Role of the Perioperative Surgical Home in Optimizing the Perioperative Use of Opioids:

Creating a Framework for Minimizing Opioid Consumption after Office Based Surgery

PURPOSE OF REVIEW

Herein we review recent trends in opioid prescribing, the rise in office-based surgeries, and propose a framework to minimize opioid consumption following such procedures.

RECENT FINDINGS

Outpatient surgical procedures are increasing year over year in the United States. This observed increase is expected to continue due to the financial incentives to perform outpatient procedures. Office-based surgery is a setting that is expected to have tremendous growth. Still, currently there are scant safety guidelines concerning how to manage perioperative pain related to surgeries in this setting safely and effectively. Opioid abuse is rampant across the United States, and we anticipate that an increase in outpatient procedures will create a rise in opioid prescribing without appropriate discourse and planning. There are a variety of systematic factors in play to minimize opioid consumption after office-based surgery that must be considered at each operative phase. Careful planning and consideration of the multitude of factors can increase patient satisfaction while minimizing opioid prescriptions.

Chronic postsurgical pain and transitional pain services: a narrative review highlighting European perspectives

BACKGROUND/IMPORTANCE

Chronic postsurgical pain (CPSP) is a significant, often debilitating outcome of surgery, impacting patients' quality of life and placing a substantial burden on healthcare systems worldwide. CPSP (pain persisting for more than 3 months postsurgery) leads to both physical and psychological distress. Recognized as a distinct chronic pain entity in International Classification of Diseases, 11th Revision, CPSP enables better reporting and improved management strategies. Despite advancements in surgical care, CPSP remains prevalent, affecting 5%-85% of patients, with higher rates following thoracotomies, amputations, mastectomies and joint replacements.

OBJECTIVE

The acute to chronic pain transition involves complex interactions between peripheral and central mechanisms, with central sensitization playing a key role. Identifying high-risk patients is crucial for prevention, with factors such as surgical type, nerve injury, neuropathic elements in acute postoperative pain, and psychosocial conditions being significant contributors.

EVIDENCE REVIEW

Current pain management strategies, including multimodal therapy and regional anesthesia, show limited effectiveness in preventing CPSP. Neuromodulation interventions, though promising, are not yet established as preventive modalities.

FINDINGS

Transitional pain services (TPSs) offer a comprehensive, multidisciplinary approach to managing CPSP and reducing opioid dependence, addressing both physical and psychosocial aspects of functional recovery. While promising results have been seen in Canada and Finland, TPSs are not yet widely implemented in Europe. There is also growing interest in pain biomarkers, through initiatives such as the A2CPS program, aiming to improve CPSP prediction and develop targeted interventions.

CONCLUSIONS

Future research should focus on large-scale studies integrating various factors to facilitate CPSP prediction, refine prevention strategies and reduce its long-term impact.

Perioperative Opioid Use in Urogynecologic Mesh Removal

IMPORTANCE

Forty percent of patients with urogynecologic mesh pain complications are taking narcotics.

OBJECTIVES

We aimed to compare comorbidities and pain scores between patients with and without narcotic use and assess postoperative narcotic use rates.

STUDY DESIGN

This was a secondary analysis of a prospective cohort study of patients undergoing urogynecologic mesh removal. Patients with mesh removal for pain within 7 years were included due to data availability. Narcotic prescriptions were verified using the Pennsylvania Prescription Drug Monitoring Program. Pain scores were assessed at baseline and 6-24 months postoperatively.

RESULTS

Of 139 patients, 30 (21.6%) filled narcotic prescriptions within 3 months preceding surgery. These patients were younger and more likely to have a chronic pain condition. Narcotic use did not differ by sling versus prolapse mesh, or presence of exposure. Patients taking preoperative narcotics had a 27-point higher median baseline visual analog scale pelvic pain score (P = 0.01). Patients with pain comorbidities had 6 times odds of using preoperative narcotics. Younger patients had less improvement in pelvic pain after removal. Only 8 (27%) of those taking narcotics discontinued use postoperatively with no significant predictors of prolonged (≥3 months) use. Eighty-seven percent of patients with prolonged postoperative use had a prior pain diagnosis, commonly joint and back pain.

CONCLUSIONS

In patients with mesh-related pain, those with chronic pain conditions had much higher odds of taking preoperative narcotics, and in most, mesh removal did not eliminate narcotic use. Counseling is warranted in patients with chronic pain conditions that pain and narcotic use are likely to persist after removal.

Impact of a Transitional Pain Service on postoperative opioid trajectories: a retrospective cohort study

INTRODUCTION

It has been well described that a small but significant proportion of patients continue to use opioids months after surgical discharge. We sought to evaluate postdischarge opioid use of patients who were seen by a Transitional Pain Service compared with controls.

METHODS

We conducted a retrospective cohort study using administrative data of individuals who underwent surgery in Ontario, Canada from 2014 to 2018. Matched cohort pairs were created by matching Transitional Pain Service patients to patients of other academic hospitals in Ontario who were not enrolled in a Transitional Pain Service. Segmented regression was performed to assess changes in monthly mean daily opioid dosage.

RESULTS

A total of 209 Transitional Pain Service patients were matched to 209 patients who underwent surgery at other academic centers. Over the 12 months after surgery, the mean daily dose decreased by an estimated 3.53 morphine milligram equivalents (95% CI 2.67 to 4.39, p<0.001) per month for the Transitional Pain Service group, compared with a decline of only 1.05 morphine milligram equivalents (95% CI 0.43 to 1.66, p<0.001) for the controls. The difference-in-difference change in opioid use for the Transitional Pain Service group versus the control group was -2.48 morphine milligram equivalents per month (95% CI -3.54 to -1.43, p=0.003).

DISCUSSION

Patients enrolled in the Transitional Pain Service were able to achieve opioid dose reduction faster than in the control cohorts. The difficulty in finding an appropriate control group for this retrospective study highlights the need for future randomized controlled trials to determine efficacy.

Postsurgical opioid prescribing among veterans using community care for orthopedic surgery at non-VA hospitals compared to a VA hospital with a transitional pain service: a retrospective cohort study

BACKGROUND

The USA provides medical services to its military veterans through Veterans Health Administration (VHA) medical centers. Passage of recent legislation has increased the number of veterans having VHA-paid orthopedic surgery at non-VHA facilities.

METHODS

We conducted a retrospective cohort study among veterans who underwent orthopedic joint surgery paid for by the VHA either at the Salt Lake City VHA Medical Center (VAMC) or at non-VHA hospitals between January 2018 and December 2021. 562 patients were included in the study, of which 323 used a non-VHA hospital and 239 patients the VAMC. The number of opioid tablets prescribed at discharge, the total number prescribed by postdischarge day 90, and the number of patients still filling opioid prescriptions between 90 and 120 days after surgery were compared between groups.

RESULTS

Veterans who underwent orthopedic surgery at a non-VHA hospital were prescribed more opioid tablets at discharge (median (IQR)); (40 (30-60) non-VHA vs 30 (20-47.5) VAMC, p<0.001) and in the first 90 days after surgery than patients who had surgery at the Salt Lake City VAMC (60 (40-120) vs 35 (20-60), p<0.001). Patients who had surgery at Salt Lake City VAMC were also significantly less likely to fill opioid prescriptions past 90 days after hospital discharge (OR (95% CI) 0.06 (0.01 to 0.48), p=0.007).

CONCLUSION

These results suggest that veterans who have surgery at a veterans affairs hospital with a transitional pain service are at lower risk for larger opioid prescriptions both at discharge and within 90 days after surgery as well as persistent opioid use beyond 90 days after discharge than if they have surgery at a community hospital.

Transitional Pain Service: Optimizing Complex Surgical Patients

PURPOSE OF REVIEW

The care of patients with complex postsurgical pain can be challenging and burdensome for the healthcare system. Transitional pain service (TPS) is a relatively new concept and has not been widely adopted in the USA. This article explores the benefits and barriers of transitional pain services and describes the development of a TPS at our institution.

RECENT FINDINGS

Evidence from a few institutions that have adopted TPS has shown decreased postsurgical opioid consumption for patients on chronic opioids and decreased incidence of chronic postsurgical opioid use for opioid-naïve patients. The development of a transitional pain service may improve outcomes for these complex patients by providing longitudinal and multidisciplinary perioperative pain care. In this article, we describe the implementation of a TPS at a tertiary medical center. Our TPS model involves a multidisciplinary team of anesthesiologists, pain psychologists, surgeons, and advanced practice providers. We provide longitudinal care, including preoperative education and optimization; perioperative multimodal analgesic care; and longitudinal follow-up for 90 days post-procedure. With our TPS service, we aim to reduce long-term opioid use and improve functional outcomes for our patients.

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

Development and expansion of a pediatric transitional pain service to prevent complex chronic pain

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

Feasibility of a multidisciplinary Transitional Pain Service in spine surgery patients to minimise opioid use and improve perioperative outcomes: a quality improvement study

INTRODUCTION

Spine surgery patients have high rates of perioperative opioid consumption, with a chronic opioid use prevalence of 20%. A proposed solution is the implementation of a Transitional Pain Service (TPS), which provides patient-tailored multidisciplinary care. Its feasibility has not been demonstrated in spine surgery. The main objective of this study was to evaluate the feasibility of a TPS programme in patients undergoing spine surgery.

METHODS

Patients were recruited between July 2020 and November 2021 at a single, tertiary care academic centre. Success of our study was defined as: (1) enrolment: ability to enrol ≥80% of eligible patients, (2) data collection: ability to collect data for ≥80% of participants, including effectiveness measures (oral morphine equivalent (OME) and Visual Analogue Scale (VAS)-perceived analgesic management and overall health) and programme resource requirements measures (appointment attendance, 60-day return to emergency and length of stay), and (3) efficacy: estimate potential programme effectiveness defined as ≥80% of patients weaned back to their intake OME requirements at programme discharge.

RESULTS

Thirty out of 36 (83.3%) eligible patients were enrolled and 26 completed the TPS programme. The main programme outcomes and resource measures were successfully tracked for >80% of patients. All 26 patients had the same or lower OME at programme discharge than at intake (intake 38.75 mg vs discharge 12.50 mg; p<0.001). At TPS discharge, patients reported similar overall health VAS (pre 60.0 vs post 70.0; p=0.14), improved scores for VAS-perceived analgesic management (pre 47.6 vs post 75.6; p<0.001) and improved Brief Pain Inventory pain intensity (pre 39.1 vs post 25.0; p=0.02).

CONCLUSION

Our feasibility study successfully met or exceeded our three main objectives. Based on this success and the defined clinical need for a TPS programme, we plan to expand our TPS care model to include other surgical procedures at our centre.

Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF?

OBJECTIVE

The purpose of this study is to determine if increased postoperative prescription opioid dosing is an isolated predictor of chronic opioid use after anterior cervical diskectomy and fusion (ACDF).

METHODS

A retrospective cohort analysis of patients undergoing ACDF for degenerative diseases from 2016-2019 at a single institution was performed. Preoperative and postoperative opioid and benzodiazepine prescriptions, including morphine milligram equivalents (MMEs) and duration of use, were obtained from the Pennsylvania Prescription Drug Monitoring Program. Univariate analysis compared patient demographics and surgical factors across groups on the basis of postoperative opioid dose (high: MME ≥90, low: MME <90) and chronicity of use (chronic: ≥120 days or >10 prescriptions). Logistic regressions identified predictors of high opioid dose and chronic use.

RESULTS

A total of 385 patients were included. Preoperative opioid tolerance and tobacco use were associated with high postoperative opioid dose and chronic usage. Younger age correlated with high-dose prescriptions. Increased body mass index and preoperative benzodiazepine use were associated with chronic opioid use. Chronic postoperative opioid use correlated with high-dose prescriptions, change in opioid prescribed, private pay scripts, and more than 1 prescriber and pharmacy. Logistic regression identified high postoperative opioid dose, opioid tolerance, increased body mass index, and no prior cervical surgery as predictors of chronic opioid use. Regression analysis determined younger age, increased medical comorbidities, and opioid tolerance to be predictors for high MME prescriptions.

CONCLUSIONS

High postoperative opioid dose independently predicted chronic opioid use after ACDF regardless of preoperative opioid tolerance.

Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery

OBJECTIVES

To compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital.

DESIGN

We conducted a retrospective cohort study of Veterans who had orthopedic surgery at the Salt Lake City VA Medical Center (VAMC) between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital.

SETTING AND PARTICIPANTS

Veterans not already on chronic opioid therapy who had orthopedic surgery at the Salt Lake City VAMC and were followed by a transitional pain service.

METHODS

448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models.

RESULTS

Patients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P = .009].

CONCLUSIONS AND IMPLICATIONS

Veterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.

Incidence and patterns of persistent opioid use in children following appendectomy

BACKGROUND

The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children.

STUDY DESIGN

A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis.

RESULTS

1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%).

CONCLUSION

Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population.

LEVEL OF EVIDENCE

III.

A Web-based Educational Intervention to Increase Perianesthesia Nurses' Knowledge, Attitude, and Intention to Promote Safe Use, Storage, and Disposal of Opioids

PURPOSE

The purpose of this study was to determine if a web-based educational intervention increased knowledge, attitudes, and intention of perianesthesia nurses regarding opioid discharge education (including safe use, storage, and disposal of opioids). Secondary outcomes were to determine Perceived Behavioral Control, subjective norms, and familiarity with American Society of PeriAnesthesia Nurses (ASPAN) guidance on opioid education.

DESIGN

A pre-test, post-test longitudinal design.

METHODS

An email described the study and had a link for those choosing to participate. The intervention was a web-based voiceover module with patient education scenarios focused on information required for patients before discharge home. Responses to the evidence-based pre-survey, post-survey one, and post-survey two were collected. The survey was developed using components of the Theory of Planned Behavior. Data analysis included descriptive summary and evaluation of changes in knowledge and domains of Theory of Planned Behavior using repeated measures mixed modeling.

FINDINGS

The participants were invited to complete a pre-test survey (n = 672), the immediate post-test (n = 245), and the 4-week post-test (n = 172). The analysis presented is limited to 245 who completed at least the first post-survey. Most were staff nurses (82%), and the majority had a BSN (62%); participants most typically worked in a hospital-based PACU (73%). For all outcomes, there was an immediate increase in the measure following the intervention; this pairwise difference (between pretest and the immediate post-test) was significant in all but one of the models. The immediate and 4-week post-test scores exceeded the corresponding pre-test score, though for Perceived Behavioral Control, attitude, and intention, the degree of increase between baseline and week 4 was not significant.

CONCLUSIONS

In all cases, both the immediate and 4-week post-test scores exceeded the corresponding pre-test score, though, for three of the TPB constructs, the difference between baseline and week 4 was not significant, while nearly all of the increases between baseline and immediately following the intervention were significant. These findings suggest a more intensive intervention, possibly with the inclusion of booster sessions, may be needed.

Patient risk screening to improve transitions of care in surgical opioid prescribing: a qualitative study of provider perspectives

Introduction

In patients undergoing surgical procedures, transitions in opioid prescribing occur across multiple providers during the months before and after surgery. These transitions often result in high-risk and uncoordinated prescribing practices, especially for surgical patients with prior opioid exposure. However, perspectives of relevant providers about screening and care coordination to address these risks are unknown.

Methods

We conducted qualitative interviews with 24 surgery, primary care, and anesthesia providers in Michigan regarding behaviors and attitudes about screening surgical patients to inform perioperative opioid prescribing in relation to transitions of care. We used an interpretive description framework to topically code interview transcripts and synthesize underlying themes in analytical memos.

Results

Providers believed that coordinated, multidisciplinary approaches to identify patients at risk of poor pain and opioid-related outcomes could improve transitions of care for surgical opioid prescribing. Anesthesia and primary care providers saw value in knowing patients’ preoperative risk related to opioid use, while surgeons’ perceptions varied widely. Across specialties, most providers favored a screening tool if coupled with actionable recommendations, sufficient resources, and facilitated coordination between specialties. Providers identified a lack of pain specialists and a dearth of actionable guidelines to direct interventions for patients at high opioid-related risk as major limitations to the value of patient screening.

Discussion

These findings provide context to address risk from prescription opioids in surgical transitions of care, which should include identifying high-risk patients, implementing a coordinated plan, and emphasizing actionable recommendations.

A Multidisciplinary Transitional Pain Management Program Is Associated With Reduced Opioid Dependence After Primary Total Joint Arthroplasty

BACKGROUND

Overprescription of opioids after total joint arthroplasty (TJA) increases risks of opioid dependence, overdose, and death. The authors hypothesized that a multidisciplinary, perioperative pain management program (the Transitional Pain Service or TPS) for TJA would lead to fewer patients becoming opioid dependent.

METHODS

A TPS was implemented at a Veterans Affairs Medical Center focused on nonopioid pain management, cessation support, and prospective data tracking. A historical control, interventional study design was used to assess opioid use at 90 days post-discharge. Secondary analysis of the implementation group included post-operative outcome scores, time to opioid cessation, and median opioid tablets consumed at 90 days.

RESULTS

Fewer patients in the TPS group demonstrated persistent opioid use at 90 days post-discharge (0.7% vs 9.9%; P = .004). Independent predictors of total opioid tablet prescriptions included TPS (β = -19.41; 95% confidence interval [CI] -35.37 to -3.47), number of tablets prescribed at discharge (β = 1.08; 95% CI 0.86-1.31), and TKA surgery (β = 16.84; 95% CI 4.58-29.10). Under the TPS, median tablets consumed was 20.5 for THA and 36.5 for TKA; median time to cessation was shorter in THA (7 days; 95% CI 2-10) when compared to TKA (13 days; 95% CI 11-16).

CONCLUSION

In opioid-naïve veterans undergoing TJA, the TPS was associated with a 93% reduction in opioid dependence and a 60% reduction in opioid tablet prescriptions at 90 days post-discharge. Under the TPS, median 90-day opioid consumption was 20.5 and 36.5 tablets for THA and TKA, respectively. Widespread adoption of similar programs may greatly reduce opioid use and dependence in orthopedic patients nationally.

LEVEL OF EVIDENCE

III.

Intraoperative Acupuncture as Part of a Multimodal Analgesic Regimen to Reduce Opioid Usage After Total Knee Arthroplasty: A Prospective Cohort Trial

Objective: Given the U.S. opioid crisis, surgeons and anesthesiologists must collaborate to optimize nonopioid analgesics perioperatively. A common surgical procedure, total knee arthroplasty (TKA) is a critical target for opioid reduction and development of enhanced recovery protocols. Auricular therapy can help reduce pain and opioid analgesic use in the perioperative timeperiod, but intraoperative use for TKA has yet to be explored. The aim of the present study was to investigate the effect of integrating intraoperative auricular therapy as part of an opioid-sparing protocol for TKA. Materials and Methods: In this prospective cohort study, 41 patients undergoing primary unilateral TKA under neuraxial anesthesia received a standardized, opioid-free intraoperative protocol including electroauricular acupuncture. The primary outcome was the number of patients able to remain on a low-dose opioid regimen: ≤112.5 oral morphine equivalents. Additional outcomes included patient-reported pain scores, side-effects, and prior experience with acupuncture. Results: Of the 40 patients who completed the study, 26 (65%) maintained a low-dose opioid regimen, with 3 (7%) remaining opioid-free for 30 days. No subjects used opioids beyond 30 days. Mean pain scores were low at rest (Day 0: 3.4, standard deviation [SD] 2.4; Day 1: 2.4, SD 1.8) and moderate with movement (Day 0: 4.8, SD 2.6; Day 1: 5.1, SD 2.1). The most-common side-effects were dry mouth (43.2%), drowsiness (24.3%), and lightheadedness (24.3%). Conclusions: Incorporating intraoperative electroauricular acupuncture into an existing multimodal analgesia regimen is a feasible way to maintain a low-dose opioid regimen after TKA. This research was registered at clinicaltrials.gov as Clinical Trial Number: NCT#04084288.

Preoperative Opioid Use and Readmissions Following Surgery

OBJECTIVE

To assess the association between preoperative opioid exposure and readmissions following common surgery.

SUMMARY BACKGROUND DATA

Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown.

METHODS

We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type.

RESULTS

Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29).

CONCLUSIONS

Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.

Variability in discharge opioid prescribing practices for children: a historical cohort study

PURPOSE

Legitimate opioid prescriptions can increase the risk of misuse, addiction, and overdose of opioids in children and adolescents. This study aimed to describe the prescribing patterns of discharge opioid analgesics following inpatient visits and to determine patient and prescriber characteristics that are associated with prolonged opioid prescription.

METHODS

In a historical cohort study, we identified patients discharged from hospital with an opioid analgesic prescription in a tertiary pediatric hospital from 1 January 2016 to 30 June 2017. The primary outcome was the duration of opioid prescription in number of days. We assessed the association between patient and prescriber characteristics and an opioid prescription duration > five days using a generalized estimating equation to account for clustering due to repeated admissions of the same patient.

RESULTS

During the 18-month study period, 15.4% of all admitted patients (3,787/24,571) were given a total of 3,870 opioid prescriptions at discharge. The median [interquartile range] prescribed duration of outpatient opioid therapy was 3.75 [3.00-5.00] days. Seventy-seven percent of the opioid prescriptions were for five days or less. Generalized estimating equation analysis revealed that hospital stay > four days, oxycodone prescription, and prescription by clinical fellows and the orthopedics service were all independently associated with a discharge opioid prescription of > five days.

CONCLUSIONS

Most discharge opioids for children were prescribed for less than five days, consistent with current guidelines for adults. Nevertheless, the dosage and duration of opioids prescribed at discharge varied widely.

Validation of the Hospital Frailty Risk Score in older surgical patients: A population-based retrospective cohort study

BACKGROUND

There is a need for standardized and cost-effective identification of frailty risk. The objective was to validate the Hospital Frailty Risk Score which utilizes International Classification Diagnoses in a cohort of older surgical patients, assess the score as an independent risk factor for adverse outcomes and compare discrimination properties of the frailty risk score with other risk stratification scores.

METHODS

Data were analysed from all patients ≥65 years undergoing primary surgical procedures from 2006-2018. Patients were categorized based on the frailty risk score. The primary outcomes were 30-day mortality and 180-day risk of readmission.

RESULTS

Of 16 793 patients evaluated, 7480 (45%), 7605 (45%) and 1708 (10%) had a low, intermediate and high risk of frailty. There was a higher incidence of 30-day mortality for individuals with intermediate (2.9%) and high (8.3%) compared with low (1.4%) risk of frailty (P < .001 for both comparisons). Similarly, the hazard of readmission within the first 180 days was higher for intermediate (HR 1.25; 95% CI: 1.16-1.34) and high (HR 1.84; 95% CI: 1.66-2.03) compared with low (HR 1.00, P < .001 for both comparisons) risk of frailty. The hazard of long-term mortality was higher for intermediate (HR 1.70; 95% CI: 1.61-1.80) and high (HR 4.16; 95% CI: 3.84-4.49) compared with low (HR 1.00, P < .001 for both comparisons) risk of frailty. Finally, long length of primary hospitalization occurred for 9.3%, 15.0% and 27.3% of individuals with low, intermediate and high frailty risk (P < .001 for all comparisons). A model including age and ASA classification had the best discrimination for 30-day mortality (AUC 0.862; 95% CI: 0.847-0.877).

CONCLUSION

Our findings suggest that the Hospital Frailty Risk Score might be used to screen older surgical patients for risk of frailty. While only slightly improving prediction of 30-day mortality using the ASA classification, the Hospital Frailty Risk Score can be used to independently classify older patients for the risk of important outcomes using pre-existing readily available electronic data.

Impact of Structured Patient-Centered Preoperative Pain Consult and Interventions From a Dedicated Perioperative Pain Service: A Case Series of 4 Patients

Opioid-tolerant individuals have greater risk of perioperative complications and worse clinical outcomes. A preoperative screening process and structured approach to opioid-tolerant patients was developed to identify and optimize these patients before elective surgery.

Impact of Substance Use and Abuse on Opioid Demand in Lower Extremity Fracture Surgery

OBJECTIVES

To describe the perioperative opioid demand in a large population of patients undergoing lower extremity fracture fixation and to evaluate mental disorders such as substance abuse as risk factors for increased use.

DESIGN

Retrospective, observational.

SETTING

National insurance claims database.

PATIENTS/PARTICIPANTS

Twenty-three four hundred forty-one patients grouped by mental disorders such as depression, psychoses, alcohol abuse, tobacco abuse, drug abuse, and preoperative opioid filling undergoing operative treatment of lower extremity fractures (femoral shaft through ankle) between 2007 and 2017.

INTERVENTION

Operative treatment of lower extremity fractures.

MAIN OUTCOME MEASURES

The primary outcome was filled opioid prescription volume converted to oxycodone 5-mg pill equivalents. Secondary outcomes included the number of filled prescriptions and the risk of obtaining 2 or more opioid prescriptions.

RESULTS

Of 23,441 patients, 16,618 (70.9%), 8862 (37.8%), and 18,084 (77.1%) filled opioid prescriptions within 1-month preop to 90-day postop, 3-month postop to 1-year postop, and 1-month preop to 1-year postop, respectively. On average, patients filled 104, 69, and 173 oxycodone 5-mg pills at those time intervals. Alcohol, tobacco, drug abuse, and preoperative opioid filling were associated with increased perioperative opioid demand. Psychoses had a small effect on opioid demand, and depression had no significant impact.

CONCLUSIONS

This study reports the rate and volume of opioid prescription filling in patients undergoing lower extremity fracture surgery. Substance use and abuse were the main risk factors for increased perioperative opioid prescription filling. Providers should recognize these risk factors for increased use and be judicious when prescribing opioids. Enhanced patient education, increased nonopioid pain management strategies, and referral for substance use and abuse treatment may be helpful for these patients.

LEVEL OF EVIDENCE

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

LEVEL OF EVIDENCE

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

Perioperative Opioid Administration

Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.

In the Arms of Morpheus without Morphia; Mitigating the United States Opioid Epidemic by Decreasing the Surgical Use of Opioids

The opioid epidemic is a major public health issue in the United States. Exposure of opioid naïve-patients to opioids in the perioperative period is a well-documented source of continued use with one in 20 opioid-naïve surgical patients continuing to use opioids beyond 90 days. There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure. Causal factors include over reliance on opioids for intraoperative and postoperative analgesia and excessive ambulatory opioid prescribing. Opioid-induced hyperalgesia can paradoxically result from intraoperative (anesthesia controlled) opioid administration. Increasing size of initial prescription is a strong predictor of continued use necessitating procedure specific supplies limited to under 3-days. Alternative multimodal pain management (non-opioid medications and regional anesthesia) that limit opioid use must be a high priority with opioids reserved for severe breakthrough pain. Barriers to implementation of opioid-sparing pathways include reluctance to adopt protocols and apprehension about opioid elimination. Considering the number of surgeries performed annually in the United States, perioperative physicians must aggressively address modifiable factors in surgical patients. Patient care pathways need to be constructed collaboratively by surgeons and anesthesiologists with continuing feedback to optimize patient outcomes including iatrogenic opioid dependence.

The Impact of Mental Health and Substance Use on Opioid Demand After Hip Fracture Surgery

INTRODUCTION

Mental health and substance use and abuse disorders have been associated with poor patient-reported outcomes. Despite the prevalence of hip fractures in the United States, the relationship between opioid demand and these factors in hip fracture surgery is not well understood. The purpose of this study is to describe opioid filling volume and rates after hip fracture surgery and to identify mental health risk factors for increased demand. The study hypothesis is that psychiatric comorbidities such as depression and psychoses as well as substance use and abuse indicators such as pre-op opioid dependence, drug, alcohol, and tobacco abuse would be associated with increased perioperative opioid demand.

METHODS

This is a retrospective cohort study of 40,514 patients undergoing surgical fixation of hip fractures using a commercially available insurance database. The primary patient-level outcome was filled opioid prescription volume in oral morphine milliequivalents converted to oxycodone 5-mg equivalents up to 1-year post-op. Adjusted measures of overall quantities filled and refill rates were assessed with multivariable main effects linear and logistic regression models.

RESULTS

Twenty four thousand four hundred forty-one of 40,514 patients (60.3%) filled opioid prescriptions within 7 days pre-op to 1-year post-op. Patients filling prescriptions filled a mean of 187.7 oxycodone 5-mg equivalents. Sixteen thousand five hundred seventy-seven patients (41.1%) filled two or more opioid prescriptions within 7 days pre-op to 1-year post-op. Fifteen thousand two hundred seventy-nine patients (37.7%) filled an opioid prescription between 3 months post-op and 1-year post-op, and 8,502 patients (21%) filled an opioid prescription between 9 months post-op and 1-year post-op. In multivariable models, age, pre-op opioid filling, depression, tobacco abuse, and drug abuse were risk factors significantly associated with increased perioperative opioid filling. Psychoses had a mixed effect on outcomes with decreased early perioperative filling and increased late perioperative filling. Pre-op opioid filling had the largest impact on perioperative opioid demand.

DISCUSSION

Pre-op opioid filling and drug abuse were the main mental health-related drivers of increased perioperative opioid prescription filling. Depression, psychoses, alcohol abuse, and tobacco abuse had small effects on prescription filling. These results can help identify patients at risk for increased opioid demand who may benefit from additional counseling, maximizing alternative pain management strategies, and possible referral to pain management specialists.

LEVEL OF EVIDENCE

Level III, retrospective, prognostic cohort study.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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.

Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction

BACKGROUND

With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions. Enhanced Recovery After Surgery (ERAS) is a comprehensive multidisciplinary perioperative protocol that includes minimization of opioid analgesia in favor of non-opioid alternatives and regional analgesia. While ERAS protocols have consistently been shown to decrease inpatient opioid utilization, the impact on opioid prescribing practices and use after discharge in pediatric surgical patients is unclear.

OBJECTIVE

This study aims to assess the impact of an ERAS protocol on outpatient opioid prescription patterns after pediatric lower urinary tract reconstructive surgery. We hypothesize that implementation of an ERAS protocol leads to fewer outpatient opioid prescriptions as measured by number and total quantity of oral morphine milligram equivalents by body weight per patient.

METHODS

All patients who underwent bladder augmentation, creation of a continent catheterizable channel, bladder neck reconstruction or closure, or revision of prior reconstructive procedures at our tertiary care facility between 2011 and 2017 were reviewed. Patients were divided into pre-ERAS and ERAS cohorts based on whether surgery occurred before or after ERAS implementation. The Colorado Prescription Drug Monitoring Program was used to track filling of postoperative opioid prescriptions for patients covered by the database.

RESULTS

A total of 167 urologic reconstructive surgeries were analyzed, including 83 before ERAS and 84 after ERAS implementation. Patients in the ERAS cohort received and filled more outpatient opioid prescriptions at time of discharge (82.6% historical vs 93.9% ERAS, p = 0.015; 76.1% vs 57.9%, p = 0.012). There were no differences in prescription total morphine milligram equivalents normalized to body mass, total days supplied, or 90-day opioid prescription refill rates.

DISCUSSION

We found an unexpected increase in postoperative outpatient opioid prescriptions following implementation of an ERAS protocol for lower urinary tract reconstructive surgery. Possible reasons include worry about pain crisis at home in the setting of decreased hospital length of stay in the ERAS cohort or generalized upward drift in opioid prescribing patterns over time. ERAS protocols in other subspecialties reveal mixed findings but consistently suggest standardization of outpatient opioid prescribing patterns leads to a decrease in opioid prescriptions.

CONCLUSIONS

Patients received more, not fewer, outpatient opioid prescriptions following major urologic reconstructive surgery after implementation of an ERAS protocol. Purposeful efforts should be made to standardize opioid prescriptions at discharge based on meaningful clinical criteria.

Effects of an anesthesia perioperative surgical home for total knee and hip arthroplasty at a Veterans Affairs Hospital: a quality improvement before-and-after cohort study

BACKGROUND

A perioperative surgical home, the Anesthesia Perioperative Care Service (APCS), was created to execute enhanced recovery after surgery pathways for total knee and total hip arthroplasty patients at the Tennessee Valley Health System Nashville VA Medical Center. We hypothesized that the APCS would be associated with reduced length of stay, in-hospital and post-discharge opioid exposure, costs, and hospital readmissions.

METHODS

Data were collected for all patients admitted to the Nashville VA Medical Center following their respective surgery, for 400 days after the initiation of the APCS and for a 400-day period prior. This cohort study was based on a quality improvement project set up at the initiation of the service. The adjusted effect on each quantitative outcome was evaluated using proportional odds logistic regression methods. In addition, each regression analysis was performed in segmented regression fashion to identify changes in the outcomes over time.

RESULTS

We included 282 patients in our cohort-96 prior and 186 post-implementation. Median hospital length of stay, intravenous (IV) and per os (PO) inpatient opioid administration, outpatient opioid quantity, and total days of supply were all reduced in the cohort cared for by the APCS. After adjusting for potential cofounders and evaluated outcome over time, the APCS remained independently associated with a reduction of hospital length of stay of one day (95% confidence interval, 0.09 to 1.97; P = 0.05) and with decreased IV and PO inpatient opioid administration, while continuing to show no increase in hospital readmissions.

CONCLUSIONS

This cohort study showed significant improvements in important post-surgical outcomes after total knee and hip arthroplasty that were associated with the implementation of an APCS.

Incidence of and Factors Associated With Prolonged and Persistent Postoperative Opioid Use in Children 0-18 Years of Age

BACKGROUND

Long-term opioid use has negative health care consequences. Opioid-naïve adults are at risk for prolonged and persistent opioid use after surgery. While these outcomes have been examined in some adolescent and teenage populations, little is known about the risk of prolonged and persistent postoperative opioid use after common surgeries compared to children who do not undergo surgery and factors associated with these issues among pediatric surgical patients of all ages.

METHODS

Using a national administrative claims database, we identified 175,878 surgical visits by opioid-naïve children aged ≤18 years who underwent ≥1 of the 20 most common surgeries from each of 4 age groups between December 31, 2002, and December 30, 2017, and who filled a perioperative opioid prescription 30 days before to 14 days after surgery. Prolonged opioid use after surgery (filling ≥1 opioid prescription 90-180 days after surgery) was compared to a reference sample of 1,354,909 nonsurgical patients randomly assigned a false "surgery" date. Multivariable logistic regression models were used to estimate the association of surgical procedures and 22 other variables of interest with prolonged opioid use and persistent postoperative opioid use (filling ≥60 days' supply of opioids 90-365 days after surgery) for each age group.

RESULTS

Prolonged opioid use after surgery occurred in 0.77%, 0.76%, 1.00%, and 3.80% of surgical patients ages 0-<2, 2-<6, 6-<12, and 12-18, respectively. It was significantly more common in surgical patients than in nonsurgical patients (ages 0-<2: odds ratio [OR] = 4.6 [95% confidence interval (CI), 3.7-5.6]; ages 2-<6: OR = 2.5 [95% CI, 2.1-2.8]; ages 6-<12: OR = 2.1 [95% CI, 1.9-2.4]; and ages 12-18: OR = 1.8 [95% CI, 1.7-1.9]). In the multivariable models for ages 0-<12 years, few surgical procedures and none of the other variables of interest were associated with prolonged opioid use. In the models for ages 12-18 years, 10 surgical procedures and 5 other variables of interest were associated with prolonged opioid use. Persistent postoperative opioid use occurred in <0.1% of patients in all age groups.

CONCLUSIONS

Some patient characteristics and surgeries are positively and negatively associated with prolonged opioid use in opioid-naïve children of all ages, but persistent opioid use is rare. Specific pediatric subpopulations (eg, older patients with a history of mood/personality disorder or chronic pain) may be at markedly higher risk.

Multidisciplinary Transitional Pain Service for the Veteran Population

BACKGROUND

For patients with existing chronic opioid use or a history of substance use disorder, often little presurgical planning or postsurgical coordination of care among surgeons, primary care providers, or addiction care providers occurs.

METHODS

In 2018, we developed the Transitional Pain Service (TPS) to identify at-risk patients as soon as they were indicated for surgery, to allow time for evaluation, education, and developing an individualized pain plan, and opioid taper prior to surgery if indicated. An electronic dashboard registry of surgical episodes provided data to TPS providers and included baseline history, morphine equivalent daily dose, and patient-reported pain outcomes, using measures from the Patient-Reported Outcome Measurement System for pain intensity, pain interference, and physical function, and a pain-catastrophizing scale score.

RESULTS

Two-hundred thirteen patients were enrolled between January and December 2018. Nearly all (99%) patients had ≥ 1 successful follow-up within 14 days after discharge; 96% had ≥ 1 follow-up between 14 and 30 days after surgery; and 72% had completed personal follow-up 90 days after discharge.

CONCLUSIONS

In 2018 the overall use of opioids after orthopedic surgery decreased by > 40% from the previous year. Despite this more restricted use of opioids, pain interference and physical function scores indicated that surgical patients do not seem to experience increased pain or reduced physical function.

Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service

BACKGROUND

Chronic postsurgical pain and opioid use is a problem among patients undergoing many types of surgical procedures. A multidisciplinary approach to perioperative pain management known as a transitional pain service (TPS) may lower these risks.

METHODS

This retrospective cohort study was conducted at the Salt Lake City VA Medical Center to compare patients undergoing elective primary or revision total knee, hip, or shoulder replacement or rotator cuff repair in the year before (2017) and after (2018) implementation of a TPS. The primary outcome is the proportion of patients taking opioids 90 days after surgery. Secondary outcomes include new chronic opioid use (COU) after surgery as well as the proportion of previous chronic opioid users who stopped or decreased opioid use after surgery.

RESULTS

At 90 days after surgery, patients enrolled in TPS were significantly less likely to be taking opioids (13.4% TPS vs 27.3% pre-TPS; p=0.002). This relationship remained statistically significant in a multivariable logistic regression analysis, where the TPS group had 69% lower odds of postoperative COU compared with the preintervention group (OR: 0.31; 95% CI: 0.14 to 0.66; p=0.03). Opioid-naive patients enrolled in TPS were less likely to have new COU after surgery (0.7% TPS vs 8.4% pre-TPS; p=0.004). Further, patients enrolled in TPS with existing COU prior to surgery were more likely to reduce or completely stop opioid use after surgery (67.5% TPS vs 45.3% pre-TPS; p=0.037) as compared with pre-TPS.

CONCLUSIONS

These data suggest that a TPS is an effective strategy for preventing new COU and reducing overall opioid use following orthopedic joint procedures in a Veterans Affairs hospital.

Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study

BACKGROUND

Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery.

MATERIALS AND METHODS

We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis.

RESULTS

One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription.

CONCLUSIONS

Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.

[Transdermal buprenorphine for acute postoperative pain: a systematic review]

BACKGROUND AND OBJECTIVES

Postoperative pain is still a major concern in several surgical procedures. Multimodal analgesia is best for postoperative pain management; however, opioid therapy is still the main treatment for pain after surgical procedures. Transdermal buprenorphine is a partial μ agonist opioid widely used for chronic pain syndromes, with limited evidence for acute postoperative pain. A systematic review of studies examining transdermal buprenorphine for acute pain management after surgery was conducted.

CONTENTS

Data from PubMed, Embase, The Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL via EBSCOhost, and LILACS were reviewed, including randomized clinical trials that evaluated total postoperative pain, postoperative analgesic consumption, drug-related side effects and patient satisfaction with analgesia regimen. Data from nine studies (615 patients) were included in this review. Most studies initiated transdermal buprenorphine use 6 to 48 hours before surgery, maintaining use from 1 to 8 days after the procedure. Most studies showed lower or similar postoperative pain scores, postoperative analgesic consumption and patient satisfaction comparing buprenorphine to placebo, tramadol, celecoxib, flurbiprofen and parecoxib. The incidence of side effects varied between studies, with most showing no increase in drug-related side effects with buprenorphine use, except one study, which compared buprenorphine to oral tramadol, and one to transdermal fentanyl. However, most results were derived from evidence with an overall high or unclear risk of bias.

CONCLUSIONS

Although more studies are necessary, initial results show that transdermal buprenorphine seems to be an effective and safe opioid choice for management of acute postoperative pain.

Opioid free anesthesia: feasible?

PURPOSE OF REVIEW

The present review aims to address the feasibility of opioid free anesthesia (OFA). The use of opioids to provide adequate perioperative pain management has been a central practice of anesthesia, and only recently has been challenged. Understanding the goals and challenges of OFA is essential as the approach to intraoperative analgesia and postsurgical management of pain has shifted in response to the opioid epidemic in the United States.

RECENT FINDINGS

OFA is an opioid sparing technique, which focuses on multimodal or balanced analgesia, relying on nonopioid adjuncts and regional anesthesia. Enhanced recovery after surgery protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery.

SUMMARY

The feasibility of OFA is evident. However, there are limitations of this approach that warrant discussion including the potential for adverse drug interactions with multimodal analgesics, the need for providers trained in regional anesthesia, and the management of pain expectations. Additionally, minimizing opioid use perioperatively also requires a change in current prescribing practices. Monitors that can reliably quantify nociception would be helpful in the titration of these analgesics and enable anesthesiologists to achieve the goal in providing personalized perioperative medicine.

Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework

Purpose

Millions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.

Methods

We reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.

Results

Opioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment’s ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.

Conclusions

The severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.

Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program

Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.

Transition from acute to chronic pain after surgery

Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Research into how and why this transition occurs has led to a stronger appreciation of opioid-induced hyperalgesia, use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. This Series provides an overview of the epidemiology and societal effect, basic science, and current recommendations for managing persistent postsurgical pain. We discuss the advances in the prevention of this transitional pain state, with the aim to promote safer analgesic regimens to better manage patients with acute and chronic pain.