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Martinez M, Kirkegaard A, Bouskill K, Yan XS, Wagner Z, Watkins KE. Surgeons' views of peer comparison and guideline-based feedback on postsurgery opioid prescriptions: a qualitative investigation. BMJ Open Qual 2024; 13:e002750. [PMID: 38580444 PMCID: PMC11002351 DOI: 10.1136/bmjoq-2024-002750] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Excess opioid prescribing after surgery can lead to prolonged opioid use and diversion. We interviewed surgeons who were part of a three-group cluster-randomised controlled trial aimed at reducing prescribed opioid quantities after surgery via two versions of a monthly emailed behavioural 'nudge' (messages encouraging but not mandating compliance with social norms and clinical guidelines around prescribing) at the end of the implementation year in order to understand surgeons' reasoning for changing or continuing their prescribing behaviour as a result of the intervention and the context for their rationale. METHODS The study took place at a large healthcare system in northern California with surgeons from three surgical specialties-orthopaedics, obstetrics/gynaecology and general surgery. Following the intervention period, we conducted semistructured interviews with 36 surgeons who had participated in the trial, ensuring representation across trial arm, specialty and changes in prescribing quantities over the year. Interviews focused on reactions to the nudges, impacts of the nudges on prescribing behaviours and other factors impacting prescribing. Three study team members coded and analysed the transcribed interviews. RESULTS Nudges were equally effective in reducing postsurgical opioid prescribing across surgical specialties and between intervention arms. Surgeons were generally receptive to the nudge intervention, noting that it reduced the size of their discharge opioid prescriptions by improving their awareness and intentionality around prescribing. Most were unaware that clinical guidelines around opioid prescribing existed. Some had reservations regarding the accuracy and context of information provided in the nudges, the prescription quantities encouraged by the nudges and feelings of being watched or admonished. A few described discussing the nudges with colleagues. Respondents emphasised that the prescribing behaviours are informed by individual clinical experience and patient-related and procedure-related factors. CONCLUSIONS Surgeons were open to learning about their prescribing behaviour through comparisons to guidelines or peer behaviour and incorporating this feedback as one of several factors that guide discharge opioid prescribing. Increasing awareness of clinical guidelines around opioid prescribing is important for curbing postsurgical opioid overprescribing. TRIAL REGISTRATION NUMBER NCT05070338.
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Affiliation(s)
- Meghan Martinez
- Palo Alto Medical Foundation Research Institute and Center for Health Systems Research, Sutter Health, Palo Alto, California, USA
| | | | | | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | | | - Katherine E Watkins
- Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California, USA
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Beaulieu-Jones BR, Berrigan MT, Robinson KA, Marwaha JS, Kent TS, Brat GA. An Institutional Curriculum for Opioid Prescribing Education: Outcomes From 2017 to 2022. J Surg Res 2024; 295:1-8. [PMID: 37951062 PMCID: PMC10922287 DOI: 10.1016/j.jss.2023.09.058] [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: 05/26/2023] [Revised: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 11/13/2023]
Abstract
INTRODUCTION Prescription opioids, including those prescribed after surgery, have greatly contributed to the US opioid epidemic. Educating opioid prescribers is a crucial component of ensuring the safe use of opioids among surgical patients. METHODS An annual opioid prescribing education curriculum was implemented among new surgical prescribers at our institution between 2017 and 2022. The curriculum includes a single 75-min session which is comprised of several components: pain medications (dosing, indications, and contraindications); patients at high risk for uncontrolled pain and/or opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations. Participants were asked to complete an opioid knowledge assessment before and after the didactic session. RESULTS Presession and postsession assessments were completed by 197 (89.6%) prescribers. Across the five studied years, the median presession score was 54.5%. This increased to 63.6% after completion of the curriculum, representing a median relative knowledge increase of 18.2%. The median relative improvement was greatest for preinterns and interns (18.2% for both groups); smaller improvements were observed for postgraduate year 2-5 residents (9.1%) and advanced practice providers (9.1%). On a scale of 1 to 10 (with 5 being comfortable), median (interquartile range) self-reported comfort in prescribing opioids increased from 3 (2-5) before education to 5 (4-6) after education (P < 0.001). CONCLUSIONS Each year, the curriculum substantially improved provider knowledge of and comfort in opioid prescribing. Despite increased national awareness of the opioid epidemic and increasing institutional initiatives to improve opioid prescribing practices, there was a sustained knowledge and comfort gap among new surgical prescribers. The observed effects of our opioid education curriculum highlight the value of a simple and efficient educational initiative.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Margaret T Berrigan
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts
| | - Kortney A Robinson
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts
| | - Jayson S Marwaha
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts
| | - Gabriel A Brat
- Department of Surgery, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts.
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Wagner Z, Kirkegaard A, Mariano LT, Doctor JN, Yan X, Persell SD, Goldstein NJ, Fox CR, Brummett CM, Romanelli RJ, Bouskill K, Martinez M, Zanocco K, Meeker D, Mudiganti S, Waljee J, Watkins KE. Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions: A Randomized Clinical Trial. JAMA Health Forum 2024; 5:e240077. [PMID: 38488780 PMCID: PMC10943416 DOI: 10.1001/jamahealthforum.2024.0077] [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] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 03/18/2024] Open
Abstract
Importance Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration ClinicalTrials.gov NCT05070338.
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Affiliation(s)
| | | | | | - Jason N. Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Xiaowei Yan
- Palo Alto Medical Foundation, Palo Alto, California
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noah J. Goldstein
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | - Craig R. Fox
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | | | - Robert J. Romanelli
- Palo Alto Medical Foundation, Palo Alto, California
- RAND Europe, Westbrook Centre, Cambridge, United Kingdom
| | | | | | - Kyle Zanocco
- Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Daniella Meeker
- Keck School of Medicine, USC Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California
- Yale School of Medicine, New Haven, Connecticut
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Thirukumaran CP, Fiscella KA, Rosenthal MB, Doshi JA, Schloemann DT, Ricciardi BF. Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements. J Am Geriatr Soc 2024; 72:102-112. [PMID: 37772461 PMCID: PMC10841259 DOI: 10.1111/jgs.18605] [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: 03/02/2023] [Revised: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics – University of Rochester, NY
- Department of Public Health Sciences – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Kevin A. Fiscella
- Department of Public Health Sciences – University of Rochester, NY
- Department of Family Medicine – University of Rochester, NY
| | - Meredith B. Rosenthal
- Department of Health Policy and Management – Harvard T. H. Chan School of Public Health, MA
| | - Jalpa A. Doshi
- Division of General Internal Medicine – University of Pennsylvania Perelman School of Medicine, PA
| | - Derek T. Schloemann
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Benjamin F. Ricciardi
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
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Dun C, Overton HN, Walsh CM, Hennayake S, Wang P, Fahim C, Bicket MC, Makary MA. A Peer Data Benchmarking Intervention to Reduce Opioid Overprescribing: A Randomized Controlled Trial. Am Surg 2023; 89:4379-4387. [PMID: 35762831 DOI: 10.1177/00031348221111519] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Driving physician behavior change has been an elusive goal for quality improvement efforts aimed at reducing low-value care. We proposed the use of "nudge" interventions at the surgeon level in order to reduce post-surgical opioid overprescribing in accordance with consensus guidelines. METHODS We used 2017 Medicare data to identify outlier surgeons. A peer data benchmarking report that showed each surgeon the average number of opioid tablets they prescribed for an open inguinal hernia repair procedure from January 1, 2017 to December 31, 2017. We conducted a 1:1 randomized controlled trial providing outlier surgeons a report of their opioid prescribing patterns for a standard operation compared to the national average and prescribing guidelines. RESULTS There were 489 surgeons randomized to the intervention, of which 180 (36.8%) had data in the post-intervention period. Data was available for 87 surgeons in the intervention group and 93 surgeons in the control group. 97.7% of surgeons in the intervention group reduced their opioid prescribing pattern compared to 95.7% in the control group. Surgeons who received the data benchmarking report intervention prescribed 14.3% less opioids than surgeons in the control group (10.54 (SD 5.34) vs. 12.30 (SD 6.02), P = .04). The intervention was associated with a 1.83 lower mean number of opioid tablets prescribed per patient in the multivariable linear regression model after controlling for other factors (Intervention group vs. control group 95% CI [-3.61, -.04], P = .04). DISCUSSION The implementation of a peer data benchmarking intervention can drive physician behavior change towards high-value care.
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Affiliation(s)
- Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heidi N Overton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christi M Walsh
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sanuri Hennayake
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine Fahim
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, MA, USA
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MA, USA
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
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Melucci AD, Loria A, Swanson H, White Q, Moalem J, Fleming FJ, Temple LK. Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project. Surgery 2023; 174:517-523. [PMID: 37407396 DOI: 10.1016/j.surg.2023.05.036] [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] [Received: 04/03/2023] [Revised: 04/28/2023] [Accepted: 05/24/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Opioid stewardship protocols reduce opioid overprescription, but many require corrective action within 1 year. Because there are limited data on the sustainability of opioid reduction protocols, we sought to evaluate prescribing trends beyond 1 year. METHODS We reviewed prescribing data from a tertiary care center to establish a consensus discharge opioid-prescribing guideline. Subsequently, we performed a prospective quality-improvement study for patients on an enhanced recovery protocol undergoing elective colectomies, proctectomies, and stoma-related procedures. We gathered process (protocol compliance), balance (rates of patient-controlled analgesia and nerve blocks, inpatient opioid utilization, pain scores within 48 hours of discharge), and clinical measures (median discharge opioid pills, postdischarge day 7 satisfaction). RESULTS In total, 1,049 patients with similar ages, operative indications, and rates of substance use pre- and postintervention were included. Over 2 years, compliance was 88.6%, and there was a 43.6% reduction in the total discharge number of opioid pills. Phone calls for opioid refills were stable (10.2% pre- vs 7.8% postintervention, P = .16), and the following all decreased significantly: intraoperative nerve blocks, patient-controlled analgesia use, and final 48-hour and total median inpatient opioid use. There was a clinically negligible, statistically significant reduction in pain scores within 48 hours of discharge. Fifty patients provided satisfaction data, and 92% were satisfied or somewhat satisfied with their analgesia. CONCLUSION Over 2 years, reduced opioid prescribing was maintained without escalating resources. Sustainability suggests that after successfully implementing an opioid reduction protocol, institutions may safely redeploy quality improvement resources elsewhere.
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Affiliation(s)
- Alexa D Melucci
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY.
| | - Anthony Loria
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY. http://www.twitter.com/apl2018
| | - Holli Swanson
- Department of Surgery, University of Rochester Medical Center, NY
| | - Quarnisha White
- Department of Surgery, University of Rochester Medical Center, NY
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, NY. http://www.twitter.com/jacobmoalem
| | - Fergal J Fleming
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY. http://www.twitter.com/fergaljfleming
| | - Larissa K Temple
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY
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Mondoñedo JR, Brescia AA, Clark MJ, Chang ML, Jiang S, He C, Welsh RJ, Popoff AM, Kulkarni MG, Lall SC, Pratt JW, Adams KN, Alnajjar RM, Martin JR, Gandhi DB, Brummett CM, Chang AC, Lagisetty KH. Evidence-based opioid prescribing guidelines after lung resection: a prospective, multicenter analysis. J Thorac Dis 2023; 15:3285-3294. [PMID: 37426143 PMCID: PMC10323572 DOI: 10.21037/jtd-22-1621] [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] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/24/2023] [Indexed: 07/11/2023]
Abstract
Background Opioid prescribing guidelines have significantly decreased overprescribing and post-discharge use after cardiac surgery; however, limited recommendations exist for general thoracic surgery patients, a similarly high-risk population. We examined opioid prescribing and patient-reported use to develop evidence-based, opioid prescribing guidelines after lung cancer resection. Methods This prospective, statewide, quality improvement study was conducted between January 2020 to March 2021 and included patients undergoing surgical resection of a primary lung cancer across 11 institutions. Patient-reported outcomes at 1-month follow-up were linked with clinical data and Society of Thoracic Surgery (STS) database records to characterize prescribing patterns and post-discharge use. The primary outcome was quantity of opioid used after discharge; secondary outcomes included quantity of opioid prescribed at discharge and patient-reported pain scores. Opioid quantities are reported in number of 5-mg oxycodone tablets (mean ± standard deviation). Results Of the 602 patients identified, 429 met inclusion criteria. Questionnaire response rate was 65.0%. At discharge, 83.4% of patients were provided a prescription for opioids of mean size 20.5±13.1 pills, while patients reported using 8.2±13.0 pills after discharge (P<0.001), including 43.7% who used none. Those not taking opioids on the calendar day prior to discharge (32.4%) used fewer pills (4.4±8.1 vs. 11.7±14.9, P<0.001). Refill rate was 21.5% for patients provided a prescription at discharge, while 12.5% of patients not prescribed opioids at discharge required a new prescription before follow-up. Pain scores were 2.4±2.5 for incision site and 3.0±2.8 for overall pain (scale 0-10). Conclusions Patient-reported post-discharge opioid use, surgical approach, and in-hospital opioid use before discharge should be used to inform prescribing recommendations after lung resection.
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Affiliation(s)
| | | | - Melissa J. Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Matthew L. Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shannon Jiang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Robert J. Welsh
- Beaumont Hospital, Royal Oak, MI, USA
- Beaumont Hospital, Troy, MI, USA
| | | | | | | | | | | | | | | | | | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew C. Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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DiScala S, Uritsky TJ, Brown ME, Abel SM, Humbert NT, Naidu D. Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists. J Pain Palliat Care Pharmacother 2023; 37:3-15. [PMID: 36519288 DOI: 10.1080/15360288.2022.2149670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.
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Jogerst K, Coe TM, Gupta N, Pockaj B, Fingeret A. How to teach ERAS protocols: surgical residents' perspectives and perioperative practices for breast surgery patients. Global Surg Educ 2023; 2:33. [PMID: 38013861 PMCID: PMC9904524 DOI: 10.1007/s44186-022-00048-7] [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] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/16/2022] [Accepted: 09/15/2022] [Indexed: 11/29/2023]
Abstract
Purpose Breast enhanced recovery after surgery (ERAS) protocols emphasize multimodal analgesia to expedite home recovery, but variable implementation remains. This study examines how residents learn and use ERAS protocols, how they conceptualize pain management, and what influences breast surgery patients' same-day discharges. Methods Interviews were conducted with surgical residents following their breast surgery rotation using an interview guide adapted from existing pain management literature. Interviews were transcribed, de-identified, and independently inductively coded by two researchers. A codebook was developed and refined using the constant comparative method. Codes were grouped into categories and explored for thematic analysis. Results Twelve interviews were completed with plastic and general surgery residents. Ultimately, 365 primary codes were organized into 26 parent codes, with a Cohen's kappa of 0.93. A total of six themes were identified. Three themes described how participants learn through a mixture of templated care, formal education, and informal experiential learning. Two themes delineated how residents would teach breast surgery ERAS: by emphasizing buy-in and connecting the impetus behind ERAS with daily workflow implementation. One theme illustrated how a patient-centered culture impacts postoperative management and same-day discharges. Conclusions Residents describe learning breast surgery ERAS and postoperative pain management by imitating their seniors, observing patient encounters, completing templated orders, and translating concepts from other ERAS services more so than from formal lectures. When implementing breast ERAS protocols, it is important to consider how informal learning and local culture influence pain management and discharge practices. Ultimately, residents believe in ERAS and often request further educational tools to better connect the daily how-to of breast ERAS pathways with the why behind the enhanced recovery principles.
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Affiliation(s)
- Kristen Jogerst
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Taylor M. Coe
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Nikita Gupta
- Alix School of Medicine, Mayo Clinic Arizona, Phoenix, AZ USA
| | - Barbara Pockaj
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 USA
| | - Abbey Fingeret
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
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Zhang KK, Blum KM, Chu JJ, Sharma S, Skoracki RJ, Moore AM, Janis JE, Barker JC. Reducing Opioid Overprescribing through Procedure-specific Prescribing Guidelines. Plast Reconstr Surg Glob Open 2023; 11:e4776. [PMID: 36699205 DOI: 10.1097/GOX.0000000000004776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/28/2022] [Indexed: 01/27/2023]
Abstract
Despite advances in opioid-sparing pain management, postdischarge opioid overprescribing in plastic surgery remains an issue. Procedure-specific prescribing protocols have been implemented successfully in other surgical specialties but not broadly in plastic surgery. This study examined the efficacy of procedure-specific prescribing guidelines for reducing postdischarge opioid overprescribing. Methods A total of 561 plastic surgery patients were evaluated retrospectively after a prescribing guideline, which recommended postdischarge prescription amounts based on the type of operation, was introduced in July 2020. Prescription and postdischarge opioid consumption amounts before (n = 428) and after (n = 133) guideline implementation were compared. Patient satisfaction and prescription frequency of nonopioid analgesia were also compared. Results The average number of opioid pills per prescription decreased by 25% from 19.3 (27.4 OME) to 15.0 (22.7 OME; P = 0.001) after guideline implementation, with no corresponding decrease in the average number of postdischarge opioid pills consumed [10.6 (15.1 OME) to 8.2 (12.4 OME); P = 0.147]. Neither patient satisfaction with pain management (9.6-9.6; P > 0.99) nor communication (9.6-9.5; P > 0.99) changed. The rate of opioid-only prescription regimens decreased from 17.9% to 7.6% (P = 0.01), and more patients were prescribed at least two nonopioid analgesics (27.5% to 42.9%; P = 0.003). The rate of scheduled acetaminophen prescription, in particular, increased (54.7% to 71.4%; P = 0.002). Conclusions A procedure-specific prescribing model is a straight-forward intervention to promote safer opioid-prescribing practices in plastic surgery. Its usage in clinical practice may lead to more appropriate opioid prescribing.
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Melucci AD, Dave YA, Lynch OF, Hsu S, Erlick MR, Linehan DC, Moalem J. Predictors of opioid-free discharge after laparoscopic cholecystectomy. Am J Surg 2023; 225:206-211. [PMID: 35948514 DOI: 10.1016/j.amjsurg.2022.07.027] [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] [Received: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA. https://twitter.com/AlexaMelucci
| | - Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Olivia F Lynch
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - Shawn Hsu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mariah R Erlick
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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12
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Chan KY, Keogh S, Aucharaz N, Merrigan A, Tormey S. Opioid prescribing after breast surgery: A systematic review of guidelines. Surgeon 2022:S1479-666X(22)00139-1. [PMID: 36593160 DOI: 10.1016/j.surge.2022.12.004] [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] [Received: 08/30/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite advances in opioid-sparing analgesia, opioid prescribing in breast surgery remains suboptimal. Besides delayed rehabilitation, excess post-operative opioids may contribute significantly to opioid dependence. This systematic review of guidelines evaluates current opioid-prescribing recommendations after breast surgery to identify trends in prescribing. Additionally, it compares recommendations on different non-opioid and non-pharmacological adjuncts. METHODS Electronic databases were searched systematically using terms "breast surgery", "analgesia", "opioid" and "guidelines". The grey literature was used to supplement the search. All articles that provided guidance on opioid prescribing in breast surgery were included. Quality of the guidelines were assessed using the AGREE II tool. Recommendations pertaining to opioid prescribing, analgesic adjuncts and non-pharmacological interventions were summarised and reported with descriptive statistics. RESULT Eight guidelines pertaining to mastectomies, breast conserving surgery and breast reconstructions were included in this review. Although an opioid-sparing approach was unanimous, there were conflicting recommendations on opioid doses. Opioid requirements were stratified by procedure in 3 guidelines, and by patient risk factors in 2 guidelines. There was significant variability in the recommended multimodal adjuncts. Notably, non-pharmacological interventions such as patient education were infrequently included in guidelines. CONCLUSION There is a lack of high-quality guidance on opioid prescribing after breast surgery. The optimum approach for personalised opioid prescribing remains unknown. Significant variability between guidelines provide little actionable interventions for prescribers. This could be driven by the paucity in evidence supporting a single efficacious analgesic regimen for patients undergoing breast surgery. Future guidelines should also regularly incorporate non-pharmacological adjuncts to reduce opioid prescribing.
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Affiliation(s)
- Kin Yik Chan
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland.
| | - Shane Keogh
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Nitin Aucharaz
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Anne Merrigan
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
| | - Shona Tormey
- Department of Breast Surgery, University Hospital Limerick, Limerick V94 F858, County Limerick, Ireland
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13
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Kirkegaard A, Wagner Z, Mariano LT, Martinez MC, Yan XS, Romanelli RJ, Watkins KE. Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial. BMJ Open 2022; 12:e061980. [PMID: 36123066 PMCID: PMC9486294 DOI: 10.1136/bmjopen-2022-061980] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Surgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment and opioid diversion. This study tests the effectiveness of two behavioural nudges, one based on peer behaviour and one based on best practice guidelines, in reducing excessive postoperative opioid prescriptions. METHODS AND ANALYSIS The study will be conducted at 19 hospitals within a large healthcare delivery system in northern California, USA. Three surgical specialties (general surgery, orthopaedic surgery and obstetric/gynaecological surgery) at each hospital will be randomised either to a control group or to one of two active intervention arms. One intervention is grounded in the theory of injunctive norms, and provides feedback to surgeons on their postoperative opioid prescribing relative to prescribing guidelines endorsed by their institution. The other intervention draws from the theory of descriptive norms, and provides feedback similar to the first intervention but using peers' behaviour rather than guidelines as the benchmark for the surgeon's prescribing behaviour. The interventions will be delivered by a monthly email. Both interventions will be active for twelve months. The effects of each intervention relative to the control group and to each other will be tested using a four-level hierarchical model adjusted for multiple hypothesis testing. ETHICS AND DISSEMINATION Using behavioural nudges rather than rigid policy changes allows us to target excessive prescribing without preventing clinicians from using their clinical judgement to address patient pain. All study activities have been approved by the RAND Human Subjects Protection Committee (ID 2018-0988). Findings will be disseminated through conference presentations, peer-reviewed publications and social media accounts. TRIAL REGISTRATION NUMBER NCT05070338.
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Affiliation(s)
| | | | | | - Meghan C Martinez
- Center for Health Systems Research (West), Palo Alto, California, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research (East), Walnut Creek, California, USA
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14
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Hlavin C, Muluk S, Muluk V, Ryan J, Wagner J, Dhupar R. A Program to Reduce Post-Operative Opioid Prescribing at a Veteran's Affairs Hospital. J Clin Med 2022; 11:jcm11185453. [PMID: 36143098 PMCID: PMC9506192 DOI: 10.3390/jcm11185453] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
Variability in surgeon prescribing patterns is common in the post-operative period and can be the nidus for dependence and addiction. This project aims to reduce opioid overprescribing at the Veteran’s Affairs Pittsburgh Healthcare System (VAPHS). The VAPHS Opioid Stewardship Committee collaborated to create prescribing guidelines for inpatient and outpatient general, thoracic, and vascular surgery procedures. We incorporated bundled order sets into the provider workflow in the electronic medical system and performed a retrospective cohort study comparing opioid prescription patterns for Veterans who underwent any surgical procedure for a three-month period pre- and post- guideline implementation. After implementation of opioid prescribing guidelines, morphine milligram equivalents (MME), quantity of pills prescribed, and days prescribed were statistically significantly reduced for procedures with associated guidelines, including cholecystectomy (MME 140.8 vs. 57.5, p = 0.002; quantity 18.8 vs. 8, p = 0.002; days 5.1 vs. 2.8, p = 0.021), inguinal hernia repair (MME 129.9 vs. 45.3, p = 0.002; quantity 17.3 vs. 6.1, p = 0.002; days 5.0 vs. 2.4, p = 0.002), and umbilical hernia repair (MME 128.8 vs. 53.8, p = 0.002; quantity 17.1 vs. 7.8, p = 0.002; days 5.1 vs. 2.5, p = 0.022). Procedures without associated recommendations also preceded a decrease in overall opioid prescribing. Post-operative opioid prescribing guidelines can steer clinicians toward more conscientious opioid disbursement. There may also be reductions in prescribing opioids for procedures without guidelines as an indirect effect of practice change.
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Affiliation(s)
- Callie Hlavin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Sruthi Muluk
- School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Visala Muluk
- Department of Medicine, Veteran’s Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - John Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jeffrey Wagner
- Division of Clinical Pharmacy, Veteran’s Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Rajeev Dhupar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Correspondence:
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15
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Pourali SP, Gutierrez Y, Jones ME, Rajkumar JR, Kucharik AH, Armstrong AW. Are we contributing to the opioid epidemic? A systematic review on systemic opioid use in dermatology. Int J Dermatol 2022; 61:1056-1068. [PMID: 34870325 DOI: 10.1111/ijd.16011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 11/11/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although dermatologists treat many painful skin conditions and perform procedures that may require analgesic use, there is a lack of evidence synthesis on opioid use in dermatology. OBJECTIVE To conduct a systematic review of the evidence on the use of opioid analgesics in dermatology. METHODS We applied the PRISMA guidelines and systematically reviewed literature that examined opioid use in dermatology published between 1980 and 2020 in the PubMed, EMBASE, and Cochrane databases. This review was registered with PROSPERO (CRD42020204864). RESULTS We identified 24 studies that analyzed 52,705,201 patients and 13,099 dermatologists. Between 34% and 87.5% of patients received opioids following dermatologic procedures; however, many did not use the entirety of their prescriptions, and 35-69% did not use any of their prescription. Top opioid prescribers were more likely to be Mohs surgeons, male, and practice in the South. Variability exists in the current evidence for opioid prescribing for nonprocedural dermatologic disease. CONCLUSION While opioid prescribing in dermatology is low compared with other specialties, patients are not utilizing the entirety of their prescriptions. Opioid prescribing for nonprocedural dermatologic disease varies; treatments focused on targeting the pathogenesis of these diseases is important to minimize opioid use. Dermatologists should consider limiting opioid prescribing and utilizing nonnarcotic analgesics.
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Affiliation(s)
- Sarah P Pourali
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Yasmin Gutierrez
- University of California Riverside School of Medicine, Riverside, CA, USA
| | - Madison E Jones
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Alison H Kucharik
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - April W Armstrong
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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16
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Jivraj NK, Ladha K, Goel A, Hill A, Wijeysundera DN, Bateman BT, Wunsch H. Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study. Can J Anaesth 2022; 69:974-985. [DOI: 10.1007/s12630-022-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/15/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
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17
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Cogan JC, Accordino MK, Beauchemin MP, Spivack JH, Ulene SR, Elkin EB, Melamed A, Taback B, Wright JD, Hershman DL. Efficacy of a password-protected, pill-dispensing device with mail return capacity to enhance disposal of unused opioids after cancer surgery. Cancer 2022; 128:3392-3399. [PMID: 35819926 DOI: 10.1002/cncr.34384] [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] [Received: 03/25/2022] [Revised: 05/22/2022] [Accepted: 06/15/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery. METHODS A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction. RESULTS Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved. CONCLUSIONS Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.
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Affiliation(s)
- Jacob C Cogan
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Melissa K Accordino
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Melissa P Beauchemin
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Columbia University School of Nursing, New York, New York, USA
| | - John H Spivack
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Sophie R Ulene
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Elena B Elkin
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Bret Taback
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, New York, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA.,Joseph L. Mailman School of Public Health, Columbia University, New York, New York, USA
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18
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Fu R, Xu H, Lai Y, Sun X, Zhu Z, Zang H, Wu Y. A VOSviewer-Based Bibliometric Analysis of Prescription Refills. Front Med (Lausanne) 2022; 9:856420. [PMID: 35801215 PMCID: PMC9254907 DOI: 10.3389/fmed.2022.856420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/11/2022] [Indexed: 11/27/2022] Open
Abstract
Purpose Prescription refills are long-term prescriptions for chronic patients in stable status, which varies from country to country. A well-established prescription refill system is beneficial for chronic patients’ medication management and facilitates the efficacy of clinical care. Therefore, we carried out a bibliometric analysis to examine the development of this field. Summary Publications on prescription refills from 1970 to 2021 were collected in the Web of Science Core Collection (WoSCC). Search strategy TS = “prescri* refill*” OR “medi* refill*” OR “repeat prescri*” OR “repeat dispens*” OR TI = refill* was used for search. VOSviewer was applied to visualize the bibliometric analysis. A total of 319 publications were found in WoSCC. Study attention on prescription refills has shown a steady rise but is still low in recent years. The United States was the most productive country, which had the highest total citations, average citations per publication, and the highest H-index, and participated in international collaboration most frequently. The University of California system was the most productive institution. The U.S. Department of Veterans Affairs was the institution with the most citations, most average citation, and highest H-index. Sundell was the most productive author, and Steiner J. F. was the most influential author. “Adherence,” “medication,” and “therapy” were the most prominent keywords. Conclusion Publications on prescription refills have increased rapidly and continue to grow. The United States had the leading position in the area. It is recommended to pay closer attention to the latest hotspots, such as “Opioids,” “Surgery,” “Differentiated care,” and “HIV.”
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Affiliation(s)
- Runchen Fu
- School of Pharmaceutical Sciences, Shandong First Medical University, Tai’an, China
| | - Haiping Xu
- School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Yongjie Lai
- School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Xinying Sun
- School of Public Health, Peking University, Beijing, China
| | - Zhu Zhu
- Pharmaceutical Preparation Section, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hengchang Zang
- NMPA Key Laboratory for Technology Research and Evaluation of Drug Products, School of Pharmaceutical Sciences, Shandong University, Jinan, China
- Hengchang Zang,
| | - Yibo Wu
- School of Public Health, Peking University, Beijing, China
- *Correspondence: Yibo Wu,
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19
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Chitwood C, Haug KL, Wenthur C, Gillis C, Maloney JD, Johnson D. Evaluation of Prescribing Patterns Following Surgical Procedures in Opioid Naïve Patients at a Veterans Affairs Teaching Hospital. Mil Med 2022; 188:usac106. [PMID: 35451478 DOI: 10.1093/milmed/usac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/11/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates. METHODS This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations. RESULTS Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation. CONCLUSION Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.
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Affiliation(s)
- Caleb Chitwood
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
| | - Karlie L Haug
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
| | - Cody Wenthur
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI 53705, USA
| | - Carly Gillis
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI 53705, USA
| | - James D Maloney
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
| | - Diane Johnson
- Department of Surgery, William S. Middleton Memorial VA Hospital, Madison, WI 53705, USA
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20
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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21
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Witt RG, Cope B, Chiang YJ, Newhook T, Lillemoe H, Tzeng CWD, Chen IB, Fisher SB, Lucci A, Wargo JA, Lee JE, Ross MI, Gershenwald JE, Robinson J, Keung EZ. Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy. J Surg Oncol 2022; 125:719-729. [PMID: 34904258 PMCID: PMC9108995 DOI: 10.1002/jso.26768] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy. METHODS A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed. RESULTS Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001). CONCLUSIONS Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.
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Affiliation(s)
- Russell G. Witt
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Brandon Cope
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Timothy Newhook
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Heather Lillemoe
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Iris B. Chen
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Sarah B. Fisher
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Anthony Lucci
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jennifer A. Wargo
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Merrick I. Ross
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Gershenwald
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Justine Robinson
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Emily Z. Keung
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
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22
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Ren Y, Mehranpour P, Moshtaghi O, Schwartz MS, Friedman RA. Opioid Prescribing Patterns After Skull Base Surgery for Vestibular Schwannoma. Otol Neurotol 2022; 43:e116-e121. [PMID: 34889846 DOI: 10.1097/mao.0000000000003349] [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: 11/25/2022]
Abstract
OBJECTIVE Excessive opioid prescription is a source of prescription diversion and could contribute to chronic opioid abuse. This study describes the opioid prescribing patterns and risk factors for additional opioid prescription after surgical resection of vestibular schwannoma (VS). STUDY DESIGN Retrospective chart review. SETTING Single tertiary referral center. PATIENTS Adult VS patients undergoing surgical resection between May 2019 and March 2020. INTERVENTIONS Opioid use postoperatively and up to 60 days following surgery were characterized from medical records and by querying the state-wide Controlled Substance Utilization Review and Evaluation System. MAIN OUTCOME MEASURES The presence of additional opioid prescriptions within 60 days of surgery. RESULTS A total of 109 patients (mean age 50 yrs, 65.5% female) were prescribed an average of 138.2 ± 117.8 mg of morphine equivalents (MME). Twenty-two (20.9%) required additional prescriptions of 163.2 ± 103.2 MME. Age, gender, tumor size, or surgical approach (translabyrinthine, retrosigmoid, versus middle fossa) were not associated with additional prescriptions. Patients with additional prescriptions had higher body mass index (BMI 28.8 vs. 25.8 kg/m2, p = 0.015) and required more opioid medications during hospitalization (51.8 vs. 29.1 MME, p = 0.002). On multivariate logistic regression, higher BMI (odds ratio [OR] 1.32; p = 0.001), history of headaches (OR 11.9, p = 0.011), and history of opioid use (OR 29.3, p = 0.008) were associated with additional prescription. CONCLUSIONS Additional opioid prescriptions may be necessary in a portion of VS patients undergoing surgery. The choice of surgical approach is not associated with excess opioid requirements. Patients with higher BMI, history of headaches, or preoperative opioid use may require additional prescriptions.
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Affiliation(s)
- Yin Ren
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology Head and Neck Surgery, The Ohio State University, Columbus, Ohio
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery
| | | | - Omid Moshtaghi
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery
| | - Marc S Schwartz
- Department of Neurosurgery, University of California San Diego, La Jolla, California
| | - Rick A Friedman
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery
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23
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Zhu D, Macdonald EJ, Lesko RP, Watts KL. National trends and prescription patterns in opiate analgesia for urolithiasis presenting to Emergency Departments: Analysis of the National Hospital Ambulatory Medical Care Survey, 2006-2018. Urology 2021; 164:80-87. [PMID: 34968567 DOI: 10.1016/j.urology.2021.09.047] [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] [Received: 07/14/2021] [Revised: 08/29/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To analyze the National Hospital Ambulatory Medical Care Survey (NHAMCS) database to determine geographic and temporal trends, as well as variables associated with the likelihood of receiving an opioid prescription for urolithiasis in US EDs. METHODS All ED visits for urolithiasis between 2006-2018 in the NHAMCS database were analyzed. Age, race/ethnicity, insurance status, ED provider credentials, geographic region, and urban vs. rural hospital status were extracted. Linear regression was used to examine overall/regional trends in opioid prescriptions over time. Logistic regression was used to estimate factors associated with higher odds of receiving opioids. RESULTS Fourteen million visits were analyzed, of which, 79.1% (11.0 million) received an opioid prescription. From 2014-2018 there was a decline of 3.65%/year of the proportion of visits receiving an opioid prescription (R2=0.86, p=0.008). Non-Hispanic Black race was associated with a lower chance of receiving opioid prescription (OR=0.57, p=0.02) compared to Non-Hispanic Whites (NHW). Midwestern hospitals had higher odds of opioid prescription compared to the Northeast (OR=2.05, p=0.006). Rural hospitals had lower odds of opioid prescription compared to urban hospitals (OR=0.62, p=0.02). CONCLUSION Opioid prescriptions for patients presenting with urolithiasis to the ED have steadily declined from 2014-2018, except in the Midwest. NHW race, Midwest region, and urban EDs increase the likelihood of receiving opioids. Continued efforts encouraging non-opioid alternatives for urolithiasis are essential, specifically in Midwestern EDs, to mitigate the ongoing opioid epidemic in the US.
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Affiliation(s)
- Denzel Zhu
- Albert Einstein College of Medicine, Bronx, NY
| | | | | | - Kara L Watts
- Albert Einstein College of Medicine, Bronx, NY; Department of Urology, Montefiore Medical Center, Bronx, NY.
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24
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Brescia AA, Clark MJ, Theurer PF, Lall SC, Nemeh HW, Downey RS, Martin DE, Dabir RR, Asfaw ZE, Robinson PL, Harrington SD, Gandhi DB, Waljee JF, Englesbe MJ, Brummett CM, Prager RL, Likosky DS, Kim KM, Lagisetty KH. Establishment and Implementation of Evidence-Based Opioid Prescribing Guidelines in Cardiac Surgery. Ann Thorac Surg 2021; 112:1176-1185. [PMID: 33285132 PMCID: PMC8550876 DOI: 10.1016/j.athoracsur.2020.11.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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] [Received: 06/22/2020] [Revised: 10/13/2020] [Accepted: 11/22/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite the risk of new persistent opioid use after cardiac surgery, postdischarge opioid use has not been quantified and evidence-based prescribing guidelines have not been established. METHODS Opioid-naive patients undergoing primary cardiac surgery via median sternotomy between January and December 2019 at 10 hospitals participating in a statewide collaborative were selected. Clinical data were linked to patient-reported outcomes collected at 30-day follow-up. An opioid prescribing recommendation stratified by inpatient opioid use on the day before discharge (0, 1-3, or ≥4 pills) was implemented in July 2019. Interrupted time-series analyses were performed for prescription size and postdischarge opioid use before (January to June) and after (July to December) guideline implementation. RESULTS Among 1495 patients (729 prerecommendation and 766 postrecommendation), median prescription size decreased from 20 pills to 12 pills after recommendation release (P < .001), while opioid use decreased from 3 pills to 0 pills (P < .001). Change in prescription size over time was +0.6 pill/month before and -0.8 pill/month after the recommendation (difference = -1.4 pills/month; P = .036). Change in patient use was +0.6 pill/month before and -0.4 pill/month after the recommendation (difference = -1.0 pills/month; P = .017). Pain levels during the first week after surgery and refills were unchanged. Patients using 0 pills before discharge (n = 710) were prescribed a median of 0 pills and used 0 pills, while those using 1 to 3 pills (n = 536) were prescribed 20 pills and used 7 pills, and those using greater than or equal to 4 pills (n = 249) were prescribed 32 pills and used 24 pills. CONCLUSIONS An opioid prescribing recommendation was effective, and prescribing after cardiac surgery should be guided by inpatient use.
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Affiliation(s)
- Alexander A Brescia
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Patricia F Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | | | | | | | | | | | | | | | | | | | - Jennifer F Waljee
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan; Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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25
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Abstract
This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 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).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
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26
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Woodward MA, Zhang Y, Tannen B, Behunin N, Niziol LM, Waljee J. Association of Limiting Opioid Prescriptions With Use of Opioids After Corneal Surgery. JAMA Ophthalmol 2021; 138:76-80. [PMID: 31670751 DOI: 10.1001/jamaophthalmol.2019.4432] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Opioids, which carry a high risk for addiction and overdose, are commonly prescribed after corneal surgery. Data are lacking describing opioid prescribing practices and opioid needs by patients after ophthalmic surgery. Objectives To quantify opioid use and to assess the association of decreasing the number of opioid tablets prescribed after corneal surgery with postsurgical use. Design, Setting, and Participants This prospective cohort study investigated opioid use after corneal surgery using direct interviews of 2 adult patient cohorts separated by an updated opioid prescribing guideline. The first cohort survey assessed the quantity of opioid tablets used after surgery. The cornea division of a tertiary care academic medical center reviewed the use needs and decreased the number of tablets prescribed after routine cases. Simultaneously, a statewide opioid monitoring program began that provided patients with opioid information. A second unique cohort received a more detailed survey to assess use, opioid disposal, and pain control. Data for the first cohort were collected from December 1, 2017, through January 19, 2018; for the second cohort, from June 1 to September 15, 2018. Data were analyzed from October 24, 2018, through September 24, 2019. Exposure Corneal surgery. Main Outcomes and Measures Differences in use of opioid tablets used by both patient cohorts, assessed using the 2-sample t test. Results Of 112 eligible, contacted patients, 82 consented to participate (42 men [51%]; mean [SD] age, 42.5 [17.8] years) and were included in the analysis; 38 of 42 participated in the first cohort and 44 of 70 participated in the second cohort. Of those receiving opioid prescriptions, the first cohort was prescribed significantly more tablets than the second cohort (mean [SD], 18.8 [4.2] vs 6.6 [3.1]; difference, 12.2 [95% CI, 10.4-14.0]; P < .001). The first cohort used significantly more tablets than the second cohort (mean [SD], 8.3 [7.0] vs 4.0 [3.2]; difference, 4.3 [95% CI, 1.4-7.2]; P = .005) and had significantly more leftover tablets (mean [SD], 10.3 [6.9] vs 2.9 [2.7]; difference, 7.5 [95% CI, 4.7-10.2]; P < .001). In the detailed survey for the second cohort, 19 of 27 patients reported pain control as adequate (70% [95% CI, 50%-86%]); 6 of 27, as more than needed (22% [95% CI, 9%-42%]). Twenty of 28 participants (71% [95% CI, 55%-88%]) had leftover tablets; 17 of these (85% [95% CI, 62%-97%]) did not dispose of leftovers, and 3 (15% [95% CI, 3%-38%]) threw away or flushed leftovers. Conclusions and Relevance After an assessment of opioid needs, physicians prescribed fewer opioid pills. However, patients who underwent cornea surgery and received fewer tablets continued to have adequate pain control and used even fewer tablets compared with the initial cohort. Patients with unused opioid tablets did not dispose of them properly.
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Affiliation(s)
- Maria A Woodward
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Yibing Zhang
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Bradford Tannen
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Nicholas Behunin
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Leslie M Niziol
- W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Jennifer Waljee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
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27
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Dualeh SHA, McMurry K, Herman AE, Maryan S, Pacurar LA, Waits SA, Tischer S. Evaluation of an opioid restrictive pain management initiative in adult kidney transplant recipients. Clin Transplant 2021; 35:e14313. [PMID: 33838060 DOI: 10.1111/ctr.14313] [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] [Received: 10/15/2020] [Revised: 03/24/2021] [Accepted: 04/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Evidence to guide opioid utilization following kidney transplantation is lacking. The purpose of this study is to evaluate the implementation of an opioid restrictive post-operative pain management protocol in adult kidney transplant recipients. METHODS We analyzed patients who underwent kidney transplant between 1/1/2017 to 8/15/2018. A standardized, opioid restrictive pain management protocol was implemented in February 2018. The primary outcome was quantity of opioid tablets prescribed at discharge. Secondary outcomes included amount of opioid prescribed within first 30 days, number of patient calls for pain, and opioid prescription in electronic medical record (EMR) at 90 days and 1 year. RESULTS After implementation, significantly fewer opioid tablets were prescribed at discharge (4 vs. 60 tablets, p < .001) and less oral morphine milligram equivalence (OME) were prescribed within 30 days of transplant (38 vs. 300, p < .001). In cohort 2, fewer patients received more than one opioid prescription, more patients received truncal block and only 5 patients received patient controlled analgesia compared to all in cohort 1. CONCLUSION A standardized, patient-centered pain management strategy after kidney transplantation reduced opioid prescribing without increasing readmissions or clinic calls. This data may be used to inform guidelines for appropriate OME prescribing at discharge after kidney transplantation.
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Affiliation(s)
| | - Katie McMurry
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Samantha Maryan
- Heart and Vascular Department, ProHealth Care, Waukesha, WI, USA
| | | | - Seth A Waits
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Sarah Tischer
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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28
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Van Boerum MS, Mann SL, Veith JP, Collier W, Hosein RC, Manum JS, Agarwal J, Kwok AC. Patient-reported opioid use for tissue expander-based breast reconstruction. J Plast Reconstr Aesthet Surg 2021; 74:2899-2905. [PMID: 34078588 DOI: 10.1016/j.bjps.2021.03.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/07/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use. METHODS Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use. RESULTS A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026). CONCLUSIONS These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.
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Affiliation(s)
- Melody S Van Boerum
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Sara L Mann
- University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Jacob P Veith
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Willem Collier
- Department of Population Health Sciences, University of Utah School of Medicine, Williams Building, Room 1N490 295 Chipeta Way, Salt Lake City, UT 84108
| | - Rayaad C Hosein
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Joanna S Manum
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Jayant Agarwal
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132
| | - Alvin C Kwok
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, 30 North 1900 East, 3B400, Salt Lake City, Utah 84132.
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29
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Huynh V, Colborn K, Rojas KE, Christian N, Ahrendt G, Cumbler E, Schulick R, Tevis S. Evaluation of opioid prescribing preferences among surgical residents and faculty. Surgery 2021; 170:1066-1073. [PMID: 33858683 DOI: 10.1016/j.surg.2021.02.067] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. METHODS Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. RESULTS Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. CONCLUSION There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/THuynhMD
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/ColbornKathryn
| | - Kristin E Rojas
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, FL. https://twitter.com/kristinrojasMD
| | - Nicole Christian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Gretchen Ahrendt
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO. https://twitter.com/@ahrendt50
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Richard Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sarah Tevis
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO.
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30
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Elhage SA, Thielen ON, Huber AT, Otero J, Suddreth CE, Monjimbo GA, Prasad T, Gersin KS, Augenstein VA, Colavita PD, Heniford BT. Preoperative patient opioid education, standardization of prescriptions, and their impact on overall patient satisfaction. Surgery 2021; 169:655-9. [DOI: 10.1016/j.surg.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/17/2020] [Accepted: 09/07/2020] [Indexed: 01/06/2023]
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31
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Baker JE, Luketic K, Niziolek GM, Freeman CM, Grannan KJ, Pritts TA, Paquette IM, Goodman MD. Attending and Resident Surgeon Perspectives and Prescribing Practices of Pain Medication During the Opioid Epidemic. J Surg Educ 2021; 78:579-589. [PMID: 32843318 DOI: 10.1016/j.jsurg.2020.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 05/19/2020] [Revised: 07/21/2020] [Accepted: 08/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes. DESIGN Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play. SETTING Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest. PARTICIPANTS Attending and resident physicians within the Departments of Surgery participated anonymously. RESULTS Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p < 0.05), discuss the potential of opioid abuse (31% vs. 6%; p < 0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p < 0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with >5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%). CONCLUSION AND RELEVANCE Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.
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Affiliation(s)
- Jennifer E Baker
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | - Karla Luketic
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | - Grace M Niziolek
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | | | - Kevin J Grannan
- TriHealth Physician Partners, Department of Surgery, Cincinnati, Ohio
| | - Timothy A Pritts
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | - Ian M Paquette
- University of Cincinnati, Department of Surgery, Cincinnati, Ohio
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Vitzthum LK, Nalawade V, Riviere P, Sumner W, Nelson T, Mell LK, Furnish T, Rose B, Martínez ME, Murphy JD. Racial, Ethnic, and Socioeconomic Discrepancies in Opioid Prescriptions Among Older Patients With Cancer. JCO Oncol Pract 2021; 17:e703-e713. [PMID: 33534647 DOI: 10.1200/op.20.00773] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Minority race and lower socioeconomic status are associated with lower rates of opioid prescription and undertreatment of pain in multiple noncancer healthcare settings. It is not known whether these differences in opioid prescribing exist among patients undergoing cancer treatment. METHODS AND MATERIALS This observational cohort study involved 33,872 opioid-naive patients of age > 65 years undergoing definitive cancer treatment. We compared rates of new opioid prescriptions by race or ethnicity and socioeconomic status controlling for differences in baseline patient, cancer, and treatment factors. To evaluate downstream impacts of opioid prescribing and pain management, we also compared rates of persistent opioid use and pain-related emergency department (ED) visits. RESULTS Compared with non-Hispanic White patients, the covariate-adjusted odds of receiving an opioid prescription were 24.9% (95% CI, 16.0 to 33.9, P < .001) lower for non-Hispanic Blacks, 115.0% (84.7 to 150.3, P < .001) higher for Asian-Pacific Islanders, and not statistically different for Hispanics (-1.0 to 14.0, P = .06). There was no significant association between race or ethnicity and persistent opioid use or pain-related ED visits. Patients living in a high-poverty area had higher odds (53.9% [25.4 to 88.8, P < .001]) of developing persistent use and having a pain-related ED visit (39.4% [16.4 to 66.9, P < .001]). CONCLUSION For older patients with cancer, rates of opioid prescriptions and pain-related outcomes significantly differed by race and area-level poverty. Non-Hispanic Black patients were associated with a significantly decreased likelihood of receiving an opioid prescription. Patients from high-poverty areas were more likely to develop persistent opioid use and have a pain-related ED visit.
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Affiliation(s)
- Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Whitney Sumner
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Tyler Nelson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Timothy Furnish
- Division of Pain Management, Department of Anesthesiology, University of California San Diego, La Jolla, CA
| | - Brent Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - María Elena Martínez
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
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Herb JN, Williams BM, Chen KA, Young JC, Chidgey BA, McNaull PP, Stitzenberg KB. The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review. Surgery 2021; 170:180-185. [PMID: 33536118 DOI: 10.1016/j.surg.2020.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/09/2020] [Accepted: 12/26/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. METHODS This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan-Jun 2018) versus postintervention (Jan-Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. RESULTS A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5-36.5). There was no significant difference in 2019 (-8 morphine milligram equivalents, 95% confidence interval -20.5 to 4.6). CONCLUSION Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.
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Affiliation(s)
- Joshua N Herb
- Department of Surgery, University of North Carolina at Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC.
| | - Brittney M Williams
- Department of Surgery, University of North Carolina at Chapel Hill, NC. https://twitter.com/BMWilliamsMD
| | - Kevin A Chen
- Department of Surgery, University of North Carolina at Chapel Hill, NC
| | - Jessica C Young
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC
| | - Brooke A Chidgey
- Department of Anesthesiology, University of North Carolina at Chapel Hill, NC
| | - Peggy P McNaull
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
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Eyrich NW, Sloss KR, Howard RA, Klueh MP, Englesbe MJ, Waljee JF, Brummett CM, Sabel MS, Dossett LA, Lee JS. Opioid prescribing exceeds consumption following common surgical oncology procedures. J Surg Oncol 2021; 123:352-356. [PMID: 33125747 PMCID: PMC7770117 DOI: 10.1002/jso.26272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/08/2020] [Revised: 09/24/2020] [Accepted: 10/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. METHODS We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. RESULTS Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them. CONCLUSIONS This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.
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Affiliation(s)
| | | | - Ryan A. Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michael P. Klueh
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael S. Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Division of Surgical Oncology, University of Michigan, Ann Arbor, MI
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Division of Surgical Oncology, University of Michigan, Ann Arbor, MI
| | - Jay S. Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Crystal DT, Cuccolo NG, Plewinski MJ, Ibrahim AMS, Sinkin JC, Lin SJ, Agag RL, Lee BT. Assessment of Opioid-Prescribing Practices in Breast Augmentation: Future Directions for Prescribing Guidelines. Ann Plast Surg 2021; 86:11-18. [PMID: 32568754 DOI: 10.1097/sap.0000000000002430] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The United States (US) is in the mid of an opioid epidemic propagated, in part, by prescription opioids. With excess overprescribing documented in a variety of surgical procedures, several societies have recommended opioid-prescribing guidelines. Considering the scope and postoperative pain associated with aesthetic plastic surgery procedures, earnest evaluation into opioid-prescribing practices for breast augmentation was conducted. METHODS Members of the American Society for Aesthetic Plastic Surgery were electronically surveyed on their opioid-prescribing patterns. The survey was distributed to 1709 plastic surgeons. Descriptive statistics were collated into percentages, deviations, and morphine milligram equivalents (MMEs), when appropriate. RESULTS Two hundred twenty-nine American Society for Aesthetic Plastic Surgery members (13.4%) provided responses. A total of 91.2% of respondents prescribe opioids to patients undergoing breast augmentation. The most commonly prescribed agents included oxycodone/acetaminophen (Percocet, 47.0%) and hydrocodone/acetaminophen (Vicodin, 38.3%). On average, 165.3 ± 81.7 MMEs were dispensed (range, 25.0-600.0 MMEs; number tablets, 5-60). Prescribers felt that a lack of phone-in prescribing (52.4%) and the ease of preemptively prescribing opioids (52.4%) propagate opioid overprescribing. A total of 61.3% of respondents reported that they are or may be in favor of developing plastic surgery societal guidelines related to opioid prescribing. These respondents indicated support for guidelines on opioid-sparing pain management strategies (74.2%) and guidelines identifying the type (54.7%), duration of use (69.5%), and number of opioid tablets (61.7%) necessary for procedures. CONCLUSIONS Considerable variability exists among prescribing patterns after breast augmentation. Societal guidelines aimed at providers and patients may serve a future role in opioid prescribing.
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Affiliation(s)
| | | | - Michael J Plewinski
- Division of Plastic Surgery, Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ahmed M S Ibrahim
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeremy C Sinkin
- Division of Plastic Surgery, Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Samuel J Lin
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Richard L Agag
- Division of Plastic Surgery, Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Bernard T Lee
- From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Ivanics T, Nasser H, Kandagatla P, Leonard-Murali S, Jones A, Abouljoud M, Gupta AH, Woodward A. Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines. Am Surg 2020; 87:1039-1047. [PMID: 33295200 DOI: 10.1177/0003134820956332] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. METHODS This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). RESULTS Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). CONCLUSIONS Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.
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Affiliation(s)
- Tommy Ivanics
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Hassan Nasser
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | | | | | - Adam Jones
- Department of Strategic and Operation Analytics, Henry Ford Hospital, Detroit MI, USA
| | - Marwan Abouljoud
- Department of Transplantation Surgery, Henry Ford Hospital, Detroit MI, USA
| | | | - Ann Woodward
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
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Kwan SY, Lancaster E, Dixit A, Inglis-Arkell C, Manuel S, Suh I, Shen WT, Seib CD. Reducing Opioid Use in Endocrine Surgery Through Patient Education and Provider Prescribing Patterns. J Surg Res 2020; 256:303-310. [PMID: 32712445 PMCID: PMC7855097 DOI: 10.1016/j.jss.2020.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 02/18/2020] [Revised: 05/31/2020] [Accepted: 06/16/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Postoperative opioid use can lead to dependence, contributing to the opioid epidemic in the United States. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increased documentation of persistent opioid use postoperatively, surgeons must pursue interventions to reduce opioid use perioperatively. METHODS We performed a prospective cohort study to assess the feasibility of a preoperative intervention via patient education or counseling and changes in provider prescribing patterns to reduce postoperative opioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from January 22, 2019 to February 28, 2019 at a tertiary referral, academic endocrine surgery practice. Surveys were administered to assess pain and patient satisfaction postoperatively. Prescription, demographic, and comorbidity data were collected from the electronic health record. RESULTS Sixty six patients (74.2% women, mean age 58.6 [SD 14.9] y) underwent thyroidectomy (n = 35), parathyroidectomy (n = 24), and other cervical endocrine operations (n = 7). All patients received a preoperative educational intervention in the form of a paper handout. 90.9% of patients were discharged with prescriptions for nonopioid pain medications, and 7.6% were given an opioid prescription on discharge. Among those who received an opioid prescription, the median quantity of opioids prescribed was 135 (IQR 120-150) oral morphine equivalents. On survey, four patients (6.1%) reported any postoperative opioid use, and 94.6% of patients expressed satisfaction with their preoperative education and postoperative pain management. CONCLUSIONS Clear and standardized education regarding postoperative pain management is feasible and associated with high patient satisfaction. Initiation of such education may support efforts to minimize unnecessary opioid prescriptions in the population undergoing endocrine surgery.
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Affiliation(s)
- Stephanie Y. Kwan
- University of California- San Francisco, School of Medicine, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Elizabeth Lancaster
- University of California- San Francisco, Department of Surgery, 513 Parnassus Ave, Room S-321, San Francisco, CA, USA 94143
| | - Anjali Dixit
- University of California- San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Christina Inglis-Arkell
- University of California- San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Solmaz Manuel
- University of California- San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave, San Francisco, CA, USA 94143
| | - Insoo Suh
- University of California- San Francisco, Department of Surgery, Section of Endocrine Surgery, 1600 Divisadero St, 4 Floor, San Francisco, CA, USA 94115
| | - Wen T. Shen
- University of California- San Francisco, Department of Surgery, Section of Endocrine Surgery, 1600 Divisadero St, 4 Floor, San Francisco, CA, USA 94115
| | - Carolyn D. Seib
- Stanford University, Department of Surgery, 300 Pasteur Drive, H3680, Stanford, CA 94305
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Brown CS, Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee J, Englesbe M. Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system. BMJ Qual Saf 2020; 30:251-259. [PMID: 32938775 DOI: 10.1136/bmjqs-2020-011295] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 04/07/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system. METHODS We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time. RESULTS We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged. CONCLUSIONS The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA .,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Ryan A Howard
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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40
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Morin C, Rojas KE. ASO Author Reflections: Effective Opioid-Minimizing Protocols Are Not One Size Fits All. Ann Surg Oncol 2020; 27:709-710. [PMID: 32725522 DOI: 10.1245/s10434-020-08953-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Claudya Morin
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kristin E Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA.
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Vu J, Cleary RK, Englesbe MJ, Brummett CM, Waljee JF, Suwanabol PA. Post-discharge Opioid Consumption After Minimally Invasive and Open Colectomy: Does Operative Approach Matter? Ann Surg 2020. [PMID: 32657943 DOI: 10.1097/SLA.0000000000004240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if patients consume less opioid after minimally invasive colectomy compared to open colectomy. BACKGROUND Opioids are overprescribed after surgery, and surgeons are under increasing pressure to reduce postoperative opioid prescribing. In colorectal surgery, minimally invasive approaches are partly justified by reduced inpatient opioid use, but there are no studies comparing post-discharge opioid consumption between minimally invasive and open colectomy. METHODS This was a retrospective observational study of adult patients undergoing colectomy from January 2017 to May 2018 in the Michigan Surgical Quality Collaborative database. After postoperative day 30, patients were contacted by phone or email and asked to report post-discharge opioid consumption. The main outcome measure was post-discharge opioid consumption, and the primary predictor was surgical approach (minimally invasive vs open). Zero-inflated negative binomial regression analysis was used to test for an association between surgical approach and opioid consumption. RESULTS We identified 562 patients who underwent minimally invasive or open colectomy from 43 hospitals. After multivariable adjustment, no significant difference was demonstrated in opioid consumption (P = 0.54) or the likelihood of using no opioids (P = 0.39) between patients undergoing minimally versus open colectomy. Larger prescriptions were associated with more opioid use and a lower likelihood of using no opioids. Age greater than 65 and diagnosis of cancer/adenoma were associated with less opioid use. CONCLUSIONS Patients undergoing minimally invasive and open colectomy consume similar amounts of opioid after discharge. The size of the postoperative prescription, patient age, and diagnosis are more important in determining opioid use. Understanding factors influencing postoperative opioid requirements may allow surgeons to better tailor prescriptions to patient needs.
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Crystal DT, Blankensteijn LL, Ibrahim AMS, Brownstein GM, Reed LS, Watts DC, Lin SJ. Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery. Plast Reconstr Surg 2020; 145:687-95. [PMID: 32097308 DOI: 10.1097/PRS.0000000000006570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery. METHODS A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events. RESULTS Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days' hospital length of stay. CONCLUSIONS Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
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Abstract
OBJECTIVE Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. SUMMARY BACKGROUND DATA During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. METHODS We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. RESULTS Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. CONCLUSION A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.
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Abstract
IMPORTANCE Dentists commonly prescribe opioids to relieve pain after tooth extraction. Understanding the differences in patient-reported outcomes between opioid users and nonusers could encourage the adoption of more conservative and appropriate prescribing practices in dental medicine. OBJECTIVE To evaluate whether pain and satisfaction scores reported by patients who used opioids after tooth extraction were similar to the levels reported by patients with no opioid use. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study was conducted in the 14 dental clinics of the University of Michigan School of Dentistry. Eligible adult patients of these clinics who underwent routine or surgical extractions between June 1, 2017, and December 31, 2017, were contacted by telephone within 6 months of the procedure. Patients were surveyed about the type of extraction, use of prescription opioid (if given), use of nonopioid analgesics, pain levels, and satisfaction with care after the procedure. Data analysis was conducted from February 1, 2018, to July 31, 2018. MAIN OUTCOMES AND MEASURES The primary outcome was self-reported pain as assessed by the question, "Thinking back, how would you rate your pain in the first week after your dental procedure?" with a 4-point pain scale of no pain, minimal pain, moderate pain, or severe pain. Secondary outcomes included self-reported satisfaction with care as assessed by a Likert scale ranging from 1 to 10, in which 1 was extremely dissatisfied and 10 was extremely satisfied. RESULTS The final cohort comprised 329 patients, of whom 155 (47.1%) underwent surgical extraction (mean [SD] age, 41.8 [18.1] years; 80 [51.6%] were men) and 174 (52.9%) underwent routine extraction (mean [SD] age, 52.4 [17.9] years; 79 [45.4%] were men). Eighty patients (51.6%) with surgical extraction and 68 (39.1%) with routine extraction used opioids after their procedure. In both extraction groups, patients who used opioids reported higher levels of pain compared with those who did not use opioids (surgical extraction group: 51 [63.8%] vs 34 [45.3%], P < .001; routine extraction group: 44 [64.7%] vs 35 [33.0%], P < .001). No statistically significant difference in satisfaction was found between groups after surgical extraction (median [interquartile range] scores: 9 [7-10] for nonopioid group vs 9 [8-10] for opioid group) and routine extraction (median [interquartile range] scores: 10 [8-10] for nonopioid group vs 9 [7-10] for opioid group). CONCLUSIONS AND RELEVANCE This study found that patients who used opioids after tooth extraction reported significantly higher levels of pain compared with nonusers, but no difference in satisfaction was observed.
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Affiliation(s)
- Romesh P. Nalliah
- University of Michigan School of Dentistry, Ann Arbor
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Ann Arbor
| | - Kenneth R. Sloss
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Ann Arbor
| | - Brooke C. Kenney
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Ann Arbor
| | | | | | - Kendall Dubois
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Ann Arbor
| | - Jennifer F. Waljee
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chad M. Brummett
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Ann Arbor
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
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Affiliation(s)
- Sarah M DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Zhang DDQ, Sussman J, Dossa F, Jivraj N, Ladha K, Brar S, Urbach D, Tricco AC, Wijeysundera DN, Clarke HA, Baxter NN. A Systematic Review of Behavioral Interventions to Decrease Opioid Prescribing After Surgery. Ann Surg 2020; 271:266-78. [DOI: 10.1097/sla.0000000000003483] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Jivraj NK, Scales DC, Gomes T, Bethell J, Hill A, Pinto R, Wijeysundera DN, Wunsch H. Evaluation of opioid discontinuation after non-orthopaedic surgery among chronic opioid users: a population-based cohort study. Br J Anaesth 2020; 124:281-291. [PMID: 32000975 DOI: 10.1016/j.bja.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Many patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. METHODS We performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. RESULTS The cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. CONCLUSIONS For chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.
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Affiliation(s)
- Naheed K Jivraj
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
| | - Damon C Scales
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Tara Gomes
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | | | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Department of Anaesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
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Woeste MR, Bhutiani N, Geller AE, Eldridge-Hindy H, McMasters KM, Ajkay N. Identifying Factors Predicting Prolonged Opioid Use After Mastectomy. Ann Surg Oncol 2020; 27:993-1001. [DOI: 10.1245/s10434-019-08171-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Indexed: 01/14/2023]
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McGee LM, Kolli A, Harbaugh CM, Howard RA, Englesbe MJ, Brummett CM, Waljee JF, Gadepalli SK. Spillover Effect of Opioid Reduction Interventions From Adult to Pediatric Surgery. J Surg Res 2020; 249:18-24. [PMID: 31918326 DOI: 10.1016/j.jss.2019.11.021] [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: 05/06/2019] [Revised: 09/30/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Procedure-specific prescribing guidelines and trainee education have reduced opioid overprescribing in adult surgical patients, but tailored interventions do not yet exist for children. It is unknown what effect these adult interventions have had on postoperative opioid prescribing in children at the same institution, where trainees rotate across both adult and pediatric services. MATERIALS AND METHODS This retrospective study of patients (<18 y) undergoing pediatric surgery (PS), pediatric otolaryngology (ENT), or pediatric urology (URO) procedures at a single tertiary academic center assessed opioid doses per patient before (January 01, 2015 to September 30, 2016) and after (January 01, 2017 to March 31, 2018) opioid prescribing guidelines and trainee education were instituted for adult laparoscopic cholecystectomy. Patient demographics, postoperative opioid prescribing, opioid refills, and emergency department (ED) visits <21 d after surgery were compared using chi-squared analyses and t-tests. Interrupted time-series analyses (ITSA) assessed changes in the rate of opioid prescribing pre- and postintervention for each subspecialty. RESULTS There were 3371 patients preintervention and 2439 patients postintervention. After the intervention, fewer patients were prescribed opioids (ENT: 97% versus 93%, P < 0.001; URO: 98% versus 94%, P < 0.001; PS: 61% versus 25%, P < 0.001) and fewer opioid doses were prescribed in each prescription (ENT: 63.8 ± 26.1 versus 50.8 ± 22.0 doses, P < 0.001; URO: 33.5 ± 23.4 versus 22.1 ± 11.3, P < 0.001; PS: 20.4 ± 12.8 versus 13.8 ± 11.4 doses, P < 0.001). There were no changes in opioid refill or ED visit rates postintervention. A decreasing rate in ENT prescribing was seen preintervention, with no significant change postintervention (-2.3 ± 1.1 versus -3.3 ± 0.7; P = 0.24). Whereas, the rate of decrease in PS and URO prescribing significantly slowed postintervention (PS: -2.0 ± 0.1 versus -0.9 ± 0.1, P < 0.001; URO: -4.2 ± 0.2 versus -2.3 ± 0.5, P = 0.005). CONCLUSIONS Opioid prescribing rates are decreasing, but adult interventions did not achieve reductions in pediatric opioid prescribing at the same institution. There was no concomitant rise in postoperative ED visits or opioid refills as prescribing declined, indicating that the risks of reducing opioid prescriptions may be minimal. Development of evidence-based, procedure-specific prescribing guidelines that specifically address pediatric patients are needed to effectively minimize opioid overprescribing in this population.
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Affiliation(s)
- Lauren M McGee
- University of Michigan Medical School, Ann Arbor, Michigan.
| | - Ajay Kolli
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Calista M Harbaugh
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ryan A Howard
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Chad M Brummett
- University of Michigan Health System Department of Anesthesiology, Ann Arbor, Michigan
| | - Jennifer F Waljee
- University of Michigan Health System Department of Anesthesiology, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
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Park KU, Kyrish K, Yi M, Bedrosian I, Caudle AS, Kuerer HM, Hunt KK, Miggins MV, DeSnyder SM. Opioid Use after Breast-Conserving Surgery: Prospective Evaluation of Risk Factors for High Opioid Use. Ann Surg Oncol 2019; 27:730-735. [DOI: 10.1245/s10434-019-08091-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Indexed: 12/18/2022]
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