.7 pills for laparoscopic cholecystectomy to 7.0 pills for ileostomy/colostomy.

CONCLUSIONS

This study demonstrates that profiles of opioid consumption share more similarities than differences for certain surgical procedures. Future investigations on patient-reported consumption are required for procedures not currently included in prescribing guidelines to ensure surgeons and perioperative providers can appropriately tailor recommendations to the postoperative needs of patients.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons

Importance

Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons.

Objective

To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender.

Design, Setting, and Participants

A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience.

Main Outcomes and Measures

Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons.

Results

A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals.

Conclusions and Relevance

The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Perceived Implications of Compensation Structure for Academic Surgical Practice: A Qualitative Study

This qualitative study examines how incentive-based and salary-only compensation models affect academic surgeons.

Opioid Prescribing by US Surgeons, 2016-2022

This cross-sectional study investigates the rate and dosing of opioid prescriptions among US surgeons from 2016 to 2022.

Perioperative opioid prescribing and iatrogenic opioid use disorder and overdose: a state-of-the-art narrative review

BACKGROUND/IMPORTANCE

Considerable attention has been paid to identifying and mitigating perioperative opioid-related harms. However, rates of postsurgical opioid use disorder (OUD) and overdose, along with associated risk factors, have not been clearly defined.

OBJECTIVE

Evaluate the evidence connecting perioperative opioid prescribing with postoperative OUD and overdose, compare these data with evidence from the addiction literature, discuss the clinical impact of these conditions, and make recommendations for further study.

EVIDENCE REVIEW

State-of-the-art narrative review.

FINDINGS

Nearly all evidence is from large retrospective studies of insurance claims and Veterans Health Administration (VHA) data. Incidence rates of new OUD within the first year after surgery ranged from 0.1% to 0.8%, while rates of overdose events ranged from 0.01% to 0.8%. Higher rates were seen among VHA patients, which may reflect differences in data completeness and/or risk factors. Identified risk factors included those related to substance use (preoperative opioid use; non-opioid substance use disorders; preoperative sedative, anxiolytic, antidepressant, and gabapentinoid use; and postoperative new persistent opioid use (NPOU)); demographic attributes (chiefly male sex, younger age, white race, and Medicaid or no insurance coverage); psychiatric comorbidities such as depression, bipolar disorder, and PTSD; and certain medical and surgical factors. Several challenges related to the use of administrative claims data were identified; there is a need for more granular retrospective studies and, ideally, prospective cohorts to assess postoperative OUD and overdose incidence with greater accuracy.

CONCLUSIONS

Retrospective data suggest an incidence of new postoperative OUD and overdose of up to 0.8% during the first year after surgery, but prospective studies are lacking.

Association between the COVID-19 outbreak and opioid prescribing by U.S. dentists

BACKGROUND

U.S. data on opioid prescribing by dentists are limited to 2019. More recent data are needed to understand the effect of the COVID-19 outbreak on dental opioid prescribing, characterize current practices, and determine if dental opioid stewardship initiatives are still warranted.

OBJECTIVE

To evaluate the association between the COVID-19 outbreak and the rate of opioid prescribing by U.S. dentists.

METHODS

During February-April 2023, the authors conducted a cross-sectional analysis of the IQVIA Longitudinal Prescription Database, which reports 92% of prescriptions dispensed in U.S. retail pharmacies. The authors calculated the monthly dental opioid dispensing rate, defined as the monthly number of dispensed opioid prescriptions from dentists per 100,000 U.S. individuals, during January 2016-February 2020 and June 2020-December 2022. To prevent distortions in trends, data from March-May 2020, when dental opioid dispensing declined sharply, were excluded. Using linear segmented regression models, the authors assessed for level and slope changes in the dental opioid dispensing rate during June 2020.

RESULTS

Analyses included 81,189,605 dental opioid prescriptions. The annual number of prescriptions declined from 16,105,634 in 2016 to 8,910,437 in 2022 (-44.7%). During January 2016-February 2020, the dental opioid dispensing rate declined -3.9 (95% CI: -4.3, -3.6) per month. In June 2020, this rate abruptly increased by 31.4 (95% CI: 19.3, 43.5) and the monthly decline in the dental opioid dispensing rate slowed to -2.1 (95% CI: -2.6, -1.6) per month. As a result, 6.1 million more dental opioid prescriptions were dispensed during June 2020-December 2022 than would be predicted had trends during January 2016-February 2020 continued.

DISCUSSION

U.S. dental opioid prescribing is declining, but the rate of this decline slowed after the COVID-19 outbreak. Findings highlight the continued importance of dental opioid stewardship initiatives.

Impact of state opioid laws on prescribing in trauma patients

BACKGROUND

Excessive opioid prescribing has resulted in opioid diversion and misuse. In July 2018, Michigan's Public Act 251 established a state-wide policy limiting opioid prescriptions for acute pain to a 7-day supply. Traumatic injury increases the risk for new persistent opioid use, yet the impact of prescribing policy in trauma patients remains unknown. To determine the relationship between policy enactment and prescribing in trauma patients, we compared oral morphine equivalents prescribed at discharge before and after implementation of Public Act 251.

METHODS

In this cross-sectional study, adult patients who received any oral opioids at discharge from a Level 1 trauma center between January 1, 2016, and June 30, 2021, were identified. The exposure was patients admitted starting July 1, 2018. Inpatient oral morphine equivalents per day 48 hours before discharge and discharge prescription oral morphine equivalents per day were calculated. Student's t test and an interrupted time series analysis were performed to compare mean oral morphine equivalents per day pre- and post-policy. Multivariable risk adjustment accounted for patient/injury factors and inpatient oral morphine equivalent use.

RESULTS

A total of 3,748 patients were included in the study (pre-policy n = 1,685; post-policy n = 2,063). Implementation of the prescribing policy was associated with a significant decrease in mean discharge oral morphine equivalents per day (34.8 ± 49.5 vs 16.7 ± 32.3, P < .001). After risk adjustment, post-policy discharge prescriptions differed by -19.2 oral morphine equivalents per day (95% CI -21.7 to -16.8, P < .001). The proportion of patients obtaining a refill prescription 30 days post-discharge did not increase after implementation (0.38 ± 0.48 vs 0.37 ± 0.48, P = .7).

CONCLUSION

Discharge prescription amounts for opioids in trauma patients decreased by approximately one-half after the implementation of opioid prescribing policies, and there was no compensatory increase in subsequent refill prescriptions. Future work is needed to evaluate the effect of these policies on the adequacy of pain management and functional recovery after injury.

Changes in Surgical Opioid Prescribing and Patient-Reported Outcomes After Implementation of an Insurer Opioid Prescribing Limit

Importance

Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain.

Objective

To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan.

Design, Setting, and Participants

This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019.

Exposure

Policy limiting opioid prescriptions to a 5-day supply in February 2018.

Main Outcomes and Measures

Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume.

Results

Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone.

Conclusions

This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.

Strengthening Association through Causal Inference

SUMMARY

Understanding causal association and inference is critical to study health risks, treatment effectiveness, and the impact of health care interventions. Although defining causality has traditionally been limited to rigorous, experimental contexts, techniques to estimate causality from observational data are highly valuable for clinical questions in which randomization may not be feasible or appropriate. In this review, the authors highlight several methodologic options to deduce causality from observational data, including regression discontinuity, interrupted time series, and difference-in-differences approaches. Understanding the potential applications, assumptions, and limitations of quasi-experimental methods for observational data can expand our interpretation of causal relationships for surgical conditions.

Prevalence of Unhealthy Substance Use and Associated Characteristics Among Patients Presenting for Surgery

OBJECTIVE

To assess the prevalence of and identify characteristics associated with unhealthy use before surgery.

BACKGROUND

Although the escalation in US drug overdose deaths is apparent, the unhealthy use of substances among patients presenting for surgery is unclear.

METHODS

We conducted a retrospective study of patients presenting for elective surgical procedures between December 2018 and July 2021 and prospectively recruited to 1 of 2 clinical research studies (Michigan Genomics Initiative, Prevention of Iatrogenic Opioid Dependence after Surgery Study). The primary outcome was unhealthy substance use in the past 12 months as determined using the Tobacco, Alcohol, Prescription medication, and other Substance use tool.

RESULTS

Among 1912 patients, unhealthy substance use was reported in 768 (40.2%). The most common substances with unhealthy use were illicit drugs [385 (20.1%)], followed by alcohol 358 (18.7%)], tobacco [262 (13.7%)], and prescription medications [86 (4.5%)]. Patients reporting unhealthy substance use were significantly more likely to be younger, male [aOR: 1.95 (95% CI, 1.58-2.42)], and have higher scores for pain [aOR: 1.07 (95% CI, 1.02-1.13)], and anxiety [aOR: 1.03 (95% CI, 1.01-1.04)]. Unhealthy substance use was more common among surgical procedures of the forearm, wrist, and hand [aOR: 2.58 (95% CI, 1.01-6.55)].

CONCLUSIONS

As many as 2 in 5 patients in the preoperative period may present with unhealthy substance use before elective surgery. Given the potential impact of substance use on surgical outcomes, increased recognition of the problem by screening patients is a critical next step for surgeons and perioperative care teams.

Comparative Outcomes of Groin Hernia Repair by Sex Among Medicare Beneficiaries

OBJECTIVE

To compare the rates of operative recurrence between male and female patients undergoing groin hernia repair.

BACKGROUND DATA

Groin hernia repair is common but understudied in females. Limited prior work demonstrates worse outcomes among females.

METHODS

Using Medicare claims, we performed a retrospective cohort study of adult patients who underwent elective groin hernia repair between January 1, 2010 and December 31, 2017. We used a Cox proportional hazards model to evaluate the risk of operative recurrence up to 5 years following the index operation. Secondary outcomes included 30-day complications following surgery.

RESULTS

Among 118,119 patients, females comprised the minority of patients (n=16,056, 13.6%). Compared with males, female patients were older (74.8 vs. 71.9 y, P <0.01), more often white (89.5% vs. 86.7%, P <0.01), and had a higher prevalence of nearly all measured comorbidities. In the multivariable Cox proportional hazards model, we found that female patients had a significantly lower risk of operative recurrence at 5-year follow-up compared with males (aHR 0.70, 95% CI 0.60-0.82). The estimated cumulative incidence of recurrence was lower among females at all time points: 1 year [0.68% (0.67-0.68) vs. 0.88% (0.88-0.89)], 3 years [1.91% (1.89-1.92) vs. 2.49% (2.47-2.5)], and 5 years [2.85% (2.82-2.88) vs. 3.7% (3.68-3.75)]. We found no significant difference in the 30-day risk of complications.

CONCLUSIONS

We found that female patients experienced a lower risk of operative hernia recurrence following elective groin hernia repair, which is contrary to what is often reported in the literature. However, the risk of operative recurrence was low overall, indicating excellent surgical outcomes among older adults for this common surgical condition.

Study Design and Analysis in Hand Surgery Research: Tips for Success

Hand surgeons are constantly faced with evaluation of new evidence to identify best practices in clinical care. However, even the most rigorous study designs have limitations due to biases, generalizability, and other flaws. Here, we highlight seven common aspects of study design and analysis that should be considered by hand surgeons when interpreting findings. The evaluation of these practices can optimize the peer-review process and assess the value of evidence to be incorporated into clinical practice.

Long-term Health Outcomes of New Persistent Opioid Use After Surgery Among Medicare Beneficiaries

OBJECTIVE

We examined long-term health outcomes associated with new persistent opioid use after surgery and hypothesized that patients with new persistent opioid use would have poorer overall health outcomes compared with those who did not develop new persistent opioid use after surgery.

BACKGROUND

New persistent opioid use is a common surgical complication. Long-term opioid use increases risk of mortality, fractures, and falls; however, less is known about health care utilization among older adults with new persistent opioid use after surgical care.

METHODS

We analyzed claims from a 20% national sample of Medicare beneficiaries ≥65 years undergoing surgery between January 1, 2009, and June 30, 2019. We estimated associations between new persistent use and subsequent health events between 6 and 12 months after surgery, including mortality, serious fall/fall-related injury, and respiratory or opioid/pain-related readmission/emergency department (ED) visits using a Cox proportional hazards model to estimate mortality and multivariable logistic regression for the remaining outcomes, adjusting for demographic/clinical characteristics. Our primary outcome was mortality within 6 to 12 months after surgery. Secondary outcomes included falls and readmissions or ED visits (respiratory, pain related/opioid related) within 6 to 12 months after surgery.

RESULTS

Of 229,898 patients, 6874 (3.0%) developed new persistent opioid use. Compared with patients who did not develop new persistent opioid use, patients with new persistent opioid use had a higher risk of mortality (hazard ratio 3.44, CI, 2.99-3.96), falls [adjusted odds ratio (aOR): 1.21, 95% CI, 1.05-1.39], and respiratory-related (aOR: 1.67, 95% CI, 1.49-1.86) or pain-related/opioid-related (aOR: 1.68, 95% CI, 1.55-1.82) readmissions/ED visits.

CONCLUSIONS

New persistent opioid use after surgery is associated with increased mortality and poorer health outcomes after surgery. Although the mechanisms that underlie this risk are not clear, persistent opioid use may also be a marker for greater morbidity requiring more care in the late postoperative period. Increased awareness of individuals at risk for new persistent use after surgery and close follow-up in the late postoperative period is critical to mitigate the harms associated with new persistent use.

Prescribed Opioid Dosages, Payer Type, and Self-Reported Outcomes After Surgical Procedures in Michigan, 2018-2020

Importance

Collaborative quality improvement (CQI) models, often supported by private payers, create hospital networks to improve health care delivery. Recently, these systems have focused on opioid stewardship; however, it is unclear whether reduction in postoperative opioid prescribing occurs uniformly across health insurance payer types.

Objective

To evaluate the association between insurance payer type, postoperative opioid prescription size, and patient-reported outcomes in a large statewide CQI model.

Design, Setting, and Participants

This retrospective cohort study used data from 70 hospitals within the Michigan Surgical Quality Collaborative clinical registry for adult patients (age ≥18 years) undergoing general, colorectal, vascular, or gynecologic surgical procedures between January 1, 2018, and December 31, 2020.

Exposure

Insurance type, classified as private, Medicare, or Medicaid.

Main Outcomes and Measures

The primary outcome was postoperative opioid prescription size in milligrams of oral morphine equivalents (OME). Secondary outcomes were patient-reported opioid consumption, refill rate, satisfaction, pain, quality of life, and regret about undergoing surgery.

Results

A total of 40 149 patients (22 921 [57.1%] female; mean [SD] age, 53 [17] years) underwent surgery during the study period. Within this cohort, 23 097 patients (57.5%) had private insurance, 10 667 (26.6%) had Medicare, and 6385 (15.9%) had Medicaid. Unadjusted opioid prescription size decreased for all 3 groups during the study period from 115 to 61 OME for private insurance patients, from 96 to 53 OME for Medicare patients, and from 132 to 65 OME for Medicaid patients. A total of 22 665 patients received a postoperative opioid prescription and had follow-up data for opioid consumption and refill. The rate of opioid consumption was highest among Medicaid patients throughout the study period (16.82 OME [95% CI, 12.57-21.07 OME] greater than among patients with private insurance) but increased the least over time. The odds of refill significantly decreased over time for patients with Medicaid compared with patients with private insurance (odds ratio, 0.93; 95% CI, 0.89-0.98). Adjusted refill rates for private insurance remained between 3.0% and 3.1% over the study period; adjusted refill rates among Medicare and Medicaid patients decreased from 4.7% to 3.1% and 6.5% to 3.4%, respectively, by the end of the study period.

Conclusions and Relevance

In this retrospective cohort study of surgical patients in Michigan from 2018 to 2020, postoperative opioid prescription size decreased across all payer types, and differences between groups narrowed over time. Although funded by private payers, the CQI model appeared to have benefitted patients with Medicare and Medicaid as well.

Identifying Persistent Opioid Use After Surgery: The Reliability of Pharmacy Dispensation Databases

OBJECTIVE

The present study assessed concordance in perioperative opioid fulfillment data between Michigan's prescription drug monitoring program (PDMP) and a national pharmacy prescription database.

BACKGROUND

PDMPs and pharmacy dispensation databases are widely utilized, yet no research has compared their opioid fulfilment data postoperatively.

METHODS

This retrospective study included participants (N=19,823) from 2 registry studies at Michigan Medicine between July 1, 2016, and February 7, 2019. We assessed the concordance of opioid prescription fulfilment between the Michigan PDMP and a national pharmacy prescription database (Surescripts). The primary outcome was concordance of opioid fill data in the 91 to 180 days after surgical discharge, a time period frequently used to define persistent opioid use. Secondary outcomes included concordance of opioid dose and number of prescriptions fulfilled. Multinomial logistic regression analysis examined concordance across key subgroups.

RESULTS

In total, 3076 participants had ≥1 opioid fulfillments 91 to 180 days after discharge, with 1489 (49%) documented in PDMP only, 243 (8%) in Surescripts only, and 1332 (43%) in both databases. Among participants with fulfillments in both databases, there were differences in the number (n=239; 18%) and dose (n=227; 17%). The PDMP database was more likely to capture fulfillment among younger and publicly insured participants, while Surescripts was more likely to capture fulfillment from counties bordering neighboring states. The prevalence of persistent opioid use was 10.7% using PDMP data, 5.5% using Surescripts data only, and 11.7% using both data resources.

CONCLUSIONS

The state PDMP appears reliable for detecting opioid fulfillment after surgery, detecting 2 times more patients with persistent opioid use compared with Surescripts.

Safety and Distribution of Opioid Prescribing by U.S. Surgeons

OBJECTIVE

To estimate high-risk prescribing patterns among opioid prescriptions from U.S. surgeons; to characterize the distribution of high-risk prescribing among surgeons.

BACKGROUND

National data on the prevalence of opioid prescribing and high-risk opioid prescribing by U.S. surgeons are lacking.

METHODS

Using the IQVIA Prescription Database, which reports dispensing from 92% of U.S. pharmacies, we identified opioid prescriptions from surgeons dispensed in 2019 to patients ages ≥12 years. "High-risk" prescriptions were characterized by: days supplied >7, daily dosage ≥50 oral morphine equivalents (OMEs), opioid-benzodiazepine overlap, and extended-release/long-acting opioid. We determined the proportion of opioid prescriptions, total OMEs, and high-risk prescriptions accounted for by "high-volume surgeons" (those in the ≥95th percentile for prescription counts). We used linear regression to identify characteristics associated with being a high-volume surgeon.

RESULTS

Among 15,493,018 opioid prescriptions included, 7,036,481 (45.4%) were high-risk. Among 114,610 surgeons, 5753 were in the 95th percentile or above for prescription count, with ≥520 prescriptions dispensed in 2019. High-volume surgeons accounted for 33.5% of opioid prescriptions, 52.8% of total OMEs, and 44.2% of high-risk prescriptions. Among high-volume surgeons, 73.9% were orthopedic surgeons and 60.6% practiced in the South. Older age, male sex, specialty, region, and lack of affiliation with academic institutions or health systems were correlated with high-risk prescribing.

CONCLUSIONS

The top 5% of surgeons account for 33.5% of opioid prescriptions and 45.4% of high-risk prescriptions. Quality improvement initiatives targeting these surgeons may have the greatest yield given their outsized role in high-risk prescribing.

Attributions and perpetrators of incivility in academic surgery

Purpose

Although incivility has been described in other specialties, little is known about the attributes and perpetrators of it in academic surgery. The goal of this study was to identify attributes and commonly associated perpetrators of incivility experienced by trainees and faculty at academic surgery programs in the U.S.

Methods

A web-based survey including the Workplace Incivility Scale (WIS) and questions regarding attributions and perpetrators of incivility was sent to trainees and faculty at academic institutions across the U.S. In addition to descriptive statistics, multivariable regression models were built to determine the impact of perpetrator type and number on overall incivility scores.

Results

We received 367 of 2,661 (13.8%) responses. Top three reasons for incivility were surgery hierarchy (50.1%), respondent's gender (33.8%) and intergenerational differences (28.1%). Faculty (58.6%), patients (36.8%), and nursing staff (31.9%) were the most reported parties responsible for incivility. Female surgeons reported experiencing incivility more frequently from all three top responsible parties (i.e., faculty, patients, and nurses) when compared to other gender identities. Additionally, those who reported faculty (β = 0.61, 95%CI 0.39-0.82) or nurses (β = 0.23, 95%CI 0.009-0.45) as perpetrators of incivility reported an increase in overall incivility scores.

Conclusions

Incivility in surgery is frequently attributed to surgery hierarchy, gender, and intergenerational differences. Surgical trainees and faculty reported that faculty, patients, and nurses were the most commonly identified as responsible for uncivil events in the surgical workforce. Exposure to a greater variety of perpetrators of incivility increases overall levels of incivility, emphasizing the importance of eliminating incivility from all sources.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44186-023-00129-1.

High-risk Opioid Prescribing Associated with Postoperative New Persistent Opioid Use in Adolescents and Young Adults

OBJECTIVE

In this study, we explored which postoperative opioid prescribing practices were associated with persistent opioid use among adolescents and young adults.

BACKGROUND

Approximately 5% of adolescents and young adults develop postoperative new persistent opioid use. The impact of physician prescribing practices on persistent use among young patients is unknown.

METHODS

We identified opioid-naïve patients aged 13 to 21 who underwent 1 of 13 procedures (2008-2016) and filled a perioperative opioid prescription using commercial insurance claims (Optum Deidentified Clinformatics Data Mart Database). Persistent use was defined as ≥ 1 opioid prescription fill 91 to 180 days after surgery. High-risk opioid prescribing included overlapping opioid prescriptions, co-prescribed benzodiazepines, high daily prescribed dosage, long-acting formulations, and multiple prescribers. Logistic regression modeled persistent use as a function of exposure to high-risk prescribing, adjusted for patient demographics, procedure, and comorbidities.

RESULTS

High-risk opioid prescribing practices increased from 34.9% to 43.5% over the study period; the largest increase was in co-prescribed benzodiazepines (24.1%-33.4%). High-risk opioid prescribing was associated with persistent use (aOR 1.235 [1.12,1.36]). Receipt of prescriptions from multiple opioid prescribers was individually associated with persistent use (aOR 1.288 [1.16,1.44]). The majority of opioid prescriptions to patients with persistent use beyond the postoperative period were from nonsurgical prescribers (79.6%).

CONCLUSIONS

High-risk opioid prescribing practices, particularly receiving prescriptions from multiple prescribers across specialties, were associated with a significant increase in adolescent and young adult patients' risk of persistent opioid use. Prescription drug monitoring programs may help identify young patients at risk of persistent opioid use.

Postpartum Opioid Prescribing in Patients with Opioid Use Prior to Birth

OBJECTIVE

 This study aimed to describe opioid prescribing patterns for pregnant patients with a history of or active opioid use to inform postpartum pain management strategies.

STUDY DESIGN

 We conducted a retrospective cohort analysis of all patients with a history of opioid use disorder (OUD) or chronic pain seen at a single outpatient clinic specializing in opioid use and OUD in pregnancy from January 2019 to August 2021. Patient characteristics, delivery outcomes, and opioid prescribing information were collected through electronic health record fields. We used descriptive statistics to characterize differences in receipt of an opioid prescription, prescription size, and receipt of a prescription refill across three patient groups: patients with OUD on medication, patients with OUD maintaining abstinence, and patients with chronic pain using opioids. In the study period, the institutional average rate of opioid prescribing after cesarean and vaginal birth were 80.0 and 2.8%, respectively.

RESULTS

 Of the 69 patients included in this study, 46 (66.7%) had a history of OUD on medication, 14 (20.3%) had a history of OUD maintaining abstinence, and 9 (13.0%) had a history of chronic pain. Receipt of an opioid prescription after childbirth was more common after cesarean birth (12/23, 52.2%) than vaginal birth (3/46, 6.5%). Refills were common in patients who received an opioid proscription (cesarean: 5/12, 41.7%; vaginal: 1/3, 33.3%).

CONCLUSION

 Compared with institutional averages, postpartum opioid prescribing rates for people with a history of OUD or chronic pain were 50 to 60% lower for cesarean birth and three times higher for vaginal birth. Future work is needed to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations.

KEY POINTS

· Opioid prescribing rates for patients with OUD/chronic pain were 60% lower for cesarean birth than institutional averages.. · Opioid prescribing rates for patients with OUD/chronic pain were three times higher for vaginal birth than institutional averages.. · Refill rates following birth were high overall for cesarean (40%) and vaginal (33%) birth.. · More work is needed to balance opioid prescribing with adequate pain control in high-risk patients..

Association Between State Limits on Opioid Prescribing and the Incidence of Persistent Postoperative Opioid Use Among Surgical Patients

OBJECTIVE

To examine whether laws limiting opioid prescribing have been associated with reductions in the incidence of persistent postoperative opioid use.

SUMMARY OF BACKGROUND DATA

In an effort to address the opioid epidemic, 26 states (as of 2018) have passed laws limiting opioid prescribing for acute pain. However, it is unknown whether these laws have achieved their reduced the risk of persistent postoperative opioid use.

METHODS

We identified 957,639 privately insured patients undergoing one of 10 procedures between January 1, 2004 and September 30, 2018. We then estimated the association between persistent postoperative opioid use, defined as having filled ≥10 prescriptions or ≥120 days supply of opioids during postoperative days 91-365, and whether opioid prescribing limits were in effect on the day of surgery. States were classified as having: no limits, a limit of ≤7 days supply, or a limit of >7 days supply. The regression models adjusted for observable confounders such as patient comorbidities and also utilized a difference-in-differences approach, which relied on variation in state laws over time, to further minimize confounding.

RESULTS

The adjusted incidence of persistent postoperative opioid use was 3.5% (95%CI 3.3%-3.7%) for patients facing a limit of ≤7 days supply, compared with 3.3% (95%CI 3.3%-3.3%) for patients facing no prescribing limits ( P = 0.13 for difference compared to no prescribing limits) and 3.4%, (95%CI 3.2%-3.6%) for patients facing a limit of >7 days supply ( P = 0.43 for difference compared to no prescribing limits).

CONCLUSIONS

Laws limiting opioid prescriptions were not associated with subsequent reductions in persistent postoperative opioid use.

Incivility, Work Withdrawal, and Organizational Commitment Among US Surgeons

OBJECTIVE

To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment.

BACKGROUND

Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large.

METHODS

Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment.

RESULTS

There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (β = 0.504, 95% CI: 0.341-0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (β = 0.178, 95% CI: 0.153-0.203).

CONCLUSIONS

Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large.

Association Between Loneliness and Postoperative Mortality Among Medicare Beneficiaries

This cohort study uses data from the Health and Retirement Study and Medicare claims to examine the association between loneliness and postoperative mortality after elective vs nonelective surgery among older adults.

Association Between State Opioid Prescribing Limits and Duration of Opioid Prescriptions From Dentists

IMPORTANCE

In part to prevent the harms associated with dental opioid prescriptions, most states have enacted policies limiting the duration of opioid prescriptions for acute pain. Whether these limits are associated with changes in the duration of opioid prescriptions written by dentists is unclear.

OBJECTIVE

To evaluate the association between state opioid prescribing limits and the duration of opioid prescriptions from dentists.

DESIGN, SETTING, AND PARTICIPANTS

This difference-in-differences cross-sectional study used data from the IQVIA Longitudinal Prescription Database, an all-payer database reporting prescription dispensing from 92% of retail pharmacies in the US. The sample included opioid prescriptions from dentists dispensed to children aged 0 to 17 years and adults 18 years or older from January 2014 through February 2020. Treatment states were those that implemented limits between January 2016 and December 2018. Control states were those that did not implement limits during the study period. Data on opioid prescribing limits were derived from the Prescription Drug Abuse Policy System. Data were analyzed from January 1 to September 30, 2022.

EXPOSURES

State opioid prescribing limits.

MAIN OUTCOMES AND MEASURES

The outcome was opioid prescription duration, as measured by days' supply. The association between limits and duration was evaluated using a linear model with a 2-way fixed-effects specification. Covariates included patient characteristics, prescription characteristics, and indicators of implementation of prescription drug monitoring program use mandates. Separate analyses of data from adults and children were conducted owing to differences in the number of treatment states and restrictiveness of limits by age.

RESULTS

The adult analysis included 56 607 314 opioid prescriptions for 34 364 775 patients (18 448 788 females [53.7%]; mean [SD] age at the earliest fill, 44.0 [17.4] years) in 22 treatment states and 12 control states. The child analysis included 3 720 837 opioid prescriptions for 3 165 880 patients (1 740 449 females [55.0%]; mean [SD] age at the earliest fill, 14.4 [3.5] years) in 23 treatment states and 12 control states. In both analyses, the median (25th-75th percentile) duration of opioid prescriptions was 3.0 (2-5) days. Implementation of limits, most of which allowed up to a 7-day supply of opioids, was not associated with changes in the duration of opioid prescriptions for adults (mean days' supply: -0.06 days; 95% CI, -0.11 to <0.001 days) or children (mean days' supply: -0.07 days; 95% CI, -0.15 to 0.02 days).

CONCLUSIONS AND RELEVANCE

In this study of national pharmacy dispensing data, opioid prescribing limits were not associated with changes in the duration of opioid prescriptions from dentists. Future research should investigate the potential role of alternative interventions in reducing opioid prescribing by dentists.

Comparison of Opioids Prescribed by Advanced Practice Clinicians vs Surgeons After Surgical Procedures in the US

Importance

Advanced practice clinicians (APCs), defined as nurse practitioners and physician assistants, are increasingly being incorporated into surgical teams. Despite this inclusion, there are no recent national data on the role of these clinicians in surgical opioid prescribing or the dosing of such prescriptions.

Objective

To calculate the proportion of surgical opioid prescriptions written by APCs and to compare the total and daily dosages of these prescriptions with those written by surgeons.

Design, Setting, and Participants

This cross-sectional study used the Optum's De-Identified Clinformatics Data Mart, which contains deidentified claims from patients with private insurance and Medicare Advantage plans across the US. Adults and children who underwent 1 of 31 inpatient and outpatient surgical procedures from January 1, 2017, through November 30, 2019, were identified. The analysis was limited to procedures with 1 or more perioperative opioid prescriptions, defined as an opioid prescription dispensed within 3 days of the index date of surgery. Data were analyzed from April 1, 2021, to July 31, 2022.

Exposures

Prescriber specialty.

Main Outcomes and Measures

The outcome was the proportion of perioperative opioid prescriptions and refill prescriptions written by APCs. Linear regression was used to compare the total dosage of perioperative opioid prescriptions written by APCs vs surgeons measured in morphine milligram equivalents (MMEs). Models were adjusted for demographic characteristics, comorbidities, opioid-naive status, year of index date, hospitalization or observation status, surgical complications, and surgeon specialty. Analyses were conducted at the procedure level, and patients with multiple procedures were included.

Results

Analyses included 628 197 procedures for 581 387 patients (358 541 females [57.1%]; mean [SD] age, 56 [18] years). Overall, APCs wrote 119 266 (19.0%) of the 628 197 perioperative opioid prescriptions and 59 679 (25.1%) of the 237 740 refill prescriptions. Perioperative opioid prescriptions written by APCs had higher total dosages compared with those written by surgeons (adjusted difference, 40.0 MMEs; 95% CI, 31.3-48.7 MMEs). This difference persisted in a subgroup analysis limited to opioid-naïve patients (adjusted difference, 15.7 MMEs; 95% CI, 13.9-17.5 MMEs).

Conclusions and Relevance

In this cross-sectional analysis, one-fifth of perioperative opioid prescriptions and one-quarter of refill prescriptions were written by APCs. While surgeons wrote most perioperative opioid prescriptions that were intended for perioperative analgesia, higher total dosages from APCs suggest that opioid stewardship initiatives that support the role of APCs may be warranted.

Gabapentinoid Prescribing for Carpal Tunnel Syndrome

BACKGROUND

Gabapentinoids, including gabapentin and pregabalin, are commonly prescribed for neuropathic pain, but robust evidence recommends against using gabapentinoids for the treatment of carpal tunnel syndrome (CTS). We aimed to quantify national prescribing patterns of gabapentinoids for CTS.

METHODS

We performed a retrospective population-based cohort study using claims data of gabapentinoid-naïve patients with a new diagnosis of CTS (2009-2016). Our primary outcome was a new gabapentinoid fill for CTS. We assessed temporal trends and characteristics associated with a gabapentinoid fill. Multivariable logistic regression was used to evaluate the association between patient-level factors and a new gabapentinoid fill for CTS.

RESULTS

Of the 248 324 previously gabapentinoid-naïve patients with CTS, 9589 patients (4%) filled a gabapentinoid prescription. Sixty-one percent were prescribed by primary care providers or medical subspecialists. Patients with a history of neck pain (odds ratio [OR]: 1.31, 95% confidence interval [CI], 1.25-1.38), back pain (OR: 1.25, 95% CI, 1.20-1.31), arthritis (OR: 1.25, 95% CI, 1.18-1.31), and other pain conditions (OR: 1.26, 95% CI, 1.20-1.31) were associated with an increased odds of a new gabapentinoid fill. In addition, patients with a history of alcohol or substance use disorder were significantly associated with a new gabapentinoid prescription fill (OR: 1.33, 95% CI, 1.20-1.47).

CONCLUSIONS

Despite evidence recommending against the use of gabapentinoids for CTS, gabapentinoids were frequently initiated among those with higher risk for misuse, including substance use disorders. Given the effectiveness of bracing or surgery for CTS and the risks associated with gabapentinoids, efforts aimed at disseminating evidence-based treatment for CTS are critical to minimize the harms of gabapentinoid misuse.

Less is More: Fulfillment of Opioid Prescriptions Before and After Implementation of a Modifier 22 Based Quality Incentive for Opioid-Free Vasectomies

OBJECTIVE

To examine the percentage of patients who filled peri-procedural opioid prescriptions before and after Blue Cross Blue Shield of Michigan (BCBSM) launched a modifier 22 payment incentive for opioid-sparing vasectomies in Michigan on July 1, 2019.

METHODS

We evaluated BCBSM administrative claims data from February 1, 2018 - November 16, 2020 for men 20 - 64 years old who underwent vasectomy or a control office-based urologic procedure (cystourethroscopy, prostate biopsy, circumcision, and transurethral destruction of prostate tissue.) The primary outcome was the percentage of patients who filled opioid prescriptions 30 days before to 3 days after their procedure. We performed an interrupted time series analysis to estimate changes in the percentage of patients who filled opioid prescriptions in the vasectomy and control group before and after July 1, 1019.

RESULTS

Our cohort included 4,559 men who had a vasectomy and 4,679 men who had a control procedure. Within each group, demographics and clinical factors were similar before and after July 1, 2019. Before implementation of the modifier 22 policy, 32.5% of men who had a vasectomy filled an opioid prescription whereas only 12.6% of men filled an opioid prescription after July 1, 2019 -a 19.9% absolute reduction and 61.0% relative reduction (P < .001). In the control group, there was no significant change in the percentage of patients who filled opioid prescriptions before and after July 1, 2019 (0.8% absolute increase, P = .671).

CONCLUSION

Implementation of modifier 22 based financial incentive for opioid-sparing vasectomies was associated with decrease in the percentage of men who filled opioid prescriptions after vasectomy.

Impact of the COVID-19 pandemic on opioid overdose and other adverse events in the USA and Canada: a systematic review

Importance

The COVID-19 pandemic impacted healthcare beyond COVID-19 infections. A better understanding of how COVID-19 worsened the opioid crisis has potential to inform future response efforts.

Objective

To summarize changes from the COVID-19 pandemic on outcomes regarding opioid use and misuse in the USA and Canada.

Evidence review

We searched MEDLINE via PubMed, EMBASE, and CENTRAL for peer-reviewed articles published between March 2020 and December 2021 that examined outcomes relevant to patients with opioid use, misuse, and opioid use disorder by comparing the period before vs after COVID-19 onset in the USA and Canada. Two reviewers independently screened studies, extracted data, assessed methodological quality and bias via Newcastle-Ottawa Scale, and synthesized results.

Findings

Among 20 included studies, 13 (65%) analyzed service utilization, 6 (30%) analyzed urine drug testing results, and 2 (10%) analyzed naloxone dispensation. Opioid-related emergency medicine utilization increased in most studies (85%, 11/13) for both service calls (17% to 61%) and emergency department visits (42% to 122%). Urine drug testing positivity results increased in all studies (100%, 6/6) for fentanyl (34% to 138%), most (80%, 4/5) studies for heroin (-12% to 62%), and most (75%, 3/4) studies for oxycodone (0% to 44%). Naloxone dispensation was unchanged and decreased in one study each.

Interpretation

Significant increases in surrogate measures of the opioid crisis coincided with the onset of COVID-19. These findings serve as a call to action to redouble prevention, treatment, and harm reduction efforts for the opioid crisis as the pandemic evolves.

PROSPERO registration number

CRD42021236464.

Association of Postoperative Opioid Prescription Size and Patient Satisfaction

OBJECTIVE

To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients.

SUMMARY BACKGROUND DATA

Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing.

METHODS

This prospective cohort study evaluated opioid-naive adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0 to 10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates.

RESULTS

One thousand five hundred twenty patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. One thousand two hundred seventy-nine (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME).

CONCLUSIONS

In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.

Opioid Coprescribing with Sedatives after Implant-Based Breast Reconstruction

BACKGROUND

Skeletal muscle relaxants and benzodiazepines are thought to mitigate against postoperative muscle contraction. The Centers for Disease Control and Prevention and the Food and Drug Administration warn against coprescribing them with opioids because of increased risks of overdose and death. The authors evaluated the frequency of coprescribing of opioids with skeletal muscle relaxants or benzodiazepines after implant-based reconstruction.

METHODS

The authors examined health care claims to identify women (18 to 64 years old) who underwent implant-based breast reconstruction between January of 2008 and June of 2019 to determine the frequency of coprescribing, factors associated with coprescribing opioids and skeletal muscle relaxants or benzodiazepines, and the impact on opioid refills within 90 days of reconstruction.

RESULTS

A total of 86.7 percent of women ( n = 7574) who had implant-based breast reconstruction filled an opioid prescription perioperatively. Of these, 27.7 percent of women filled prescriptions for opioids and benzodiazepines, 14.4 percent for opioids and skeletal muscle relaxants, and 2.4 percent for opioids, benzodiazepines, and skeletal muscle relaxants. Risk factors for coprescribing opioids and benzodiazepines included use of acellular dermal matrix, immediate reconstruction, and history of anxiety. Women who filled prescriptions for opioids and skeletal muscle relaxants, opioids and benzodiazepines, and opioids with skeletal muscle relaxants and benzodiazepines were significantly more likely to refill opioid prescriptions, even when controlling for preoperative opioid exposure.

CONCLUSIONS

Nearly half of women filled an opioid prescription with a benzodiazepine, skeletal muscle relaxant, or both after implant-based breast reconstruction. Coprescribing of opioids with skeletal muscle relaxants may potentiate opioid use after surgery and should be avoided given the risks of sedation. Identifying strategies that avoid sedatives to manage pain after breast reconstruction is critical to mitigate high-risk prescribing practices.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Preoperative alcohol interventions for elective surgical patients: Results from a randomized pilot trial

BACKGROUND

High-risk alcohol use is a common surgical risk factor. Stopping or reducing alcohol use in the weeks before and after surgery could improve surgical health and outcomes. The purpose of this study was to evaluate the feasibility and acceptability of 2 interventions that address high-risk alcohol use in the context of surgery.

METHODS

Participants included patients scheduled for elective surgeries at an academic health system in the Midwestern United States. Recruitment took place by phone and text. Participants were included if they were 18 to 75 years old, scheduled for elective surgeries, and scored ≥5 on the Alcohol Use Disorders Identification Test-Consumption Tool. Participants were randomized to either a low-intensity intervention, brief advice (10-minute phone-based psychoeducation plus feedback session), or a higher-intensity intervention, health coaching (two 45-minute sessions including education, feedback, motivational interviewing, and goal setting). Assessments took place at baseline and at 1-month and 4-month follow-ups. Alcohol biomarkers were collected the day of surgery.

RESULTS

The final study sample included (n = 51) participants randomized to brief advice and health coaching conditions. Participants in both conditions rated interventions as satisfactory and personally relevant. Trial retention was high (86.3%) at 4 months. Attrition was significantly higher in brief advice (n = 6) relative to health coaching (n = 1). Average weekly alcohol use decreased 50% to 60% between baseline and follow-ups in both conditions. Biomarkers corroborated self-report.

CONCLUSION

The trial demonstrated intervention feasibility and acceptability. Alcohol use changed in expected directions. The next steps include a randomized controlled trial to test intervention efficacy in reducing alcohol use and surgical complications.

Association Between Initial Prescription Size and Likelihood of Opioid Refill After Total Knee and Hip Arthroplasty

BACKGROUND

The present study was designed to test the hypothesis that there was no association between initial opioid prescription size and the likelihood of refill after elective primary total knee (TKA) and hip arthroplasty (THA).

METHODS

We retrospectively analyzed large national datasets of commercial and Medicare insurance claims to identify a weighted cohort of 120,889 primary total joint arthroplasties (76,900 TKA and 43,989 THA) comprised of opioid-naive patients aged 18 to 75 years who had surgery between January 2015 and November 2019. The primary outcome was refill of any prescription opioid medication within 30 days after discharge, and the primary predictor variable was the total amount of opioid filled in the initial discharge prescription measured in oral morphine equivalents (OMEs). Logistic regressions were used to estimate the likelihood of refill, given a particular prescription size while adjusting for multiple patient factors, including age, sex, comorbidities, and year of surgery.

RESULTS

The 30-day refill rate was 59.6% following TKA and 26.1% for THA. Adjusted odds of refill decreased by 2% for every 75 OME (10 tablets of 5 mg oxycodone) increase to the initial prescription size among the THA cohort (adjusted odds ratio [OR] = 0.98; 95% CI 0.97-0.99), and decreased by 3% for the TKA cohort (aOR = 0.97; 95% CI 0.97-0.98).

CONCLUSION

These nationally representative data demonstrated that larger initial opioid prescription size was associated with small but clinically insignificant decreases in 30-day refill after total joint arthroplasty. This finding should allay concerns about efforts to decrease postsurgical opioid prescribing.

Noninferiority Trial Design: Opportunities and Challenges

Defining treatment effectiveness is the foundation of evidence-based practice. Most studies comparing the effectiveness of treatment options involve superiority designs in which a treatment is compared against a placebo, standard care, or an alternative treatment. However, in scenarios in which it is not ethical to consider these options, noninferiority designs can be considered. Noninferiority (NI) trials aim to demonstrate that a new treatment is not unacceptably worse than a standard treatment. Noninferiority is determined relative to a noninferiority margin, which is the difference between the test and active control treatment that is not unacceptably clinically inferior. However, there are important considerations with respect to the design, analysis, and interpretation of NI studies, which differ from superiority trials. This review will outline the key components of NI trials, how to interpret the findings, and understand their nuances and potential limitations.

Prospective cohort study on the trajectory and association of perioperative anxiety and postoperative opioid-related outcomes

INTRODUCTION

Although perioperative anxiety is common, its trajectory and influence on postoperative pain and opioid use are not well understood. We sought to examine the association and trajectory of perioperative anxiety, pain and opioid use following common surgical procedures.

METHODS

We conducted a prospective cohort study of 1771 patients undergoing elective surgical procedures. Self-reported opioid use, pain (Brief Pain Inventory) and anxiety (Patient-Reported Outcome Measurement Information System (PROMIS) Anxiety) were recorded on the day of surgery and at 1 month, 3 months and 6 months postsurgery. Clinically significant anxiety was defined as a PROMIS Anxiety T-score ≥55. We examined postoperative opioid use in the context of surgical site pain and anxiety using mixed-effects regression models adjusted for covariates, and examined anxiety as a mediator between pain and opioid use.

RESULTS

In this cohort, 65% of participants completed all follow-ups and 30% reported clinically significant anxiety at baseline. Anxiety and surgical site pain were highest on the day of surgery (anxiety: mean=49.3, SD=9.0; pain: mean=4.3, SD=3.3) and declined in the follow-up period. Those with anxiety reported higher opioid use (OR=1.40; 95% CI 1.0, 1.9) and 1.14-point increase in patient-reported surgical pain (95% CI 1.0, 1.3) compared with those without anxiety. Anxiety had no significant mediation effect on the relationship of pain and opioid use.

DISCUSSION

Anxiety is an independent risk factor for increased pain and opioid use after surgery. Future studies examining targeted behavioral therapies to reduce anxiety during the perioperative period may positively impact postoperative pain and opioid use.

Five year trends in surgical technique and outcomes of groin hernia repair in the United States

INTRODUCTION

Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually.

METHODS

This was a retrospective cohort study of adult patients undergoing elective groin hernia repair in a 20% representative Medicare sample from 2010-17. Surgical approach [minimally invasive (MIS) vs open] was defined using appropriate CPT codes. The primary outcome was operative recurrence at up to 5 years following surgery. We estimated the overall risk of operative recurrence using a multivariable Cox proportional hazards model.

RESULTS

Among 118119 patients, the majority (76.4%) underwent an open repair. Compared to patients who underwent MIS repair, patients in the open surgery cohort were older (mean age 72.7 vs 71.0, p < 0.001), more often female (14.4 vs 10.9%, p < 0.001), less often white (86.9 vs 87.7%, p < 0.001), and had a higher prevalence of nearly all measured comorbidities Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79-0.93).

CONCLUSIONS

In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era.

Patient risk screening to improve transitions of care in surgical opioid prescribing: a qualitative study of provider perspectives

Introduction

In patients undergoing surgical procedures, transitions in opioid prescribing occur across multiple providers during the months before and after surgery. These transitions often result in high-risk and uncoordinated prescribing practices, especially for surgical patients with prior opioid exposure. However, perspectives of relevant providers about screening and care coordination to address these risks are unknown.

Methods

We conducted qualitative interviews with 24 surgery, primary care, and anesthesia providers in Michigan regarding behaviors and attitudes about screening surgical patients to inform perioperative opioid prescribing in relation to transitions of care. We used an interpretive description framework to topically code interview transcripts and synthesize underlying themes in analytical memos.

Results

Providers believed that coordinated, multidisciplinary approaches to identify patients at risk of poor pain and opioid-related outcomes could improve transitions of care for surgical opioid prescribing. Anesthesia and primary care providers saw value in knowing patients’ preoperative risk related to opioid use, while surgeons’ perceptions varied widely. Across specialties, most providers favored a screening tool if coupled with actionable recommendations, sufficient resources, and facilitated coordination between specialties. Providers identified a lack of pain specialists and a dearth of actionable guidelines to direct interventions for patients at high opioid-related risk as major limitations to the value of patient screening.

Discussion

These findings provide context to address risk from prescription opioids in surgical transitions of care, which should include identifying high-risk patients, implementing a coordinated plan, and emphasizing actionable recommendations.

Opioid and benzodiazepine prescribing after COVID-19 hospitalization

Opioid and benzodiazepine prescribing after COVID-19 hospitalization is not well understood. We aimed to characterize opioid and benzodiazepine prescribing among naïve patients hospitalized for COVID and to identify the risk factors associated with a new prescription at discharge. In this retrospective study of patients across 39 Michigan hospitals from March to November 2020, we identified 857 opioid- and benzodiazepine-naïve patients admitted with COVID-19 not requiring mechanical ventilation. Of these, 22% received opioids, 13% received benzodiazepines, and 6% received both during the hospitalization. At discharge, 8% received an opioid prescription, and 3% received a benzodiazepine prescription. After multivariable adjustment, receipt of an opioid or benzodiazepine prescription at discharge was associated with the length of inpatient opioid or benzodiazepine exposure. These findings suggest that hospitalization represents a risk of opioid or benzodiazepine initiation among naïve patients, and judicious prescribing should be considered to prevent opioid-related harms.

Association of opioid exposure before surgery with opioid consumption after surgery

Objective

To determine the effect of prescription opioid use in the year before surgery on opioid consumption after surgery.

Background

Recently developed postoperative opioid prescribing guidelines rely on data from opioid-naïve patients. However, opioid use in the USA is common, and the impact of prior opioid exposure on the consumption of opioids after surgery is unclear.

Methods

Population-based cohort study of 26,001 adults 18 years of age and older who underwent one of nine elective general or gynecologic surgical procedures between January 1, 2017 and October 31, 2019, with prospectively collected patient-reported data from the Michigan Surgical Quality Collaborative (MSQC) linked to state prescription drug monitoring program at 70 MSQC-participating hospitals on 30-day patient-reported opioid consumption in oral morphine equivalents (OME) (primary outcome).

Results

Compared with opioid-naïve participants, opioid-exposed participants (26% of sample) consumed more prescription opioids after surgery (adjusted OME difference 12, 95% CI 10 to 14). Greater opioid exposure was associated with higher postoperative consumption in a dose-dependent manner, with chronic users reporting the greatest consumption (additional OMEs 32, 95% CI 21 to 42). However, for eight of nine procedures, 90% of opioid-exposed participants consumed ≤150 OMEs. Among those receiving perioperative prescriptions, opioid-exposed participants had higher likelihood of refill (adjusted OR 4.7, 95% CI 4.4 to 5.1), number of refills (adjusted incidence rate ratio 4.0, 95% CI 3.7 to 4.3), and average refill amount (adjusted OME difference 333, 95% CI 292 to 374)).

Conclusions

Preoperative opioid use is associated with small increases in patient-reported opioid consumption after surgery for most patients, though greater differences exist for patients with chronic use. For most patients with preoperative opioid exposure, existing guidelines may meet their postoperative needs. However, guidelines may need tailoring for patients with chronic use, and providers should anticipate a higher likelihood of postoperative refills for all opioid-exposed patients.

Estimation of the Prevalence of Delayed Dispensing Among Opioid Prescriptions From US Surgeons and Dentists

IMPORTANCE

Dispensing of opioid prescriptions from dentists and surgeons more than 30 days after writing, or delayed dispensing, could be a potential indicator that opioids were used for reasons or during a time frame other than that intended by the prescriber. The prevalence of delayed dispensing is unknown. Whether laws can prevent delayed dispensing by shortening the maximum period between prescription writing and dispensing is also unknown.

OBJECTIVE

To estimate the prevalence of delayed dispensing among opioid prescriptions from surgeons and dentists, assess the maximum period US states allow between controlled substance prescription writing and dispensing, and evaluate whether laws shortening this period decrease delayed dispensing of opioid prescriptions from surgeons and dentists.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional analysis, data from the IQVIA Formulary Impact Analyzer (representing 63% of US prescriptions) were used to identify opioid prescriptions from surgeons and dentists dispensed from 2014 through 2019.

MAIN OUTCOMES AND MEASURES

Among opioid prescriptions dispensed in 2019, the proportion with delayed dispensing was calculated. Using legal databases, the maximum state-allowed period between controlled substance prescription writing and dispensing as of December 2019 was examined. Using a difference-in-differences design and 2014 to 2019 data, changes in delayed dispensing prevalence were evaluated among opioid prescriptions from surgeons and dentists after a Minnesota law was enacted in July 2019 precluding opioid prescription dispensing more than 30 days after writing. Control states allowed dispensing beyond this period.

RESULTS

In 2019, the database included 20 858 413 opioid prescriptions from surgeons and dentists for 14 789 984 patients; 8 582 029 (58.0%) were female. The mean (SD) patient age was 47.1 (19.3) years. Of prescriptions included, 194 452 (0.9%) had delayed dispensing. As of December 2019, the maximum period between drug writing and dispensing was 180 days in 18 and 43 states for Schedule II and III drugs, respectively. Compared with control states, Minnesota's law decreased delayed dispensing prevalence by 0.22 percentage points (95% CI, -0.32 to -0.13 percentage points).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, 194 452 opioid prescriptions from surgeons and dentists were dispensed more than 30 days after writing. To mitigate any prescription opioid misuse associated with delayed dispensing, policy makers could shorten the maximum period between writing and dispensing of opioid prescriptions from surgeons and dentists.

Distribution of Opioid Prescribing and High-Risk Prescribing Among U.S. Dentists in 2019

INTRODUCTION

It is unknown whether certain dentists account for disproportionate shares of dental opioid prescriptions and high-risk prescriptions. Identifying and characterizing such dentists could inform the targeting of initiatives to improve the appropriateness and safety of dental opioid prescribing.

METHODS

In May 2021, the authors conducted a cross-sectional analysis using the IQVIA Longitudinal Prescription Database, which reports dispensing from 92% of U.S. pharmacies, and 2 provider databases (IQVIA OneKey, National Plan and Provider Enumeration System). Analyses included opioid prescriptions from dentists dispensed in 2019 to patients aged >12 years. High-risk prescriptions were those considered high risk by any of 3 metrics (prescriptions to opioid-naïve patients exceeding a 3-day supply, prescriptions with daily opioid dosage ≥50 morphine milligram equivalents, opioid prescriptions with benzodiazepine overlap). Among all prescriptions and high-risk prescriptions, the authors calculated the proportion accounted for by high-volume dentists -- those with prescription counts in the 95th percentile or higher. Using logistic regression, the characteristics associated with being a high-volume dentist were identified.

RESULTS

In 2019, a total of 141,345 dentists accounted for 10,736,743 opioid prescriptions dispensed to patients aged >12 years; 4,242,634 (39.5%) were high-risk prescriptions. The 7,079 high-volume dentists, a group representing 5.0% of the 141,345 dentists, accounted for 46.9% of all prescriptions and 47.5% of high-risk prescriptions. Male sex, younger age, non‒Northeast location, and specialization in oral and maxillofacial surgery were associated with a higher risk of being a high-volume dentist.

CONCLUSIONS

In 2019, high-volume dentists accounted for almost half of dental opioid prescriptions and high-risk prescriptions. Quality improvement initiatives targeting these dentists may be warranted.

Overcoming COVID-19: Strategies to Mitigate the Perpetuated Gender Achievement Gap

Sex inequity in academic achievement was well documented before the COVID-19 pandemic, and evolving data suggest that women in academic surgery are disproportionately disadvantaged by the pandemic. This perspective piece reviews currently accepted solutions to the sex achievement gap, with their associated shortcomings. We also propose innovative strategies to overcoming barriers to sex equity in academic medicine that broadly fall into three categories: strategies to mitigate inequitable caregiving responsibilities, strategies to reduce cognitive load, and strategies to value uncompensated, impactful work. These approaches address inequities at the system-level, as opposed to the individual-level, lifting the burden of changing the system from women.