Patient-Reported Opioid Consumption and Pain Intensity After Common Orthopedic and Urologic Surgical Procedures With Use of an Automated Text Messaging System

Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use

BACKGROUND

Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline.

STUDY DESIGN

We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed.

RESULTS

A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively.

CONCLUSIONS

Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.

Comparing Rationale for Opioid Prescribing Decisions after Surgery with Subsequent Patient Consumption: A Survey of the Highest Quartile of Prescribers

BACKGROUND

Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions-from nudges to reminders-have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown.

STUDY DESIGN

Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure-as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption.

RESULTS

During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%).

CONCLUSIONS

The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients.

Identifying Patient Characteristics Associated With Opioid Use to Inform Surgical Pain Management

Objective

Balancing surgical pain management and opioid stewardship is complex. Identifying patient-level variables associated with low or no use can inform tailored prescribing.

Methods

A prospective, observational study investigating surgical procedures, prescription data, and patient-reported outcomes at an academic health system in Pennsylvania. Surgical patients were consented following surgery, and prospective data were captured using automated text messaging (May 1, 2021-February 29, 2022). The primary outcome was opioid use.

Results

Three thousand six hundred three (30.2%) patients consented. Variation in patient reported used included 28.1% of men reported zero use versus 24.3% of women, 20.5% of Black patients reported zero use versus 27.2% of white patients. Opioid-naïve patients reported more zero use as compared with chronic use (29.7% vs 9.8%). Patients reporting higher use had more telephone calls and office visits within 30 days but no change in emergency department utilization or admissions. Higher discharge pain score was associated with higher use. In the adjusted analysis, opioid use relative to the guideline, higher use was associated with age, male sex, obesity, discharge pain score, and history of mental health disorder. In the adjusted model, younger age and being opioid-naïve to be associated with low to zero use across procedures.

Conclusions

Younger age, being opioid-naïve, and lower discharge pain score are associated with low or no postoperative opioid use. These characteristics can be used by clinicians to help tailor opioid prescribing to specific patients to reduce the risk of prolonged exposure and unused `ts in the community.

Shifting quality chronic pain treatment measures from processes to outcomes

OBJECTIVE

Misapplication of the 2016 Centers for Disease Control (CDC) opioid prescribing guidelines has led to overem-phasis of morphineequivalent daily dose (MEDD) as a "metric of success" in chronic noncancer pain (CNCP), resulting in unintentional harms to patients. This article reviews CNCP-related guidelines and patient preferences in order to identify pragmatic, patient-centered metrics to assess treatment response and safety in opioid-treated CNCP.

METHODS

We reviewed the clinical (CDC), research (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials), and implementability-related guidelines (GuideLine Implementability Appraisal), along with relevant patient-identified treatment goals. From these, we summarize a guideline-concordant, patient-centered, implementable set of measures to aid the clinical management of opioid-treated CNCP.

RESULTS

We identify metrics across three domains of care: (1) treatment response metrics, which align with the CNCP care goals (pain intensity, pain interference including function and quality of life, and global impression of change); (2) risk assessment ("safety") metrics, eg, MEDD, benzodiazepine-opioid or naloxone-opioid coprescribing, and severity of mental health disorders, which evaluate the risk-benefit profile of opioid therapy; and (3) adherence ("process") metrics, which assess clinician/patient adherence to the guideline-recommended opioid therapy monitoring practices, eg, the presence of completed treatment agreement or urine toxicology testing. All metrics should be informed by implementability principles, eg, be decidable, executable, and measurable.

CONCLUSIONS

This article summarizes guideline-concordant, patient-centered, implementable metrics for assessing treatment response, safety, and adherence in opioid-treated CNCP. Regardless of which specific treatment guidelines are applied, this approach could help conceptualize and standardize the collection and reporting of CNCP-relevant metrics, compare them across health systems, and optimize care and treatment outcomes in opioid-treated CNCP.

Pain severity scale: A methodology for classifying postoperative pain severity by surgical procedure

Background

Acute postoperative pain is common following many types of surgery, and a significant subset of patients experience severe pain, which can be difficult to manage and result in postoperative complications. Opioid agonists are commonly used to treat severe postoperative pain, but their use has been associated with adverse outcomes. This retrospective study uses data from the Veterans Administration Surgical Quality Improvement Project (VASQIP) database to develop a postoperative Pain Severity Scale (PSS) based on subjective pain reports and postoperative opioid requirements.

Methods

Postoperative pain scores and opioid prescription data were extracted from the VASQIP database for surgeries occurring between 2010 and 2020. Procedures were grouped by surgical Common Procedural Terminology (CPT) codes, and a total of 165,321 surgical procedures were examined, representing 1141 distinct CPT codes. K-means clustering analysis was used to group the surgeries based on 24-h maximum pain, 72-h average pain, and postoperative opioid prescriptions.

Results

K-means clustering analysis showed two optimal grouping strategies; one with 3 and the other with 5 groups. Both clustering strategies produced a PSS that categorized surgical procedures with generally increasing pain scores and opioid requirements. The 5-group PSS accurately captured typical postoperative pain experience across a range of procedures.

Conclusions

K-means clustering produced a Pain Severity Scale that can distinguish typical postoperative pain for a large variety of surgical procedures based on subjective and objective clinical data. The PSS will facilitate research into the optimal postoperative pain management and could be used in the development of clinical decision support tools.

Opioid Use and Associated Patient Satisfaction With Pain Control After Endoscopic Surgery and Robotic-Assisted Radical Prostatectomy

OBJECTIVE

To evaluate patient reported measures in patients undergoing endourologic procedures and robotic assisted radical prostatectomy (RARP) to demonstrate the efficacy of non-opioid postoperative pain management strategies.

MATERIALS AND METHODS

A prospective cohort study performed at an academic medical center included a patient telephone questionnaire and chart review. Opioid prescriptions, opioid use, and patient reported outcomes were recorded. Bivariate analyses were used to compare patients who did and did not use opioids in the RARP cohort while overall trends were reported for the endourologic procedures.

RESULTS

Of the 68 patients undergoing endoscopic intervention, 14 (21%) were prescribed an opioid and 6 (9%) reported any opioid use. 58 (85%) reported their pain was very well or well controlled while 9 reported their pain was poorly controlled. 59 (87%) were satisfied or very satisfied with their pain control. Fifty-three (93%) of the 57 patients undergoing RARP received an opioid prescription and only 23 reported any opioid use. All but 1 patient reported that their pain was well or very well controlled and almost all (54) of the patients were satisfied with their level of pain control. 36 (63%) reported their pain was less than expected while only 7 (12%) reported it was more than expected.

CONCLUSION

Most patients undergoing endourologic procedures do not use postoperative opioids and report favorable outcomes regarding their pain control. Similarly, after RARP, most patients do not use opioids even when they are prescribed and are satisfied with their pain control.

Real-Time Measurement of Patient Reported Outcomes and Opioid Use Following Urologic Procedures using Automated Text Messaging

OBJECTIVE

To evaluate opioid consumption and patient-reported pain intensity following urologic procedures.

METHODS

Adult patients were consented following a urologic procedure, and data was collected through post-operative day 28 in a large tertiary care academic health system. An automated text messaging platform was used to collect patient reported pain intensity, ability to manage pain, and opioid use measured in oxycodone 5 mg tablet equivalents. Outcomes were weighted based on the inverse probability of response to yield representative estimates.

RESULTS

1015 (51.8%) patients responded to the text-message survey. The median number of pills prescribed was 10 (IQR 6-10), and the median number of pills taken was 2 (IQR 0-6). By postoperative day 7, the median tablets taken overall was 0. Over the study period, 60.1% (6566) of all tablets prescribed were left unused, and 38.4% of patients did not use any of the prescribed opioids. Across urologic procedures, 6 tablets would accommodate the 75^th percentile of patient-reported use, with the exception of major open procedures.

CONCLUSIONS

In this study utilizing real-time measurement of opioid use and pain levels with text messaging, there was evidence of dramatic over-prescription of opioids relative to use and pain levels. Patient-reported data, collected via text messaging, can support clinicians and policy leaders in forming national guidelines on evidence-based best practices, personalizing prescriptions and guide shared decision making to decrease opioid excess.

Complete opioid cessation after surgery improves patient-reported pain measures among chronic opioid users

BACKGROUND

Preoperative chronic opioid use is common, but it is unclear whether complete opioid tapering can be achieved postoperatively without adversely affecting pain control and quality of life. This study was designed to assess the association between complete opioid tapering after surgery and patient-reported outcomes for pain intensity and pain interference.

METHODS

We identified chronic opioid use patients undergoing a spectrum of nonemergency surgical procedures at a single Veterans Affairs medical institution between December 2017 and 2021. All patients were prospectively followed by a transitional pain service that promoted opioid tapering, assessed opioid use (morphine milligram equivalent), and patient-reported outcomes measurement information system for pain intensity (PROMIS-3a) and pain interference (PROMIS-6b). After stratifying based on whether complete versus partial/no opioid tapering was achieved after surgery, longitudinal changes in patient-reported outcomes and morphine milligram equivalents were compared over time. Independent predictors of complete opioid tapering were assessed using logistic regression models.

RESULTS

In total, 341 surgical patients (91% male, mean age 64 years) with chronic opioid use underwent surgery during the study period, of which 44 (13%) completely tapered off opioids within 60 days after discharge from the hospital. Patients who completely tapered had significant improvement in the change in patient-reported outcomes for pain intensity and interference with significant differences at 30 and 60 days after discharge for both measures when compared to the partial/no taper group (both P < .05). In risk-adjusted analyses, patients with lower baseline morphine milligram equivalents and those staying longer in the hospital were more likely to achieve complete opioid tapering (both P < .01).

CONCLUSION

Complete opioid tapering can be successfully achieved after surgery among patients with chronic opioid use with corresponding improvements in self-reported pain intensity and pain interference. Our results suggest that the highest potential for improving patient-reported outcomes with opioid tapering occurs among patients undergoing orthopedic procedures early after surgical discharge.

Effect of Mailing an At-home Disposal Kit on Unused Opioid Disposal After Surgery: A Randomized Clinical Trial

This randomized clinical trial tests the effect of a mailed, at-home disposal kit on disposal rates of unused opioids after surgery.

Dissemination and Implementation Science in Cardiothoracic Surgery: A Review and Case Study

Dissemination and implementation (D&I) science is the practice of taking evidence-based interventions (EBI) and sustainably incorporating them in routine clinical practice. As a relatively young field, D&I techniques are underutilized in cardiothoracic surgery. This review offers an overview of D&I science from the context of the cardiothoracic surgeon. First, we provide a general introduction to D&I science and basic terminology that is used in the field. Second, to illustrate D&I techniques in a real-world example, we discuss a case study for implementing lung protective management (LPM) strategies for lung donor optimization nationally. Finally, we discuss challenges to successful implementation that are unique to cardiothoracic surgery and give several examples of EBIs that have been poorly implemented into surgical practice. We also provide examples of successful D&I interventions - including de-implementation strategies - from other surgical subspecialties. We hope that this review offers additional tools for cardiothoracic surgeons to explore when introducing EBIs into routine practice.

Testing Digital Methods of Patient-Reported Outcomes Data Collection: A prospective, cluster randomized trial to test text messaging and mobile surveys. (Preprint)

Background

Health care delivery continues to evolve, with an effort being made to create patient-centered care models using patient-reported outcomes (PROs) data. Collecting PROs has remained challenging and an expanding landscape of digital health offers a variety of methods to engage patients.

Objective

The aim of this study is to prospectively investigate two common methods of remote PRO data collection. The study sought to compare response and engagement rates for bidirectional SMS text messaging and mobile surveys following orthopedic surgery.

Methods

The study was a prospective, block randomized trial of adults undergoing elective orthopedic procedures over 6 weeks. The primary objective was to determine if the method of digital patient engagement would impact response and completion rates. The primary outcome was response rate and total completion of PRO questionnaires.

Results

A total of 127 participants were block randomized into receiving a mobile survey (n=63) delivered as a hyperlink or responding to the same questions through an automated bidirectional SMS text messaging system (n=64). Gender, age, number of comorbidities, and opioid prescriptions were similar across messaging arms. Patients receiving the mobile survey were more likely to have had a knee-related surgery (n=50, 83.3% vs n=40, 62.5%; P=.02) but less likely to have had an invasive procedure (n=26, 41.3% vs n=39, 60.9%; P=.03). Overall engagement over the immediate postoperative period was similar. Prolonged engagement for patients taking opioids past postoperative day 4 was higher in the mobile survey arm at day 7 (18/19, 94.7% vs 9/16, 56.3%). Patients with more invasive procedures showed a trend toward being responsive at day 4 as compared to not responding (n=41, 59.4% vs n=24, 41.4%; P=.05).

Conclusions

As mobile patient engagement becomes more common in health care, testing the various options to engage patients to gather data is crucial to inform future care and research. We found that bidirectional SMS text messaging and mobile surveys were comparable in response and engagement rates; however, mobile surveys may trend toward higher response rates over longer periods of time.

Trial Registration

ClinicalTrials.gov NCT03532256; https://clinicaltrials.gov/ct2/show/NCT03532256