Postoperative inpatient utilization of opioid and opioid-sparing analgesics in the United States hospitals, 2007-2017

Opioid prescribing practices and patient-requested refill patterns following laparoscopic inguinal hernia repair

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.

Perioperative Use of Gabapentinoids and Risk for Postoperative Long-Term Opioid Use in Older Adults Undergoing Total Knee or Hip Arthroplasty

BACKGROUND

Gabapentinoids are recommended by guidelines as a component of multimodal analgesia to manage postoperative pain and reduce opioid use. It remains unknown whether perioperative use of gabapentinoids is associated with a reduced or increased risk of postoperative long-term opioid use (LTOU) after total knee or hip arthroplasty (TKA/THA).

METHODS

Using Medicare claims data from 2011 to 2018, we identified fee-for-service beneficiaries aged ≥ 65 years who were hospitalized for a primary TKA/THA and had no LTOU before the surgery. Perioperative use of gabapentinoids was measured from 7 days preadmission through 7 days postdischarge. Patients were required to receive opioids during the perioperative period and were followed from day 7 postdischarge for 180 days to assess postoperative LTOU (ie, ≥90 consecutive days). A modified Poisson regression was used to estimate the relative risk (RR) of postoperative LTOU in patients with versus without perioperative use of gabapentinoids, adjusting for confounders through propensity score weighting.

RESULTS

Of 52,788 eligible Medicare older beneficiaries (mean standard deviation [SD] age 72.7 [5.3]; 62.5% females; 89.7% White), 3,967 (7.5%) received gabapentinoids during the perioperative period. Postoperative LTOU was 3.8% in patients with and 4.0% in those without perioperative gabapentinoids. After adjusting for confounders, the risk of postoperative LTOU was similar comparing patients with versus without perioperative gabapentinoids (RR = 1.07; 95% confidence interval [CI] = 0.91-1.26, P = .408). Sensitivity and bias analyses yielded consistent results.

CONCLUSION

Among older Medicare beneficiaries undergoing a primary TKA/THA, perioperative use of gabapentinoids was not associated with a reduced or increased risk for postoperative LTOU.

Effect of a Multimodal Analgesic Protocol on Short-Term and Long-Term Opioid Use After Orthopaedic Trauma

OBJECTIVE

To determine whether the use of a multimodal analgesic protocol reduced short-term and long-term opioid use in patients hospitalized after orthopaedic trauma.

DESIGN

Retrospective pre-post intervention study.

SETTING

Regional, academic, Level 1 trauma center in Central Kentucky.

PATIENTS/PARTICIPANTS

Patients were hospitalized after orthopaedic injury before (n = 393) and after (n = 378) the implementation of a multimodal analgesic protocol.

INTERVENTION

The intervention involved a multimodal analgesic protocol consisting of acetaminophen, ibuprofen/ketorolac, gabapentinoids, skeletal muscle relaxants, and standardized doses of opioids plus standardized pain management education before hospital discharge.

MAIN OUTCOME MEASUREMENTS

End points included discharge opioid prescription, days' supply and daily morphine milligram equivalent (MME), and long-term opioid use after hospitalization. Opioid use in the 90 days before and after hospitalization was assessed using state prescription drug monitoring program data.

RESULTS

Discharge opioid prescription rates were similar in the intervention and control cohorts [79.9% vs. 78.4%, odds ratio (OR) 1.30 (0.83-2.03), P = 0.256]. Patients in the intervention cohort received a shorter days' supply [5.7 ± 4.1 days vs. 8.1 ± 6.2 days, rate ratio 0.70 (0.65-0.76), P < 0.001] and lower average daily MME [34.8 ± 24.9 MME vs. 51.5 ± 44.0 MME, rate ratio 0.68 (0.62-0.75), P < 0.001]. The incidence of long-term opioid use was also significantly lower in the intervention cohort [7.7% vs. 12.0%, OR 0.53 (0.28-0.98), P = 0.044].

CONCLUSIONS

Implementation of a multimodal analgesic protocol was associated with reductions in both short-term and long-term opioid use, including long-term opioid therapy, after orthopaedic trauma.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessment of pro re nata inpatient opioid consumption following surgical treatment of severe odontogenic infections

OBJECTIVE

The purpose of this study was to analyze the pro re nata (PRN) opioid consumption of patients with severe odontogenic infections following operating room incision and drainage using odontogenic infection severity scores (SS).

STUDY DESIGN

This retrospective study reviewed consecutive charts of patients admitted for severe odontogenic infections from January 2016 to December 2020. Postoperative opioid doses were tabulated. Severity scores (SSs) were assigned based on the risk to the airway and vital structures. Patients with SS ≥5 were designated as group A and patients with SS <5 as group B. The primary predictor variable was SS, and the primary outcome variable was amount of milligram morphine equivalent consumed.

RESULTS

A total of 93 patients met the inclusion criteria. Group A included 40 patients, and group B included 53 patients. No statistically significant difference was found between the 2 groups in age, hospital duration, and American Society of Anesthesiologists classification. Group A consumed a significantly greater amount of PRN postoperative inpatient opioid medications (P = .02).

CONCLUSIONS

Patients with odontogenic infection SS ≥5 consumed more postoperative PRN opioid analgesic medications. Given that odontogenic infections are largely preventable, it is imperative to prevent progression of odontogenic infections to limit patient exposure to opioid medication.

Association Between Gabapentinoids and Postoperative Pulmonary Complications in Patients Undergoing Thoracic Surgery

OBJECTIVE

Perioperative gabapentinoids in general surgery have been associated with an increased risk of postoperative pulmonary complications (PPCs), while resulting in equivocal pain relief. This study's aim was to examine the utilization of gabapentinoids in thoracic surgery to determine the association of gabapentinoids with PPCs and perioperative opioid utilization.

DESIGN

A multicenter retrospective cohort study.

SETTING

Hospitals in the Premier Healthcare Database from 2012 to 2018.

PARTICIPANTS

A total of 70,336 patients undergoing elective open thoracotomy, video-assisted thoracic surgery, and robotic-assisted thoracic surgery.

INTERVENTIONS

Propensity score analyses were used to assess the association between gabapentinoids on day of surgery and the primary composite outcome of PPCs, defined as respiratory failure, pneumonia, reintubation, pulmonary edema, and noninvasive and invasive ventilation. Secondary outcomes included invasive and noninvasive ventilation, hospital mortality, length of stay, opioid consumption on day of surgery, and average daily opioid consumption after day of surgery.

RESULTS

Overall, 8,142 (12%) patients received gabapentinoids. The prevalence of gabapentin on day of surgery increased from 3.8% in 2012 to 15.9% in 2018. Use of gabapentinoids on day of surgery was associated with greater odds of PPCs (odds ratio [OR] 1.19, 95% CI 1.11-1.28), noninvasive mechanical ventilation (OR 1.30, 95% CI 1.16-1.45), and invasive mechanical ventilation (OR 1.14, 95% CI 1.02-1.28). Secondary outcomes indicated no clinically meaningful associations of gabapentinoid use with opioid consumption, hospital mortality, or length of stay.

CONCLUSIONS

Perioperative gabapentinoid administration in elective thoracic surgery may be associated with a higher risk of PPCs and no opioid-sparing effect.