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Ramírez Medina CR, Feng M, Huang YT, Jenkins DA, Jani M. Machine learning identifies risk factors associated with long-term opioid use in fibromyalgia patients newly initiated on an opioid. RMD Open 2024; 10:e004232. [PMID: 38772680 DOI: 10.1136/rmdopen-2024-004232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES Fibromyalgia is frequently treated with opioids due to limited therapeutic options. Long-term opioid use is associated with several adverse outcomes. Identifying factors associated with long-term opioid use is the first step in developing targeted interventions. The aim of this study was to evaluate risk factors in fibromyalgia patients newly initiated on opioids using machine learning. METHODS A retrospective cohort study was conducted using a nationally representative primary care dataset from the UK, from the Clinical Research Practice Datalink. Fibromyalgia patients without prior cancer who were new opioid users were included. Logistic regression, a random forest model and Boruta feature selection were used to identify risk factors related to long-term opioid use. Adjusted ORs (aORs) and feature importance scores were calculated to gauge the strength of these associations. RESULTS In this study, 28 552 fibromyalgia patients initiating opioids were identified of which 7369 patients (26%) had long-term opioid use. High initial opioid dose (aOR: 31.96, mean decrease accuracy (MDA) 135), history of self-harm (aOR: 2.01, MDA 44), obesity (aOR: 2.43, MDA 36), high deprivation (aOR: 2.00, MDA 31) and substance use disorder (aOR: 2.08, MDA 25) were the factors most strongly associated with long-term use. CONCLUSIONS High dose of initial opioid prescription, a history of self-harm, obesity, high deprivation, substance use disorder and age were associated with long-term opioid use. This study underscores the importance of recognising these individual risk factors in fibromyalgia patients to better navigate the complexities of opioid use and facilitate patient-centred care.
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Affiliation(s)
- Carlos Raúl Ramírez Medina
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Mengyu Feng
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Yun-Ting Huang
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, UK
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Melis EJ, Vriezekolk JE, van der Laan JCC, Smolders JMH, van den Bemt BJF, Fenten MGE. Long-term postoperative opioid use in orthopaedic patients. Eur J Pain 2024; 28:797-805. [PMID: 38108651 DOI: 10.1002/ejp.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/26/2023] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The prevalence of long-term opioid use after orthopaedic surgery varies from 1.4% to 24% and has mostly been studied with prescription data, making it difficult to estimate the size and impact of the problem. This study aims to assess the prevalence and predictors of long-term postoperative opioid use in a high volume and tertiary orthopaedic centre by using online patient reported measures. METHODS This Dutch prospective cohort study was conducted among adult patients who underwent any type of orthopaedic surgery from June to August 2021. Six months after surgery patients were invited to complete an online survey on current opioid use and patients' willingness to taper opioids. The demographics, clinical factors and preoperative opioid use were extracted from the patient file. RESULTS In total, 607 patients (mean age 61.2 years, 63.4% female) completed the survey. Seventy-six patients (12.5%) used opioids 6 months after surgery of which 20 (3.3%) did not use opioids before surgery. The median (Q1-Q3) postoperative daily dose after 6 months was 29.9 mg (10.0-76.1) morphine equivalents. Most of them (88.2%) wanted to taper opioids. Affected body region (OR's: 6.84-12.75) and pre-operative opioid use (OR = 35.33) were significant predictors of long-term opioid use. CONCLUSION The prevalence of long-term postoperative opioid use was 12.5%; one in thirty patients became a new long-term opioid user. Pre-operative opioid use and affected body region were predictive for long-term opioid use. These findings, together with the observation that long-term opioid users want to taper opioids, emphasize the relevance of prevention, recognition and tapering support in the perioperative setting. LEVEL OF EVIDENCE Level II. SIGNIFICANCE Short-term opioid use can unintentionally progress to long-term opioid use. The prevalence of long-term opioid use after orthopaedic surgery varies widely and is mostly prescription-based, making it difficult to estimate the magnitude of the problem. This study assessed long-term postoperative opioid use in a full breadth orthopaedic population using patient reported measures, making conclusions much more robust. The prevalence of long-term postoperative opioid use in this study was 12.5%.
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Affiliation(s)
- Eward J Melis
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Johanna E Vriezekolk
- Department of Research and Innovation, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | - José M H Smolders
- Department of Orthopaedics, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Research and Innovation, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maaike G E Fenten
- Department of Anaesthesiology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
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Seng EC, Mehdipour S, Simpson S, Gabriel RA. Tracking persistent postoperative opioid use: a proof-of-concept study demonstrating a use case for natural language processing. Reg Anesth Pain Med 2024; 49:241-247. [PMID: 37419509 DOI: 10.1136/rapm-2023-104629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Large language models have been gaining tremendous popularity since the introduction of ChatGPT in late 2022. Perioperative pain providers should leverage natural language processing (NLP) technology and explore pertinent use cases to improve patient care. One example is tracking persistent postoperative opioid use after surgery. Since much of the relevant data may be 'hidden' within unstructured clinical text, NLP models may prove to be advantageous. The primary objective of this proof-of-concept study was to demonstrate the ability of an NLP engine to review clinical notes and accurately identify patients who had persistent postoperative opioid use after major spine surgery. METHODS Clinical documents from all patients that underwent major spine surgery during July 2015-August 2021 were extracted from the electronic health record. The primary outcome was persistent postoperative opioid use, defined as continued use of opioids greater than or equal to 3 months after surgery. This outcome was ascertained via manual clinician review from outpatient spine surgery follow-up notes. An NLP engine was applied to these notes to ascertain the presence of persistent opioid use-this was then compared with results from clinician manual review. RESULTS The final study sample consisted of 965 patients, in which 705 (73.1%) were determined to have persistent opioid use following surgery. The NLP engine correctly determined the patients' opioid use status in 92.9% of cases, in which it correctly identified persistent opioid use in 95.6% of cases and no persistent opioid use in 86.1% of cases. DISCUSSION Access to unstructured data within the perioperative history can contextualize patients' opioid use and provide further insight into the opioid crisis, while at the same time improve care directly at the patient level. While these goals are in reach, future work is needed to evaluate how to best implement NLP within different healthcare systems for use in clinical decision support.
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Affiliation(s)
- Eri C Seng
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Soraya Mehdipour
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Sierra Simpson
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Rodney A Gabriel
- Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
- Division of Regional Anesthesia, Department of Anesthesiology, University of California, San Diego, La Jolla, California, USA
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Gerlach EB, Plantz MA, Swiatek PR, Wu SA, Arpey N, Fei-Zhang D, Divi SN, Hsu WK, Patel AA. The Drivers of Persistent Opioid Use and Its Impact on Healthcare Utilization After Elective Spine Surgery. Global Spine J 2024; 14:370-379. [PMID: 35603925 PMCID: PMC10802539 DOI: 10.1177/21925682221104731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine the incidence of and risk factors for persistent opioid use after elective cervical and lumbar spine procedures and to quantify postoperative healthcare utilization in this patient population. METHODS Patients were retrospectively identified who underwent elective spine surgery for either cervical or lumbar degenerative pathology between November 1, 2013, and September 30, 2018, at a single academic center. Patients were split into 2 cohorts, including patients with and without opioid use at 180-days postoperatively. Baseline patient demographics, underlying comorbidities, surgical variables, and preoperative/postoperative opioid use were assessed. Health resource utilization metrics within 1 year postoperatively (ie, imaging studies, emergency and urgent care visits, hospital readmissions, opioid prescriptions, etc.) were compared between these 2 groups. RESULTS 583 patients met inclusion criteria, of which 16.6% had opioid persistence after surgery. Opioid persistence was associated with ASA score ≥3 (P = .004), diabetes (P = .019), class I obesity (P = .012), and an opioid prescription in the 60 days prior to surgery (P = .006). Independent risk factors for opioid persistence assessed via multivariate regression included multi-level lumbar fusion (RR = 2.957), cervical central stenosis (RR = 2.761), and pre-operative opioid use (RR = 2.668). Opioid persistence was associated with higher rates of health care utilization, including more radiographs (P < .001), computed tomography (CT) scans (.007), magnetic resonance imaging (MRI) studies (P = .014), emergency department (ED) visits (.009), pain medicine referrals (P < .001), and spinal injections (P = .003). CONCLUSIONS Opioid persistence is associated with higher rates of health care utilization within 1 year after elective spine surgery.
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Affiliation(s)
- Erik B. Gerlach
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Mark A. Plantz
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Peter R. Swiatek
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Scott A. Wu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Nicholas Arpey
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - David Fei-Zhang
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Srikanth N. Divi
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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Ruskin D, Szczech K, Tyrrell J, Isaac L. Innovative Program to Prevent Pediatric Chronic Postsurgical Pain: Patient Partner Feedback on Intervention Development. Healthcare (Basel) 2024; 12:360. [PMID: 38338245 PMCID: PMC10855720 DOI: 10.3390/healthcare12030360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The risk of developing chronic postsurgical pain (CPSP) in youth is related to psychological factors, including preoperative anxiety, depression, patient/caregiver pain catastrophizing, and poor self-efficacy in managing pain. While interventions exist to address these factors, they are generally brief and educational in nature. The current paper details patient partner feedback on the development of a psychologist-delivered perioperative psychological program (PPP) designed to identify and target psychological risk factors for CPSP and improve self-efficacy in managing pain. METHODS Qualitative interviews were conducted with two patients and their caregivers to discuss their surgical and pain management experience and to advise on components of the PPP. RESULTS Reflexive thematic analysis of interviews generated the following themes, which were incorporated into the content and implementation of the PPP: caregiver involvement, psychological and physical strategies for pain management, biopsychosocial pain education, intervention structure, and supporting materials. CONCLUSIONS The development of a novel psychologist-led PPP is a promising approach to mitigate mental health risks associated with pediatric CPSP and potentially boost postoperative outcomes and family wellbeing. Integrating patient partner feedback ensures that the PPP is relevant, acceptable, and aligned with the needs and preferences of the patients it is designed to serve.
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Affiliation(s)
- Danielle Ruskin
- Department of Psychology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (J.T.); (L.I.)
- Department of Psychology, York University, Toronto, ON M3J 1P3, Canada
| | - Klaudia Szczech
- Department of Psychology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
| | - Jennifer Tyrrell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (J.T.); (L.I.)
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (J.T.); (L.I.)
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
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Abed V, Khalily CD, Landy DC, Lemaster NG, Stone AV. Risk Factors Associated With Prolonged Opioid Use After Revision Total Shoulder Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202311000-00013. [PMID: 37976449 PMCID: PMC10659687 DOI: 10.5435/jaaosglobal-d-23-00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/20/2023] [Accepted: 10/10/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The purpose of this study was to determine which preoperative factors are associated with prolonged opioid use after revision total shoulder arthroplasty (TSA). METHODS The M157Ortho PearlDiver database was used to identify patients undergoing revision TSA between 2010 and 2021. Opioid use for longer than 1 month after surgery was defined as prolonged opioid use. Postoperative opioid use from 1 to 3 months was independently assessed. Multivariable logistic regression was used to evaluate the association between preoperative patient-related risk factors (age, Charlson Comorbidity Index, sex, depression, anxiety, substance use disorder, opioid use between 12 months to 1 week of surgery, tobacco use, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, osteoporosis, previous myocardial infarction, and chronic ischemic heart disease) with prolonged postoperative opioid use. Odds ratios (OR) and their associated 95% confidence intervals (CI) were calculated for each risk factor. RESULTS A total 14,887 patients (mean age = 67.1 years) were included. Most of the patients were female (53.3%), and a large proportion were opioid familiar (44.1%). Three months after revision TSA, older age (OR = 0.96, CI 0.96 to 0.97) and male sex (OR = 0.90, CI 0.81 to 0.99) were associated with a decreased risk of prolonged postoperative opioid usage. Patients with preexisting depression (OR = 1.21, CI 1.08 to 1.35), substance use disorder (OR = 1.47, CI 1.29 to 1.68), opioid use (OR = 16.25, CI 14.27 to 18.57), and chronic obstructive pulmonary disorder (OR = 1.24, CI 1.07 to 1.42) were at an increased risk of prolonged postoperative opioid use. DISCUSSION Older age and male sex were associated with a decreased risk of prolonged opioid use after revision TSA. Depression, substance use disorder, opioid familiarity, and COPD were associated with prolonged opioid use after revision TSA.
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Affiliation(s)
- Varag Abed
- From the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Camille D. Khalily
- From the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - David C. Landy
- From the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Nicole G. Lemaster
- From the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Austin V. Stone
- From the Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
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Lee Y, Issa TZ, Lambrechts MJ, Brush PL, Toci GR, Reddy YC, Fras SI, Mangan JJ, Canseco JA, Kurd M, Rihn JA, Kaye ID, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Comparison of Postoperative Opioid Use After Anterior Cervical Diskectomy and Fusion or Posterior Cervical Fusion. J Am Acad Orthop Surg 2023; 31:e665-e674. [PMID: 37126845 DOI: 10.5435/jaaos-d-23-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/28/2023] [Indexed: 05/03/2023] Open
Abstract
INTRODUCTION Posterior cervical fusion (PCF) and anterior cervical diskectomy and fusion (ACDF) are two main surgical management options for the treatment of cervical spondylotic myelopathy. Although ACDF is less invasive than PCF which should theoretically reduce postoperative pain, it is still unknown whether this leads to reduced opioid use. Our objective was to evaluate whether PCF increases postoperative opioid use compared with ACDF. METHODS We retrospectively identified all patients undergoing 2-level to 4-level ACDF or PCF at a single center from 2017 to 2021. Our state's prescription drug-monitoring program was queried for filled opioid prescriptions using milligrams morphine equivalents (MMEs) up to 1 year postoperatively. In-hospital opioid use was collected from the electronic medical record. Bivariate statistics compared ACDF and PCF cohorts. Multivariate linear regression was done to assess independent predictors of in-hospital opioid use and short-term (0 to 30 days), subacute (30 to 90 days), and long-term (3 to 12 months) opioid prescriptions. RESULTS We included 211 ACDF patients and 91 PCF patients. Patients undergoing PCF used more opioids during admission (126.7 vs. 51.0 MME, P < 0.001) and refilled more MMEs in the short-term (118.2 vs. 86.1, P = 0.001) but not subacute (33.6 vs. 19.7, P = 0.174) or long-term (85.6 vs. 47.8, P = 0.310) period. A similar percent of patients in both groups refilled at least one prescription after 90 days (39.6% vs. 33.2%, P = 0.287). PCF (β = 56.7, P = 0.001) and 30-day preoperative MMEs (β = 0.28, P = 0.041) were associated with greater in-hospital opioid requirements. PCF (β = 26.7, P = 0.039), C5 nerve root irritation (β = 51.4, P = 0.019), and a history of depression (β = 40.9, P < 0.001) were independently associated with 30-day postoperative MMEs. CONCLUSIONS PCF is initially more painful than ACDF but does not lead to persistent opioid use. Surgeons should optimize multimodal analgesia protocols to reduce long-term narcotic usage rather than change the surgical approach.Level of Evidence:III.
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Affiliation(s)
- Yunsoo Lee
- From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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