Age and postoperative opioid prescriptions: a population-based cohort study of opioid-naïve adults

Long-term postoperative opioid use in orthopaedic patients

BACKGROUND

The prevalence of long-term opioid use after orthopaedic surgery varies from 1.4% to 24% and has mostly been studied with prescription data, making it difficult to estimate the size and impact of the problem. This study aims to assess the prevalence and predictors of long-term postoperative opioid use in a high volume and tertiary orthopaedic centre by using online patient reported measures.

METHODS

This Dutch prospective cohort study was conducted among adult patients who underwent any type of orthopaedic surgery from June to August 2021. Six months after surgery patients were invited to complete an online survey on current opioid use and patients' willingness to taper opioids. The demographics, clinical factors and preoperative opioid use were extracted from the patient file.

RESULTS

In total, 607 patients (mean age 61.2 years, 63.4% female) completed the survey. Seventy-six patients (12.5%) used opioids 6 months after surgery of which 20 (3.3%) did not use opioids before surgery. The median (Q1-Q3) postoperative daily dose after 6 months was 29.9 mg (10.0-76.1) morphine equivalents. Most of them (88.2%) wanted to taper opioids. Affected body region (OR's: 6.84-12.75) and pre-operative opioid use (OR = 35.33) were significant predictors of long-term opioid use.

CONCLUSION

The prevalence of long-term postoperative opioid use was 12.5%; one in thirty patients became a new long-term opioid user. Pre-operative opioid use and affected body region were predictive for long-term opioid use. These findings, together with the observation that long-term opioid users want to taper opioids, emphasize the relevance of prevention, recognition and tapering support in the perioperative setting.

LEVEL OF EVIDENCE

Level II.

SIGNIFICANCE

Short-term opioid use can unintentionally progress to long-term opioid use. The prevalence of long-term opioid use after orthopaedic surgery varies widely and is mostly prescription-based, making it difficult to estimate the magnitude of the problem. This study assessed long-term postoperative opioid use in a full breadth orthopaedic population using patient reported measures, making conclusions much more robust. The prevalence of long-term postoperative opioid use in this study was 12.5%.

Defining opioid naïve and implications for monitoring opioid use: A population-based study in Alberta, Canada

PURPOSE

Reducing initial exposure of "opioid naïve" patients to opioids is a public health priority. Identifying opioid naïve patients is difficult, as numerous definitions are used. The objective is to summarize current definitions and evaluate their impact on opioid naïve measures in Alberta.

METHODS

An exploratory data analysis of the literature was conducted over the last 10 years to identify definitions commonly used in the literature to define opioid naïve. Then, using these definitions as a guide, we descriptively report the proportion of patients in Alberta between 2017 and 2021 who would be considered as opioid naïve using these definitions and all opioid dispensing data.

RESULTS

Three categories of definitions were broadly identified: (1) no opioid use within the previous 30 days/6 months/1 year, based on dispensation date; (2) no opioid use based on dispensation date plus days of supply; and, (3) exclusion of codeine from Definitions 1 and 2. Applying these definitions to the Alberta population showed a very wide range in the proportion who would be considered as opioid naïve. Overall, 36.4% of Albertans (n = 1 551 075) had an opioid dispensation in 2017-2021. The average age was 46.6 ± 18.8 and 52.8% were female. The proportion of opioid naïve were most affected by the "opioid free" period, with 97.4%, 83.2%, and 65.6% being classified as opioid naïve using time windows from Definition 1 (30 days, 6 months, 1 year of no prior opioid use). Definitions 2 and 3 did not materially change the results. Further extending the "opioid free" period to 2 years showed only 35% were opioid naïve.

CONCLUSIONS

The most convenient definition for "opioid naïve" was the use of an "opioid free" period. The choice of window would depend on how the information may be used to assistant in clinical decisions with longer windows more likely to reflect true opioid naïve patients. Irrespective of definition used, a large proportion of opioid users would be considered opioid naïve in Alberta.

Opioid utilization after lower extremity amputation for peripheral vascular disease and discharge prescribing recommendations

OBJECTIVES

Opioids are commonly used for pain control after lower extremity amputations (LEA)-below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge.

METHODS

Patients undergoing LEA (2008-2016) with identified peripheral vascular disease were selected from Cerner's Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate.

RESULTS

2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6.

CONCLUSIONS

This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325 mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.

Association of Reported Nonsteroidal Anti-Inflammatory Drug (NSAID) Adverse Drug Reactions With Opioid Prescribing After Total Joint Arthroplasty

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for postoperative pain management, but use may be precluded by the report of adverse drug reactions (ADRs). The effect of NSAID ADR labeling on opioid prescribing after total joint arthroplasty (TJA) is unknown.

OBJECTIVE

To assess the association between NSAID ADRs and postoperative opioid prescribing after TJA, a common surgical procedure.

METHODS

We performed a retrospective cohort study of adults who underwent total joint (knee or hip) replacement in a single hospital network between April, 1, 2016, and December 31, 2019. Demographic information, clinical and surgical characteristics, and prescription data were obtained from the electronic health record. We studied the association between reported NSAID ADRs and postoperative opioid prescribing in a propensity score-matched sample over 1 year of follow-up.

RESULTS

NSAID ADRs were reported by 9.6% of the entire cohort (n = 584/6091). NSAID ADR was associated with 41% higher odds of receipt of opioid prescriptions at 181 to 365 days after hospital discharge (95% confidence interval: 13%-75%) in a propensity score-matched sample. Over 98% of individuals received an opioid prescription at the time of hospital discharge, with no difference in overall median opioid dose prescribed by NSAID ADR status. However, more patients with NSAID ADRs (7.6% vs 4.7%) received cumulative opioid doses ≥ 750 morphine milligram equivalents (MME) at discharge (P = .004).

CONCLUSION

Reported NSAID ADR was associated with increased risk for prolonged receipt of opioids at 181 to 365 days postoperatively. Patients with NSAID ADRs more frequently received cumulative opioid doses ≥ 750 MME at discharge after TJA. Clarification and evaluation of reported NSAID ADRs may be particularly beneficial for surgical patients at high risk for prolonged receipt of opioids.

Nonopioid Analgesic Prescriptions Filled after Surgery among Older Adults in Ontario, Canada: A Population-based Cohort Study

BACKGROUND

The objective was to assess changes over time in prescriptions filled for nonopioid analgesics for older postoperative patients in the immediate postdischarge period. The authors hypothesized that the number of patients who filled a nonopioid analgesic prescription increased during the study period.

METHODS

The authors performed a population-based cohort study using linked health administrative data of 278,366 admissions aged 66 yr or older undergoing surgery between fiscal year 2013 and 2019 in Ontario, Canada. The primary outcome was the percentage of patients with new filled prescriptions for nonopioid analgesics within 7 days of discharge, and the secondary outcome was the analgesic class. The authors assessed whether patients filled prescriptions for a nonopioid only, an opioid only, both opioid and nonopioid prescriptions, or a combination opioid/nonopioid.

RESULTS

Overall, 22% (n = 60,181) of patients filled no opioid prescription, 2% (n = 5,534) filled a nonopioid only, 21% (n = 59,608) filled an opioid only, and 55% (n = 153,043) filled some combination of opioid and nonopioid. The percentage of patients who filled a nonopioid prescription within 7 days postoperatively increased from 9% (n = 2,119) in 2013 to 28% (n = 13,090) in 2019, with the greatest increase for acetaminophen: 3% (n = 701) to 20% (n = 9,559). The percentage of patients who filled a combination analgesic prescription decreased from 53% (n = 12,939) in 2013 to 28% (n = 13,453) in 2019. However, the percentage who filled both an opioid and nonopioid prescription increased: 4% (n = 938) to 21% (n = 9,880) so that the overall percentage of patients who received both an opioid and a nonopioid remained constant over time 76% (n = 18,642) in 2013 to 75% (n = 35,391) in 2019.

CONCLUSIONS

The proportion of postoperative patients who fill prescriptions for nonopioid analgesics has increased. However, rather than a move to use of nonopioids alone for analgesia, this represents a shift away from combination medications toward separate prescriptions for opioids and nonopioids.

EDITOR’S PERSPECTIVE

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Surgeon Bias in Postoperative Opioid Prescribing

BACKGROUND

The misuse of opioids is a serious national crisis that is fueled by prescriptions medications. Opioid prescribing habits are known to be highly varied amongst providers. The purpose of this study is to identify patient and surgeon characteristics that predict postoperative opioid prescribing patterns.

METHODS

This is a serial cross-sectional analysis of 20,497 patients who underwent general surgical procedures at a large academic center. Our primary outcome was the total amount of opioids prescribed within 30 days of the surgery. Univariate and multivariate linear regression models were used to identify patient and provider characteristics that were associated with increased opioids prescribed.

RESULTS

Among patient characteristics studied, patient age, sex, ethnicity, and insurance status were found to have a significant association with the amount of opioids prescribed. Younger patients and male patients received higher morphine milligram equivalents (MMEs) on discharge (p < 0.05). Patients of Hispanic background were prescribed significantly lower opioids compared to Non-Hispanic patients (p < 0.0001). Among the provider characteristics studied, surgeon sex and years in practice were significantly predictive of the amount of opioids prescribed, with surgeons in practice for <15 years prescribing the highest MMEs (p < 0.0001).

CONCLUSION

While opioid prescribing habits after surgery seem highly varied and arbitrary, we have identified key predictors that highlight biases in surgeon opioid prescribing patterns. Surgeons tend to prescribe significantly larger amounts of opioids to younger, male patients and those of certain ethnic backgrounds, and surgeons with fewer years in practice are more likely to prescribe more opioids.

Persistent postoperative opioid use in Europe: A systematic review

BACKGROUND

In the United States, postoperative opioid prescriptions have been implicated in the so-called 'opioid epidemic'. In Europe, the extent of overprescribing or misuse of opioids is not known.

OBJECTIVES

To describe the proportion of persistent postoperative opioid use in adults (>18 years) in European countries.

DESIGN

Systematic review of the published data.

DATA SOURCES

We searched the electronic literature databases MEDLINE (Ovid), Embase (Ovid), PubMed/MEDLINE and Scopus.

ELIGIBILITY CRITERIA

Studies describing opioid use in adult patients (>18 years) at least 3 months after surgery.

RESULTS

One thousand three hundred and seven studies were found, and 12 studies were included in this review. The rate of opioid use after 3 to 6 months was extracted from the studies and categorised by the type of surgery. Nine studies investigated opioid use after total hip or total knee arthroplasties (THA and TKA) and reported opioid user rates between 7.9 and 41% after 3 months. In all the included studies, a proportion between 2 and 41% of patients were opioid users 3 months after surgery. The level of evidence varied from high to very low.

CONCLUSION

To describe persistent opioid use in relation to specific countries or types of surgery is not possible. Because of the wide ranges observed, we can neither confirm nor rule out a possible public health problem linked to the persistent use of opioids in Europe.

STUDY REGISTRATION

PROSPERO: CRD42019154292.

Analgesic effects of piritramide in acute postoperative pain - comparison of intramuscular administration with patient-controlled intravenous analgesia and impact of OPRM1 and ABCB1 polymorphisms

AIMS

The aim of this study was to compare the efficacy, consumption and safety after piritramide administered either intramuscularly (IM) on demand or via patient-controlled intravenous analgesia (PCA) and to examine the impact of OPRM1 and ABCB1 gene polymorphisms on the drug efficacy/safety in both regimens.

METHODS

One hundred and four patients scheduled for elective inguinal hernioplasty received piritramide with PCA or IM for postoperative pain management. We evaluated piritramide consumption, pain intensity using visual analogue scale (VAS) and adverse effects.

RESULTS

Median (IQR) piritramide consumption was 18.5 (13.5-31.2) and 15.0 (15.0-15.0) mg in the PCA and IM groups, respectively (P=0.0092). The respective values of area under the VAS_2-16-time curve were 40 and 280 mm.h (P=0.0027). Opioid-induced adverse effects were more frequent in the PCA than in the IM group. Variant OPRM1 allele was associated with decreased pain relief, increased opioid consumption and increased incidence of adverse effects, while ABCB1 polymorphisms showed no impact on the observed parameters.

CONCLUSIONS

We observed higher piritramide consumption, better pain relief and slightly worse safety profile in the PCA group compared with IM administration. Variant OPRM1 118G allele carriers required higher opioid dosing and suffered from more adverse effects, however, the differences between genotypes have been less pronounced in the PCA patients likely due to improved pain management via PCA.