Racial Differences in Postoperative Opioid Prescribing Practices in Spine Surgical Patients

Disparities in Postoperative Pain Management: A Scoping Review of Prescription Practices and Social Determinants of Health

Background: Opioid analgesic therapy has been traditionally used for pain management; however, the variability in patient characteristics, complexity in evaluating pain, availability of treatment within facilities, and U.S. physicians overprescribing opioids have contributed to the current opioid epidemic. Despite large research efforts investigating the patterns of postsurgical pain management and influencing factors, it remains unclear how these overall trends vary across the varying sizes and available resources of academic hospitals, community hospitals, and outpatient surgery centers. The primary aim of this scoping review was to examine the patterns of contemporary postoperative pain management across healthcare settings, including academic medical centers, community hospitals, and outpatient surgery centers. Specifically, this study investigates how prescription practices for opioids, NSAIDs, and acetaminophen are influenced by patient demographics, including sex, race, gender, insurance status, and other social determinants of health (SDoH), to inform equitable and patient-centered pain management strategies. Methods: This study utilized The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and was used as a reference checklist. The Arksey and O'Malley methodological framework was used to guide the review process. To ensure comprehensive coverage, searches were conducted across three major databases: PubMed, Embase, and Cochrane Library. Results: A total of 43 eligible studies were retained for analysis. The highest reported Healthy People 2030 category was Social and community context (n = 39), while the highest reported category of SDoH was age (n = 36). A total of 34 articles listed sex and age as SDoH. Additional SDoH examined were race/ethnicity (n = 17), insurance (n = 7), employment (n = 1), education (n = 4), and income (n = 1). This review suggests that there are significant gaps in the implementation of institution-specific, patient-centered, and equitable pain management strategies, particularly in academic hospitals, which our findings show have the highest rates of opioid and NSAID prescriptions (n = 26) compared to outpatient surgical centers (n = 8). Findings from our review of the literature demonstrated that while academic hospitals often adopt enhanced recovery protocols aimed at reducing opioid dependence, these protocols can fail to address the diverse needs of at-risk populations, such as those with chronic substance use, low socioeconomic status, or racial and ethnic minorities. Conclusions: Findings from this review are expected to have implications for informing both organizational-specific and nationwide policy recommendations, potentially leading to more personalized and equitable pain management strategies across different healthcare settings. These include guidelines for clinicians on addressing various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care.

Incidence and influential factors of postoperative pruritus in morphine-based intravenous patient-controlled analgesia

BACKGROUND

Pruritus is a distressing symptom of systemic opioid analgesia that responds poorly to conventional anti-pruritus treatments. This study aimed to determine the incidence and risk factors for postoperative pruritus using intravenous patient-controlled analgesia (IV-PCA).

METHODS

Opioid-naïve patients who underwent morphine-based IV-PCA for postoperative pain at a tertiary center between January 1, 2020 and June 30, 2023, were included retrospectively. The primary outcome was pruritus within 72 hours after surgery. Cumulative morphine consumption and pain numerical rating scores were measured to evaluate the potential impact of pruritus on postoperative pain control.

RESULTS

A total of 1696 patients were enrolled, of whom 119 (7.0%) developed pruritus during the study period. Five independent factors for pruritus were identified, including intraoperative uses of hydroxyethyl starch solutions (adjusted odds ratio [aOR]: 0.13, 95% CI, 0.04-0.43), lockout interval of IV-PCA (aOR: 0.50, 95% CI, 0.27-0.94, on base-2 logarithmic scale), droperidol addition to morphine solutions (aOR: 0.53, 95% CI, 0.35-0.81), cumulative morphine dose (aOR: 1.76, 95% CI, 1.47-2.12, on base-2 logarithmic scale), and postoperative uses of antihistamines (aOR: 2.90, 95% CI, 1.83-4.60) (c-statistic = 0.745). Patients with pruritus had higher postoperative morphine consumption (median: 67.5 mg, interquartile range: 38.3-94.0 vs 38.0 mg, 21.0-65.4, p < 0.001) but similar pain intensity compared to those without pruritus.

CONCLUSION

Increasing the lockout interval and the droperidol regimen may protect patients from morphine-induced pruritus after IV-PCA. Further studies are warranted to clarify the mechanisms underlying the anti-pruritus effects of hydroxyethyl starch.

Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty

BACKGROUND

There is increasing interest in documenting disparities in pain management for racial and ethnic minorities and patients with language barriers. Previous studies have found differential prescription patterns of opioids for racial and ethnic minority group and patients having limited English proficiency (LEP) after arthroplasty. However, there is a knowledge gap regarding how the intersection of these sociodemographic factors is associated with immediate postoperative pain management. This study aimed to explore language and racial-ethnic disparities in short-term opioid utilization after total hip and knee arthroplasty.

METHODS

We conducted a retrospective cohort study of adult patients who underwent total hip and knee arthroplasty from 2015 to 2019 at an urban medical center. The primary predictor variables included LEP status and racial-ethnic category, and the primary outcome variables were oral morphine equivalents (OMEs) during 2 distinct postoperative periods: the first 12 hours after surgery and from the end of surgery to the end of postoperative day (POD) 1. Patient characteristics and perioperative metrics were described by language status, race, and ethnicity using nonparametric tests, as appropriate. We performed an adjusted generalized estimating equation to assess the total effect of the intersection of LEP and racial-ethnic categories on short-term postoperative opioid use in mean ratios (MRs).

RESULTS

This study included a total of 4090 observations, in which 7.9% (323) patients had LEP. Patients reported various racial-ethnic categories, with 72.7% (2975) non-Hispanic White, and minority groups including non-Hispanic Asian and Pacific Islander (AAPI), Hispanic/Latinx, non-Hispanic Black/African American, and Others. Patients self-identifying as non-Hispanic AAPI received fewer OME regardless of LEP status during the first 12 hours postoperatively (MR for English proficient [EP], 0.12 [95% confidence interval, CI, 0.08-0.18]; MR for LEP, 0.22 [95% CI, 0.13-0.37]) and from end of surgery to the end of POD 1 (MR for EP, 0.24 [95% CI, 0.16-0.37]; MR for LEP, 0.42, [95% CI, 0.24-0.73]) than EP non-Hispanic White. Hispanic/Latinx patients with LEP received lower amounts of OME during the first postoperative 12 hours (MR, 0.29; 95% CI, 0.17-0.53) and from end of surgery to the end of POD 1 (MR, 0.42; 95% CI 0.23-0.79) than EP non-Hispanic White. Furthermore, within the non-Hispanic White group, those with LEP received fewer OME within the first 12 hours (MR, 0.33; 95% CI, 0.13-0.83).

CONCLUSIONS

We identified an association between LEP, racial-ethnic identity, and short-term postoperative OME utilization after total knee and hip arthroplasty. The observed differences in opioid utilization imply there may be language and racial-ethnic disparities in acute pain management and perioperative care.

Characterizing discharge opioid prescription in postoperative neurosurgical patients: a systematic review

Over the past two decades, the United States has experienced a rise of opioid misuse, with a significant increase in drug overdose deaths- many of these deaths have been attributed to prescription opiate misuse. Given this epidemic, numerous specialties have created enhanced recovery after surgery protocols to decrease opiate usage post-operatively and some specialties have even created guidelines advising how many morphine milligram equivalents per day are recommended at discharge. The neurosurgical literature is lacking on best practices for discharge opiate prescribing. The goal of this review is to assess opiate prescribing practices at discharge for both cranial and spine neurosurgical patients, and to determine if neurosurgeons are over-prescribing opiates to their patients. A systematic literature review was performed according to PRISMA guidelines. After searching PubMed, Cochrane, and Embase, a total of 288 abstracts were identified, 71 studies underwent full text review and 23 were included in this study. Studies that quantified opiate usage (number of pills prescribed, morphine equivalents, prescription refills) were included. The range of opiate prescribing varied and there was a tendency to both over-prescribe and under-prescribe; therefore, no conclusions could be made. This review underscores the need to take individual patient pain needs into account and shows the need for higher quality literature that can help formulate guideline creation.

Beyond Discharge Disposition: A Scoping Review on Sociodemographic Disparities in Rehabilitation Use After Hip and Knee Arthroplasty

OBJECTIVE

The aims of this scoping review were to summarize the evidence regarding sex, racial, ethnic, geographic, and socioeconomic disparities in post-acute rehabilitation following total hip arthroplasty (THA) and knee arthroplasty (TKA).

METHODS

Literature searches were conducted in Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and PEDro. Studies were included if they were original research articles published 1993 or later; used data from the US; included patients after THA and/or TKA; presented results according to relevant sociodemographic variables, including sex, race, ethnicity, geography, or socioeconomic status; and studied the utilization of post-acute rehabilitation as an outcome.

RESULTS

Twelve studies met the inclusion criteria. Five examined disparities in inpatient rehabilitation and found that Black patients and women experience longer lengths of stay after arthroplasty, and women are less likely than men to be discharged home after inpatient THA rehabilitation. Four studies examined data from skilled nursing facilities and found that insurance type and dual eligibility impact length of stay and rates of community discharge but found conflicting results regarding racial disparities in skilled nursing facility utilization after TKA. Five studies examined home health data and noted that rural agencies provide less care after TKA. Results regarding racial disparities in home health utilization after arthroplasty were conflicting. Six studies of outpatient rehabilitation noted geographic differences in timing of outpatient rehabilitation but mixed results regarding race differences in outpatient rehabilitation.

CONCLUSION

Current evidence indicates that sex, race, ethnicity, geography, and socioeconomic status are associated with disparities in postacute rehabilitation use after arthroplasty.

IMPACT

Rehabilitation providers across the postacute continuum should be aware of disparities in the population of patients after arthroplasty and regularly assess social determinants of health and other factors that may contribute to disparities. Customized care plans should ensure optimal timing and amount of rehabilitation is provided, and advocate for patients who need additional care to achieve the desired functional outcome.

Opioid alternatives in spine surgeries

PURPOSE OF REVIEW

The escalating opioid crisis has intensified the need to explore alternative pain management strategies for patients undergoing spine surgery. This review is timely and relevant as it synthesizes recent research on opioid alternatives for perioperative management, assessing their efficacy, side effects, and postoperative outcomes.

RECENT FINDINGS

A systematic search was conducted to capture articles from the past 18 months that examined opioid-sparing strategies. Findings indicate that multimodal analgesia, incorporating nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, lidocaine, gabapentinoids, N-methyl-D-aspartate (NMDA) antagonists, dexmedetomidine, and emerging regional block techniques like the erector spinae block and TLIF (thoraco lumbar interfascial block), can significantly reduce opioid consumption without compromising pain relief. Additionally, these approaches reduce opioid-related side effects such as postoperative nausea, vomiting, and prolonged hospital stays.

SUMMARY

The use of multimodal analgesia aligns with current pain management guidelines and addresses public health concerns related to opioid misuse. While effective, these alternatives are not without side effects, and the ultimate outcome depends on balancing benefits and risks. Future research should focus on the long-term outcomes of opioid alternatives, their effectiveness across diverse populations, and further validation and optimization of these strategies.

Spine Pain

OBJECTIVE

Spine pain is one of the most common presenting concerns in health care settings. This article reviews clinical strategies for evaluating and managing patients with spine pain.

LATEST DEVELOPMENTS

Minimally invasive interventional procedures, virtual reality, predictive analytics, neuromodulation, and other evolving technologies are significantly impacting the management of spine pain. Advances in modern pain science have also led to effective skills and treatment strategies, including patient interviews and queries for insight regarding pain, education, and cognitive restructuring, and adjusting the timing of examination (after reeducation) and examination techniques to encourage the experience of movement in the absence of assumed tissue damage. An evolving understanding of the influence of patient-centric thoughts, framing, emotional status, and cognitive restructuring's influence on the brain's response to perceived threat are important aspects of spine pain management.

ESSENTIAL POINTS

The correlation of clinical presentations with structural abnormalities is necessary but insufficient to evaluate and manage spine pain. Modern pain science acknowledges pain as a subjective experience but recognizes a critical distinction between tissue damage, nociception, and the experience of pain. What and how we communicate with patients, as well as evolving neuromodulation technologies, augment conventional approaches.

The role of cultural competency training to address health disparities in surgical settings

BACKGROUND

Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.

SOURCES OF DATA

In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.

AREAS OF AGREEMENT

The unjustness of health care disparities is universally accepted.

AREAS OF CONTROVERSY

Whether the outcome of CCT justifies the cost has not been effectively answered.

GROWING POINTS

These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

The full spectrum of SLC22 OCT1 mutations illuminates the bridge between drug transporter biophysics and pharmacogenomics

Mutations in transporters can impact an individual's response to drugs and cause many diseases. Few variants in transporters have been evaluated for their functional impact. Here, we combine saturation mutagenesis and multi-phenotypic screening to dissect the impact of 11,213 missense single-amino-acid deletions, and synonymous variants across the 554 residues of OCT1, a key liver xenobiotic transporter. By quantifying in parallel expression and substrate uptake, we find that most variants exert their primary effect on protein abundance, a phenotype not commonly measured alongside function. Using our mutagenesis results combined with structure prediction and molecular dynamic simulations, we develop accurate structure-function models of the entire transport cycle, providing biophysical characterization of all known and possible human OCT1 polymorphisms. This work provides a complete functional map of OCT1 variants along with a framework for integrating functional genomics, biophysical modeling, and human genetics to predict variant effects on disease and drug efficacy.

Mismatched opioid prescription in patients discharged after neurological surgeries: a retrospective cohort study

ABSTRACT

Although postsurgical overprescription has been well-studied, postsurgical opioid underprescription remains largely overlooked. This retrospective cohort study was to investigate the extent of discharge opioid overprescription and underprescription in patients after neurological surgeries. Six thousand nine hundred forty-nine adult opioid-naive patients who underwent inpatient neurosurgical procedures at the University of California San Francisco were included. The primary outcome was the discrepancy between individual patient's prescribed daily oral morphine milligram equivalent (MME) at discharge and patient's own inpatient daily MME consumed within 24 hours of discharge. Analyses include Wilcoxon, Mann-Whitney, Kruskal-Wallis, and χ 2 tests, and linear or multivariable logistic regression. 64.3% and 19.5% of patients were opioid overprescribed and underprescribed, respectively, with median prescribed daily MME 360% and 55.2% of median inpatient daily MME in opioid overprescribed and underprescribed patients, respectively. 54.6% of patients with no inpatient opioid the day before discharge were opioid overprescribed. Opioid underprescription dose-dependently increased the rate of opioid refill 1 to 30 days after discharge. From 2016 to 2019, the percentage of patients with opioid overprescription decreased by 24.8%, but the percentage of patients with opioid underprescription increased by 51.2%. Thus, the mismatched discharge opioid prescription in patients after neurological surgeries presented as both opioid overprescription and underprescription, with a dose-dependent increased rate of opioid refill 1 to 30 days after discharge in opioid underprescription. Although we are fighting against opioid overprescription to postsurgical patients, we should not ignore postsurgical opioid underprescription.

Acute Pain and Development of Opioid Use Disorder: Patient Risk Factors

PURPOSE OF REVIEW

Pharmacological therapy for acute pain carries the risk of opioid misuse, with opioid use disorder (OUD) reaching epidemic proportions worldwide in recent years. This narrative review covers the latest research on patient risk factors for opioid misuse in the treatment of acute pain. In particular, we emphasize newer findings and evidence-based strategies to reduce the prevalence of OUD.

RECENT FINDINGS

This narrative review captures a subset of recent advances in the field targeting the literature on patients' risk factors for OUD in the treatment for acute pain. Besides well-recognized risk factors such as younger age, male sex, lower socioeconomic status, White race, psychiatric comorbidities, and prior substance use, additional challenges such as COVID-19 further aggravated the opioid crisis due to associated stress, unemployment, loneliness, or depression. To reduce OUD, providers should evaluate both the individual patient's risk factors and preferences for adequate timing and dosing of opioid prescriptions. Short-term prescription should be considered and patients at-risk closely monitored. The integration of non-opioid analgesics and regional anesthesia to create multimodal, personalized analgesic plans is important. In the management of acute pain, routine prescription of long-acting opioids should be avoided, with implementation of a close monitoring and cessation plan.

The full spectrum of OCT1 (SLC22A1) mutations bridges transporter biophysics to drug pharmacogenomics

Membrane transporters play a fundamental role in the tissue distribution of endogenous compounds and xenobiotics and are major determinants of efficacy and side effects profiles. Polymorphisms within these drug transporters result in inter-individual variation in drug response, with some patients not responding to the recommended dosage of drug whereas others experience catastrophic side effects. For example, variants within the major hepatic Human organic cation transporter OCT1 (SLC22A1) can change endogenous organic cations and many prescription drug levels. To understand how variants mechanistically impact drug uptake, we systematically study how all known and possible single missense and single amino acid deletion variants impact expression and substrate uptake of OCT1. We find that human variants primarily disrupt function via folding rather than substrate uptake. Our study revealed that the major determinants of folding reside in the first 300 amino acids, including the first 6 transmembrane domains and the extracellular domain (ECD) with a stabilizing and highly conserved stabilizing helical motif making key interactions between the ECD and transmembrane domains. Using the functional data combined with computational approaches, we determine and validate a structure-function model of OCT1s conformational ensemble without experimental structures. Using this model and molecular dynamic simulations of key mutants, we determine biophysical mechanisms for how specific human variants alter transport phenotypes. We identify differences in frequencies of reduced function alleles across populations with East Asians vs European populations having the lowest and highest frequency of reduced function variants, respectively. Mining human population databases reveals that reduced function alleles of OCT1 identified in this study associate significantly with high LDL cholesterol levels. Our general approach broadly applied could transform the landscape of precision medicine by producing a mechanistic basis for understanding the effects of human mutations on disease and drug response.