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Pence ST, Findlay BL, Bearrick EN, Pinkhasov AM, Fadel A, Anderson KT, Viers BR. Evaluation of an Opioid-free Pathway for Perineal Reconstructive Surgery: A 1-year Pilot Study. Urology 2024:S0090-4295(24)00304-2. [PMID: 38677369 DOI: 10.1016/j.urology.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE To evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution. METHODS Patients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record (EHR) in order to assess the efficacy of an opioid-free pathway. RESULTS Sixty-seven patients met the criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription. CONCLUSION An opioid-free pathway is appropriate for opioid naive men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain.
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Affiliation(s)
| | | | | | | | | | | | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN.
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Pattullo C, Suckling B, Salanowski J, Donovan P, Hall L. Describing the acceptability and use of an opioid stewardship self-assessment tool in real-world settings. Res Social Adm Pharm 2024; 20:203-208. [PMID: 38049350 DOI: 10.1016/j.sapharm.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND The Stewardship Framework (Framework) was developed by an expert clinician group and was designed to provide a mechanism for continuous monitoring of improvement in opioid prescribing in acute hospitals. The aim of this study was to modify the Framework into an Opioid Stewardship Self-Assessment Tool (Self-Assessment Tool), and pilot test the acceptability and its use in a variety of acute hospital settings. METHODS The Framework was converted into the Self-Assessment Tool to allow hospitals to undertake a gap analysis of their current opioid stewardship activities. To participate hospitals were required to establish a small team and complete the Self-Assessment Tool. Participating sites were recruited using purposive sampling. Responses were tabulated and coded to enable assessment. 'Acceptability' was defined as the completion of the Self-Assessment Tool (response rate, proportion of questions answered) and responder feedback relating to its content. The use of the Tool was categorised based on the level of detail of responses. RESULTS Nineteen of the 20 facilities approached, agreed to participate. The 16 sites which established a small team to facilitate survey completion are included in the final analysis. The overall response rate was 96 % (413/432) for the (27 survey questions across 16 participating sites), 4 % (19/432) of questions were left unanswered or were not interpretable by the study team. Opportunities were identified to enhance the use of the Self-Assessment Tool, particularly to support its potential to assist reflection and planning of local strategies. CONCLUSION This study demonstrated that the Self-Assessment Tool was an acceptable method of assessing a facility's opioid stewardship capabilities in a real-world setting. The next iteration will be modified using the insights on how the Tool was used by study participants.
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Affiliation(s)
- Champika Pattullo
- Safety and Implementation Service, Lower Ground Floor, James Mayne Building, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia; School of Public Health, University of Queensland, Herston, Queensland, Australia.
| | - Benita Suckling
- Medication Safety Pharmacist, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Julia Salanowski
- Clinical Pharmacist, Analgesic Stewardship Pharmacist, Pharmacy Department, Barwon Health, Victoria, Queensland, Australia
| | - Peter Donovan
- Clinical Pharmacology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Lisa Hall
- School of Public Health, University of Queensland, Herston, Queensland, Australia
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Alshawadfy A, Elewa AM, Mewafy MA, Ellilly AA. Comparison between pericapsular nerve group block and morphine infusion in reducing pain of proximal femur fracture in the emergency department: A randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2165888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Abdelrhman Alshawadfy
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ahmed M. Elewa
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mahmoud Ahmed Mewafy
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ahmed A. Ellilly
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Law V, Cohen D, Chan B, Singh S, Jones C, Papachristos A, Logan E, Yoon S, Rubio-Reyes P, Terpstra K, Ward S. Successful implementation of a quality improvement bundle to reduce opioid overprescribing following total hip and knee arthroplasty. BMJ Open Qual 2023; 12:e002360. [PMID: 38148117 PMCID: PMC10753738 DOI: 10.1136/bmjoq-2023-002360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 12/02/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Opioid overprescribing is commonplace after total hip (THA) and total knee arthroplasty (TKA). Preliminary data demonstrated that approximately 32% of the opioids prescribed at discharge from our hospital following THA and TKA remain unused. This is a concern given that unused prescribed opioids are available for diversion and may result in misuse and abuse. METHODS Pre-intervention data were collected between 1 November 2018 and 10 December 2018. An intervention bundle was then introduced, including education of patients and providers, a standardised pain management algorithm and an autopopulated discharge prescription. The aim of this quality improvement initiative was to reduce the amount of opioid (average oral morphine equivalents (OME)) dispensed (based on the discharge prescription provided) following THA and TKA at our institution by 15% by 1 April 2019. DESIGN Using an interrupted time series design, the outcome measure was the amount of opioid (OME) dispensed from the discharge prescription provided. Process measures included the percentage of autopopulated discharge prescriptions, the percentage of patients receiving education at discharge and the percentage of nurses and residents receiving standardised education. Balancing measures included patient satisfaction with postoperative pain management, and the percentage of patients filling the second half of the part-fill or requiring a subsequent opioid prescription. RESULTS With 600 patients identified, mean OME dispensed at discharge was reduced by 26.3% (from 522.2 to 384.9 mg) after our interventions started. Utilisation of autopopulated part-fill prescriptions was 95.8%. There was no change in patient satisfaction nor in the proportion of patients requiring an additional opioid prescription post-intervention. Only 39% of patients filled the second half of the part-fill prescription post-intervention. CONCLUSIONS Mean OME dispensed at discharge per patient was reduced with no change in patient satisfaction after introduction of the intervention bundle.
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Affiliation(s)
- Vivian Law
- St Michael's Hospital, Toronto, Ontario, Canada
| | - Daniel Cohen
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bokman Chan
- Anaesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Shawna Singh
- Orthopedics, St Michael's Hospital, Toronto, Ontario, Canada
| | - Caroline Jones
- Orthopedics, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Elizabeth Logan
- Surgery and Critical Care, St Michael's Hospital, Toronto, Ontario, Canada
| | - Samuel Yoon
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Kristen Terpstra
- Trauma & Neurosurgery ICU, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sarah Ward
- Division of Orthopaedic Surgery, St Michael's Hospital, Toronto, Ontario, Canada
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Krebsbach MN, Alexander KM, Miller JJ, Doll EL, Lee YL, Simmons JD. Implementing a Discharge Opioid Bundle in Adult Trauma Patients Decreases the Amount of Opioids Prescribed at Discharge. Am Surg 2023; 89:4281-4287. [PMID: 35622969 DOI: 10.1177/00031348221101483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioids remain the mainstay treatment of acute pain caused by trauma. The lack of evidence driven prescribing creates a challenging situation for providers. We hypothesized that the implementation of a trauma discharge opioid bundle (TDOB) would decrease the total morphine milligram equivalents (MME) prescribed at discharge while maintaining pain control. METHODS This was a pre-post study of adult trauma patients before and after implementation of a TDOB to guide the prescription of opioids and discharge prescription education in patients discharged from a level one trauma center. The pre-group and post-group, included consecutively discharged patients from September through November in 2018 and 2019. The primary outcome was the total MME prescribed at discharge. RESULTS A total of 377 patients met inclusion criteria. One hundred and fifty-one patients were included in the pre-group and 226 in the post-group. The total MME prescribed at discharge (225 ± [150-300] pre vs 200 ± [100-225] post, P = < .001) and maximum MME/day (45 ± [30-45] vs 30 ± [20-45], P = .004) were significantly less in the post-group. Incidence of outpatient refills within fourteen days were similar. More non-opioid pain adjuncts were prescribed post-intervention and discharge pain education was provided more frequently. CONCLUSION The implementation of a TDOB significantly reduced the MME prescribed at discharge without increasing the number of opioid refills.
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Affiliation(s)
- Mackenzie N Krebsbach
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | | | - Jennifer J Miller
- College of Nursing, Department of Adult Health Nursing, University of South Alabama, Mobile, AL, USA
| | - Elizabeth L Doll
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | - Yann-Leei Lee
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
| | - Jon D Simmons
- USA Health, Department of Surgery, Division of Trauma, Acute Care Surgery & Burns, Mobile, AL, USA
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Babino JM, Thornton JD, Putney K, Bethany Taylor R, Wanat MA. Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers. J Pharm Pract 2023; 36:1077-1084. [PMID: 35410543 DOI: 10.1177/08971900221088797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.
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Affiliation(s)
- Justin M Babino
- Department of Pharmacy, Baylor St Luke's Medical Center, Houston, TX, USA
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX, USA
- Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kimberly Putney
- Department of Pharmacy, Baylor St Luke's Medical Center, Houston, TX, USA
| | | | - Matthew A Wanat
- Prescription Drug Misuse Education and Research Center, University of Houston College of Pharmacy, Houston, TX, USA
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
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Phinn K, Liu S, Patanwala AE, Penm J. Effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge: A systematic review. Br J Clin Pharmacol 2023; 89:982-1002. [PMID: 36495313 DOI: 10.1111/bcp.15633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/24/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022] Open
Abstract
This study aims to summarize the effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge. A systematic search was conducted on 6 electronic databases by 2 independent reviewers. We included original research articles reporting on quantitative outcomes of organizational interventions targeting appropriate opioid prescribing on hospital discharge. Quality assessment was performed by 2 independent reviewers. The protocol for this review was prospectively registered on PROSPERO (ID: CRD42020156104). Out of 173 full texts assessed for eligibility, 43 were included in this review. The majority of studies had a moderate to serious risk of bias (33 out of 43). Most of the studies implemented a multifaceted organizational intervention (16 studies). Other interventions included guideline implementation, prescriber education and default opioid-prescribing quantity changes in electronic medical records. Multiple studies found that the dissemination of patient-specific and procedure-specific guidelines reduced the quantity of opioids prescribed by 44 to 57%. Prescriber education provided with feedback was implemented in 4 studies and resulted in a 33 to 44% decrease in prescribing rates. Lowering the default quantities in the electronic medical records produced a 40% decrease in opioids prescribed in 1 study. Guideline implementation, prescriber education and default opioid-prescribing quantity changes all appear effective in improving the appropriate prescribing of opioids on hospital discharge. However, the extent of reduction of opioid prescribing upon hospital discharge after the implementation of multifaceted intervention strategies appears similar to that of simpler interventions which require fewer resources.
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Affiliation(s)
- Katelyn Phinn
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia
| | - Shania Liu
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Asad E Patanwala
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Tyson K, Karam BS, Peppard WJ, Morris R, Murphy P, Elegbede A, Schroeder M, Somberg L, Trevino CM. Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study. Surgery 2023; 173:794-798. [PMID: 36371358 DOI: 10.1016/j.surg.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. METHODS This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. RESULTS We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. CONCLUSION A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.
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Affiliation(s)
- Katherine Tyson
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Basil S Karam
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - William J Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Anuoluwapo Elegbede
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Schroeder
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lewis Somberg
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen M Trevino
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Gentle CK, Thomas JD, Montelione KC, Tu C, Prabhu AS, Krpata DM, Beffa LR, Rosenblatt S, Rosen MJ, Lo Menzo E, Alaedeen D, Szomstein S, Massier CG, Petro CC. Opioid prescribing practices and patient-requested refill patterns following laparoscopic inguinal hernia repair. Hernia 2023; 27:85-92. [PMID: 36418792 PMCID: PMC9685134 DOI: 10.1007/s10029-022-02708-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Excessive post-operative opioid prescribing has led to efforts to match prescriptions with patient need after surgery. We investigated opioid prescribing practices, rate of patient-requested opioid refills, and associated factors after laparoscopic inguinal hernia repair (LIHR). METHODS LIHRs at a single institution from 3/2019 to 3/2021 were queried from the Abdominal Core Health Quality Collaborative for demographics, perioperative details, and patient-reported opioid usage. Opioid prescriptions at discharge and opioid refills were extracted from the medical record. Univariate and multivariable regression were used to identify factors associated with opioid refills within 30-days of surgery. RESULTS Four hundred and ninety LIHR patients were analyzed. The median number of opioid tablets prescribed was 12 [interquartile range (IQR) 10-15], and 4% requested a refill. On univariate analysis, patients who requested refills were younger [55 years (IQR 37-61) vs. 62 years (IQR 36.8-61), p = 0.012], more likely to have undergone transabdominal preperitoneal repair (75% vs. 26.4%, p < 0.001), have a scrotal component (30% vs. 11%, p = 0.022), and have permanent tacks used (80% vs. 49.4%, p = 0.014). There was a 12% increase in the odds of opioid refill for every 1 tablet of oxycodone prescribed at discharge (95% CI for OR 1.04-1.21, p = 0.003) after controlling for age and surgery type. Patient-reported opioid use was available for 289 (59%) patients. Post-operatively, 67% of patients used ≤ 4 opioid tablets, and 87% used no more than 10 opioid tablets. CONCLUSION Most patients use fewer opioid tablets than prescribed. Requests for opioid refills are rare following LIHR (4%) and associated with higher opioid prescribing.
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Affiliation(s)
- C. K. Gentle
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - J. D. Thomas
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - K. C. Montelione
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - C. Tu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH USA
| | - A. S. Prabhu
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - D. M. Krpata
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - L. R. Beffa
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - S. Rosenblatt
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - M. J. Rosen
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
| | - E. Lo Menzo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston, FL USA
| | - D. Alaedeen
- Department of General Surgery, Fairview Hospital, Cleveland, OH USA
| | - S. Szomstein
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Florida, Weston, FL USA
| | - C. G. Massier
- Department of General Surgery, Marymount Hospital, Garfield Heights, OH USA
| | - C. C. Petro
- Department of General Surgery, Digestive Disease and Surgery Institute, Center for Abdominal Core Health, Cleveland Clinic, 9500 Euclid Avenue, A-100, Cleveland, OH 44195 USA
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Bougie O, Blom J, Zhou G, Murji A, Thurston J. Use and misuse of opioid after gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022; 85:23-34. [PMID: 35973919 DOI: 10.1016/j.bpobgyn.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/25/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.
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Affiliation(s)
- Olga Bougie
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA.
| | - Jessica Blom
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA
| | - Grace Zhou
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Ally Murji
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Jackie Thurston
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, USA
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Livingston CJ, Berenji M, Titus TM, Caplan LS, Freeman RJ, Sherin KM, Mohammad A, Salisbury-Afshar EM. American College of Preventive Medicine: Addressing the Opioid Epidemic Through a Prevention Framework. Am J Prev Med 2022; 63:454-465. [PMID: 35750550 DOI: 10.1016/j.amepre.2022.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022]
Abstract
The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.
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Affiliation(s)
- Catherine J Livingston
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Health Management and Policy, School of Public Health, OHSU-Portland State University, Portland, Oregon.
| | - Manijeh Berenji
- Department of Occupational Health, VA Long Beach Healthcare System, Long Beach, California; Department of Occupational Medicine, UC Irvine School of Medicine, Irvine, California; Department of Environmental and Occupational Health, School of Public Health, University of California, Irvine, Irvine, California
| | - Tisha M Titus
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Lee S Caplan
- Department of Community Health & Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Randall J Freeman
- Department of Occupational Medicine, Tripler Army Medical Center, Schofield Barracks, Hawaii
| | - Kevin M Sherin
- Department of Family Medicine and Rural Health Florida State University College of Medicine, Orlando, Florida; Department of Medicine University of Central Florida College of Medicine, Orlando, Florida
| | - Amir Mohammad
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Elizabeth M Salisbury-Afshar
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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Ingram MCE, Tian Y, Kennedy S, Schäfer WLA, Johnson JK, Apley DW, Mehrotra S, Holl JL, Raval MV. Pilot implementation of opioid stewardship measures using the national surgical quality improvement program-pediatric platform. J Pediatr Surg 2022; 57:130-136. [PMID: 34996606 PMCID: PMC9203599 DOI: 10.1016/j.jpedsurg.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Data surrounding optimal pediatric postoperative opioid prescribing are incomplete. The objective of this study was to leverage the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-P) and assess feasibility of added data collection surrounding pediatric perioperative pain management practices including opioid prescribing at discharge. METHODS Nineteen (19) novel data elements were added to NSQIP-P data collection of selected patients, ages 5-18 years, who had undergone surgery at a single, free-standing children's hospital. Metrics around data abstraction and completion of variables were collected. Univariate analyses (using Chi-square or Wilcoxon Rank Sum tests) and multiple logistic regressions were performed to describe predictors of opioid prescribing at discharge and to monitor adherence to Food and Drug Administration (FDA) prescribing recommendations. RESULTS Median abstraction time of the novel variables decreased from 12 to 5 min per patient over 13 months with 94% variable completion rate. Of 878 patients, 302 (36.4%) were prescribed opioids at discharge. Factors associated with an opioid prescription included older age (p < 0.001), white race (p < 0.05), undergoing an orthopedic surgery (p < 0.001), and receiving a regional block perioperatively (p < 0.001). All opioid prescriptions met FDA guidelines with no patients receiving codeine, and 98% of patients receiving opioid prescriptions < 50 morphine milli-equivalents per day. CONCLUSION Collecting data on current pain management practices, opioid prescribing, and adherence to safety recommendations is feasible using the NSQIP-P with little added burden. Further expansion of data collection is needed to develop generalizable optimal prescribing practices for post-discharge pain management for children.
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Affiliation(s)
- Martha-Conley E Ingram
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA.
| | - Yao Tian
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Sarah Kennedy
- American College of Surgeons, National Surgical Quality Improvement Program Pediatric (NSQIP-Peds), Ann And Robert H Lurie Children's Hospital Of Chicago, Chicago, IL, USA
| | - Willemijn L A Schäfer
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Julie K Johnson
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Daniel W Apley
- Department Of Engineering, Northwestern University, Chicago, IL, USA
| | - Sanjay Mehrotra
- Department Of Engineering, Northwestern University, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Delivery, Science, and Innovation, University of Chicago Medicine, Chicago, IL, USA
| | - Mehul V Raval
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
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Chua KP, Thorne MC, Ng S, Donahue M, Brummett CM. Association Between Default Number of Opioid Doses in Electronic Health Record Systems and Opioid Prescribing to Adolescents and Young Adults Undergoing Tonsillectomy. JAMA Netw Open 2022; 5:e2219701. [PMID: 35771572 PMCID: PMC9247741 DOI: 10.1001/jamanetworkopen.2022.19701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE In prior studies, decreasing the default number of doses in opioid prescriptions written in electronic health record systems reduced opioid prescribing. However, these studies did not rigorously assess patient-reported outcomes, and few included pediatric patients. OBJECTIVE To evaluate the association between decreasing the default number of doses in opioid prescriptions written in electronic health record systems and opioid prescribing and patient-reported outcomes among adolescents and young adults undergoing tonsillectomy. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized clinical trial included adolescents and young adults aged 12 to 50 years undergoing tonsillectomy from October 1, 2019, through July 31, 2021, at a tertiary medical center. The treatment group comprised patients from a pediatric otolaryngology service (mostly aged 12-21 years) and the control group comprised patients from a general otolaryngology service (mostly aged 18-25 years). INTERVENTIONS Data on patient-reported opioid consumption and outcomes were collected via a survey on postoperative day 14. Based on opioid consumption among pediatric otolaryngology patients before the intervention, the default number of opioid doses was decreased from 30 to 12 in a tonsillectomy order set. This change occurred only for pediatric otolaryngology patients. MAIN OUTCOMES AND MEASURES Proportion of patients with 12 doses in the discharge opioid prescription, number of doses in this prescription, and refills and pain-related visits within 2 weeks of surgery. In a secondary analysis of patients completing the postoperative survey, patient-reported opioid consumption, pain control, sleep disturbance, anxiety, and depression were assessed. Linear or log-linear difference-in-differences models were fitted, adjusting for patients' demographic characteristics and presence of a mental health or substance use disorder. RESULTS The study included 237 patients (147 female patients [62.0%]; mean [SD] age, 17.3 [3.6] years). Among 131 pediatric otolaryngology patients, 1 of 70 (1.4%) in the preintervention period and 27 of 61 (44.3%) in the postintervention period had 12 doses in the discharge opioid prescription (differential change, 45.5 percentage points; 95% CI, 32.2-58.8 percentage points). Among pediatric otolaryngology patients, the mean (SD) number of doses prescribed in the preintervention period was 22.3 (7.4) and in the postintervention period was 16.1 (6.5) (differential percentage change, -29.2%; 95% CI, -43.2% to -11.7%). The intervention was not associated with changes in refills or pain-related visits. The secondary analysis included 150 patients. The intervention was not associated with changes in patient-reported outcomes except for a 3.5-point (95% CI, 1.5-5.5 points) differential increase in a sleep disturbance score that ranged from 4 to 20, with higher scores indicating poorer sleep quality. CONCLUSIONS AND RELEVANCE This nonrandomized clinical trial suggests that evidence-based default dosing settings may decrease perioperative opioid prescribing among adolescents and young adults undergoing tonsillectomy, without compromising analgesia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04066829.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Marc C. Thorne
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Michigan Medical School, Ann Arbor
| | - Sophia Ng
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
| | - Mary Donahue
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | - Chad M. Brummett
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
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Beyene KA, Chan AHY, Aquite OM, Kumar M, Moore S, Park YJ, Ruohonen T, Gong J. Postdischarge opioid use and persistent use after general surgery: A retrospective study. Surgery 2022; 172:602-611. [DOI: 10.1016/j.surg.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/08/2022] [Accepted: 02/28/2022] [Indexed: 11/28/2022]
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Luo W, Liang J, Wu J, Luo Q, Wu H, Ou Y, Li Y, Ma W. Effects of pericapsular nerve group (PENG) block on postoperative recovery in elderly patients with hip fracture: study protocol for a randomised, parallel controlled, double-blind trial. BMJ Open 2022; 12:e051321. [PMID: 35351697 PMCID: PMC8966559 DOI: 10.1136/bmjopen-2021-051321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hip fracture is a common and serious emergency in the elderly, and it is associated with severe pain, significant morbidity and mortality. The use of peripheral nerve block can relieve pain effectively and reduce opioid requirements, which may accelerate patient's recovery. The pericapsular nerve group (PENG) block has been found to provide an effective blockade to the hip joint with a potential motor-sparing effect, so we hypothesised that the PENG block may be an effective tool to enhance the recovery in elderly patients after hip fracture surgery. METHODS AND ANALYSIS This study is a single-centred, randomised, parallel controlled, double-blind trial. A total of 92 elderly patients scheduled for hip fracture surgery will be divided into two groups at random to receive either ultrasound-guided femoral nerve block or ultrasound-guided PENG block. The primary outcome will be to compare the Quality of Recovery-15 scores at 24 hours postoperatively between the two groups. The secondary outcomes will include measuring and comparing the strength of the quadriceps, the visual analogue scale at rest and on movement, the total morphine consumption, the rescue analgesic, the first time of postoperative out-of-bed mobilisation and complications. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board of the Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine on 15 December 2020 (reference K2020-110). The results of this study will be published in peer-reviewed international journals. TRIAL REGISTRATION NUMBER ChiCTR2100042341.
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Affiliation(s)
- Wei Luo
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jianhui Liang
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jieting Wu
- Department of Anesthesiology, The Third People's Hospital of Guangzhou Baiyun District, Guangzhou, Guangdong, China
| | - Quehua Luo
- Department of Anesthesiology, Guangdong Provincial People's Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Huiyi Wu
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yanhua Ou
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yuhui Li
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - WuHua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Raval MV. Invited Commentary: Moving the Needle on Postoperative Pediatric Opioid Prescribing. J Am Coll Surg 2022; 234:298-299. [PMID: 35213492 DOI: 10.1097/xcs.0000000000000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.
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Daoust R, Paquet J, Marquis M, Chauny JM, Williamson D, Huard V, Arbour C, Émond M, Cournoyer A. Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2143425. [PMID: 35024834 PMCID: PMC8759006 DOI: 10.1001/jamanetworkopen.2021.43425] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
Importance Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse. Objective To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED. Data Sources MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021. Study Selection Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers. Data Extraction and Synthesis Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values. Main Outcomes and Measures The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies. Results Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients' satisfaction. Conclusions and Relevance This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed. Trial Registration PROSPERO Identifier: CRD42020187251.
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Affiliation(s)
- Raoul Daoust
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
| | - Martin Marquis
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
| | - Jean-Marc Chauny
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
| | - David Williamson
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Vérilibe Huard
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Caroline Arbour
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
- Faculté des Sciences Infirmières, Université de Montréal, Montréal, Québec, Canada
| | - Marcel Émond
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Alexis Cournoyer
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
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Kharasch ED, Clark JD, Adams JM. Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology 2022; 136:10-30. [PMID: 34874401 PMCID: PMC10715730 DOI: 10.1097/aln.0000000000004065] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.
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Affiliation(s)
- Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - J David Clark
- the Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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20
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Montague E, Bungum M, Sherman L, Gravenor S, Courtney DM, Czerniak A, Wolf M, McCarthy D. Using a sociotechnical systems analysis to evaluate an intervention to improve opioid prescribing in emergency medicine. APPLIED ERGONOMICS 2021; 97:103495. [PMID: 34298388 DOI: 10.1016/j.apergo.2021.103495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/27/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
The United States is facing an unprecedented epidemic of opioid addiction and death due to opioid overdose. In an effort to improve patient knowledge and safe use about opioids, an Electronic Medication Complete Communication (EMC2) opioid strategy was developed targeting opioid naïve patients in the Emergency Department (ED). We conducted pre and post sociotechnical systems analyses to evaluate the variance between the process before the intervention and whether or not the process changed as expected with the new intervention. Results were analyzed using thematic qualitative analysis. Sociotechnical systems modeling illustrates the complexity of designing interventions for emergency medicine that affect multiple patients, providers, work systems, technologies, and processes. The post work systems model illustrates that several elements in the external ED environment can affect the effectiveness of the intervention. Sociotechnical systems analysis is an effective tool to illustrate the opportunities for designing health system interventions and evaluating the fidelity of such interventions.
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Affiliation(s)
| | | | - Lauren Sherman
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Stephanie Gravenor
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Alyssa Czerniak
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Mike Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Danielle McCarthy
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
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Zhu CY, Schumm MA, Hu TX, Nguyen DT, Kim J, Tseng CH, Lin AY, Yeh MW, Livhits MJ, Wu JX. Patient-Centered Decision-making for Postoperative Narcotic-Free Endocrine Surgery: A Randomized Clinical Trial. JAMA Surg 2021; 156:e214287. [PMID: 34495283 DOI: 10.1001/jamasurg.2021.4287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Historically, opioid pain medications have been overprescribed following thyroid and parathyroid surgery. Many narcotic prescriptions are incompletely consumed, creating waste and opportunities for abuse. Objective To determine whether limiting opioid prescriptions after outpatient thyroid and parathyroid surgery to patients who opt in to narcotic treatment reduces opioid consumption without increasing postoperative pain compared with usual care (routine narcotic prescriptions). Design, Setting, and Participants A randomized clinical trial of Postoperative Opt-In Narcotic Treatment (POINT) or routine narcotic prescription (control) was conducted at a single tertiary referral center from June 1 to December 30, 2020. A total of 180 adults undergoing ambulatory cervical endocrine surgery, excluding patients currently receiving opioids, were assessed for eligibility. POINT patients received perioperative pain management counseling and were prescribed opioids only on patient request. Patients reported pain scores (0-10) and medication use through 7 daily postoperative surveys. Logistic regression was used to determine factors associated with opioid consumption. Interventions Patients in the POINT group were able to opt in or out of receiving prescriptions for opioid pain medication on discharge. Control patients received routine opioid prescriptions on discharge. Main Outcomes and Measures Daily peak pain score through postoperative day 7 was the primary outcome. Noninferiority was defined as a difference less than 2 on an 11-point numeric rating scale from 0 to 10. Analysis was conducted on the evaluable population. Results Of the 180 patients assessed for eligibility, the final study cohort comprised 102 patients: 48 randomized to POINT and 54 to control. Of these, 79 patients (77.5%) were women and median age was 52 (interquartile range, 43-62) years. A total of 550 opioid tablets were prescribed to the control group, and 230 tablets were prescribed to the POINT group, in which 23 patients (47.9%) opted in for an opioid prescription. None who opted out subsequently required rescue opioids. In the first postoperative week, 17 POINT patients (35.4% of survey responders in the POINT group) reported consuming opioids compared with 27 (50.0%) control patients (P = .16). Median peak outpatient pain scores were 6 (interquartile range, 4-8) in the control group vs 6 (interquartile range, 5-7) in the POINT group (P = .71). In multivariate analysis, patients with a history of narcotic use were 7.5 times more likely to opt in (95% CI, 1.61-50.11; P = .02) and 4.8 times more likely to consume opioids (95% CI, 1.04-1.52; P = .01). Higher body mass index (odds ratio, 1.11; 95% CI, 1.01-1.23; P = .03) and highest inpatient postoperative pain score (odds ratio, 1.24; 95% CI, 1.04-1.52; P = .02) were also associated with opioid consumption. Conclusions and Relevance In this trial, an opt-in strategy for postoperative narcotics reduced opioid prescription without increasing pain after cervical endocrine surgery. Trial Registration ClinicalTrials.gov Identifier: NCT04710069.
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Affiliation(s)
- Catherine Y Zhu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Max A Schumm
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Theodore X Hu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Dalena T Nguyen
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jiyoon Kim
- Department of Biostatistics, UCLA School of Public Health, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Anne Y Lin
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Michael W Yeh
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Masha J Livhits
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - James X Wu
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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Pattullo C, Suckling B, Donovan P, Hall L. Developing a framework for implementing Opioid Stewardship Programs in Australian Hospital Settings. Intern Med J 2021; 52:530-541. [PMID: 34617378 DOI: 10.1111/imj.15555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/24/2021] [Accepted: 10/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is growing interest in strategies to improve patient safety with prescription opioids, collectively known as Opioid stewardship (OS). This study aimed to develop a framework to facilitate the implementation of OS in the Australian acute hospital setting. METHODS Using a Modified Delphi Technique, a diverse stakeholder panel (including patient representatives and multidisciplinary healthcare professionals) was selected. A survey based on the results of a literature review was sent to the panel for appraisal. In line with standard Delphi methodology, the primary outcome for each element was reaching consensus of at least 70% of the participants on the importance of its inclusion in the framework. The survey allowed the participants to suggest new items for inclusion in subsequent rounds or rephrase existing items. RESULTS Of the 29 participants who completed the survey, a majority (23/29) were regularly involved in providing direct patient care. Twenty-six of 27 items reached the 70% threshold for agreement for importance after the first round. The remaining item not agreed upon in the initial round was modified based on comments received and reached 100% agreement on importance at the second round. There was greater than 85% agreement on importance of 24/27 items for inclusion in a framework with 8/27 reaching a 100% level of agreement. CONCLUSION We have developed a framework for OS in the Australian acute hospital settings which may be used to guide health services to prioritise and plan strategies to improve opioid use. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Champika Pattullo
- Quality Use of Medicine Pharmacist, Royal Brisbane and Women's Hospital, Queensland Opioid Stewardship Program, Clinical Excellence Queensland
| | - Benita Suckling
- Quality Use of Medicine Pharmacist, Royal Brisbane and Women's Hospital, Queensland Opioid Stewardship Program, Clinical Excellence Queensland
| | | | - Lisa Hall
- School of Public Health, University of Queensland
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Wetzel M, Hockenberry JM, Raval MV. Opioid Fills in Children Undergoing Surgery From 2011 to 2014: A Retrospective Analysis of Relationships Among Age, Initial Days Supplied, and Refills. Ann Surg 2021; 274:e174-e180. [PMID: 31188211 DOI: 10.1097/sla.0000000000003387] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The primary objective is to describe the relationship between the days supplied of postsurgical filled opioid prescriptions and refills. BACKGROUND The American College of Surgeons (ACS) has called for surgeons to alter opioid prescribing to counteract the opioid epidemic while simultaneously providing pain relief. However, there is insufficient evidence to inform perioperative prescribing guidelines and quality metrics in children. METHODS We performed a secondary data analysis of nationwide commercial claims from the Health Care Cost Institute (HCCI) data spanning 2010 and 2014. Based on initial opioid fill and refill rates for 11 common pediatric procedures, the refill analysis focused on anterior cruciate ligament repair, humerus fracture repair, cholecystectomy, posterior spinal fusion, and tonsillectomy. RESULTS There were 178,990 cases with a median age of 6. Overall, 48.5% of patients filled an opioid prescription between 30 days before surgery through 7 days after surgery, and 14.2% filled a second opioid prescription within 30 days. There was a significant negative relationship between days supplied in the initial prescription and probability of a refill for humerus fracture, spinal fusion, and tonsillectomy. The largest effect was seen for tonsillectomy, with the odds of having a refill decreasing by approximately 12% for each day supplied in the initial prescription (odds ratio 0.88, 95% confidence interval 0.87-0.89, P < 0.001). CONCLUSIONS Pediatric postoperative opioid-prescribing guidelines need to be procedure-specific and based on patient age. We provide the days supplied associated with a 20% probability of a refill by age to further guideline development.
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Affiliation(s)
- Martha Wetzel
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Carper M, Contreras KM, Walentiny DM, Beardsley PM, Damaj MI. Validation and characterization of oxycodone physical dependence in C57BL/6J mice. Eur J Pharmacol 2021; 903:174111. [PMID: 33901461 DOI: 10.1016/j.ejphar.2021.174111] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/07/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Opioid use disorder is a growing concern in the United States. Mice were used to investigate the mechanisms involving opioid physical dependence and for evaluating medications for treating opioid use disorders. While there are many preclinical reports describing protocols for inducing physical dependence upon morphine, there are fewer preclinical reports describing more contemporary abused prescription opiates. The goal of this study was to characterize and validate a mouse model of oxycodone dependence. Male C57BL/6J mice were injected with saline or increasing doses of oxycodone (9-33 mg/kg) twice daily for 8 days. On the 9th day, mice were challenged with 1 mg/kg naloxone and observed for somatic signs. Mice were pretreated with oxycodone (17, 33, or 75 mg/kg) prior to withdrawal to determine if it could attenuate somatic withdrawal signs. Additional mouse groups were pretreated with 1 mg/kg clonidine. Lastly, we measured somatic signs for 6, 24, and 48 h post-withdrawal during spontaneous and precipitated withdrawal. Pretreating with oxycodone or clonidine dose-dependently prevented the emergence of withdrawal signs. Mice chronically treated with oxycodone exhibited more withdrawal signs than vehicle at 24 h after the final injection during spontaneous withdrawal. In contrast, mice that received repeated naloxone challenges showed peak withdrawal signs at 6 h, and withdrawal signs were significantly greater at all time points compared to vehicle. Reversal of withdrawal effects by positive controls, and establishing spontaneous and precipitated withdrawal paradigms, serve as validation of this model and provide a means to examine novel therapeutics to treat opioid withdrawal.
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Affiliation(s)
- Moriah Carper
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Katherine M Contreras
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - D Matthew Walentiny
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Patrick M Beardsley
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA; Center for Biomarker Research and Precision Medicine, USA
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, 23298, USA; Translational Research Initiative for Pain and Neuropathy at VCU, USA.
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Woodward MA, Zhang Y, Tannen B, Behunin N, Niziol LM, Waljee J. Association of Limiting Opioid Prescriptions With Use of Opioids After Corneal Surgery. JAMA Ophthalmol 2021; 138:76-80. [PMID: 31670751 DOI: 10.1001/jamaophthalmol.2019.4432] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Opioids, which carry a high risk for addiction and overdose, are commonly prescribed after corneal surgery. Data are lacking describing opioid prescribing practices and opioid needs by patients after ophthalmic surgery. Objectives To quantify opioid use and to assess the association of decreasing the number of opioid tablets prescribed after corneal surgery with postsurgical use. Design, Setting, and Participants This prospective cohort study investigated opioid use after corneal surgery using direct interviews of 2 adult patient cohorts separated by an updated opioid prescribing guideline. The first cohort survey assessed the quantity of opioid tablets used after surgery. The cornea division of a tertiary care academic medical center reviewed the use needs and decreased the number of tablets prescribed after routine cases. Simultaneously, a statewide opioid monitoring program began that provided patients with opioid information. A second unique cohort received a more detailed survey to assess use, opioid disposal, and pain control. Data for the first cohort were collected from December 1, 2017, through January 19, 2018; for the second cohort, from June 1 to September 15, 2018. Data were analyzed from October 24, 2018, through September 24, 2019. Exposure Corneal surgery. Main Outcomes and Measures Differences in use of opioid tablets used by both patient cohorts, assessed using the 2-sample t test. Results Of 112 eligible, contacted patients, 82 consented to participate (42 men [51%]; mean [SD] age, 42.5 [17.8] years) and were included in the analysis; 38 of 42 participated in the first cohort and 44 of 70 participated in the second cohort. Of those receiving opioid prescriptions, the first cohort was prescribed significantly more tablets than the second cohort (mean [SD], 18.8 [4.2] vs 6.6 [3.1]; difference, 12.2 [95% CI, 10.4-14.0]; P < .001). The first cohort used significantly more tablets than the second cohort (mean [SD], 8.3 [7.0] vs 4.0 [3.2]; difference, 4.3 [95% CI, 1.4-7.2]; P = .005) and had significantly more leftover tablets (mean [SD], 10.3 [6.9] vs 2.9 [2.7]; difference, 7.5 [95% CI, 4.7-10.2]; P < .001). In the detailed survey for the second cohort, 19 of 27 patients reported pain control as adequate (70% [95% CI, 50%-86%]); 6 of 27, as more than needed (22% [95% CI, 9%-42%]). Twenty of 28 participants (71% [95% CI, 55%-88%]) had leftover tablets; 17 of these (85% [95% CI, 62%-97%]) did not dispose of leftovers, and 3 (15% [95% CI, 3%-38%]) threw away or flushed leftovers. Conclusions and Relevance After an assessment of opioid needs, physicians prescribed fewer opioid pills. However, patients who underwent cornea surgery and received fewer tablets continued to have adequate pain control and used even fewer tablets compared with the initial cohort. Patients with unused opioid tablets did not dispose of them properly.
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Affiliation(s)
- Maria A Woodward
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Yibing Zhang
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Bradford Tannen
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Nicholas Behunin
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Leslie M Niziol
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Jennifer Waljee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
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Zorrilla-Vaca A, Mena GE, Ramirez PT, Lee BH, Sideris A, Wu CL. Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis. Anesth Analg 2021; 134:940-951. [PMID: 34125081 DOI: 10.1213/ane.0000000000005634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills. METHODS The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months. RESULTS In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], -3.39 pills; 95% confidence interval [CI], -6.40 to -0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04-1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45-1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17-2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28-1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59-1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66-6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, -4.05 pills; 95% CI, -6.59 to -1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, -2.31 pills; 95% CI, -12.21 to 7.59; P = .65; I2 = 80%). CONCLUSIONS Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.
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Affiliation(s)
- Andres Zorrilla-Vaca
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Pedro T Ramirez
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bradley H Lee
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weil Cornell Medicine, New York, New York
| | - Alexandra Sideris
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Christopher L Wu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weil Cornell Medicine, New York, New York
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Awadalla R, Gnjidic D, Patanwala A, Sakiris M, Penm J. The Effectiveness of Stewardship Interventions to Reduce the Prescribing of Extended-Release Opioids for Acute Pain: A Systematic Review. PAIN MEDICINE 2021; 21:2401-2411. [PMID: 32488237 DOI: 10.1093/pm/pnaa139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of stewardship interventions in reducing the prescribing of extended-release opioids for acute pain. DESIGN Systematic review of randomized controlled trials, pre-post intervention studies, cohort studies and case-control studies. METHODS A search was conducted using Medline, Scopus, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, and PsycINFO from inception to March 24, 2019. Search terms included opioids, interventions, extended-release, and acute pain. Included articles were original research articles outlining the impact of stewardship interventions on reducing the prescribing of extended-release opioids for acute pain. RESULTS The search resulted in 1,264 articles after the removal of duplicates. Of these, 141 full texts were assessed, with three eligible for inclusion. One additional article was obtained via a manual search. Three studies explored forcing function interventions; two included prior authorization policies, which saw decreases in extended-release/long-acting scripts by 18-36%, while another evaluated order restrictions producing increased adherence to guidelines by 36%. One study explored the impact of education targeting prescribers and patients through a risk mitigation and evaluation strategy, which decreased extended-release/long-acting quarterly script volumes by 4.3%. All studies were performed at system levels. Forcing function interventions decreased extended-release/long-acting prescriptions and increased adherence to guidelines to a greater extent than less restrictive interventions such as education. CONCLUSIONS Forcing function interventions implemented at system levels show promise in decreasing the prescribing of extended-release opioids for acute pain. The current lack of literature warrants future research to increase understanding of the effectiveness of such interventions.
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Affiliation(s)
- Rebecca Awadalla
- The University of Sydney, Faculty of Medicine and Health, Sydney Pharmacy School, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- The University of Sydney, Faculty of Medicine and Health, Sydney Pharmacy School, Sydney, New South Wales, Australia
| | - Asad Patanwala
- The University of Sydney, Faculty of Medicine and Health, Sydney Pharmacy School, Sydney, New South Wales, Australia
| | - Marissa Sakiris
- The University of Sydney, Faculty of Medicine and Health, Sydney Pharmacy School, Sydney, New South Wales, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, Sydney Pharmacy School, Sydney, New South Wales, Australia
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Bethell J, Neuman MD, Bateman BT, Ladha KS, Hill A, Li G, Wijeysundera DN, Wunsch H. Association between mothers' postoperative opioid prescriptions and opioid-related events in their children: A population-based cohort study. HEALTH REPORTS 2021; 31:12-19. [PMID: 32672924 DOI: 10.25318/82-003-x202000600002-eng] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND Postoperative opioid prescriptions may be associated with risks of unintentional poisoning and drug diversion in other household members. The objective of this study was to explore the association between mothers' postoperative opioid prescriptions and incidence of opioid-related events in their children (aged 1 to 24 years). DATA AND METHODS This retrospective cohort study used individually linked administrative health data from Ontario, Canada. A population-based sample of 170,156 opioid-naïve mothers (aged 15 to 64) (see Figure 1) who underwent surgery between 2013 and 2017 in Ontario was linked through birth records to create a cohort of their 283,550 opioid-naïve children (aged 1 to 24). The association between postoperative opioid analgesic prescriptions filled by mothers within seven days of discharge after surgery and opioid-related events (emergency department presentations or inpatient admissions for opioid poisoning, or mental and behavioural disorders attributable to opioid use) in their children within one year of their mother's discharge was assessed. RESULTS Overall, 60.4% of the children in the cohort had a mother who filled a postoperative opioid prescription. The incidence of opioid-related events in children in the year after a mother's surgery was low overall (n=36/283,550, 0.01%), but higher among children whose mother filled a postoperative opioid prescription (n=29/171,139, 0.02%, vs. n=7/112,411, 0.01%, p=0.02), including in an analysis adjusting for child's age, mother's age, rural residence, neighbourhood income quintile and mother's Charlson comorbidity index score (adjusted odds ratio, 2.42 [95% confidence interval (CI), 1.05 to 5.54], p=0.04). DISCUSSION Postoperative opioid prescriptions for mothers may contribute to opioid-related events in their children. These findings further underscore the importance of safe, effective opioid prescribing, as well as of patient and public education about the use, storage and disposal of these medications.
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Affiliation(s)
- Jennifer Bethell
- Sunnybrook Research Institute, ICES, the Toronto Rehabilitation Institute at the University Health Network, and the Institute of Health Policy Management and Evaluation at the University of Toronto, Toronto, Ontario
| | - Mark D Neuman
- The Department of Anesthesiology and Critical Care, the Center for Perioperative Outcomes Research and Transformation, and the Center for Pharmacoepidemiology Research and Training at the University of Pennsylvania Perelman School of Medicine, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian T Bateman
- The Department of Anesthesia, Perioperative, and Pain Medicine, and the Division of Pharmacoepidemiology and Pharmacoeconomics in the Department of Medicine at Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Karim S Ladha
- The Department of Anesthesia at St. Michael's Hospital, and the Department of Anesthesia at the University of Toronto, Toronto, Ontario
| | - Andrea Hill
- Sunnybrook Research Institute, and the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Guohua Li
- The Department of Epidemiology, Mailman School of Public Health, and the Department of Anesthesiology, College of Physicians and Surgeons at Columbia University, and the Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York, New York
| | - Duminda N Wijeysundera
- ICES, the Institute of Health Policy Management and Evaluation and the Department of Anesthesia at the University of Toronto, and the Department of Anesthesia at St. Michael's Hospital, Toronto, Ontario
| | - Hannah Wunsch
- Sunnybrook Research Institute, ICES, the Department of Anesthesia at the University of Toronto, the Department of Critical Care Medicine at the Sunnybrook Health Sciences Centre, and the Interdepartmental Division of Critical Care Medicine at the University of Toronto, Toronto, Ontario
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Razi SS, Stephens-McDonnough JA, Haq S, Fabbro M, Sanchez AN, Epstein RH, Villamizar NR, Nguyen DM. Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol. J Thorac Cardiovasc Surg 2021; 161:1689-1701. [DOI: 10.1016/j.jtcvs.2019.12.137] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/28/2019] [Accepted: 12/17/2019] [Indexed: 12/14/2022]
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Xie Y, Joseph AW, Rudy SF, Elner VM, Demirci H, Kim DS, Nelson CC, Joseph SS. Change in Postoperative Opioid Prescribing Patterns for Oculoplastic and Orbital Procedures Associated With State Opioid Legislation. JAMA Ophthalmol 2021; 139:157-162. [PMID: 33300973 DOI: 10.1001/jamaophthalmol.2020.5446] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Understanding whether statewide legislation, such as the Michigan Opioid Laws, is associated with reduction in postoperative opioid prescriptions is informative in guiding future legislation. Objective To identify changes in opioid prescribing patterns for oculoplastic and orbital procedures associated with the enactment of the Michigan Opioid Laws in 2017 and 2018. Design, Setting, and Participants This cross-sectional study included 3781 patients who underwent any of 10 common oculoplastic and orbital procedures between June 1, 2016, and November 30, 2019, at a tertiary care institution. Exposures From 2017 to 2018, Michigan enacted a series of laws to address the state's worsening opioid epidemic. Two major components of this legislation enacted on June 1, 2018, required prescribers to review a report of patients' opioid use history and obtain signed consent after educating patients on the use and disposal of opioids prior to prescribing. Main Outcomes and Measures Demographic information, type of surgery, type and amount of opioid prescriptions, and morphine milligram equivalent (MME) were analyzed. MME was calculated as the product of dose, quantity, and opioid-specific conversion factor for each prescription. Linear interpolation spline regression was used to evaluate the association of prescription MME with time. Results Of 3781 patients, 1614 (42.7%) were male. The mean (SD) age at the time of surgery was 63.3 (16.6) years. Of 2026 patients undergoing surgery before June 1, 2018, 1782 (88.0%) were prescribed postoperative opioids; of 1755 patients undergoing surgery after June 1, 2018, 878 (50.0%) were prescribed postoperative opioids (P < .001). There was no difference in age, sex, race/ethnicity, surgery type, or opioids prescribed between these 2 cohorts. Linear interpolation spline regression showed a decrease of 26.025 MMEs (equivalent to a 36.2% reduction of mean MME) between June 1, 2017, and September 30, 2018 (β, -1.735; 95% CI, -0.088 to -0.024; P < .001), stabilizing at a persistently reduced rate of MME prescribed through the end of the study period (October 1, 2018, to November 30, 2019; β, -0.005; 95% CI, -0.039 to 0.016; P = .42). Changes in MME in the 12 months before or 12 months after the period of legislation enactment were not identified. Conclusions and Relevance In this cross-sectional study, reduction in opioid prescriptions for oculoplastic and orbital procedures was observed during the enactment period of the Michigan Opioid Laws and appeared to be sustained through the end of the study period. Similar statewide or national legislations aimed at increasing prescriber awareness and patient education on opioid use may help curtail the prescription opioid epidemic.
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Affiliation(s)
- Yanjun Xie
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Andrew W Joseph
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Shannon F Rudy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
| | - Victor M Elner
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Hakan Demirci
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Denise S Kim
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Christine C Nelson
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Shannon S Joseph
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
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Cartmill RS, Yang DY, Walker BJ, Bradfield YS, Kille TL, Su RR, Kohler JE. Opioid prescribing to preteen children undergoing ambulatory surgery in the United States. Surgery 2021; 170:925-931. [PMID: 33902922 DOI: 10.1016/j.surg.2021.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Overuse and misuse of opioids is a continuing crisis. The most common reason for children to receive opioids is postoperative pain, and they are often prescribed more than needed. The amount of opioids prescribed varies widely, even for minor ambulatory procedures. This study uses a large national sample to describe filled opioid prescriptions to preteen patients after all ambulatory surgical procedures and common standard procedures. METHODS We analyzed Truven Health MarketScan data for July 2012 through December 2016 to perform descriptive analyses of opioid fills by age and geographic area, change over time, second opioid fills in opioid-naïve patients, and variation in the types and amount of medication prescribed for 18 common and standard procedures in otolaryngology, urology, general surgery, ophthalmology, and orthopedics. RESULTS Over 10% of preteen children filled perioperative opioid prescriptions for ambulatory surgery in the period 2012 to 2016. The amount prescribed varied widely (median 5 days' supply, IQR 3-8, range 1-90), even for the most minor procedures, for example, frenotomy (median 4 days' supply, IQR 2-5, range 1-60). Codeine fills were common despite safety concerns. Second opioid prescriptions were filled by opioid-naïve patients after almost all procedures studied. The rate of prescribing declined significantly over time and varied substantially by age and across census regions. CONCLUSIONS We identified opioid prescribing outside of the norms of standard practice in all of the specialties studied. Standardizing perioperative opioid prescribing and developing guidelines on appropriate prescribing for children may reduce the opioids available for misuse and diversion.
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Affiliation(s)
- Randi S Cartmill
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI; Department of Surgery, University of Wisconsin, Madison, WI.
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Yasmin S Bradfield
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI
| | - Tony L Kille
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Ruthie R Su
- Department of Urology, University of Wisconsin, Madison, WI
| | - Jonathan E Kohler
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI; Department of Surgery, University of Wisconsin, Madison, WI
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Juprasert JM, Obeid L, Yeo HL. Public perception on opioids & pain management after major surgery. Am J Surg 2021; 223:280-286. [PMID: 33781511 DOI: 10.1016/j.amjsurg.2021.03.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND In the US, opioids are overprescribed after surgery contributing to the opioid epidemic. Patients' expectations regarding postoperative opioids remains unclear. METHODS A representative survey using random-digit dial telephone sampling of English-speaking adults in US was conducted from August 28 to December 11, 2019. RESULTS Of the 1533 eligible persons contacted, 1000 completed the interviews yielding a cooperation rate of 65%. The mean age was 47 (±18) years, half were men, and most were non-Hispanic white (73%). Forty-eight percent expected an opioid prescription after major surgery, 50% worry about addiction, and 61% believe they contribute to the opioid epidemic. Interestingly, 31% assume that opioid-dependent users were first exposed to opioids following surgery. CONCLUSION Many Americans surveyed expect to receive an opioid containing pain medication after major surgery, but fear the risk of addiction and believe that they are contributing to the opioid epidemic. They do not think that opioid-dependent users were first exposed to opioids after surgery. This discordance may represent an area of policy action and education.
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Affiliation(s)
- Jackly M Juprasert
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, 525 E 68th St, New York, NY, 10065, USA.
| | - Lama Obeid
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, 525 E 68th St, New York, NY, 10065, USA.
| | - Heather L Yeo
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, 525 E 68th St, New York, NY, 10065, USA; Weill Cornell Medicine, Department of Healthcare Policy and Research, 1300 York Ave, New York, NY, 10065, USA.
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Zhong H, Ladenhauf HN, Wilson LA, Liu J, DelPizzo KR, Poeran J, Memtsoudis SG. Persistent opioid use after surgical treatment of paediatric fracture. Br J Anaesth 2021; 126:1192-1199. [PMID: 33640119 DOI: 10.1016/j.bja.2020.12.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The opioid epidemic is one of the most pressing public health crises in the USA. With fractures being amongst the most common reasons for a child to require surgical intervention and receive post-surgical pain management, characterisation of opioid prescription patterns and risk factors is critical. We hypothesised that the numbers of paediatric patients receiving opioids, or who developed persistent opioid use, are significant, and a number of risk factors for persistent opioid use could be identified. METHODS We conducted a retrospective population-based cohort study. National claims data from the Truven Health Analytics® MarketScan database were used to (i) characterise opioid prescription patterns and (ii) describe the epidemiology and risk factors for single use and persistent use of opioids amongst paediatric patients who underwent surgical intervention for fracture treatment. RESULTS Amongst 303 335 patients, 21.5% received at least one opioid prescription within 6 months after surgery, and 1671 (0.6%) developed persistent opioid use. Risk factors for persistent opioid use include older age; female sex; lower extremity trauma; surgeries involving the spine, rib cage, or head; closed fracture treatment; earlier surgery years; previous use of opioid; and higher comorbidity burden. CONCLUSIONS Amongst a cohort of paediatric patients who underwent surgical fracture treatment, 21.5% filled at least one opioid prescription, and 0.6% (N=1671) filled at least one more opioid prescription between 3 and 6 months after surgery. Understanding risk factors related to persistent opioid use can help clinicians devise strategies to counter the development of persistent opioid use for paediatric patients.
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MESH Headings
- Adolescent
- Age Factors
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Child
- Child, Preschool
- Databases, Factual
- Drug Administration Schedule
- Drug Prescriptions
- Drug Utilization
- Female
- Fracture Fixation/adverse effects
- Fractures, Bone/surgery
- Humans
- Infant
- Infant, Newborn
- Male
- Pain, Postoperative/diagnosis
- Pain, Postoperative/etiology
- Pain, Postoperative/prevention & control
- Practice Patterns, Physicians'
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Time Factors
- Treatment Outcome
- United States
- Young Adult
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Affiliation(s)
- Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Hannah N Ladenhauf
- Department of Paediatric and Adolescent Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Kathryn R DelPizzo
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA.
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Lam L, Richardson MG, Zhao Z, Thampy M, Ha L, Osmundson SS. Enhanced discharge counseling to reduce outpatient opioid use after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol MFM 2020; 3:100286. [PMID: 33451618 DOI: 10.1016/j.ajogmf.2020.100286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/27/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Strategies to curb overprescribing have focused primarily on the prescriber as the point of intervention. Less is known about how to empower patients to use fewer opioids and decrease the quantity of leftover opioids. Previous studies in nonobstetrical populations suggest that patient counseling about appropriate opioid use improves disposal of unused opioids and overall knowledge about opioid use. Less is known about whether counseling reduces opioid use after hospital discharge. OBJECTIVE This study examines whether enhanced discharge counseling on optimal analgesic use after cesarean delivery reduces opioid use and improves proper disposal of unused opioids and opioid use knowledge after hospital discharge. STUDY DESIGN Women who underwent an uncomplicated cesarean delivery were randomized to enhanced counseling on optimal analgesic use or usual care. Enhanced counseling addressed the following 4 points: (1) pain is normal after cesarean delivery; (2) scheduled ibuprofen should be taken to maintain baseline pain control; (3) opioids should be used sparingly and should be tapered over several days; and (4) all unused opioids should be returned to pharmacy or flushed in a toilet. All participants received 30 tablets of 5 mg hydrocodone-acetaminophen and 30 tablets of 600 mg ibuprofen at discharge. They were contacted 14 days later to determine opioid use and location of leftover opioids and to complete a 10-question analgesic strategies quiz with a score of 1 to 10. We estimated that outcome data on 172 women total would provide an 80% power to detect a 30% reduction in postdischarge opioid use with enhanced counseling. RESULTS Notably, 79% of eligible women consented to the study and 175 of 196 participants (84 enhanced counseling, 91 usual care) completed the follow-up. Compared with usual care, the enhanced counseling group was more likely to follow recommendations for proper opioid disposal (risk ratio, 2.3; 95% confidence interval, 1.3-3.9). They also scored significantly higher on the analgesic strategies quiz (10 points [interquartile range, 9-10] vs 8 points [interquartile range, 7-9]; P<.001) than the usual care group. Although the enhanced counseling group used less opioids (7.5 tablets [interquartile range, 2-15] vs 10.0 tablets [interquartile range, 2-16]; P=.55) and a smaller proportion of prescribed opioids (25.0% [6.7-50.0] vs 33.3% [6.7-53.3], P=.55) than the usual care group, differences were not statistically significant. There was no statistically significant evidence of interaction between participant education level and any of the study outcomes. CONCLUSION Enhanced discharge opioid counseling doubled the frequency of participants reporting proper opioid disposal and improved overall knowledge about the risks associated with opioids. This intervention did not decrease opioid use in a population of women with low overall opioid use. These findings highlight possible methods to intervene on the short-term (misuse and diversion) and long-term (persistent opioid use) consequences of overprescribing.
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Affiliation(s)
- LeAnn Lam
- Vanderbilt University School of Medicine, Nashville, TN
| | - Michael G Richardson
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Zhiguo Zhao
- Departments of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Mallika Thampy
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Laura Ha
- Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah S Osmundson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN.
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Abstract
BACKGROUND Surgeons contribute to the opioid epidemic by overprescribing opioids for postoperative pain. Excess, unused opioids may be diverted for misuse/abuse. OBJECTIVE This study aimed to characterize opioid prescribing and use among patients undergoing outpatient anorectal procedures and to assess the adequacy of postoperative pain management. DESIGN This is a retrospective cohort study, prospective cross-sectional survey. SETTINGS Patients were treated by colorectal surgeons in an academic medical center between January 2018 and September 2019. PATIENTS Six hundred twenty-seven patients undergoing an outpatient anorectal procedure were included. MAIN OUTCOME MEASURES The primary outcomes measured were the opioids prescribed at discharge, opioid prescription refills, patient-reported outcomes regarding opioid use, and the adequacy of postoperative pain management in terms of pain intensity and pain interference. Opioids were standardized to 5-mg oxycodone pills. Patient-reported outcomes were assessed by using previously validated instruments. RESULTS The majority of patients underwent fistula surgery (n = 234) followed by examination under anesthesia (n = 183), hemorrhoidectomy (n = 131), incision and drainage (n = 51), and pilonidal excision (n = 28). Most patients received opioids (78% fistula, 49% examination under anesthesia, 87% hemorrhoidectomy, 71% incision and drainage, 96% pilonidal). Patients undergoing examination under anesthesia received the fewest opioid pills (median 10; range 3-50) followed by patients undergoing fistula surgery (median13, range 1-50), incision and drainage (median 15, range 3-120), pilonidal excisions (median 15, range 3-60), and hemorrhoidectomies (median 28, range 3-60). Regardless of procedure, the majority of patients used fewer than 5 opioid pills postoperatively. Patients undergoing pilonidal excisions had the largest number of excess unused pills (median 14, range 0-30) followed by patients undergoing fistula surgery and incision and drainage (median 7, ranges 0-30 and 5-17), hemorrhoidectomy (median 6, range 0-50), and examination under anesthesia (median 2, range 0-23). Whereas patients undergoing hemorrhoidectomy reported higher pain levels following discharge, most reported minimal interference with day-to-day activities due to pain regardless of the procedure performed. LIMITATIONS The limitations of this study included recall bias and sample bias. CONCLUSIONS The majority of patients do not need more than five to ten 5-mg oxycodone equivalents to achieve adequate pain management after outpatient anorectal surgical procedures. See Video Abstract at http://links.lww.com/DCR/B347. EXCESO DE PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE UNA CIRUGÍA ANORRECTAL AMBULATORIA: UN ESTUDIO DE UNA SOLA INSTITUCIÓN: Cirujanos contribuyen a la epidemia de opioides al recetar en exceso opioides para el dolor postoperatorio. El exceso de opioides no utilizados puede ser desviado por para mal uso o abuso.Caracterizar la prescripción y el uso de opioides entre pacientes sometidos a procedimientos anorrectales ambulatorios y evaluar la efectividad del tratamiento del dolor postoperatorio.Estudio de cohorte retrospectivo, encuesta transversal prospectiva.pacientes tratados por cirujanos colorrectales en un centro médico académico entre enero de 2018 y septiembre de 2019.se incluyeron 627 pacientes que se sometieron a un procedimiento anorrectal ambulatorio.Opioides recetados al alta, reabastecimientos de prescripción de opioides, resultados informados por el paciente con respecto al uso de opioides y efectividad del manejo del dolor postoperatorio en términos de intensidad del dolor y trastornos secundarios a dolor. Los opioides se estandarizaron con píldoras de oxicodona de 5 mg. Los resultados informados por los pacientes se evaluaron utilizando instrumentos previamente validados.La mayoría de los pacientes fueron sometidos a cirugía de fístula (n = 234) seguida de un examen bajo anestesia (EUA; n = 183), hemorroidectomía (n = 131), incisión y drenaje (I&D) (n = 51) y escisión pilonidal (n = 28). La mayoría de los pacientes recibieron opioides (78% fístula, 49% EUA, 87% hemorroidectomía, 71% I&D, 96% pilonidal). Las EUA recibieron la menor cantidad de píldoras opioides (mediana 10, rango 3-50) seguidas de fístula (mediana 13, rango 1-50), I y D (mediana 15, rango 3-120), pilonidales (mediana 15, rango 3-60) y hemorroides. (mediana 28, rango 3-60). Independientemente del procedimiento, la mayoría de los pacientes usaron menos de cinco píldoras opioides después de la operación. Los pacientes pilonidales tuvieron el mayor número de píldoras no utilizadas en exceso (mediana 14, rango 0-30) seguido de fístula e I&D (mediana 7, rangos 0-30 y 5-17, respectivamente), hemorroidectomía (mediana 6, rango 0-50) y EUA (mediana 2, rango 0-23). Si bien los pacientes con hemorroidectomía informaron niveles de dolor más altos después del alta, la mayoría de pacientes informaron un mínimo de interferencia con las actividades diarias debido al dolor, independientemente del procedimiento realizado.Sesgo de recuerdo autoinformado, sesgo de muestra.La mayoría de los pacientes no necesitan más de cinco a diez equivalentes de oxicodona de 5 mg para lograr un manejo adecuado del dolor después de procedimientos quirúrgicos anorrectales ambulatorios. Consulte Video Resumen en http://links.lww.com/DCR/B347. (Traducción-Dr. Adrian Ortega).
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Effect of drug disposal bag provision on families' disposal of children's unused opioids. J Am Pharm Assoc (2003) 2020; 61:109-114.e2. [PMID: 33127313 DOI: 10.1016/j.japh.2020.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE One strategy to combat opioid misuse is to remove excess opioids from circulation by providing patients with drug disposal products that enable the safe disposal of opioids. We aimed to evaluate opioid use and disposal of unused opioids among children and young adults before and after pharmacy staff at our institution began to provide patients and families filling opioid prescriptions with a drug disposal bag. METHODS We performed a prospective pre-post cohort study of patients who filled an opioid prescription in May-August 2019 at the outpatient pharmacies of a large tertiary children's hospital. Patients and caregivers were enrolled at the time the opioids were dispensed. During the first half of the study period, standard opioid-related education was offered by pharmacy staff. During the second half of the study period, standard education was offered, and a drug disposal bag and instructions on its use were provided when the opioids were dispensed. A follow-up survey to assess opioid use and disposal was completed online or by telephone 4-7 weeks after the opioids were dispensed. RESULTS A total of 215 participants were enrolled; 117 received a drug disposal bag and 98 did not. Of those, 68% of the participants completed a follow-up survey. In both groups, the median patient age was 11 years, and most patients had been prescribed opioids after a procedure. More than 70% had opioids leftover after they had stopped taking them, and this did not vary by group. However, among families with leftover opioids, the receipt of a drug disposal bag was associated with a higher likelihood of disposal of the unused opioids (71.7% vs. 52.1%, P = 0.04). CONCLUSION Providing a drug disposal bag to families of children receiving opioids increases the likelihood of excess opioid disposal. Greater availability of drug disposal products can complement prescribing reduction efforts aimed at decreasing prescription opioid misuse.
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Implementing an opioid reduction protocol in renal transplant recipients. Am J Surg 2020; 220:1284-1289. [DOI: 10.1016/j.amjsurg.2020.06.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/24/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022]
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Hah JM, Trafton JA, Narasimhan B, Krishnamurthy P, Hilmoe H, Sharifzadeh Y, Huddleston JI, Amanatullah D, Maloney WJ, Goodman S, Carroll I, Mackey SC. Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): A prospective, assessor-blind, randomized controlled pilot trial. EClinicalMedicine 2020; 28:100596. [PMID: 33294812 PMCID: PMC7700897 DOI: 10.1016/j.eclinm.2020.100596] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Postoperative opioid use can lead to chronic use and misuse. Few studies have examined effective approaches to taper postoperative opioid use while maintaining adequate analgesia. METHODS This randomized, assessor-blinded, pilot trial of postoperative motivational interviewing and guided opioid tapering support (MI-Opioid Taper) added to usual care (UC) enrolled patients undergoing total hip or knee arthroplasty at a single U.S. academic medical center. MI-Opioid Taper involved weekly (to seven weeks) and monthly (to one year) phone calls until patient-reported opioid cessation. Opioid tapering involved 25% weekly dose reductions. The primary feasibility outcome was study completion in the group to which participants were randomized. The primary efficacy outcome, time to baseline opioid use, was the first of five consecutive days of return to baseline preoperative dose. Intention-to-treat analysis with Cox proportional hazards regression was adjusted for operation. ClinicalTrials.gov registration: NCT02070003. FINDINGS From November 26, 2014, to April 27, 2018, 209 patients were screened, and 104 patients were assigned to receive MI-Opioid Taper (49 patients) or UC only (55 patients). Study completion after randomization was similar between groups (96.4%, 53 patients receiving UC, 91.8%, 45 patients receiving MI-Opioid Taper). Patients receiving MI-Opioid Taper had a 62% increase in the rate of return to baseline opioid use after surgery (HR 1.62; 95%CI 1.06-2.46; p = 0•03). No trial-related adverse events occurred. INTERPRETATION In patients undergoing total joint arthroplasty, MI-Opioid Taper is feasible and future research is needed to establish the efficacy of MI-Opioid Taper to promote postoperative opioid cessation. FUNDING National Institute on Drug Abuse.
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Affiliation(s)
- Jennifer M. Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, 1070 Arastradero Rd., Suite 200, Stanford, CA 94304, United States
- Corresponding author.
| | - Jodie A. Trafton
- Psychiatry and Behavioral Sciences, Stanford University, Director, VA Program Evaluation and Resource Center, VHA Office of Mental Health and Suicide Prevention, Menlo Park, CA, United States
| | - Balasubramanian Narasimhan
- Department of Statistics, Department of Biomedical Data Sciences, Stanford University, Stanford CA, United States
| | - Partha Krishnamurthy
- Department of Marketing and Entrepreneurship, C. T. Bauer College of Business, University of Houston, Houston, Texas, United States
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, California, United States
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, California, United States
| | - James I. Huddleston
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, United States
| | - Derek Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, United States
| | | | - Stuart Goodman
- Department of Orthopaedic Surgery and (by courtesy) Bioengineering, Department of Orthopaedic Surgery, Stanford University, United States
| | - Ian Carroll
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California, United States
| | - Sean C. Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, United States
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Stakeholder Perspective on Opioid Stewardship After Prostatectomy: Evaluating Barriers and Facilitators From the Pennsylvania Urology Regional Collaborative. Urology 2020; 145:120-126. [DOI: 10.1016/j.urology.2020.05.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 02/01/2023]
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Bass KD, Heiss KF, Kelley-Quon LI, Raval MV. Opioid use in children's surgery: Awareness, current state, and advocacy. J Pediatr Surg 2020; 55:2448-2453. [PMID: 32145973 DOI: 10.1016/j.jpedsurg.2020.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/04/2020] [Accepted: 02/17/2020] [Indexed: 01/18/2023]
Abstract
In response to the ongoing opioid epidemic, many surgeons who care for children have reflected upon current practices and the history of our own prescribing. In this editorial review, we provide a brief summary of the origins of opioid use in medicine and surgery, we describe how the ongoing opioid epidemic specifically impacts children and adolescents, and we explore contemporary efforts underway to facilitate evidence-based opioid prescribing. Resources for pediatric surgeons including national guidelines related to safe opioid prescribing and web-based toolkits that may be used to implement change locally are highlighted. The goal of the present manuscript is to introduce opioid stewardship as a guiding principle in pediatric surgery. LEVEL OF EVIDENCE: LEVEL V (Expert opinion).
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Affiliation(s)
- Kathryn D Bass
- Division of Pediatric Surgery, Department of Surgery, University of Buffalo, John R. Oishei Children's Hospital, Buffalo, NY
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
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Shen TS, Driscoll DA, Islam W, Bovonratwet P, Haas SB, Su EP. Modern Internet Search Analytics and Total Joint Arthroplasty: What Are Patients Asking and Reading Online? J Arthroplasty 2020; 36:1224-1231. [PMID: 33162279 PMCID: PMC7573653 DOI: 10.1016/j.arth.2020.10.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/03/2020] [Accepted: 10/14/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients considering total joint arthroplasty often search for information online regarding surgery; however, little is known about the specific topics that patients search for and the nature of the information provided. Google compiles frequently asked questions associated with a search term using machine learning and natural language processing. Links to individual websites are provided to answer each question. Analysis of this data may help improve understanding of patient concerns and inform more effective counseling. METHODS Search terms were entered into Google for total hip and total knee arthroplasty. Frequently asked questions and associated websites were extracted to a database using customized software. Questions were categorized by topic; websites were categorized by type. JAMA Benchmark Criteria were used to assess website quality. Pearson's chi-squared and Student's t-tests were performed as appropriate. RESULTS A total of 620 questions (305 total knee arthroplasties, 315 total hip arthroplasties) were extracted with 602 associated websites. The most popular question topics were Specific Activities (23.5%), Indications/Management (15.6%), and Restrictions (13.4%). Questions related to Pain were more common in the TKA group (23.0% vs 2.5%, P < .001) compared to THA. The most common website types were Academic (31.1%), Commercial (29.2%), and Social Media (17.1%). JAMA scores (0-4) were highest for Government websites (mean 3.92, P = .005). CONCLUSION The most frequently asked questions on Google related to total joint arthroplasty are related to arthritis management, rehabilitation, and ability to perform specific tasks. A sizable proportion of health information provided originate from non-academic, non-government sources (64.4%), with 17.1% from social media websites.
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Affiliation(s)
- Tony S. Shen
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY,Department of Orthopaedic Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY,Reprint requests: Tony S. Shen, MD, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | - Daniel A. Driscoll
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY,Department of Orthopaedic Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Wasif Islam
- Department of Orthopaedic Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Patawut Bovonratwet
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY,Department of Orthopaedic Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Steven B. Haas
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Edwin P. Su
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
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Agamawi YM, Cass LM, Mouzourakis M, Pannu JS, Brinkmeier JV. Pediatric Post-Tonsillectomy Opioid Prescribing Practices. Laryngoscope 2020; 131:1386-1391. [PMID: 33022125 DOI: 10.1002/lary.29157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 09/03/2020] [Accepted: 09/13/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding. METHODS Retrospective chart review of pre- and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre- and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed. RESULTS Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI, 43.6-49.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre- and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age. CONCLUSION Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1386-1391, 2021.
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Affiliation(s)
- Yusuf M Agamawi
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Lauren M Cass
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | | | - Jaibir S Pannu
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jennifer V Brinkmeier
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
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Brown CS, Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee J, Englesbe M. Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system. BMJ Qual Saf 2020; 30:251-259. [PMID: 32938775 DOI: 10.1136/bmjqs-2020-011295] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system. METHODS We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time. RESULTS We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged. CONCLUSIONS The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA .,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Ryan A Howard
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
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Shellito AD, Sareh S, Hart HC, Keeley JA, Tung C, Neville AL, Putnam B, Kim DY. Trauma patients returning to the emergency department after discharge. Am J Surg 2020; 220:1492-1497. [PMID: 32921401 DOI: 10.1016/j.amjsurg.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/10/2020] [Accepted: 08/19/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND While readmission rates of trauma patients are well described, little has been reported on rates of re-presentation to the emergency department (ED) after discharge. This study aimed to determine rates and contributing factors of re-presentation of trauma patients to the ED. METHODS One-year retrospective analysis of discharged adult trauma patients at a county-funded safety-net level one trauma center. RESULTS Of 1416 trauma patients, 195 (13.8%) re-presented to the ED within 30 days. Of those that re-presented, 47 (24.1%) were re-admitted (3.3% overall). The most common reasons for re-presentation were pain control and wound complications. Patients with Medicare (AOR 2.6, 95% CI 1.3 to 5.2) or other government insurance (AOR 2.5, 95% CI 1.6 to 4.1) were more likely to re-present than patients with private insurance. CONCLUSION A considerable number of trauma patients re-presented to the ED after discharge for reasons that did not require hospitalization. Discharge planning for certain vulnerable groups should emphasize wound care, pain control and scheduled follow-up to decrease the reliance on the ED.
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Affiliation(s)
- Adam D Shellito
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA.
| | - Sohail Sareh
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Hayley C Hart
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jessica A Keeley
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Christine Tung
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Angela L Neville
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Brant Putnam
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Dennis Y Kim
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
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Deen JT, Stone WZ, Gray CF, Prieto HA, Iams DA, Boezaart AP, Parvataneni HK. A Simple, Personalized Opioid Stratification Pathway Dramatically Reduces Opioid Utilization. Arthroplast Today 2020; 6:731-735. [PMID: 32923559 PMCID: PMC7475051 DOI: 10.1016/j.artd.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/09/2020] [Accepted: 07/09/2020] [Indexed: 11/12/2022] Open
Abstract
Orthopaedic surgeons account for the largest proportion of opioid prescriptions in the United States among surgical specialties. In total joint arthroplasty, increased opioid use has been associated with poorer clinical and functional outcomes. Despite an abundance of literature on opioid mitigation strategies, most fail to provide personalized prescriptions. Typically, most protocols prescribe the same opioid regimen regardless of patient factors or the extent of the planned procedure. We present a simple opioid stratification pathway that can be used by physicians and office staff as they prepare patients for arthroplasty. We have found this to be easy to implement, effective, and sustainable at a tertiary academic institution and allows for iterative improvements over time.
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Affiliation(s)
- Justin T Deen
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - William Z Stone
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Chancellor F Gray
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hernan A Prieto
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dane A Iams
- Department of Orthopedic Surgery, Denver Health, Denver, CO, USA
| | - Andre P Boezaart
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hari K Parvataneni
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
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Li NY, Kuczmarski AS, Hresko AM, Goodman AD, Gil JA, Daniels AH. Four-Corner Arthrodesis versus Proximal Row Carpectomy: Risk Factors and Complications Associated with Prolonged Postoperative Opioid Use. J Hand Microsurg 2020; 14:163-169. [DOI: 10.1055/s-0040-1715426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction This article compares opioid use patterns following four-corner arthrodesis (FCA) and proximal row carpectomy (PRC) and identifies risk factors and complications associated with prolonged opioid consumption.
Materials and Methods The PearlDiver Research Program was used to identify patients undergoing primary FCA (Current Procedural Terminology [CPT] codes 25820, 25825) or PRC (CPT 25215) from 2007 to 2017. Patient demographics, comorbidities, perioperative opioid use, and postoperative complications were assessed. Opioids were identified through generic drug codes while complications were defined by International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification codes. Multivariable logistic regressions were performed with p < 0.05 considered statistically significant.
Results A total of 888 patients underwent FCA and 835 underwent PRC. Three months postoperatively, more FCA patients (18.0%) continued to use opioids than PRC patients (14.7%) (p = 0.033). Preoperative opioid use was the strongest risk factor for prolonged opioid use for both FCA (odds ratio [OR]: 4.91; p < 0.001) and PRC (OR: 6.33; p < 0.001). Prolonged opioid use was associated with an increased risk of implant complications (OR: 4.96; p < 0.001) and conversion to total wrist arthrodesis (OR: 3.55; p < 0.001) following FCA.
Conclusion Prolonged postoperative opioid use is more frequent in patients undergoing FCA than PRC. Understanding the prevalence, risk factors, and complications associated with prolonged postoperative opioid use after these procedures may help physicians counsel patients and implement opioid minimization strategies preoperatively.
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Affiliation(s)
- Neill Y. Li
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Alexander S. Kuczmarski
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Andrew M. Hresko
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Avi D. Goodman
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Joseph A. Gil
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
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Hill AG. Prescribing of opioids in surgical patients on discharge from Australian public hospitals: work to do. ANZ J Surg 2020; 90:950. [PMID: 32592299 DOI: 10.1111/ans.15940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Andrew G Hill
- Department of Surgery, The University of Auckland, Middlemore Hospital, Auckland, New Zealand
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Angelo JL, Wu J, Sirody J, Deugarte DA. Reduction in Prescribed Opioids after General Surgery Procedures at a Public Hospital. Am Surg 2020. [DOI: 10.1177/000313481908501027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Overdose of opioids is the number one cause of accidental death in the United States, and surgeons are overprescribing these medications. The aim of this study was to assess the feasibility of implementing postoperative opioid prescribing guidelines for general surgery procedures at a public hospital, where patients have lower socioeconomic status, public insurance, and limited access to care. We implemented a quality improvement project, which included in-service training for surgical staff and distribution of standardized guidelines. An infographic for patients was created to facilitate education on postoperative pain management. Pre- and postintervention opioid prescriptions and emergency room visits were compared for patients undergoing common general surgery procedures (inguinal hernia repair, appendectomy, and laparoscopic cholecystectomy). The median number of narcotic pills prescribed significantly decreased from 30 (n = 64) to 15 (n = 63) after the intervention ( P < 0.0001). Morphine milligram equivalents decreased from a median [range] of 150 [20,600] to 90 [5,300] ( P < 0.0001). The percentage of patients with postoperative pain-related emergency department visits remained low (1.6%). Standardization of postoperative opioid prescription practices was successfully implemented at a public hospital without an increase in the number of emergency room visits for pain.
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Affiliation(s)
| | - Jennifer Wu
- Harbor-UCLA Medical Center, Torrance, California
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Jivraj NK, Raghavji F, Bethell J, Wijeysundera DN, Ladha KS, Bateman BT, Neuman MD, Wunsch H. Persistent Postoperative Opioid Use: A Systematic Literature Search of Definitions and Population-based Cohort Study. Anesthesiology 2020; 132:1528-1539. [PMID: 32243330 PMCID: PMC8202398 DOI: 10.1097/aln.0000000000003265] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events. METHODS The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery. RESULTS Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00. CONCLUSIONS The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
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Affiliation(s)
- Naheed K Jivraj
- From the Department of Anesthesiology and Pain Medicine (N.K.J., D.N.W., K.S.L., H.W.) Interdepartmental Division of Critical Care Medicine (H.W.), University of Toronto, Toronto, Canada the Institute of Health Policy Management and Evaluation, Toronto, Canada (N.K.J., D.N.W., K.S.L., H.W.) the University of Limerick, Limerick, Ireland (F.R.) the Sunnybrook Research Institute, Toronto, Canada (J.B., H.W.) the Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada (D.N.W., K.S.L.) the Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B.) the Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (M.D.N.) the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada (H.W.)
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Abstract
OBJECTIVE Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. SUMMARY BACKGROUND DATA During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. METHODS We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. RESULTS Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. CONCLUSION A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.
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