Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis

Comparing modalities of opioid education in patients undergoing total knee arthroplasty: a randomized pilot trial

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain and routinely require opioids, yet they often lack knowledge regarding appropriate use and handling of these medications. Evidence suggests that educational interventions in various formats may help reinforce proper usage and improve postoperative pain control. The aim of this study is to compare the institution standard of care (webinar) with two novel educational interventions-one in-person and the other a video recording-that focus specifically on the use of opioids and pain control.

METHODS

This prospective, randomized pilot study included 42 patients undergoing TKA. Patients were randomized into one of three groups: (1) webinar: 50 min virtual session standard of care at Hospital for Special Surgery (HSS), (2) in-person education, or (3) video education. The primary outcomes of this study were the number of opioid refill requests through postoperative day (POD) 30 and POD 60. The secondary outcomes evaluated Numerical Rating Scale (NRS) pain scores, opioid consumption in oral morphine equivalents (OME), surveys on medication usage and opioid knowledge, reported medication storage and disposal. We hypothesize that the novel educational interventions, presented either in-person or by video, will lead to a decrease in opioid refills within 60 days compared with current education delivered through virtual webinar.

RESULTS

No significant differences were found among groups in the number of opioid refill requests, average NRS pain score, or OME consumption at any time point. Opioid refill requests ranged from 0% to 16.7% at POD 30 (Fisher's exact test, p=0.625) and from 0% to 8.3% at POD 60 (p=1.000). The median opioid refill request was zero requests per group from POD 21 to 60 (webinar 0 (0.0, 0.0), in-person 0 (0.0, 0.0), video 0 (0.0, 0.0), Kruskal-Wallis test, p=0.381). Average NRS pain scores were 5 or below for all groups on POD 1, 7 and 14. By POD 7, all groups had an average daily intake OME of 14 or below.

CONCLUSIONS

Overall, patients in each group did well with postoperative pain management after TKA and had minimal opioid refill requests. There were no statistically significant differences in outcomes of NRS pain scores or opioid usage among groups suggesting that educational interventions were similarly effective. As a pilot trial, study demonstrated successful recruitment and retention of participants, and important feedback was elicited from patients regarding education, as well. Of note, this was a pilot study and was likely underpowered to detect a difference.

TRIAL REGISTRATION NUMBER

NCT05593341.

Deprescribing: An umbrella review

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Opioid prescribing for acute postoperative pain: an overview of systematic reviews related to two consensus statements relevant at patient, prescriber, system and public health levels

BACKGROUND

National guidelines for rational opioid prescribing for acute postoperative pain are needed to optimise postoperative pain control and function whilst minimising opioid-related harm.

OBJECTIVES

This overview of systematic reviews aims to summarise and critically assess the quality of systematic reviews related to the 20 recommendations from two previously published consensus guideline papers (ten relevant at patient and prescriber levels and ten at a system / Public Health level). It also aims to identify gaps in research that require further efforts to fill these in order to augment the evidence behind creating national guidelines for rational opioid prescribing for acute postoperative pain.

METHODS

A systematic database search using PubMed/MEDLINE and Cochrane was conducted in November 2022. Furthermore, reference lists were reviewed. All identified systematic reviews were assessed for eligibility. Data from each study was extracted using a pre-standardised data extraction form. The methodological quality of the included reviews was assessed by two independent reviewers using the AMSTAR 2 checklist. Descriptive synthesis of the results was performed.

RESULTS

A total of 12 papers were eligible for analysis. Only eight out of the total 20 prioritised recommendations had systematic reviews that provided evidence related to them. These systematic reviews were most commonly of critically low quality.

CONCLUSION

The consensus papers provide guidance and recommendations based on the consensus of expert opinion that is based on the best available evidence. However, there is a lack of evidence supporting many of these consensus statements. Efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should therefore continue.

How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients

Introduction

Diversion of unused prescription opioids is a common source of opioid sensitization in the community. Educating patients about safe opioid use has been shown to be effective in decreasing opioid use. However, decreasing diversion will also require educating patients on proper opioid disposal. A survey was administered to better understand patients’ habits with opioid disposal for opioids prescribed after orthopedic surgery.

Methods

A cross-sectional survey study of 469 patients who had undergone orthopedic surgery was conducted to learn their preferences and habits regarding the disposal of unused prescription opioids received after orthopedic surgery.

Results

The survey respondents consisted of 48.8% female and 51.2% male patients. Ninety-four point two percent (94.2%) of those receiving opioid prescriptions reported having leftover unused opioids. In terms of voluntary disposal, 68.8% claimed to dispose of their prescription opioids while 31.2% did not. Gender, but not age, had a significant effect on plans for opioid disposal and how seriously respondents viewed issues of opioid misuse. When asked their preferred location for prescription opioid disposal, the most common preference was a local pharmacy.

Discussion

This survey identified that most patients do not store their prescription opioids in a locked location, claim to dispose of their unused prescription opioids, and would prefer to dispose of them at a pharmacy if possible. This information points to the need for close prescriber-to-pharmacy collaboration to promote the safe disposal of prescription opioids and mitigate drug diversion.