Decrease in Urologic Discharge Opioid Prescribing after Mandatory Query of Statewide Prescription Drug Monitoring Program

Predictors of persistent opioid use in bladder cancer patients undergoing radical cystectomy: A SEER-Medicare analysis

PURPOSE

To evaluate patient and provider characteristics that predict persistent opioid use following radical cystectomy for bladder cancer including non-opioid naïve patients.

METHODS

Patients undergoing cystectomy between July 2007 and December 2015 were identified using the SEER-Medicare database. Opioid exposure was identified before and after cystectomy using Medicare Part D data. Multivariable analyses were used to identify predictors of the primary outcomes: persistent opioid use (prescription 3-6 months after surgery) and postoperative opioid prescriptions (within 30 days of surgery). Secondary outcomes included physician prescribing practices and rates of persistent opioid use in their patient cohorts.

RESULTS

A total of 1,774 patients were included; 29% had prior opioid exposure. Compared to opioid-naïve patients, non-opioid naïve patients were more frequently younger, Black, and living in less educated communities. The percentage of persistent postoperative use was 10% overall and 24% in non-opioid naïve patients. Adjusting for patient factors, opioid naïve individuals were less likely to develop persistent use (OR 0.23) while a 50-unit increase in oral morphine equivalent per day prescribed following surgery nearly doubled the likelihood of persistent use (OR 1.98). Practice factors such as hospital size, teaching affiliation, and hospital ownership failed to predict persistent use. 29% of patients filled an opioid prescription postoperatively. Opioid naïve patients (OR 0.13) and those cared for at government hospitals (OR 0.59) were less likely to fill an opioid script along with those residing in the Northeast. Variability between physicians was seen in prescribing practices and rates of persistent use.

CONCLUSIONS

Non-opioid naïve patients have higher rates of post-operative opioid prescription than opioid-naïve patients. Physician prescribing practices play a role in persistent use, as initial prescription amount predicts persistent use even in non-opioid naïve patients. Significant physician variation in both prescribing practices and rates of persistent use suggest a role for standardizing practices.

Transcorporal Artificial Urinary Sphincter Technique Video

OBJECTIVE

The artificial urethral sphincter (AUS) is the gold standard treatment for male stress urinary incontinence which commonly results from prostatectomy or pelvic radiation for prostate cancer. Patients with prior pelvic radiation history experience increased risk of developing urethral erosion. Transcorporal AUS (TAUS) placement can be used as an alternative for compromised urethras to incorporate a small portion of the corporal bodies for additional support. The inclusion of an additional tissue barrier has been shown to improve outcomes. Patients who undergo this technique require device explanation and AUS revision less often than those with AUS devices placed in the standard fashion. Additionally, TAUS placement has been shown to improve functional urinary outcomes such as postoperative Internal prostate symptom score (IPSS), and postoperative IPSS Quality of Life (QoL) scores.

MATERIALS AND METHODS

A 67-year-old male with a past medical history of prostate cancer treated with surgery and radiation underwent a TAUS placement which was filmed to demonstrate placement technique and tips. Informed consent was obtained prior to filming this video.

RESULTS

This technique can serve as a successful primary or salvage AUS placement technique as seen in this video.

CONCLUSION

This video is used to demonstrate the technique of TAUS placement.

Opioid-Free Ureteroscopy: Are Academic Urologists Lagging Behind Private Practice?

OBJECTIVE

To examine overall trends in opioid prescribing after ureteroscopy and compared opioid use between private and academic practice settings. We also analyzed the potential for spillover effect from an unrelated opioid-reduction initiative for major oncologic surgery.

METHODS

We conducted a retrospective chart review of all ureteroscopies performed within our system at four distinct time points from 2016-2019. We recorded the type and number of opioid pills prescribed and calculated oral morphine equivalents. Analysis included comparison between community and academic hospitals as well as pre- and post-initiative.

RESULTS

555 patients undergoing ureteroscopy and 29 attending surgeons were included in the analysis. The median prescription size per ureteroscopy decreased throughout the study period in both the private and academic settings. From 2016-2017, median oral morphine equivalents (OMEs) decreased from 60 to 0 in the private setting and remained at 0 for the duration of the study period. Opioid reduction in the academic setting lagged behind private practitioners but median OMEs did steadily decrease to 0 in 2019. No significant spillover effect was observed.

CONCLUSION

Since 2016, opioid prescribing following ureteroscopy has decreased in both the private and academic practice settings. Notably, private practice urologists achieved a median of 0 opioids 2 years prior to academic urologists. These data suggest that, in some circumstances, academic institutions may have been slower to respond to the opioid epidemic.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

A government mandated consent safely reduces opioid utilization for major pediatric genitourinary surgeries

INTRODUCTION

We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries.

METHODS

All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data.

RESULTS

After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p<0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75)(p<0.001). The rate of delayed non-opioid analgesic prescriptions (6.6% vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%)(p = 0.809) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p = 0.425).

CONCLUSIONS

A state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries.

LEVEL OF EVIDENCE

Level III.

Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program

Importance

Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)-based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation.

Objective

To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge.

Design Setting and Participants

This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included.

Exposures

Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively.

Main Outcomes and Measures

The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days.

Results

Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = -10.00 [95% CI, -19.52 to -0.48]; obstetric/gynecologic surgery: β = -18.65 [95% CI, -22.00 to -15.30]; and orthopedic surgery: β = -30.59 [95% CI, -40.19 to -21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = -3.02 [95% CI, -3.47 to -2.57]; obstetric/gynecologic surgery: β = -4.86 [95% CI, -5.38 to -4.34]; and orthopedic surgery: β = -4.06 [95% CI, -5.07 to -3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = -10.00; 95% CI, -10.10 to -9.90), but median MMEs did not (β = 0; 95% CI, -9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = -33.33 [95% CI, -38.48 to -28.19]; tablets: β = -10.00 [95% CI, -11.17 to -8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, -22.33 to 42.33; tablets: β = 0.83; 95% CI, -3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties.

Conclusions and Relevance

In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers' attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing.

Opioid-Free Discharge is Not Associated With Increased Unplanned Healthcare Encounters After Ureteroscopy: Results From a Statewide Quality Improvement Collaborative

OBJECTIVES

To evaluate patient factors associated with post-ureteroscopy opioid prescriptions, provider-level variation in opioid prescribing, and the relationship between opioid-free discharges and ED visits.

METHODS

This is a retrospective analysis of a prospective cohort study of adults age 18 years and older who underwent primary ureteroscopy for urinary stones from June 2016 to September 2019 within the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) quality improvement initiative. Postoperative opioid prescription trends and variation among practices and surgeons were examined. Multivariable logistic regression models defined risk factors for receipt of opioid prescriptions. The association among opioid prescriptions and postoperative ED visits within 30 days of surgery was assessed among complete case and propensity matched cohorts, matched on all measured characteristics other than opioid receipt.

RESULTS

13,143 patients underwent ureteroscopy with 157 urologists across 28 practices. Post-ureteroscopy opioid prescriptions and ED visits declined (86% to 39%, P<.001; 10% to 6%, P<.001, respectively). Practice and surgeon-level opioid prescribing varied from 8% to 98%, and 0% to 98%, respectively. Patient-related factors associated with opioid receipt included male, younger age, and history of chronic pain. Procedure-related factors associated with opioid receipt included pre- and post-ureteroscopy ureteral stenting and access sheath use. An opioid-free discharge was not associated with increased odds of an ED visit (OR 0.77, 95% CI 0.62-0.95, P=.014).

CONCLUSIONS

There was no increase in ED utilization among those not prescribed an opioid after ureteroscopy, suggesting their routine use may not be necessary in this setting.

Pediatric Urologic Surgery: Reducing Opioid Use

Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement

BACKGROUND

This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

METHODS

An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

CONCLUSIONS

This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin

Background and aims:

Prescription Drug Monitoring Programs (PDMPs) were designed to curb opioid misuse and diversion by tracking scheduled medications prescribed by medical providers and dispensed by pharmacies. The effects of PDMPs on opioid prescription, misuse and overdose rates have been mixed due in part to variability in states’ PDMPs and difficulties measuring this complexity, and a lack of attention to implementation and enforcement of PDMP components. The current study uses qualitative interviews with key informants from 3 states with different PDMPs, Connecticut, Kentucky and Wisconsin to explore differences in the characteristics of the PDMPs in each state; how they are implemented, monitored and enforced; and unintended negative consequences of these programs.

Methods:

We conducted in-depth interviews with key informants from each state representing the following sectors: PDMP and pain clinic regulation agencies, Medicaid programs, state licensing boards, pharmacies, emergency medicine departments, pain management clinics, first responders, drug courts, drug treatment programs, medication assisted treatment (MAT) providers, and harm reduction organizations. Interview guides explored participants’ experiences with and opinions of PDMPs according to their roles. Data analysis was conducted using a collaborative, constant comparison method.

Results:

While all 3 states had mandated registration and reporting requirements, the states differed in the implementation and enforcement of these and the extent to which provider prescribing was monitored. These, in turn, influenced how medical providers perceived the PDMP and changed how providers prescribed opioids. Unintended consequences of state PDMPs included under-prescribing for pain and “dumping” patients who were long term users of opioids or who had developed opioid use disorders and may explain the increase in illicit heroin or opioid use.

Conclusion:

State PDMPs with similar mandates may differ greatly in implementation and enforcement. These differences are important to consider when determining the effects of PDMPs on opioid misuse and overdose.