Predictors of Prescription Opioid Use 4 Months After Traumatic Musculoskeletal Injury and Corrective Surgery: A Prospective Study

Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis

INTRODUCTION

 Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma.

MATERIALS AND METHODS

A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery.

RESULTS

Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study.

CONCLUSIONS

 Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Incidence of persistent opioid use following traumatic injury

INTRODUCTION

Major traumatic injuries are a known risk factor for persistent opioid use, but data describing the relationship between specific traumatic injuries and opioid use is lacking.

METHODS

We used insurance claims data from January 1, 2001 to December 31, 2020 to estimate the incidence of new persistent opioid use in three hospitalized trauma populations: individuals hospitalized after burn injury (3809, 1504 of whom required tissue grafting), individuals hospitalized after motor vehicle collision (MVC; 9041), and individuals hospitalized after orthopedic injury (47, 637). New persistent opioid use was defined as receipt of ≥1 opioid prescriptions 90-180 days following injury in an individual with no opioid prescriptions during the year prior to injury.

RESULTS

New persistent opioid use was observed in 12% (267/2305) of individuals hospitalized after burn injury with no grafting, and 12% (176/1504) of burn injury patients requiring tissue grafting. In addition, new persistent opioid use was observed in 16% (1454/9041) of individuals hospitalized after MVC, and 20% (9455/47, 637) of individuals hospitalized after orthopedic trauma. In comparison, rates of persistent opioid use in all trauma cohorts (19%, 11, 352/60, 487) were greater than the rates of persistent opioid use in both non-traumatic major surgery (13%) and non-traumatic minor surgery (9%).

CONCLUSIONS

These data demonstrate that new persistent opioid use frequently occurs in these common hospitalized trauma populations. Improved interventions to reduce persistent pain and opioid use in patients hospitalized after these and other traumas are needed.

Feasibility of implementing a screening tool for risk of opioid misuse in a trauma surgical population

Background

As the opioid crisis continues to affect communities across the United States, new interventions for screening and prevention are needed to mitigate its impact. Mental health diagnoses have been identified as a risk factor for opioid misuse, and surgical populations and injury survivors are at high risk for prolonged opioid use and misuse. This study investigated the implementation of a novel opioid risk screening tool that incorporated putative risk factors from a recent study in four trauma units across Wisconsin.

Method

The screening tool was implemented across a 6-month period at four sites. Data was collected via monthly meeting notes and "Plan, Do, Study, Act" (PDSA) forms. Following implementation, focus groups reflected on the facilitators and barriers to implementation. Meeting notes, PDSA forms, and focus group data were analyzed using the consolidated framework for implementation research, followed by thematic analyses, to generate themes surrounding the facilitators and barriers to implementing an opioid misuse screener.

Results

Implementation facilitators included ensuring patient understanding of the screener, minimizing staff burden from screening, and educating staff to encourage engagement. Barriers included infrastructure limitations that prevented seamless administration of the screener within current workflows, overlap of the screener with existing measures, and lack of guidance surrounding treatment options corresponding to risk. Recommended solutions to address barriers include careful timing of screener administration, accommodating workflows, integration of the screening tool within the electronic health record, and evidence-based interventions guided by screener results.

Conclusion

Four trauma centers across Wisconsin successfully implemented a pilot opioid misuse screening tool. Trauma providers and unit staff members believe that this tool would be a beneficial addition to their repertoire if their recommendations were adopted. Future research should refine opioid misuse risk factors and ensure screening items are well-validated with psychometric research supporting treatment responses to screener-indicated risk categories.

Regional anesthesia improves inpatient but not outpatient opioid demand in tibial shaft fracture surgery

BACKGROUND

Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use.

METHODS

This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured.

RESULTS

RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05).

CONCLUSIONS

RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Comparison of Different Modeling Approaches for Prescription Opioid Use and Its Association With Adverse Events

Previous research linking opioid prescribing to adverse drug events has failed to properly account for the time-varying nature of opioid exposure. This study aimed to explore how the risk of opioid-related emergency department visits, readmissions, or deaths (composite outcome) varies with opioid dose and duration, comparing different novel modeling techniques. A prospective cohort of 1,511 hospitalized patients discharged from 2 McGill-affiliated hospitals in Montreal, 2014-2016, was followed from the first postdischarge opioid dispensation until 1 year after discharge. Marginal structural Cox proportional hazards models and their flexible extensions were used to explore the association between time-varying opioid use and the composite outcome. Weighted cumulative exposure models assessed cumulative effects of past use and explored how its impact depends on the recency of exposure. The patient mean age was 69.6 (standard deviation = 14.9) years; 57.7% were male. In marginal structural model analyses, current opioid use was associated with a 71% increase in the hazard of opioid-related adverse events (adjusted hazard ratio = 1.71, 95% confidence interval: 1.21, 2.43). The weighted cumulative exposure results suggested that the risk cumulates over the previous 50 days of opioid consumption. Flexible modeling techniques helped assess how the risk of opioid-related adverse events may be associated with time-varying opioid exposures while accounting for nonlinear relationships and the recency of past use.

Long-term opioid use following bicycle trauma: a register-based cohort study

PURPOSE

Chronic opioid use is a significant public health burden. Orthopaedic trauma is one of the main indications for opioid prescription. We aimed to assess the risk for long-term opioid use in a healthy patient cohort.

METHODS

In this matched cohort study, bicycle trauma patients from a Swedish Level-I-Trauma Centre in 2006-2015 were matched with comparators on age, sex, and municipality. Information about dispensed opioids 6 months prior until 18 months following the trauma, data on injuries, comorbidity, and socioeconomic factors were received from national registers. Among bicycle trauma patients, the associations between two exposures (educational level and injury to the lower extremities) and the risk of long-term opioid use (> 3 months after the trauma) were assessed in multivariable logistic regression models.

RESULTS

Of 907 bicycle trauma patients, 419 (46%) received opioid prescriptions, whereof 74 (8%) became long-term users. In the first quarter after trauma, the mean opioid use was significantly higher in the trauma patients than in the comparators (253.2 mg vs 35.1 mg, p < 0.001) and fell thereafter to the same level as in the comparators. Severe injury to the lower extremities was associated with an increased risk of long-term opioid use [OR 4.88 (95% CI 2.34-10.15)], whereas high educational level had a protecting effect [OR 0.42 (95% CI 0.20-0.88)].

CONCLUSION

The risk of long-term opioid use after a bicycle trauma was low. However, opioids should be prescribed with caution, especially in those with injury to lower extremities or low educational level.

Determinants of long-term opioid use in hospitalized patients

BACKGROUND

Long-term opioid use is an increasingly important problem related to the ongoing opioid epidemic. The purpose of this study was to identify patient, hospitalization and system-level determinants of long term opioid therapy (LTOT) among patients recently discharged from hospital.

DESIGN

To be eligible for this study, patient needed to have filled at least one opioid prescription three-months post-discharge. We retrieved data from the provincial health insurance agency to measure medical service and prescription drug use in the year prior to and after hospitalization. A multivariable Cox Proportional Hazards model was utilized to determine factors associated with time to the first LTOT occurrence, defined as time-varying cumulative opioid duration of ≥ 60 days.

RESULTS

Overall, 22.4% of the 1,551 study patients were classified as LTOT, who had a mean age of 66.3 years (SD = 14.3). Having no drug copay status (adjusted hazard ratio (aHR) 1.91, 95% CI: 1.40-2.60), being a LTOT user before the index hospitalization (aHR 6.05, 95% CI: 4.22-8.68) or having history of benzodiazepine use (aHR 1.43, 95% CI: 1.12-1.83) were all associated with an increased likelihood of LTOT. Cardiothoracic surgical patients had a 40% lower LTOT risk (aHR 0.55, 95% CI: 0.31-0.96) as compared to medical patients. Initial opioid dispensation of > 90 milligram morphine equivalents (MME) was also associated with higher likelihood of LTOT (aHR 2.08, 95% CI: 1.17-3.69).

CONCLUSIONS AND RELEVANCE

Several patient-level characteristics associated with an increased risk of ≥ 60 days of cumulative opioid use. The results could be used to help identify patients who are at high-risk of continuing opioids beyond guideline recommendations and inform policies to curb excessive opioid prescribing.

Outpatient Opioid Prescriptions are Associated With Future Substance Use Disorders and Overdose Following Adolescent Trauma

OBJECTIVE

This study aims to determine if outpatient opioid prescriptions are associated with future SUD diagnoses and overdose in injured adolescents 5 years following hospital discharge.

SUMMARY OF BACKGROUND DATA

Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the 5 years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained.

METHODS

This was a retrospective cohort study of patients ages 12-18 admitted to 2 level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing 5 years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, and depression and posttraumatic stress disorder diagnoses.

RESULTS

We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (odds ratio: 1.55, confidence interval: 1.04-2.32). Odds of overdose increased with ongoing opioid use over 2-4 years post-discharge ( P = 0.016-0.025).

CONCLUSIONS

Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.

Association between spine injury and opioid misuse in a prospective cohort of Level I trauma patients

Objective

To explore patient and treatment factors explaining the association between spine injury and opioid misuse.

Design

Prospective cohort study.

Setting

Level I trauma center in a Midwestern city.

Participants

English speaking patients aged 18 to 75 on Trauma and Orthopedic Surgical Services receiving opioids during hospitalization and prescribed at discharge.

Exposure

Spine injury on the Abbreviated Injury Scale.

Main outcome measures

Opioid misuse was defined by using opioids: in a larger dose, more often, or longer than prescribed; via a non-prescribed route; from someone other than a prescriber; and/or use of heroin or opium. Exploratory factor groups included demographic, psychiatric, pain, and treatment factors. Multivariable logistic regression estimated the association between spine injury and opioid misuse when adjusting for each factor group.

Results

Two hundred eighty-five eligible participants consented of which 258 had baseline injury location data and 224 had follow up opioid misuse data. Most participants were male (67.8%), white (85.3%) and on average 43.1 years old. One-quarter had a spine injury (25.2%). Of those completing follow-up measures, 14 (6.3%) developed misuse. Treatment factors (injury severity, intubation, and hospital length of stay) were significantly associated with spine injury. Spine injury significantly predicted opioid misuse [odds ratio [OR] 3.20, 95% confidence interval [CI] (1.05, 9.78)]. In multivariable models, adjusting for treatment factors attenuated the association between spine injury and opioid misuse, primarily explained by length of stay.

Conclusion

Spine injury exhibits a complex association with opioid misuse that predominantly operates through treatment factors. Spine injury patients may represent a subpopulation requiring early intervention to prevent opioid misuse.

Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery

INTRODUCTION

Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand.

METHODS

This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand.

RESULTS

Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05).

DISCUSSION

In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Novel digital approaches to the assessment of problematic opioid use

The opioid epidemic continues to contribute to loss of life through overdose and significant social and economic burdens. Many individuals who develop problematic opioid use (POU) do so after being exposed to prescribed opioid analgesics. Therefore, it is important to accurately identify and classify risk factors for POU. In this review, we discuss the etiology of POU and highlight novel approaches to identifying its risk factors. These approaches include the application of polygenic risk scores (PRS) and diverse machine learning (ML) algorithms used in tandem with data from electronic health records (EHR), clinical notes, patient demographics, and digital footprints. The implementation and synergy of these types of data and approaches can greatly assist in reducing the incidence of POU and opioid-related mortality by increasing the knowledge base of patient-related risk factors, which can help to improve prescribing practices for opioid analgesics.

Psychological resilience as a predictor of opioid consumption after orthopaedic trauma

INTRODUCTION

Psychological distress after orthopaedic trauma negatively affects patient outcomes. Resilience may mediate distress and therefore be associated with post-operative outcomes, including opioid use. The purpose of this study is to evaluate the relationship between resilience and post-operative opioid demand with the hypothesis that low levels of resilience are associated with increased opioid consumption.

MATERIALS AND METHODS

Patients age 18 - 65 at a single, tertiary care level 1 trauma center who underwent operative treatment of pelvic and/ or extremity fractures between 3/2017 - 6/2018 were contacted by phone to complete the OSPRO-YF, a ten-item screening tool that assesses psychological distress. Participants were screened for scores in the worst quartile (i.e., yellow flag) for resilience. Baseline patient and injury characteristics and opioid demand were compared between patients with and without positive yellow flags for resilience using Wilcoxon rank-sum for continuous variables and Fisher exact test for categorical variables.

RESULTS

A total of 117 patients were surveyed. Patients with positive yellow flag screening scores for resilience had significantly higher opioid demand, number of opioid prescriptions filled, and were more likely to refill prescriptions long-term (3-months post-discharge to one-year post-discharge). Patients with a positive yellow flag for resilience had a significantly higher number of opioid prescriptions filled in the cumulative (one-month pre-op to one-year post-discharge) time period.

DISCUSSION/ CONCLUSION

Lower long-term resilience scores were associated with higher postoperative opioid consumption, fill and refill rates. These results suggest low resilience may be a risk factor for increased long-term opioid consumption following surgical treatment for orthopaedic trauma.

Multimodal Analgesia with Extended-Release Dinalbuphine Sebacate for Perioperative Pain Management in Upper Extremity Trauma Surgery: A Retrospective Comparative Study

Introduction

Patients undergoing upper extremity fracture surgery (UEFS) commonly suffer from unbearable acute pain. Opioids remain the mainstay of moderate to severe pain alleviation, although there is a growing concern regarding the increasing trend in misuse and abuse. This study aimed to observe the safety and efficacy of dinalbuphine sebacate (DS), a novel extended-release analgesic, along with multimodal analgesia (MMA) for post-UEFS pain control.

Methods

We retrospectively reviewed the records of patients undergoing UEFS between August 2020 and January 2021. Eligible patients were included and divided into two groups, depending on the analgesic regimen. In the DS group, 150 mg DS was administered intramuscularly at least 12 h pre-operatively, while in the conventional analgesia (CA) group, 40 mg parecoxib was given within 3 h before surgery. Intraoperative fentanyl administration was guided by the Analgesia Nociception Index System in both groups. For breakthrough pain, fentanyl was used as rescue medicine in the postanaesthesia care unit while tramadol and parecoxib were administered in the ward.

Results

Forty-nine patients were allocated to the DS group and 60 patients were allocated to the CA group. In comparison with the CA group, the proportion of patients requiring opioids for breakthrough pain post-operatively was significantly lower in the DS group (fentanyl: 31% vs. 68%, p < 0.001; tramadol: 27% vs. 70%, p < 0.001). The DS group also consumed lower amounts of post-operative rescue opioids. Furthermore, both mean worst and least pain scores were significantly lower in the DS group from post-operative day (POD) 1 to POD 5. There was no significant difference in intraoperative consumption of fentanyl or incidence of adverse events.

Conclusion

This result suggests that extended-release DS is a suitable analgesic incorporated in MMA and a promising solution to the misuse and abuse of opioids.

Adjunctive virtual reality pain relief following traumatic injury: protocol for a randomised within-subjects clinical trial

INTRODUCTION

The annual mortality and national expense of the opioid crisis continue to rise in the USA (130 deaths/day, $50 billion/year). Opioid use disorder usually starts with the prescription of opioids for a medical condition. Its risk is associated with greater pain intensity and coping strategies characterised by pain catastrophising. Non-pharmacological analgesics in the hospital setting are critical to abate the opioid epidemic. One promising intervention is virtual reality (VR) therapy. It has performed well as a distraction tool and pain modifier during medical procedures; however, little is known about VR in the acute pain setting following traumatic injury. Furthermore, no studies have investigated VR in the setting of traumatic brain injury (TBI). This study aims to establish the safety and effect of VR therapy in the inpatient setting for acute traumatic injuries, including TBI.

METHODS AND ANALYSIS

In this randomised within-subjects clinical study, immersive VR therapy will be compared with two controls in patients with traumatic injury, including TBI. Affective measures including pain catastrophising, trait anxiety and depression will be captured prior to beginning sessions. Before and after each session, we will capture pain intensity and unpleasantness, additional affective measures and physiological measures associated with pain response, such as heart rate and variability, pupillometry and respiratory rate. The primary outcome is the change in pain intensity of the VR session compared with controls.

ETHICS AND DISSEMINATION

Dissemination of this protocol will allow researchers and funding bodies to stay abreast in their fields through exposure to research not otherwise widely publicised. Study protocols are compliant with federal regulation and University of Maryland Baltimore's Human Research Protections and Institutional Review Board (protocol number HP-00090603). Study results will be published on completion of enrolment and analysis, and deidentified data can be shared by request to the corresponding author.

TRIAL REGISTRATION NUMBER

NCT04356963; Pre-results.

Regional anesthesia does not decrease inpatient or outpatient opioid demand in femoral shaft fracture surgery

INTRODUCTION

Regional anesthesia (RA) may be used in femoral shaft fracture surgery to decrease pain and opioid consumption. However, the impact of RA on inpatient and outpatient opioid demand in patients undergoing femoral shaft fracture surgery is largely unknown. The aim of this study was to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand in patients undergoing femoral shaft fracture surgery.

METHODS

Inpatient opioid consumption and outpatient opioid demand in all patients undergoing femoral shaft fracture surgery was recorded at a single, Level I trauma center from 7/2013 - 7/2018 (n=436). In addition to RA, baseline and treatment factors including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery were recorded. Unadjusted and adjusted multivariable models were used to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand.

RESULTS

Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.9 estimated OE's without RA vs 8.8 OE's with RA from 48-72 hours post-op, p<0.05) but no significant differences at other timepoints (10.3 estimated OE's without RA vs 9.2 OE's with RA from 0-24 hours post-op, 8.2 vs 8.8 from 24-48 hours post-op, p>0.05). Estimated cumulative outpatient opioid demand did not differ significantly in patients with RA (82.3 OE's without RA vs 94.8 with RA from discharge to two-weeks, 105.4 vs 116.3 OE's to 6-weeks, and 124.5 vs 137.9 OE's to 90-days, all p>0.05). Late opioid refills were significantly more common in patients with RA (1.57 odds at 2-weeks to 6-weeks, 1.69 odds at 6-weeks to 90-days, p<0.05) DISCUSSION: In femoral shaft fracture surgery, RA was not associated with decreased opioid demand after adjusting for baseline patient and treatment characteristics. These results provide a real-world estimate of the impact of RA on opioid demand in femoral shaft fracture surgery and encourage providers to seek alternative analgesic modalities.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Tapering Opioid Prescription Program for High-Risk Trauma Patients: A Pilot Randomized Controlled Trial

BACKGROUND

Chronic opioid use has been documented in up to 20% of patients with traumatic injuries. Hence, we developed the Tapering Opioids Prescription Program for high-risk Trauma (TOPP-Trauma) patients.

AIMS

To assess the feasibility and acceptability of TOPP-Trauma, examine the feasibility of the research methods, and describe its potential efficacy in reducing long-term opioid use.

DESIGN

A two-arm pilot randomized controlled trial.

METHODS

Fifty participants discharged home were assigned to TOPP-Trauma or an educational pamphlet. Feasibility was assessed based on ability to provide the program components. The acceptability was assessed with the Treatment Acceptability and Preference Questionnaire. The feasibility of the research methods was evaluated according to standard parameters. Self-reported morphine equivalent dose (MED) and MEDs supplied by pharmacies were measured at 6 and 12 weeks.

RESULTS

Eighty percent or more of TOPP-Trauma components were delivered as planned, and the program was deemed highly acceptable. Approximately 10% of screened patients were eligible. Eighty-five percent of eligible patients agreed to participate with 20% attrition rates. TOPP-Trauma participants used less MED/day compared to the control group at 6 and 12 weeks (1.2. vs. 12.2 mg; 0.4. vs 4.0 mg), and pharmacies supplied less than half of cumulative MEDs to those who received the program at 12 weeks, but the differences were not statistically significant.

CONCLUSIONS

Some challenges need to be addressed before testing TOPP-Trauma. These include creating strategies to decrease attrition, offering the program throughout the care continuum to higher risk patients, and evaluating the impacts of reduced opioid use.

The Role of Mu-Opioids for Reward and Threat Processing in Humans: Bridging the Gap from Preclinical to Clinical Opioid Drug Studies

PURPOSE OF REVIEW

Opioid receptors are widely expressed in the human brain. A number of features commonly associated with drug use disorder, such as difficulties in emotional learning, emotion regulation and anhedonia, have been linked to endogenous opioid signalling. Whereas chronic substance use and misuse are thought to alter the function of the mu-opioid system, the specific mechanisms are not well understood. We argue that understanding exogenous and endogenous opioid effects in the healthy human brain is an essential foundation for bridging preclinical and clinical findings related to opioid misuse. Here, we will examine psychopharmacological evidence to outline the role of the mu-opioid receptor (MOR) system in the processing of threat and reward, and discuss how disruption of these processes by chronic opioid use might alter emotional learning and reward responsiveness.

RECENT FINDINGS

In healthy people, studies using opioid antagonist drugs indicate that the brain's endogenous opioids downregulate fear reactivity and upregulate learning from safety. At the same time, endogenous opioids increase the liking of and motivation to engage with high reward value cues. Studies of acute opioid agonist effects indicate that with non-sedative doses, drugs such as morphine and buprenorphine can mimic endogenous opioid effects on liking and wanting. Disruption of endogenous opioid signalling due to prolonged opioid exposure is associated with some degree of anhedonia to non-drug rewards; however, new results leave open the possibility that this is not directly opioid-mediated.

SUMMARY

The available human psychopharmacological evidence indicates that the healthy mu-opioid system contributes to the regulation of reward and threat processing. Overall, endogenous opioids can subtly increase liking and wanting responses to a wide variety of rewards, from sweet tastes to feelings of being connected to close others. For threat-related processing, human evidence suggests that endogenous opioids inhibit fear conditioning and reduce the sensitivity to aversive stimuli, although inconsistencies remain. The size of effects reported in healthy humans are however modest, clearly indicating that MORs play out their role in close concert with other neurotransmitter systems. Relevant candidate systems for future research include dopamine, serotonin and endocannabinoid signalling. Nevertheless, it is possible that endogenous opioid fine-tuning of reward and threat processing, when unbalanced by e.g. opioid misuse, could over time develop into symptoms associated with opioid use disorder, such as anhedonia and depression/anxiety.

Clinical and psychological factors associated with interdose opioid withdrawal in chronic pain population

BACKGROUND

The DSM-5 diagnostic criteria for Prescription Opioid-Use Disorder (POUD) have undergone some significant changes. One of the most controversial changes has been the elimination of the withdrawal symptoms criterion when opioid use is under appropriate medical supervision. For this reason, the goal of this study was to analyze factors associated with opioid withdrawal in patients with chronic non-cancer pain (CNCP).

METHODS

This cross-sectional descriptive study involved 404 patients who use prescription opioids for long-term treatment (≥90 days) of CNCP. Measures included sociodemographic and clinical characteristics, POUD, withdrawal symptoms, craving, anxiety-depressive symptoms, and pain intensity and interference.

RESULTS

Forty-seven percent (n = 193) of the sample reported moderate-severe withdrawal symptoms, which were associated with lower age, higher daily morphine dose and duration of treatment with opioids, moderate-severe POUD, use of psychotropic drugs, higher anxiety-depressive symptoms, and greater pain intensity and interference (p < .05). Binary logistic regression analysis showed that moderate-severe POUD (OR = 2.82), anxiety (OR = 2.21), depression (OR = 1.81), higher pain interference (OR = 1.05), and longer duration of treatment with opioids were the strongest factors associated with moderate-severe withdrawal symptoms (p < .05).

CONCLUSION

Psychological factors seem to play a key role in the severity of withdrawal symptoms. Since greater intensity of these symptoms increases the risk of developing POUD, knowing the factors associated with withdrawal may be useful in developing preventive psychological interventions.

Mental health and substance use affect perioperative opioid demand in upper extremity trauma surgery

BACKGROUND

Patients undergoing upper extremity fracture surgery often have postoperative pain that can be mitigated with opioid pain medications. Opioid misuse and abuse are growing concerns regarding the liberal use of opioids in the perioperative setting. The impact of mental health disorders and substance abuse on perioperative opioid demand is largely unknown. The purpose of this study is to describe perioperative opioid filling and risk factors for increased filling after upper extremity fractures. The study hypothesis is that poor mental health and substance abuse will be associated with increased opioid demand.

METHODS

This is a retrospective, cohort study of 26,283 patients undergoing operative fixation of upper extremity fractures involving the proximal humerus through distal radius using a commercially available insurance database. Opioid prescription filling in oxycodone 5-mg equivalents and refills were tabulated from 1 month preoperation to 1 year postoperation. Multivariable linear and logistic regression models were constructed in R (Statistical Analysis Software) to evaluate associations between mental health and substance use disorders and opioid-related outcomes with adjustment for baseline patient and treatment factors such as age, sex, comorbidities, and fracture location.

RESULTS

Of the 26,283 patients in the cohort, 79.9%, 32.6%, and 83.1% filled at least 1 opioid prescription in the 1-month preoperative to 90-day postoperative, 3-month postoperative to 1-year postoperative, and 1-month preoperative to 1-year postoperative time frames, respectively. Mean opioid volume prescribed during those time frames was 103.7, 53.5, and 156.9 oxycodone 5-mg equivalents, respectively. Drug abuse, psychoses, and preoperative opioid filling were significant mental health-related drivers of increased postoperative opioid demand.

DISCUSSION

This study reports the rate and volume of opioid prescription filling in patients undergoing upper extremity fracture surgery. Mental health and substance use disorders were significant drivers of perioperative opioid demand. These study findings can guide surgeons to anticipate expected perioperative opioid demand and identify patients who may benefit from collaboration with pain management specialists during the perioperative period.

Prescription opioid misuse and its correlates among veterans and military in the United States: A systematic literature review

BACKGROUND

Prescription opioid misuse (POM) has become a critical public health issue in the United States (US), with veteran and military population being especially vulnerable to POM. However, limited behavioral interventions have been developed for veterans and military to reduce POM risk due to the lack of an adequate understanding of POM andrelated factors among veterans and military. The current study aims to review and synthesize empirical findings regarding POM and its correlates among US veterans and military.

METHODS

We conducted a systematic review of 17 empirical studies (16 quantitative studies and one qualitative study) from 1980 to 2019 that reported POM statistics (e.g., prevalence) and examined correlates of POM in veterans and military.

RESULTS

The prevalence of POM in veterans and military ranged from 6.9%-77.9% varying by study samples, individual POM behaviors, and recalled time periods. Several factors were identified to be associated with POM in veterans and military. These factors included socio-demographic factors (age, race/ethnicity, education, relationship status, and military status), pain-related factors (pain symptoms, severity, interference, and cognitions), other physical factors (e.g., common illness), opioid-medication-related factors (receipt of opioid medications and quantity of opioid medications), behavioral factors (substance use disorder, alcohol use, cigarette use, and other prescription drug use), and psychological factors (psychiatric symptoms and cognitive factors).

CONCLUSIONS

POM was prevalent in veterans and military and could be potentially influenced by multiple psycho-behavioral factors. Future research guided by a theoretical framework is warranted to examine psycho-behavioral influences on POM and their mechanisms and to inform effective psychosocial POM interventions in veterans and military.

Interventional Efforts to Reduce Psychological Distress After Orthopedic Trauma: A Systematic Review

BACKGROUND

Unanticipated severe injury to part of the musculoskeletal system, referred to as orthopedic trauma, can be debilitating. It can also be accompanied by equally debilitating psychological distress, but little is known about the effective interventions for psychological sequelae of orthopedic trauma.

QUESTIONS/PURPOSES

We sought to determine the effectiveness of interventions on psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and pain catastrophizing (feelings of helplessness, excessive rumination, and exaggerated description of pain), after major orthopedic trauma.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement as guidelines, we systematically searched Scopus, PubMed, and Google Scholar. Studies included for review were English-language interventional studies in an orthopedic trauma population that included assessment of post-injury psychological distress or disability as either a primary or secondary aim.

RESULTS

Twelve studies were identified, including six randomized trials, three prospective cohort studies, and three retrospective cohort studies. Study sample sizes ranged from 48 to 569 patients, the mean age ranged from 29 to 52.8 years, and the percentage of male patients ranged from 38 to 90%. We examined four categories of interventions. Peer group treatment (one study) significantly reduced rates of depression but had low participation rates. Brief interventions to teach coping and self-efficacy skills (two studies) decreased depression, pain catastrophizing, and anxiety scores while increasing self-efficacy on short-term follow-up. Individualized counseling and rehabilitation (four studies) resulted in a consistent reduction in the risk of PTSD. Early amputation was found to result in lower rates of PSTD than limb salvage in US military personnel (four studies). One study examined surgeons' confidence in dealing with possible psychological distress; surgeons who participated in a program on collaborative care were significantly more confident that they could help their patients with such issues.

CONCLUSION

Interventional strategies, including group interventions, brief individual interventions, longitudinal counseling, and consideration of early amputation in selected populations have proved effective in reducing negative psychological sequelae of major orthopedic trauma. Further research that determines the effects of interventions in this population is needed.

A Time-Series Analysis of the Association Between Occupational Health Policies and Opioid Prescription Patterns in United States Active Duty Military Service Members From 2006 to 2018

OBJECTIVE

The Department of Defense (DoD) implemented numerous occupational health policies to guide opioid prescribing to active duty military service members (ADSM). This retrospective time series analysis evaluated the impact of DoD policies on opioid prescribing trends in ADSM from 2006 to 2018.

METHODS

Bayesian structural time-series models with a Markov chain Monte Carlo algorithm for posterior inference and a semi-local linear trend were constructed to estimate the impact of polices.

RESULTS

Results indicate annual opioid proportions significantly decreased after the introduction of occupational health policies introduced in 2011 to 2012. Collectively, occupational policies were associated with a significant reduction (6.6%) in annual opioid rates to ADSM following 2012. This observed effect was associated with approximately 121,000 less opioid prescriptions dispensed in 2018 alone.

CONCLUSIONS

Occupational health policy interventions were associated with reductions in opioid prescribing within the DoD.

Evidence-Based Strategies for the Prevention of Chronic Post-Intensive Care and Acute Care-Related Pain

Chronic pain is prevalent in intensive care survivors and in patients who require acute care treatments. Many adverse consequences have been associated with chronic post-intensive care and acute care-related pain. Hence, interest in interventions to prevent these pain disorders has grown. To improve the understanding of the mechanisms of action of these interventions and their potential impacts, this article outlines the pathophysiology involved in the transition from acute to chronic pain, the epidemiology and consequences of chronic post-intensive care and acute care- related pain, and risk factors for the development of chronic pain. Pharmacological, nonpharmacological, and multimodal preventive interventions specific to the targeted populations and their levels of evidence are presented. Nursing implications for preventing chronic pain in patients receiving critical and acute care are also discussed.

Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis

IMPORTANCE

Prolonged opioid use after surgery may be associated with opioid dependency and increased health care use. However, published studies have reported varying estimates of the magnitude of prolonged opioid use and risk factors associated with the transition of patients to long-term opioid use.

OBJECTIVES

To evaluate the rate and characteristics of patient-level risk factors associated with increased risk of prolonged use of opioids after surgery.

DATA SOURCES

For this systematic review and meta-analysis, a search of MEDLINE, Embase, and Google Scholar from inception to August 30, 2017, was performed, with an updated search performed on June 30, 2019. Key words may include opioid analgesics, general surgery, surgical procedures, persistent opioid use, and postoperative pain.

STUDY SELECTION

Of 7534 articles reviewed, 33 studies were included. Studies were included if they involved participants 18 years or older, evaluated opioid use 3 or more months after surgery, and reported the rate and adjusted risk factors associated with prolonged opioid use after surgery.

DATA EXTRACTION AND SYNTHESIS

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Two reviewers independently assessed and extracted the relevant data.

MAIN OUTCOMES AND MEASURES

The weighted pooled rate and odds ratios (ORs) of risk factors were calculated using the random-effects model.

RESULTS

The 33 studies included 1 922 743 individuals, with 1 854 006 (96.4%) from the US. In studies with available sex and age information, participants were mostly female (1 031 399; 82.7%) and had a mean (SD) age of 59.3 (12.8) years. The pooled rate of prolonged opioid use after surgery was 6.7% (95% CI, 4.5%-9.8%) but decreased to 1.2% (95% CI, 0.4%-3.9%) in restricted analyses involving only opioid-naive participants at baseline. The risk factors with the strongest associations with prolonged opioid use included preoperative use of opioids (OR, 5.32; 95% CI, 2.94-9.64) or illicit cocaine (OR, 4.34; 95% CI, 1.50-12.58) and a preoperative diagnosis of back pain (OR, 2.05; 95% CI, 1.63-2.58). No significant differences were observed with various study-level factors, including a comparison of major vs minor surgical procedures (pooled rate: 7.0%; 95% CI, 4.9%-9.9% vs 11.1%; 95% CI, 6.0%-19.4%; P = .20). Across all of our analyses, there was substantial variability because of heterogeneity instead of sampling error.

CONCLUSIONS AND RELEVANCE

The findings suggest that prolonged opioid use after surgery may be a substantial burden to public health. It appears that strategies, such as proactively screening for at-risk individuals, should be prioritized.

Evaluation of a Safer Opioid Prescribing Protocol (SOPP) for Patients Being Discharged From a Trauma Service

The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose.

Alleviation of Pain After Femur and Tibia Shaft Fractures Using Nothing Stronger Than Codeine and Tramadol

OBJECTIVE

To determine whether using nothing stronger than codeine and tramadol provides adequate pain alleviation in people recovering from fixation of a fracture of the femur or tibia shaft.

DESIGN

Retrospective case series.

SETTING

Level 1 trauma center in the United States.

PATIENTS

All adult patients from October 2016 to October 2018 with femur (OTA/AO 32) and tibial (OTA/AO 42) shaft fractures who were treated surgically were included. A nurse counseled patients on safe and effective alleviation of pain. Charts were reviewed for pain medication prescribed, noting utilization of schedule II opioid medications.

MAIN OUTCOME MEASURES

Frequency of schedule II pain medication prescription on discharge or during follow-up, emergency department presentation for pain, or readmission for pain.

RESULTS

One hundred fifty patients with 162 fractures were treated for femoral (N = 73 fractures) or tibial (N = 89 fractures) shaft fractures. Sixty patients (40%) were multiple injured patients. Thirteen (8.7%) patients were discharged with hydrocodone, oxycodone, or fentanyl. Of the remaining patients with adequate follow-up (N = 109), 6.4% requested hydrocodone, oxycodone, or fentanyl after discharge. There was 1 patient presentation to the emergency department for pain, and there were no pain-related readmissions.

CONCLUSIONS

Alleviation of pain can be achieved in most patients with femoral and tibial shaft fractures, including multiply injured patients, with one-on-one patient support and by using nothing stronger than codeine and tramadol.

LEVEL OF EVIDENCE

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

Long-term opioid therapy definitions and predictors: A systematic review

PURPOSE

This review sought to (a) describe definitions of long-term opioid therapy (LTOT) outcome measures, and (b) identify the predictors associated with the transition from short-term opioid use to LTOT for opioid-naïve individuals.

METHODS

We conducted a systematic review of the peer-reviewed literature (January 2007 to July 2018). We included studies examining opioid use for more than 30 days. We classified operationalization of LTOT based on criteria used in the definitions. We extracted LTOT predictors from multivariate models in studies of opioid-naïve individuals.

RESULTS

The search retrieved 5,221 studies, and 34 studies were included. We extracted 41 unique variations of LTOT definitions. About 36% of definitions required a cumulative duration of opioid use of 3 months. Only 17% of definitions considered consecutive observation periods, 27% used days' supply, and no definitions considered dose. We extracted 76 unique predictors of LTOT from seven studies of opioid-naïve patients. Common predictors included pre-existing comorbidities (21.1%), non-opioid prescription medication use (13.2%), substance use disorders (10.5%), and mental health disorders (10.5%).

CONCLUSIONS

Most LTOT definitions aligned with the chronic pain definition (pain more than 3 months), and used cumulative duration of opioid use as a criterion, although most did not account for consistent use. Definitions were varied and rarely accounted for prescription characteristics, such as days' supply. Predictors of LTOT were similar to known risk factors of opioid abuse, misuse, and overdose. As LTOT becomes a central component of quality improvement efforts, researchers should incorporate criteria to identify consistent opioid use to build the evidence for safe and appropriate use of prescription opioids.

Can patient and fracture factors predict opioid dependence following upper extremity fractures?: a retrospective review

Background

Since the early 1990s, opioids have been used as a mainstay for pain management surrounding fracture injuries. As opioid dependence has become a major public health issue, it is important to understand what factors can leave patients vulnerable. The purpose of this study was to examine what risk factors, patient or injury severity, contribute most to postoperative opioid dependence following surgical treatment of proximal humerus fractures (PHFs).

Methods

A retrospective review of all patients who underwent an open reduction and internal fixation of PHF was performed within a large multisite hospital system. Recorded variables included age, gender, ASA class, BMI, fracture type, time to surgery, pre- and postoperative opioid prescriptions, physical and psychological comorbidities, smoking status, and complications. Pre- and postoperative opioid dependence was defined as prescription opioid use in the 3 months leading up to or following surgery. Odds ratio calculations were performed for each variable, and a multivariate logistic regression was used to compare all predictors.

Results

A total of 198 surgically treated PHFs were included in the cohort with an average age of 59.9 years. Thirty-nine cases were determined to be preoperatively opioid dependent while 159 cases were preoperatively opioid naïve. Preoperative opioid dependence was found to be a significant risk factor for postoperative narcotic dependence, carrying a 2.42 times increased risk. (CI 1.07–5.48, p = 0.034). Fracture type was also found to be a risk factor for postoperative dependence, with complex 3- and 4-part fracture patients being 1.93 times more likely to be opioid dependent postoperatively compared to 2 part fractures (CI 1.010–3.764, p = 0.049). All other factors were not found to have any significant influence on postoperative opioid dependence.

Conclusions

Our results demonstrate that the most important risk factors of postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. It is important for orthopedic surgeons to ensure that patients who have more complex fractures or are preoperatively opioid dependent receive adequate education on their increased risk and support to wean off of opioids following surgery.

Level of evidence

III

New Persistent Opioid Use and Associated Risk Factors Following Treatment of Ankle Fractures

BACKGROUND

The aim of this study was to define the rate of new persistent opioid use and risk factors for persistent opioid use after operative and nonoperative treatment of ankle fractures.

METHODS

Using a nationwide insurance claims database, Clinformatics DataMart Database, we identified opioid-naïve patients who underwent surgical treatment of unstable ankle fracture patterns between January 2009 and June 2016. Patients who underwent closed treatment of a distal fibula fracture served as a comparative group. We evaluated peritreatment and posttreatment opioid prescription fills. The primary outcome, new persistent opioid use, was defined as opioid prescription fulfillment between 91 and 180 days after the procedure. Logistic regression was used to evaluate the effect of patient factors, and the differences of the effect were tested using Wald statistics. The adjusted persistent use rates were calculated. A total of 13 088 patients underwent treatment of an ankle fracture and filled a peritreatment opioid prescription.

RESULTS

When compared with closed treatment of a distal fibula fracture, only 2 surgical treatment subtypes demonstrated significantly increased rates of persistent use compared with the closed treatment group: open treatment of bimalleolar ankle fracture (adjusted odds ratio [aOR], 1.32; 95% CI, 1.10-1.58; P = .002) and open treatment of trimalleolar ankle fracture with fixation of posterior lip (aOR, 1.47; 95% CI, 1.04-2.07; P = .027). Rates were significantly increased (aOR, 1.56; 95% CI, 1.34-1.82; P < .001) among patients who received a total peritreatment opioid dose that was in the top 25th percentile of total oral morphine equivalents. Factors independently associated with new persistent opioid use included mental health disorders, comorbid conditions, tobacco use, and female sex.

CONCLUSION

All ankle fracture treatment groups demonstrated high rates of new persistent opioid use, and persistent use was not directly linked to injury severity. Instead, we identified patient factors that demonstrated increased risk of persistent opioid use. Limiting the peritreatment opioid dose was the largest modifiable risk factor related to new persistent opioid use in this privately insured cohort.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery

BACKGROUND

The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context.

METHODS

Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases.

RESULTS

U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019).

CONCLUSIONS

Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma.

CLINICAL RELEVANCE

Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.

Feasibility of a tapering opioids prescription program for trauma patients at high risk of chronic consumption (TOPP-trauma): protocol for a pilot randomized controlled trial

BACKGROUND

Opioid use disorder (OUD) and deaths related to the chronic use of opioids have increased significantly over the last two decades. Chronic consumption of opioids has been documented in many patients with traumatic injuries. Preliminary research findings have shown that interventions using cognitive-behavioral strategies were a promising adjunct in decreasing the burden associated with opioid consumption. Accordingly, the Tapering Opioids Prescription Program in Trauma (TOPP-Trauma) was developed.

PURPOSE

To assess the feasibility of the TOPP-Trauma intervention and its research methods; and explore the potential efficacy of TOPP-Trauma in reducing opioid consumption.

METHODS

A 2-arm pilot randomized controlled trial (RCT) will be conducted in patients presenting a high risk for chronic opioid consumption. Fifty participants at high risk for chronic consumption of opioid will receive either TOPP-Trauma or an educational pamphlet. The feasibility assessment of TOPP-Trauma will be based on the ability to provide its components as initially planned. Several parameters will be evaluated to determine the feasibility of the research methods, including the adequacy of the sampling pool, the dropout rate, and the ease of data collection. The morphine equivalent dose (MED) per day between both groups will be measured at 6 and 12 weeks. Pain intensity and pain interference with activities will also be evaluated at the same time points.

DISCUSSION

This study will provide evidence on the feasibility of a preventive program aimed at reducing chronic opioid use in high risk trauma patients. Information will also be gathered on the methods that should be used to test the efficacy of such programs.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 40263056. Registered 26 May 2018.

Opioid Prescribing Practices After Isolated Pilon Fractures

The purpose of our study was to identify the opioid-prescribing practices after operative treatment of isolated pilon fractures at a level 1 trauma center. Patients ≥ 18 years of age with an operatively treated isolated pilon fracture between 2005 and 2015 were identified. Total morphine milligram equivalents (MMEs) were then calculated. Mean and standard deviations were calculated for patients without a history of opiate use and for patients with a history of opiate use within 1 year prior to injury. Data were obtained from the State Controlled Substance Monitoring Database. Seventy-two patients met our inclusion criteria; of these, 54% (39/72) were opiate exposed at the time of injury. Median MMEs prescribed were 2738 (range 375 to 12,360). Orthopedic providers prescribed 61% of all the MMEs (median 2010; range 113 to 6825), while nonorthopedic providers prescribed a median of 338 MMEs (range 0 to 10,080) (p < .05). Combined, patients with exposure 1 year before the injury received more MMEs (median 3600; range 840 to 12,360) than opiate-naive patients (median 2520; range 375 to 10,610) (p < .05). Twenty-eight (38.9%) patients continued using opiates for more than 6 months after their injury; 25% (7/28) were not previously exposed. There is great variability regarding the quantity of opiates being prescribed after isolated pilon fractures, and 39% of opiate prescriptions are coming from nonorthopedic prescribers. Opiate-exposed patients are more likely to be prescribed more opiates by orthopedists and outside physicians and for a longer duration. We believe that adequate pain control can be obtained by prescribing 40 pills of oxycodone 10 mg with a maximum of 1 additional refill. In cases in which a staged procedure is planned, an additional refill is expected (total of 3 refills).

Self-Reported Marijuana Use Is Associated with Increased Use of Prescription Opioids Following Traumatic Musculoskeletal Injury

BACKGROUND

Cannabinoids are among the psychoactive substances considered as alternatives to opioids for the alleviation of acute pain. We examined whether self-reported marijuana use was associated with decreased use of prescription opioids following traumatic musculoskeletal injury.

METHODS

Our analysis included 500 patients with a musculoskeletal injury who completed a survey about their marijuana use and were categorized as (1) never a user, (2) a prior user (but not during recovery), or (3) a user during recovery. Patients who used marijuana during recovery indicated whether marijuana helped their pain or reduced opioid use. Prescription opioid use was measured as (1) persistent opioid use, (2) total prescribed opioids, and (3) duration of opioid use. Persistent use was defined as the receipt of at least 1 opioid prescription within 90 days of injury and at least 1 additional prescription between 90 and 180 days. Total prescribed opioids were calculated as the total morphine milligram equivalents (MME) prescribed after injury. Duration of use was the interval between the first and last opioid prescription dates.

RESULTS

We found that 39.8% of patients reported never having used marijuana, 46.4% reported prior use but not during recovery, and 13.8% reported using marijuana during recovery. The estimated rate of persistent opioid use ranged from 17.6% to 25.9% and was not associated with marijuana use during recovery. Marijuana use during recovery was associated with increases in both total prescribed opioids (regression coefficient = 343 MME; 95% confidence interval [CI] = 87 to 600 MME; p = 0.029) and duration of use (coefficient = 12.5 days; 95% CI = 3.4 to 21.5 days; p = 0.027) compared with no previous use (never users). Among patients who reported that marijuana decreased their opioid use, marijuana use during recovery was associated with increased total prescribed opioids (p = 0.008) and duration of opioid use (p = 0.013) compared with never users.

CONCLUSIONS

Our data indicate that self-reported marijuana use during injury recovery was associated with an increased amount and duration of opioid use. This is in contrast to many patients' perception that the use of marijuana reduces their pain and therefore the amount of opioids used.

LEVEL OF EVIDENCE

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

A population-based study of treated mental health and persistent pain conditions after transport injury

BACKGROUND

Persistent pain and mental health conditions often co-occur after injury, cause enormous disability, reduce social and economic participation, and increase long-term healthcare costs. This study aimed to characterise the incidence, profile and healthcare cost implications for people who have a treated mental health condition, persistent pain, or both conditions, after compensable transport injury.

METHODS

The study comprised a population cohort of people who sustained a transport injury (n = 74,217) between 2008 to 2013 and had an accepted claim in the no-fault transport compensation system in Victoria, Australia. Data included demographic and injury characteristics, and payments for treatment and income replacement from the Compensation Research Database. Treated conditions were identified from 3 to 24-months postinjury using payment-based criteria developed with clinical and compensation system experts. Criteria included medications for pain, anxiety, depression or psychosis, and services from physiotherapists, psychologists, psychiatrists, and pain specialists. The data were analysed with Cox Proportional Hazards regression to examine rates of treated conditions, and general linear regression to estimate 24 month healthcare costs.

RESULTS

Overall, the incidence of treated mental health conditions (n = 2459, 3.3%) and persistent pain (n = 4708, 6.3%) was low, but rates were higher in those who were female, middle aged (35-64 years), living in metropolitan areas or neighbourhoods with high socioeconomic disadvantage, and for people who had a more severe injury. Healthcare costs totalled more than $A707 M, and people with one or both conditions (7.7%) had healthcare costs up to 7-fold higher (adjusting for demographic and injury characteristics) in the first 24 months postinjury than those with neither condition.

CONCLUSIONS

The incidence of treated mental health and persistent pain conditions was low, but the total healthcare costs for people with treated conditions were markedly higher than for people without either treated condition. While linkage with other public records of treatment was not possible, the true incidence of treated conditions is likely to be even higher than that found in this study. The present findings can be used to prioritise the implementation of timely access to treatment to prevent or attenuate the severity of pain and mental health conditions after transport injury.

Patient-Reported Outcomes Measurement Information System Outcome Measures and Mental Health in Orthopaedic Trauma Patients During Early Recovery

OBJECTIVES

This study explored the relationships between negative affective states (depression and anxiety), physical/functional status, and emotional well-being during early treatment and later in recovery after orthopaedic trauma injury.

DESIGN

This was a secondary observational analysis from a randomized controlled study performed at a Level-1 trauma center.

PATIENTS

Patients with orthopaedic trauma (N = 101; 43.5 ± 16.4 years, 40.6% women) were followed from acute care to week 12 postdischarge.

MAIN OUTCOME MEASURES

Patient-reported outcomes measurement information system measures of Physical Function, Psychosocial Illness Impact-Positive and Satisfaction with Social Roles and Activities and the Beck Depression Inventory-II and the State-Trait Anxiety Inventory were administered during acute care and at weeks 2, 6, and 12. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and surgery number.

RESULTS

At week 12, 20.9% and 35.3% of patients reported moderate-to-severe depression (Beck Depression Inventory-II score ≥20 points) and anxiety (State-Anxiety score ≥40 points), respectively. Depressed patients had greater length of stay, complex injuries, and more readmissions than those without. The study sample improved patient-reported outcomes measurement information system T-scores for Physical Function and Satisfaction with Social Roles and Activities by 40% and 22.8%, respectively (P < 0.0001), by week 12. Anxiety attenuated improvements in physical function. Both anxiety and depression were associated with lower Psychosocial Illness Impact-Positive scores by week 12.

CONCLUSIONS

Although significant improvements in patient-reported physical function and satisfaction scores occurred in all patients, patients with depression or anxiety likely require additional psychosocial support and resources during acute care to improve overall physical and emotional recovery after trauma.

LEVEL OF EVIDENCE

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

Risk Factors and Pooled Rate of Prolonged Opioid Use Following Trauma or Surgery: A Systematic Review and Meta-(Regression) Analysis

BACKGROUND

Prolonged use of opioids initiated for surgical or trauma-related pain management has become a global problem. While several factors have been reported to increase the risk of prolonged opioid use, there is considerable inconsistency regarding their significance or effect size. Therefore, we aimed to pool the effects of risk factors for prolonged opioid use following trauma or surgery and to assess the rate and temporal trend of prolonged opioid use in different settings.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched Embase, PubMed, Web of Science, EBM (Evidence-Based Medicine) Reviews - Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from inception to August 28, 2017, without language restriction. Observational studies reporting risk factors for, or the rate of, prolonged opioid use among adult patients following surgery or trauma with a minimum of 1 month of follow-up were included. Study and patient characteristics, risk factors, and the rate of prolonged opioid use were synthesized.

RESULTS

Thirty-seven studies with 1,969,953 patients were included; 4.3% (95% confidence interval [CI] = 2.3% to 8.2%) of patients continued opioid use after trauma or surgery. Prior opioid use (number needed to harm [NNH] = 3, odds ratio [OR] = 11.04 [95% CI = 9.39 to 12.97]), history of back pain (NNH = 23, OR = 2.10 [95% CI = 2.00 to 2.20]), longer hospital stay (NNH = 25, OR = 2.03 [95% CI = 1.03 to 4.02]), and depression (NNH = 40, OR = 1.62 [95% CI = 1.49 to 1.77]) showed some of the largest effects on prolonged opioid use (p < 0.001 for all but hospital stay [p = 0.042]). The rate of prolonged opioid use was higher in trauma (16.3% [95% CI = 13.6% to 22.5%]; p < 0.001) and in the Workers' Compensation setting (24.6% [95% CI = 2.0% to 84.5%]; p = 0.003) than in other subject enrollment settings. The temporal trend was not significant for studies performed in the U.S. (p = 0.07) while a significant temporal trend was observed for studies performed outside of the U.S. (p = 0.014).

CONCLUSIONS

To our knowledge, this is the first meta-analysis reporting the pooled effect of risk factors that place patients at an increased chance for prolonged opioid use. Understanding the pooled effect of risk factors and their respective NNH values can aid patients and physicians in developing effective and individualized pain-management strategies with a lower risk of prolonged opioid use.

LEVEL OF EVIDENCE

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

A systematic review of opioid use after extremity trauma in orthopedic surgery

BACKGROUND

The United States is in a prescription opioid crisis. Orthopedic surgeons prescribe more opioid narcotics than any other surgical specialty. The purpose of this study was to evaluate the state of opioid use after extremity trauma in orthopedic surgery.

METHODS

A computerized literature search of PubMed/MEDLINE was conducted to evaluate the status of opioids after extremity fractures. Six articles were identified and included in the review.

RESULTS

Patients who consume more opioids communicate greater pain intensity and less satisfaction with pain control. Intraoperative multimodal drug injection and nerve blockade are viable alternatives for postoperative pain control and can help decrease systemic opioid use. Orthopedic surgeons are overprescribing opioids. Compared to other countries, the United States consumes more opioids with no better satisfaction with pain control.

CONCLUSION

Orthopedic trauma surgeons should tailor their postoperative opioid prescriptions to the individual patient and utilize alternative options in order to control postoperative pain. Patients should be counseled regarding narcotic addiction and dependence. Patients unable to manage pain postoperatively should be followed closely and receive the proper chronic pain management, mental and social health services referrals.

Pain-related anxiety and opioid misuse in a racially/ethnically diverse young adult sample with moderate/severe pain

Pain problems are of significant public health concern, and with opioid-related problems and death due to overdose at an all-time high, there is significant public health importance to identify risk factors that link instances of pain to opioid misuse among persons with pain whether or not they have been prescribed opioids for pain management. Severe pain and pain-related problems have been associated with increased risk for opioid misuse, and recent research indicates that pain-related anxiety (worry about the negative consequences of pain) may contribute to a more debilitating pain experience. Additionally, pain-related anxiety has previously been linked to substance use motives and dependence for cannabis and tobacco. However, little research has examined pain-related anxiety as a transdiagnostic risk factor for opioid misuse. The current study examined the relationship between pain-related anxiety and self-reported opioid misuse (addiction, prescription denial, family concerns, detox) in a racially/ethnically diverse sample of young adults (N = 256, M _age = 22.84) reporting moderate to severe bodily pain over the previous four weeks. Results indicated that pain-related anxiety was significantly related to several indicators of opioid misuse as well as an increased number of opioid-related problems. Findings from the current study suggest that targeting pain-related anxiety may be one therapeutic strategy to reduce opioid misuse.