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Averkamp B, Li K, Wally MK, Roomian T, Griggs C, Runyon M, Hsu JR, Seymour RB, Beuhler M, Bosse MJ, Castro M, Gibbs M, Jarrett S, Leas D, Odum S, Yu Z, Rachal J, Saha A, Sullivan DM, Watling B. Opioid Prescribing Rate for Nonoperative Distal Radius Fractures and Clinician Response to a Clinical Decision Support Alert. J Emerg Med 2024; 66:e413-e420. [PMID: 38490894 DOI: 10.1016/j.jemermed.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Opioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures. OBJECTIVES This prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated. METHODS We performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision. RESULTS Of 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians' opioid prescribing when compared with other risk factors (p = 0.0088). CONCLUSION Over 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures.
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Affiliation(s)
- Ben Averkamp
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Katherine Li
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Tamar Roomian
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | - Michael Runyon
- Department of Emergency Medicine, Charlotte, North Carolina
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | - Michael J Bosse
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | - Michael Gibbs
- Department of Emergency Medicine, Charlotte, North Carolina
| | - Steven Jarrett
- Patient Safety, Atrium Health, Charlotte, North Carolina
| | - Daniel Leas
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - James Rachal
- Department of Psychiatry, Charlotte, North Carolina
| | | | - D Matthew Sullivan
- Atrium Health Information and Analytic Services, Atrium Health, Charlotte, North Carolina
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Gorbaty J, Wally MK, Odum S, Yu Z, Hamid N, Hsu JR, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Karunakar M, Kempton L, Leas D, Phelps K, Roomian T, Runyon M, Saha A, Sims S, Watling B, Wyatt S, Seymour R. Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting. J Opioid Manag 2023; 19:495-505. [PMID: 38189191 DOI: 10.5055/jom.0834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN A prospective observational study. SETTING One large healthcare system. PATIENTS AND PARTICIPANTS Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.
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Affiliation(s)
- Jacob Gorbaty
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; OrthoCarolina Research Institute, Charlotte, North Carolina
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Nady Hamid
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; OrthoCarolina, Shoulder and Elbow Center, Charlotte, North Carolina
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Beuhler
- North Carolina Poison Control, Atrium Health, Charlotte, North Carolina
| | - Michael Bosse
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Gibbs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Christopher Griggs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | | | - Madhav Karunakar
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Laurence Kempton
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Daniel Leas
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Kevin Phelps
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Tamar Roomian
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, North Carolina
| | - Stephen Sims
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | - Rachel Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Beuhler M, Bosse M, Castro M, Gibbs M, Griggs C, Jarrett S, Leas D, Rachal J, Roomian T, Runyon M, Saha A, Watling B, Yu Z, Seymour RB. Adherence to legislation limiting opioid prescription duration following musculoskeletal injury. J Opioid Manag 2023; 19:103-115. [PMID: 37879665 DOI: 10.5055/jom.2023.0804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions. DESIGN A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels. SETTING A large healthcare system in North Carolina. PATIENTS AND PARTICIPANTS Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury. INTERVENTIONS The STOP Act limited the duration of opioid prescriptions in North Carolina. MAIN OUTCOME MEASURE Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome. RESULTS Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97). CONCLUSIONS Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.
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Affiliation(s)
- Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina. ORCID: https://orcid.org/0000-0003-4540-532X
| | - Michael E Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; Department of Public Health Sci-ences, University of North Carolina at Charlotte; OrthoCarolina Research Institute Charlotte, Charlotte, North Carolina
| | - Donna M Kazemi
- College of Health and Human Services, School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Beuhler
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Michael Bosse
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Manuel Castro
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina
| | - Michael Gibbs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Christopher Griggs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Steven Jarrett
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Daniel Leas
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - James Rachal
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina
| | - Tamar Roomian
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, North Carolina
| | | | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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Seymour RB, Wally MK, Hsu JR. Impact of clinical decision support on controlled substance prescribing. BMC Med Inform Decis Mak 2023; 23:234. [PMID: 37864226 PMCID: PMC10588193 DOI: 10.1186/s12911-023-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 09/29/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines. METHODS This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts. RESULTS An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility. CONCLUSION The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.
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Affiliation(s)
- Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA.
- Atrium Health Musculoskeletal Institute, 2001 Vail Avenue, 6th floor, Charlotte, NC, 28207, USA.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices. Appl Clin Inform 2023; 14:961-972. [PMID: 38057261 PMCID: PMC10700149 DOI: 10.1055/s-0043-1776879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices. METHODS We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing. RESULTS This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing. CONCLUSION A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.
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Affiliation(s)
- Meghan K. Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Michael E. Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Donna M. Kazemi
- School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Joseph R. Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
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Ivan SJ, Holck HW, Robinson MM, Shea RE, Wallander ML, Parker B, Matulay JT, Gaston KE, Clark PE, Seymour R, Hsu JR, Riggs SB. Persistent opioid and benzodiazepine use after radical cystectomy in enhanced recovery after surgery (ERAS) patients. Urol Oncol 2023; 41:432.e1-432.e9. [PMID: 37455232 DOI: 10.1016/j.urolonc.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/28/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes. METHODS AND MATERIALS We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes. RESULTS Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037). CONCLUSIONS Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort.
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Affiliation(s)
- Samuel J Ivan
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Hailey W Holck
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Myra M Robinson
- Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Reilly E Shea
- Clinical Trials Office, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | - Blair Parker
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Justin T Matulay
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Kris E Gaston
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Peter E Clark
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Rachel Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Stephen B Riggs
- Department of Urology, Levine Cancer Institute, Atrium Health, Charlotte, NC.
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Changes in opioid prescription duration for musculoskeletal injury associated with the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act. Pain Med 2023; 24:926-932. [PMID: 36943361 DOI: 10.1093/pm/pnad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/20/2023] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES To assess whether implementation of the Strengthen Opioid Misuse Prevention (STOP) Act was associated with an increase in the percentage of opioid prescriptions written for 7 days or fewer among patients with acute or postsurgical musculoskeletal conditions. DESIGN An interrupted time-series study was conducted to determine the change in duration of opioid prescriptions associated with the STOP Act. SETTING Data were extracted from the electronic health record of a large health care system in North Carolina. SUBJECTS Patients presenting from 2016 to 2020 with an acute musculoskeletal injury and the clinicians treating them were included in an interrupted time-series study (n = 12 839). METHODS Trends were assessed over time, including the change in trend associated with implementation of the STOP Act, for the percentage of prescriptions written for ≤7 days. RESULTS Among patients with acute musculoskeletal injury, less than 30% of prescriptions were written for ≤7 days in January of 2016; by December of 2020, almost 90% of prescriptions were written for ≤7 days. Prescriptions written for ≤7 days increased 17.7% after the STOP Act was implemented (P < .001), after adjustment for the existing trend. CONCLUSIONS These results demonstrate significant potential for legislation to influence opioid prescribing behavior.
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Affiliation(s)
- Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Michael E Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Donna M Kazemi
- College of Health and Human Services, School of Nursing, University of North Carolina at Charlotte, Charlotte, NC 28223, United States
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, United States
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8
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Levytska K, Pena SR, Brown J, Yu Z, Wally MK, Hsu JR, Seymour RB, Naumann W. Opioid and benzodiazepine use in gynecologic oncology patients. Int J Gynecol Cancer 2023; 33:786-791. [PMID: 36810232 DOI: 10.1136/ijgc-2022-003955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE The goals of this study were to describe opioid and benzodiazepine prescribing practices in the gynecologic oncology patient population and determine risks for opioid misuse in these patients. METHODS Retrospective study of opioid and benzodiazepine prescriptions for patients treated for cervical, ovarian (including fallopian tube/primary peritoneal), and uterine cancers within a single healthcare system from January 2016 to August 2018. RESULTS A total of 7643 prescriptions for opioids and/or benzodiazepines were dispensed to 3252 patients over 5754 prescribing encounters for cervical (n=2602, 34.1%), ovarian (n=2468, 32.3%), and uterine (n=2572, 33.7%) cancer. Prescriptions were most often written in an outpatient setting (51.0%) compared with inpatient discharge (25.8%). Cervical cancer patients were more likely to have received a prescription in an emergency department or from a pain/palliative care specialist (p=0.0001). Cervical cancer patients were least likely to have prescriptions associated with surgery (6.1%) compared with ovarian cancer (15.1%) or uterine cancer (22.9%) patients. The morphine milligram equivalents prescribed were higher for patients with cervical cancer (62.6) compared with patients with ovarian and uterine cancer (46.0 and 45.7, respectively) (p=0.0001). Risk factors for opioid misuse were present in 25% of patients studied; cervical cancer patients were more likely to have at least one risk factor present during a prescribing encounter (p=0.0001). Cervical cancer was associated with a higher number of risk factors (p<0.001). CONCLUSIONS Opioid and benzodiazepine prescribing patterns differ for cervical, ovarian, and uterine cancer patients. Gynecologic oncology patients are overall at low risk for opioid misuse; however, patients with cervical cancer are more likely to have risk factors present for opioid misuse.
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Affiliation(s)
- Khrystyna Levytska
- Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina, USA
| | - Savannah R Pena
- Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina, USA
| | - Jubilee Brown
- Gynecologic Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Ziqing Yu
- Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Meghan K Wally
- Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Joseph R Hsu
- Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Wendel Naumann
- Gynecologic Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
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9
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Bloomer A, Wally M, Bailey G, Roomian T, Karunakar M, Hsu JR, Seymour R, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Leas D, Odum S, Runyon M, Saha A, Yu Z, Watling B, Wyatt S. Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221125616. [PMID: 36250188 PMCID: PMC9561667 DOI: 10.1177/21514593221125616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction This study reports on the impact of a clinical decision support tool embedded
in the electronic medical record and characterizes the demographics,
prescribing patterns, and risk factors associated with opioid and
benzodiazepine misuse in the older adult population. Significance This study reports on prescribing patterns for patients ≥65 years-old who
presented to Emergency Departments (ED) or Urgent Care (UC) facilities
across a large healthcare system following a fall (n = 34,334 encounters; n
= 25,469 patients). This system implemented a clinical decision support
intervention which provides an alert when the patient has an evidence-based
risk factor for prescription drug misuse; prescribers can continue, amend or
cancel the prescription. Results Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid
or benzodiazepine prescription. Women and younger patients (65-74) had a
higher likelihood of receiving a prescription (P <
.0001). 11% had ≥1 risk factor. Women were more likely to receive an early
refill (P = .0002) and younger (65-74) men were more likely
to have a past positive toxicology (P < .0001). A
prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an
alert. In 58 cases, the alert resulted in a prescription modification, and
in 80 the prescription was canceled. Conclusions Documented risk for opioid misuse in the elderly was 10% among patients
presenting to the ED/UC after a fall. The dangers associated with
opioid/benzodiazepine use increase with age as does fall risk. Awareness of
risk factors is an important first step; more work is needed to address
potentially hazardous prescriptions in this population.
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Affiliation(s)
- Ainsley Bloomer
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Gisele Bailey
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Tamar Roomian
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Madhav Karunakar
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA,Rachel B Seymour, Department of Orthopaedic
Surgery, Atrium Health, 1320 Scott Ave, Charlotte, NC 28204, USA.
| | | | - Michael Bosse
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Michael Gibbs
- Department of Emergency Medicine,
Atrium
Health, Charlotte, NC, USA
| | | | | | - Daniel Leas
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Susan Odum
- OrthoCarolina Research
Institute, Charlotte, NC, USA
| | - Michael Runyon
- Department of Emergency Medicine,
Atrium
Health, Charlotte, NC, USA
| | - Animita Saha
- Department of Internal Medicine,
Atrium
Health, Charlotte, NC, USA
| | - Ziquing Yu
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
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10
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Secrist E, Wally MK, Yu Z, Castro M, Seymour RB, Hsu JR. Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care. J Orthop Trauma 2022; 36:e362-e368. [PMID: 35981227 DOI: 10.1097/bot.0000000000002361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care. DESIGN Retrospective case series. SETTING Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019. PATIENTS All patients presenting to the practice during 2019 were included (n = 573). INTERVENTION We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway. MAIN OUTCOME MEASUREMENTS The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected. RESULTS Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room. CONCLUSIONS This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.
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Affiliation(s)
- Eric Secrist
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Manuel Castro
- Department of Psychiatry, Atrium Health, Charlotte, NC
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
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11
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Levytska K, Yu Z, Wally M, Odum S, Hsu JR, Seymour R, Brown J, Crane EK, Tait DL, Puechl AM, Lees B, Naumann RW. Enhanced recovery after surgery (ERAS) protocol is associated with lower post-operative opioid use and a reduced office burden after minimally invasive surgery. Gynecol Oncol 2022; 166:471-475. [DOI: 10.1016/j.ygyno.2022.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 12/11/2022]
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12
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Wohler A, Macknet D, Seymour RB, Wally MK, Irwin T, Hsu JR, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Karunakar M, Kempton L, Leas D, Odum SM, Phelps K, Roomian T, Runyon M, Saha A, Sims S, Watling B, Wyatt S, Yu Z. Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention. J Foot Ankle Surg 2022; 61:557-561. [PMID: 34836780 DOI: 10.1053/j.jfas.2021.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/14/2021] [Accepted: 09/22/2021] [Indexed: 02/03/2023]
Abstract
Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.
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Affiliation(s)
- Andrew Wohler
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - David Macknet
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Todd Irwin
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; OrthoCarolina Foot and Ankle Institute, Charlotte, NC
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | | | - Michael Bosse
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Michael Gibbs
- Department of Emergency Medicine, Atrium Health, Charlotte, NC
| | | | | | - Madhav Karunakar
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Laurence Kempton
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Daniel Leas
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; Carolina Neurosurgery and Spine Associates, Charlotte, NC
| | - Susan M Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; OrthoCarolina Research Institute, Charlotte, NC
| | - Kevin Phelps
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Tamar Roomian
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Michael Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, NC
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, NC
| | - Stephen Sims
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | | | - Stephen Wyatt
- Addiction Medicine, Adult Psychiatry, Atrium Health, Charlotte, NC
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
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13
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Bestha D, Tomatsu S, Hutcheson B, Blankenship K, Yu Z, Wally MK, Wyatt S, Seymour RB, Hsu JR, Rachal J. Impact of an opioid prescribing alert system on patients with posttraumatic stress disorder. Am J Addict 2022; 31:123-131. [PMID: 35112432 DOI: 10.1111/ajad.13261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/17/2021] [Accepted: 01/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Posttraumatic stress disorder (PTSD) is associated with higher rates of chronic pain and increased risk of developing Opioid use disorder. This paper evaluates the impact of PRIMUM, an electronic health record-embedded (EHR) clinical decision support intervention on opioid prescribing patterns for patients with diagnosis of PTSD. METHODS Inpatient, emergency department (ED), urgent care, and outpatient encounters with ICD-10 codes F43.1 (PTSD), F43.10 (PTSD, unspecified), F43.11 (PTSD, acute), and F43.12 (PTSD, chronic) at Atrium Health between 1/1/2016 and 12/29/2018 were included in the study. RESULTS A total of 3121 patients with a diagnosis of PTSD were seen in 37,443 encounters during the study period. Ten percent (n = 3761) of the encounters resulted in prescriptions for opioids and PRIMUM alerts were triggered in 1488 of these encounters. These alerts resulted in "decision influenced" for 17% of patients (n = 255) or no prescriptions for opioids or benzodiazepines for 5.8% (n = 86). The majority of the prescriptions were below 50 Morphine milligram equivalents (MME)/day, but there were 570 (15.5%) prescriptions for doses of 50-90 MME and 721 (19.6%) prescriptions for >90 MME/day. DISCUSSION AND CONCLUSION The PRIMUM alert system helps improve patient safety. PRIMUM affected clinician decisions 17% of the time, and the effect was greater in patients with opioid overdose history and those presenting for early refills. SCIENTIFIC SIGNIFICANCE The effectiveness of clinical support interventions for opioid prescribing for patients with PTSD has not been documented previously. Our findings provide novel evidence that the EHR can be used to improve patient safety among patients with PTSD in the context of substance use.
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Affiliation(s)
- Durga Bestha
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
| | - Shizuka Tomatsu
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
| | | | - Kelly Blankenship
- Department of Psychiatry, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Stephen Wyatt
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - James Rachal
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
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14
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Rigert JM, Napenas JJ, Wally M, Odum S, Yu Z, Runyon M, Hsu JR, Seymour RB. Dental pain management with prescription opioids by nondental healthcare professionals in a healthcare system network. J Public Health Dent 2021; 82:22-30. [PMID: 34080195 DOI: 10.1111/jphd.12459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 03/01/2021] [Accepted: 05/07/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Patients with dental pain seek treatment in Urgent and Emergency Care settings by physicians and advanced practice practitioners (APPs) unable to provide definitive care, often relying on prescriptions for pain management including opioids. In the face of an opioid epidemic, this study assessed the impact of an electronic health record (EHR) clinical decision support tool to identify patients at high risk for opioid misuse using objective, evidence-based criteria, and guide safer prescribing. METHODS Dental pain encounters occurring between January 2016 and June 2018 within our healthcare system were identified and linked to the database supporting a real-time clinical decision support intervention, Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM), to characterize opioid prescribing patterns and prescribers' response to alert. Descriptive analysis of the data was performed. RESULTS There were 30,649 dental pain encounters of which opioids were written in 45.5 percent (N = 13,957) encounters. A total of 16.6 percent of patients prescribed an opioid had a risk factor for misuse and triggered the PRIMUM alert at the point of care. In response to the PRIMUM alert (N = 2,501 encounters), clinician decision-making was influenced in 9.5 percent (N = 237) of encounters, which was defined by cancelation of the original opioid prescription. Of those 9.5 percent encounters, 48.1 percent (N = 114) resulted in no opioid prescription written. CONCLUSIONS There is potential for a clinical decision support tool embedded in the EHR to guide safer prescribing practice by alerting providers to objective, evidence-based risk characteristics at the point of care.
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Affiliation(s)
| | | | - Meghan Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA.,OrthoCarolina Research Institute, Charlotte, North Carolina, USA
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Michael Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, NC, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
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15
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Gorbaty J, Odum SM, Wally MK, Seymour RB, Hamid N, Hsu JR, Beuhler M, Bosse MJ, Gibbs M, Griggs C, Jarrett S, Leas D, Roomian T, Runyon M, Saha A, Watling B, Wyatt S, Yu Z. Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High. Arthrosc Sports Med Rehabil 2021; 3:e373-e379. [PMID: 34027445 PMCID: PMC8129054 DOI: 10.1016/j.asmr.2020.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/30/2020] [Indexed: 10/27/2022] Open
Abstract
Purpose To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population. Methods We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups. Results We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them. Conclusions The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations-and especially for patients identified as having a high risk of opioid misuse-is an important practice to continue in our shift away from opioid use as a health care system. Level of Evidence Level IV, case series.
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Affiliation(s)
- Jacob Gorbaty
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Susan M Odum
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Meghan K Wally
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Rachel B Seymour
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Nady Hamid
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A.,OrthoCarolina Shoulder and Elbow Center, Charlotte, North Carolina, U.S.A
| | - Joseph R Hsu
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | | | - Michael Beuhler
- NC Poison Control, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Michael J Bosse
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Michael Gibbs
- Department of Emergency Medicine, Carolinas Trauma Network Research Center of Excellence, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Christopher Griggs
- Department of Emergency Medicine, Carolinas Trauma Network Research Center of Excellence, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Steven Jarrett
- Patient Safety, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Daniel Leas
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Tamar Roomian
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Michael Runyon
- Department of Emergency Medicine, Carolinas Trauma Network Research Center of Excellence, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Bradley Watling
- US Acute Care Solutions, Atrium Health, Pineville, North Carolina, U.S.A
| | - Stephen Wyatt
- Adult Psychiatry, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Ziqing Yu
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
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16
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Alamanda VK, Wally MK, Seymour RB, Springer BD, Hsu JR. Prevalence of Opioid and Benzodiazepine Prescriptions for Osteoarthritis. Arthritis Care Res (Hoboken) 2020; 72:1081-1086. [PMID: 31127868 DOI: 10.1002/acr.23933] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 05/21/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Opioids and benzodiazepines are commonly used for management of osteoarthritis, despite evidence-based recommendations to the contrary. This study aimed to quantify the prevalence of opioid and benzodiazepine prescribing for osteoarthritis. Additionally, we aimed to characterize risk factors for prescription drug misuse, abuse, and diversion among this population. METHODS We conducted a descriptive analysis of adult outpatient encounters with a primary diagnosis of osteoarthritis during a 1-year period at a large health care system, excluding cancer and outpatient procedures. Demographic data, prescription data, and patient-specific risk factors were collected. Descriptive analysis was conducted to characterize arthritis patients who received and did not receive prescription opioids. RESULTS During 1 year, our system had 31,123 outpatient encounters for osteoarthritis. Opioids and benzodiazepines were prescribed for nearly 27% of the encounters (n = 8,420). In all, 43% of the encounters involved patients age ≥65 years. Hydrocodone-acetaminophen was the most common medication prescribed (34.3%). Most prescriptions were written by pain specialists (53%). A total of 35.5% of patients had a risk factor for prescription misuse, the most prevalent being early refill and a history of receiving ≥3 prescriptions in the past month. CONCLUSION Prescriptions for opioids and benzodiazepines continue to be written for osteoarthritis. These prescriptions may pose a risk for adverse outcomes since >1 in 5 patients receiving prescriptions had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as multimodal and alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis-related pain. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
- Vignesh K Alamanda
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Meghan K Wally
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Rachel B Seymour
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center and Atrium Health Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina
| | - Joseph R Hsu
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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17
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Krawczyk N, Eisenberg M, Schneider KE, Richards TM, Lyons BC, Jackson K, Ferris L, Weiner JP, Saloner B. Predictors of Overdose Death Among High-Risk Emergency Department Patients With Substance-Related Encounters: A Data Linkage Cohort Study. Ann Emerg Med 2020; 75:1-12. [PMID: 31515181 PMCID: PMC6928412 DOI: 10.1016/j.annemergmed.2019.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/22/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. METHODS This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories. RESULTS A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05). CONCLUSION These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.
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Affiliation(s)
- Noa Krawczyk
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Matthew Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tom M Richards
- Johns Hopkins Center for Population and Health and Information Technology, Baltimore, MD
| | - B Casey Lyons
- Behavioral Health Administration, Maryland Department of Health, Columbia, MD
| | - Kate Jackson
- Behavioral Health Administration, Maryland Department of Health, Columbia, MD
| | - Lindsey Ferris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Chesapeake Regional Information System for Our Patients, Columbia, MD
| | - Jonathan P Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins Center for Population and Health and Information Technology, Baltimore, MD
| | - Brendan Saloner
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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18
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Leas D, Seymour RB, Wally MK, Hsu JR. Use of a Prescription Drug-Monitoring Program by Emergency and Surgical Prescribers: Results of a Hospital Survey. HSS J 2019; 15:51-56. [PMID: 30863233 PMCID: PMC6384217 DOI: 10.1007/s11420-018-9633-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Drug overdoses are the leading cause of death due to injury in the USA. Currently, 49 states have prescription drug-monitoring programs (PDMPs) available to prescribers. QUESTIONS/PURPOSES We aimed to assess knowledge and practice of two groups of acute-care prescribers regarding controlled substances. METHODS A 16-question survey was distributed to a list of surgical and emergency medicine prescribers at our institution. The survey asked about prescriber demographics, previous experiences with a PDMP, and opinions about patient risk factors available within an electronic medical record (EMR). RESULTS We received 60 responses (27.1% response rate). All prescribers recognized a growing problem with opioids, both in general and in their own practices, with an average rating of 8.3/10 and 7.9/10, respectively. Although 95% were aware a PDMP was available, only 60% were registered users. Emergency medicine prescribers were significantly more likely to have registered and used the database; 52% said the PDMP was too time-consuming and 23% said the information was not easy to use. All respondents who reported PDMP use indicated it carried some clinical utility, with 87% reporting it to be "somewhat" or "very" useful. Emergency medicine prescribers were more likely to use the PDMP regularly, with 73% selecting "somewhat frequently" or higher, while only 9% of surgery prescribers indicated the same. Of all respondents, 97% agreed that an integrated alert in the existing EMR would be helpful. CONCLUSION Acute-care prescribers at our institution are universally aware of the opioid epidemic, but efficient and useful tools for identifying at-risk patients are lacking. Our prescribers desired an alert system integrated into the EMR to highlight targeted risk factors.
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Affiliation(s)
- Daniel Leas
- Department of Orthopedic Surgery, Carolinas Trauma Network Research Center of Excellence, Carolinas HealthCare System, 1000 Blythe Boulevard, Charlotte, NC 28203 USA
| | - Rachel B. Seymour
- Department of Orthopedic Surgery, Carolinas Trauma Network Research Center of Excellence, Carolinas HealthCare System, 1000 Blythe Boulevard, Charlotte, NC 28203 USA
- Charlotte, NC USA
| | - Meghan K. Wally
- Department of Orthopedic Surgery, Carolinas Trauma Network Research Center of Excellence, Carolinas HealthCare System, 1000 Blythe Boulevard, Charlotte, NC 28203 USA
| | - Joseph R. Hsu
- Department of Orthopedic Surgery, Carolinas Trauma Network Research Center of Excellence, Carolinas HealthCare System, 1000 Blythe Boulevard, Charlotte, NC 28203 USA
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Griggs C, Wyatt S, Wally MK, Runyon M, Hsu JR, Seymour RB, Beuhler M, Bosse MJ, Fogg R, Gibbs M, Haas E, Jarrett S, Leas D, Saha A, Schiro S, Watling B; PRIMUM Group. Prescribing of Opioids and Benzodiazepines Among Patients With History of Overdose. J Addict Med 2019; 13:396-402. [PMID: 30844876 DOI: 10.1097/ADM.0000000000000513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Addiction and overdose related to prescription drugs continues to be a leading cause of morbidity and mortality in the United States. We aimed to characterize the prescribing of opioids and benzodiazepines to patients who had previously presented with an opioid or benzodiazepine overdose. METHODS This was a retrospective chart review of patients who were prescribed an opioid or benzodiazepine in a 1-month time-period in 2015 (May) and had a previous presentation for opioid or benzodiazepine overdose at a large healthcare system. RESULTS We identified 60,129 prescribing encounters for opioids and/or benzodiazepines, 543 of which involved a patient with a previous opioid or benzodiazepine overdose. There were 404 unique patients in this cohort, with 97 having more than 1 visit including a prescription opioid and/or benzodiazepine. A majority of prescriptions (54.1%) were to patients with an overdose within the 2 years of the documented prescribing encounter. Prescribing in the outpatient clinical setting represented half (49.9%) of encounters, whereas emergency department prescribing was responsible for nearly a third (31.5%). CONCLUSIONS In conclusion, prescribing of opioids and benzodiazepines occurs across multiple locations in a large health care system to patients with a previous overdose. Risk factors, such as previous overdose should be highlighted through clinical decision support tools in the medical record to help prescribers identify patients at higher risk and to mobilize resources for this patient population. Prescribers need further education on factors that place their patients at risk for opioid use disorder and on alternative therapies to opioids and benzodiazepines.
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Boyle J, Clement C, Atherton A, Stock C. A retrospective chart review of opioid represcribing following nonfatal overdose at a Veterans Affairs hospital. Ment Health Clin 2017; 7:276-281. [PMID: 29955534 PMCID: PMC6007726 DOI: 10.9740/mhc.2017.11.276] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Opioid-related overdoses have risen despite extensive media coverage and apparent awareness of this public health crisis. Emergency department visits related to opioid use nearly tripled from 2004 to 2011. Patients with mental illness are more likely to be prescribed opioids and have higher rates of overdose. This retrospective chart review sought to determine if opioid represcribing occurred after patients were treated for a nonfatal opioid overdose (NFO) at a Veterans Affairs hospital. METHODS Patients who experienced an NFO between 2009 and 2013 were included and charts reviewed until January 1, 2016. Review of the electronic medical record (EMR) was performed to determine if and when opioids were again prescribed after NFO. RESULTS Fifty-six veterans met the inclusion criteria. A new opioid prescription was issued to 82% of patients within 3 months following the index NFO date. The average daily morphine equivalent dose prescribed before (122 mg) and after (120 mg) NFO did not differ. A subsequent opioid overdose event occurred in 25% of patients, and there was 1 fatal event. Only 1 patient had medication overdose on the problem list of their EMR. DISCUSSION Despite experiencing NFO, veterans continued to be prescribed opioids without significant changes in the drug or dose; some experienced repeated overdose events, possibly due to poor communication and documentation of NFO. Pharmacists can play a key role in clinical interventions and education of patients and prescribers.
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Affiliation(s)
- Julia Boyle
- Assistant Professor, Idaho State University, Meridian, Idaho; Mental Health Clinical Pharmacist, Boise VA Medical Center, Boise, Idaho, . Previously: VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Cassandra Clement
- Outpatient Mental Health Clinical Pharmacy Specialist, Orlando VA Medical Center, Orlando, Florida
| | - Abril Atherton
- Clinical Pharmacy Specialist - Mental Health, VA Salt Lake City Health Care System, Salt Lake City, Utah; Adjunct Instructor, University of Utah College of Pharmacy, Salt Lake City, Utah; Adjunct Assistant Professor, University of Utah College of Social Work, Salt Lake City, Utah
| | - Christopher Stock
- Pharmacist/Investigator, VA Salt Lake City Health Care System, Salt Lake City, Utah
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Frazier W, Cochran G, Lo-Ciganic WH, Gellad WF, Gordon AJ, Chang CCH, Donohue JM. Medication-Assisted Treatment and Opioid Use Before and After Overdose in Pennsylvania Medicaid. JAMA 2017; 318:750-752. [PMID: 28829862 PMCID: PMC5817478 DOI: 10.1001/jama.2017.7818] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study uses Medicaid data to compare prescription opioid use, duration of opioid use, and rates of medication-assisted treatment (buprenorphine, methadone, or naltrexone) among enrollees before and after an overdose event.
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Affiliation(s)
- Winfred Frazier
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Gerald Cochran
- School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Walid F. Gellad
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - Julie M. Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Abstract
OBJECTIVES To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center. DESIGN A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Adult patients with OT admitted over a 30-day period (n = 110). INTERVENTION All discharge and follow-up opioid prescriptions were recorded. MAIN OUTCOME MEASUREMENTS Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed. RESULTS One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%). CONCLUSIONS Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Seymour RB, Leas D, Wally MK, Hsu JR. Erratum to: Prescription reporting with immediate medication utilization mapping (PRIMUM): development of an alert to improve narcotic prescribing. BMC Med Inform Decis Mak 2016; 16:125. [PMID: 27670911 PMCID: PMC5036324 DOI: 10.1186/s12911-016-0364-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 11/10/2022] Open
Affiliation(s)
- Rachel B Seymour
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203, NC, USA. .,Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC, 28204, USA.
| | - Daniel Leas
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203, NC, USA.,Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC, 28204, USA
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203, NC, USA.,Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC, 28204, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203, NC, USA.,Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC, 28204, USA
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