Chronic Opioid Prescriptions Research Articles

Persistent and chronic opioid use after ambulatory surgery in US veterans (2011–2018)

BackgroundOpioid use beyond the perioperative period is a recognized adverse outcome, primarily studied in inpatients after complex major surgeries. Our goals are to determine the risk after ambulatory surgery and identify risk factors associated with long-term opioid prescriptions. MethodsOur ambulatory surgery cohort included 1,393,332 veterans from October 1, 2011, to September 30, 2018 (fiscal year [FY] 12–18). Data included age, sex, race, rurality of patient residence and facility, body mass index, tobacco use, Charlson Comorbidity Index, psychiatric disorder, pain score at surgery, substance use, and medications (benzodiazepine, tricyclics and/or selective serotonin reuptake inhibitor and opioids in the 12 months previous). ResultsIn aggregate, 9.6% had 1 or more prescriptions in the 90–180 days after surgery (“Persistent prescription[s]”) and 1.8% had more than 180 days of opioids in the 31–366 days after surgery (“Chronic prescriptions”). For persistent prescription(s), trends over time decreased from 12.5% in FY12 to 7.1% by FY18 (P < .001). Similarly chronic prescriptions decreased from 2.9% in FY12 to 0.8% in FY18 (P < .001). The strongest independent association for persistent and chronic prescriptions after ambulatory surgery was previous prescription opioids, with 2.8 times increased risk for persistent prescriptions (adjusted odds ratio, 2.8; 95% confidence interval, 2.8–2.9; P < .001) and 3.3 times increased risk for chronic opioid prescriptions (adjusted odds ratio, 3.3; 95% confidence interval, 3.2–3.4; P < .001). ConclusionsRates of persistent and chronic opioid prescriptions after ambulatory surgery in the Veterans Health Administration are small and decreasing over time. Providers and patients should have informed discussions regarding risks of opioid postoperative pain management strategies.

Chronic opioid prescription in veterans with spinal cord injury: Prevalence and associated factors

Objective Chronic opioid use presents long-term health risks for individuals with spinal cord injury (SCI). The purpose of the study was to characterize patterns and correlates of the chronic prescription of opioids among individuals with SCI in a population of Veterans receiving care though the Veteran’s Health Administration. Design A retrospective, longitudinal cohort study examined the US Department of Veterans Affairs electronic medical record data of veterans with SCI. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015–2017). Multivariable models examined associations with demographics and pre-existing medical comorbidities. Setting US Department of Veterans Affairs, Veteran’s Health Administration. Participants National sample of Veterans with SCI (N = 10,811). Main Outcome Measure Chronic prescription opioid use (≥90 days). Results All types of prescription opioid use declined across the three study years (chronic opioid use prevalence = 33.2%, 31.7%, and 29.7%, respectively). Past history of depression, COPD, diabetes, pain condition, opioid use and tobacco use disorders were associated with a greater likelihood of current chronic prescription opioid use. Non-white race, hyperlipidemia, dementia, and tetraplegia were associated with a lower likelihood of current chronic prescription opioid use. When added to the multivariable model, prior chronic opioid prescription use was robustly associated with current chronic prescription opioid use, but most other factors were no longer significantly associated with current opioid use. Conclusions This study demonstrates opioid reduction over time from 2015 to 2017, however, chronic prescription opioid use remains common among a substantial minority of Veterans with SCI. Several demographics and comorbidities may provide clinicians with important insights into factors associated with chronic prescription opioid use, with past chronic prescription opioid use being the most important.

Two Weeks of Continuous Opioid Treatment in an Adenine-Induced Mouse Model of Chronic Kidney Disease Exacerbates the Bone Inflammatory State and Increases Osteoclasts

Patients with chronic kidney disease (CKD) report high pain levels, but reduced renal clearance eliminates many analgesic options; therefore, 30–50% of CKD patients have chronic opioid prescriptions. Opioid use in CKD is associated with higher fracture rates. Opioids may directly alter bone turnover directly through effects on bone cells and indirectly via increasing inflammation. We hypothesized that continuous opioid exposure would exacerbate the high bone turnover state of CKD and be associated with elevated measures of inflammation. Male C57Bl/6J mice after 8 weeks of adenine-induced CKD (AD) and non-AD controls (CON) had 14-day osmotic pumps (0.25-µL/hr release) containing either saline or 50-mg/mL oxycodone (OXY) surgically implanted in the subscapular region. After 2 weeks, all AD mice had elevated blood urea nitrogen, parathyroid hormone, and serum markers of bone turnover compared to controls with no effect of OXY. Immunohistochemical staining of the distal femur showed increased numbers of osteocytes positive for the mu opioid and for toll-like receptor 4 (TLR4) due to OXY. Osteocyte protein expression of tumor necrosis factor-α (TNF-α) and RANKL were higher due to both AD and OXY so that AD + OXY mice had the highest values. Trabecular osteoclast-covered surfaces were also significantly higher due to both AD and OXY, resulting in AD + OXY mice having 4.5-fold higher osteoclast-covered surfaces than untreated CON. These data demonstrate that opioids are associated with a pro-inflammatory state in osteocytes which increases the pro-resorptive state of CKD.

Factors associated with unplanned clinical encounters for ureteral stent-related symptoms.

Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters. Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS. Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid usereturned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002). Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.

Longitudinal Trajectory of Opioid Prescribing and its Associated Serious Adverse Events: A Population-Wide Cohort Study in Taiwan.

Chronic opioid prescribing (COP) for noncancer pain is highly restricted in Taiwan, but tramadol is not listed in the regulation on chronic prescribing. This study investigated the trajectories of COP in noncancer pain when considering tramadol in Taiwan and identified the risk of serious adverse events. This population-wide longitudinal cohort study used the Taiwan National Health Insurance claims records from 2001 to 2016. Adults prescribed opioids (including tramadol) and without cancer were selected. Patients who received COP (opioid supply days for 28 days or continuous opioid supply for 14 days) in the first patient quarter were included, and serious adverse events were identified. Group-based trajectory models were applied to identify patients with a similar trajectory of quarterly COP. The Cox proportional hazard model was applied to assess the association between adverse events and patients' trajectories. Of the 2,360,358 noncancer opioid users, 476,934 (20.2%) received COP in the first quarter. Four groups of COP trajectory were identified, and 59,310 (12.8%) patients received COP quarterly over 2 years. Patients categorized into the trajectory of long-term COP had a significantly higher crude incidence rate of cardiovascular death, seizure, and hypoglycemia. Still, there is no newly developed opioid use disorder. There was a substantial underestimate in COP in Taiwan when tramadol was not considered. Notably, 10% of them could receive COP for over 2 years. The result raises concern about unmet pain management needs and the limited accessibility of alternative treatments for noncancer pain.

Chronic overlapping pain conditions and long-term opioid treatment.

One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT). Retrospective cohort study. We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT. Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC. Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients.

Practice variation in opioid prescribing for non-cancer pain in Dutch primary care: A retrospective database study.

Prescription opioid use has increased steadily in many Western countries over the past two decades, most notably in the US, Canada, and most European countries, including the Netherlands. Especially the increasing use of prescription opioids for chronic non-cancer pain has raised concerns. Most opioids in the Netherlands are prescribed in general practices. However, little is known about variation in opioid prescribing between general practices. To better understand this, we investigated practice variation in opioid prescribing for non-cancer pain between Dutch general practices. Data from 2017-2019 of approximately 10% of all Dutch general practices was used. Each year included approximately 1000000 patients distributed over approximately 380 practices. The primary outcome was the proportion of patients with chronic (>90 days) high-dose (≥90 oral morphine equivalents) opioid prescriptions. The secondary outcome was the proportion of patients with chronic (<90 oral morphine equivalents) opioid prescriptions. Practice variation was expressed as the ratio of the 95th/5th percentiles and the ratio of mean top 10/bottom 10. Funnel plots were used to identify outliers. Potential factors associated with unwarranted variation were investigated by comparing outliers on practice size, patient neighbourhood socioeconomic status, and urbanicity. Results were similar across all years. The magnitude of variation for chronic high-dose opioid prescriptions in 2019 was 7.51-fold (95%/5% ratio), and 15.1-fold (top 10/bottom 10 ratio). The percentage of outliers in the funnel plots varied between 13.8% and 21.7%. Practices with high chronic high-dose opioid prescription proportions were larger, and had more patients from lower income and densely populated areas. There might be unwarranted practice variation in chronic high-dose opioid prescriptions in primary care, pointing at possible inappropriate use of opioids. This appears to be related to socioeconomic status, urbanicity, and practice size. Further investigation of the factors driving practice variation can provide target points for quality improvement and reduce inappropriate care and unwarranted variation.

From ‘pain management’ to ‘integrated health clinic’: a quality improvement project to transition patients on chronic opioid therapy to more evidence-based therapies for chronic pain

BackgroundThe State of New York, along with the whole nation, is struggling to combat the opioid epidemic. Major authoritative bodies on chronic pain and addiction have advocated against the use...

Opioid and Alcohol Misuse in Veterans with Chronic Pain: A Risk Screening Study

In United States military veterans, chronic pain represents a risk factor for opioid and alcohol misuse, yet few studies have examined interactions among chronic pain, opioid prescription, and opioid and alcohol misuse. Previous work found substantial risk of co-morbid alcohol and opioid misuse in a community sample of opioid-prescribed individuals with chronic pain, a finding expanded upon here. Specifically, 211 veterans assessed within a chronic pain treatment service for opioid-prescribed individuals completed self-report measures of opioid misuse, alcohol misuse, pain intensity, depression, pain catastrophizing, and post-traumatic stress symptoms (PTS). Based on the substance misuse measures, 32% (n = 68) were misusing neither opioids nor alcohol, 23% (n = 48) were misusing both opioids and alcohol, 40% (n = 84) were misusing opioids alone, and 5% (n = 11) were misusing alcohol alone. Group comparisons indicated that individuals not misusing either substance were less distressed in comparison to those who were misusing opioids alone or both substances. The latter groups differed in PTS. Overall, misuse frequencies mirrored previous work, with approximately 1 of 3 misusing opioids and approximately 1 of 5 misusing both substances. There is a need for increased focus on both polysubstance misuse and the development of integrated treatment. PerspectiveOpioid and alcohol misuse was examined in 211 Veterans prescribed opioids for chronic pain. In total, 32% were not misusing either, 23% were misusing both, 40% were misusing opioids, and 5% were misusing alcohol. Veterans not misusing either were generally less disabled and distressed compared to those misusing opioids or both.

Opioid Prescription Monitoring in Preoperative and Postoperative Sacroiliac Joint Fusion Patients.

An estimated 15%-25% of patients with chronic low back pain may in fact suffer from sacroiliac (SI) joint dysfunction. SI joint fusion has become a common treatment option for the management of SI joint dysfunction. However, little is known about opioid use prior to and after surgical treatment in this patient population. The medical records of 62 patients treated with SI joint fusion at our institution were reviewed in this retrospective study. The Colorado Prescription Drug Monitoring Program (CPDMP) was accessed to gather opioid prescription information for these patients. Only those patients who had received an opioid prescription within 3 months prior to their surgery were included in the study. Patients who had SI joint fusion but underwent another surgical procedure during the 12-month follow-up period were excluded from analysis. Preoperative (6 and 3 months) and postoperative (3, 6, 9, and 12 months) mean morphine milligram equivalents (MME) were collected from the CPDMP database for each patient. Patient demographic and medical comorbidity data were also documented to identify any correlations or potential risk factors for chronic opioid prescribing. Visual analog scale (VAS), Oswestry Disability Index (ODI), and Denver SI Joint Questionnaire (DSIJQ) scores were recorded for each patient to assess clinical outcomes. At 3 months prior to surgery, patients were prescribed an average of 47.2 mean MME/d. At no point postoperatively did the quantity of opioids, measured in MME/d, change significantly from the 3-month preoperative prescription quantities. There was no significant difference in the quantity of opioids received by men vs women, in patients with vs without anxiety and/or depression, or in younger vs older patients. Low body mass index was correlated with decreased opioid prescriptions at 6 months postoperative but became statistically insignificant again by 9 months postoperative.Significant improvements in VAS scores were recorded for all postoperative clinical evaluation timepoints (at 6 weeks and 3, 6, and 12 months) and compared to preoperative scores. By 12 months, VAS scores had decreased from 6.2 to 3.9 (P < 0.001). This change is not only statistically significant but also meets the criteria for minimum clinically important difference in scores. Both the ODI and DSIJQ patient-reported outcomes scores also showed significant improvements at 12 months after surgery (ODI: 48.9 preoperative vs 24.6 postoperative, P = 0.02; DSIJQ: 53.2 preoperative vs 17.4 postoperative, P = 0.014). The ODI improvement also met the minimum clinically important difference criteria. By 6 months postoperatively, there was no significant correlation in VAS or ODI and opioid use. There was no significant correlation between the DSIJQ scores and the daily dose of opioids at any point postoperatively. Quantity of opioid prescriptions received by patients with SI joint pain did not change significantly from 3 months preoperatively to any point postoperatively despite significant improvements in all patient-reported outcome measures. This discordance between long-term opioid requirements and positive clinical outcomes is concerning and warrants further investigation.

Causal Effect of Chronic Pain on Mortality Through Opioid Prescriptions: Application of the Front-Door Formula.

Background:Chronic pain is the leading cause of disability worldwide and is strongly associated with the epidemic of opioid overdosing events. However, the causal links between chronic pain, opioid prescriptions, and mortality remain unclear.Methods:This study included 13,884 US adults aged ≥20 years who provided data on chronic pain in the National Health and Nutrition Examination Survey 1999–2004 with linkage to mortality databases through 2015. We employed the generalized form of the front-door formula within the structural causal model framework to investigate the causal effect of chronic pain on all-cause mortality mediated by opioid prescriptions.Results:We identified a total of 718 participants at 3 years of follow-up and 1260 participants at 5 years as having died from all causes. Opioid prescriptions increased the risk of all-cause mortality with an estimated odds ratio (OR) (95% confidence interval) = 1.5 (1.1, 1.9) at 3 years and 1.3 (1.1, 1.6) at 5 years. The front-door formula revealed that chronic pain increased the risk of all-cause mortality through opioid prescriptions; OR = 1.06 (1.01, 1.11) at 3 years and 1.03 (1.01, 1.06) at 5 years. Our bias analysis showed that our findings based on the front-door formula were likely robust to plausible sources of bias from uncontrolled exposure–mediator or mediator–outcome confounding.Conclusions:Chronic pain increased the risk of all-cause mortality through opioid prescriptions. Our findings highlight the importance of careful guideline-based chronic pain management to prevent death from possibly inappropriate opioid prescriptions driven by chronic pain.

Changes in Outpatient Opioid Prescribing During the COVID-19 Pandemic: An Interrupted Time Series Analysis.

Objectives:Changes in health care delivery during the COVID-19 pandemic may have impacted opioid prescribing. This study evaluated the impact of restrictions on in-person care on opioid prescribing in the outpatient setting. The hypothesis was that after restrictions to in-person care were implemented, there would be a reduction in the number of chronic and non-chronic opioid prescriptions.Methods:An interrupted time series analysis was conducted to compare the number of weekly opioid prescriptions between baseline (1/1/2019-3/14/2020), restriction (3/15/2020-6/6/2020), and reopening (6/7/2020-10/31/2020) periods at outpatient practices within a health system in Bronx, NY. Analyses were stratified by prescription type (chronic if the patient had been prescribed opioids for >90 days, or non-chronic).Results:For chronic opioid prescriptions, the week restrictions were implemented, there was an increase in the number of prescriptions compared to what was predicted if there had been no interruption (34.8 prescriptions, 95% CI: 8.0, 61.7). Subsequently, the weekly trend in prescribing was not different in the restriction period or in the reopening period compared to the previous time periods. For non-chronic opioid prescriptions, during the restriction period, the weekly trend in prescribing decreased compared to baseline (−5.0 prescriptions/week, 95% CI: −9.0, −1.0). Subsequently, during the reopening period, the weekly trend in prescribing increased compared to the restriction period (6.4 prescriptions/week, 95% CI: 2.2, 10.7).Conclusions:Despite abrupt restrictions on in-person care, chronic opioid prescriptions did not decrease, which is evidence that providers evolved to meet patient needs. Changes in non-chronic prescriptions are likely related to patients electing not to pursue care for acute pain or challenges with appointment availability.

Bipedicular Basi-Vertebral Nerve Ablation: A Case Report

Introduction Intraosseous ablation of the basivertebral nerve (BVNA) is an emerging minimally invasive treatment to relieve chronic mechanical axial low back pain associated with Modic type 1 or type 2 vertebral end-plate changes. Randomized controlled trials demonstrate improvements in pain and function sustained for up to five-years. Methods A 40-year-old woman presented with an eight-year history of central low back with mechanical features. There was minimal response to active physical reconditioning techniques, breast reduction surgery and chronic opioid prescription. Imaging disclosed modic type 1 vertebral end-plate changes at the L5/S1 segment. Following a positive short-term response to bilateral L5/S1 facet joint injections, the L5/S1 facets were treated with radiofrequency ablation of the L4 medial branch and L5 dorsal ramus bilaterally but with minimal benefit. BVNA at L5 and S1 was provided using a bi-pedicular bipolar radiofrequency approach (description attached). Result Six-week outcomes data disclosed decreased pain intensity from 8/10 to 3/10 and improved function with a decrease of 22 points on the oswestry disability index (ODI). Measures of depression, anxiety and stress, and quality of life improved significantly. Opioid usage decreased with a weaning plan. Magnetic resonance imaging (MRI) findings demonstrated new sclerosis with surrounding bone marrow oedema of the right and left sides of the L5 and S1 vertebral bodies consistent with the BVNA treatment. Discussion This case reports technically successful BVNA using a bipedicular approach. The early result is consistent with the published literature using the uni-pedicular approach. Follow-up plans are in place. A case series will follow. In Brief A bi-pedicular bipolar radiofrequency technique for basivertebral nerve ablation to treat vertebrogenic chronic low back pain is described, including early clinical outcomes and MRI findings.

Effects of Prescription Opioid Use on Traumatic Brain Injury Risk in Older Adults.

The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries. Five percent sample of Medicare administrative claims obtained for years 2011-2015. A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI. Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI. TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file. The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02). Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.

Video-Based, Patient-Focused Opioid Education in the Perioperative Period Increases Self-Perceived Opioid-Related Knowledge: A Pilot Study.

ObjectiveThe aim of this study was to evaluate whether a video-based, patient-focused opioid education tool delivered in the perioperative period would decrease acute and chronic post-operative opioid prescription dispensations and increase self-rated knowledge about opioids.MethodsWe enrolled 110 patients with no reported opioid use in the previous 30 days, undergoing ambulatory surgery for breast, orthopedic, gynecologic, or other outpatient procedures for which opioids would be prescribed. Patients were randomized to receive either post-operative opioid education by the surgical team (control arm) or pre-operative education via a novel 5-minute video plus post-operative education by the surgical team (intervention arm). All patients received follow-up phone calls on post-operative day (POD) 7 to assess self-rated knowledge of opioids on a scale of 1 to 10, 10 being most informed, and self-reported opioid use (primary outcome). Arkansas Prescription Drug Monitoring Program (AR PDMP) data were obtained to assess opioid dispensations at POD 90–150 days.ResultsSeventy-seven percent of participants completed POD7 survey. Participants in the intervention arm rated their knowledge of opioids after surgery significantly higher than those in the control arm (p=0.013). Data from the AR PDMP reveal trends (non-significant) that show increased use of opioids in the control group when compared to the video intervention group at POD 30 (88.7% vs 76%) and POD 90–150 (22.6% vs 10%).ConclusionVideo-based, patient-focused opioid education can be effectively implemented in a large university hospital during the perioperative period and is effective for increasing a patient’s perception of opioid-related knowledge. A fully powered, randomized control trial is needed to further explore observed trends and determine if this novel tool can decrease chronic post-operative opioid dispensations.

Opioid and non-opioid analgesic prescribing before and after the CDC's 2016 opioid guideline.

The U.S. has addressed the opioid crisis using a two-front approach: state regulations limiting opioid prescriptions for acute pain patients, and voluntary federal CDC guidelines on shifting chronic pain patients to lower opioid doses and non-opioids. No opioid policy research to date has accounted for this two-pronged approach in their research design. We develop a theory of physician prescribing behavior under this two-pronged incentive structure. Using the Medical Expenditure Panel Survey, we empirically corroborate the theory: regulations and guidelines have the intended effects of reducing opioid prescriptions for acute and chronic pain, respectively, as well as the predicted unintended effects—income effects cause regulations on acute pain treatment to increase chronic pain opioid prescriptions and the chronic pain treatment guidelines spillover to reduce opioids for acute pain. Moreover, we find that the guidelines worked as intended in terms of the reduced usage, with chronic pain patients shifting to non-opioids and also tapering opioid doses. For those who discontinued opioids under regulations and guidelines, we find no harm in terms of increased work limitations due to pain a year after discontinuing opioids. Finally, we observe an unexplained dichotomy—regulations reduce opioid use by causing fewer new starts, whereas guidelines reduce opioid use by discontinuing current users, with no impact on new starts.

Influence of Opioid Prescription Policy on Overdoses and Related Adverse Effects in a Primary Care Population.

In response to the opioid epidemic, many states have enacted policies limiting opioid prescriptions. There is a paucity of evidence of the impact of opioid prescribing interventions in primary care populations, including whether unintended consequences arise from limiting the availability of prescribed opioids. Our aim was to compare changes in opioid overdose and related adverse effects rate among primary care patients following the implementation of state-level prescribing policies. A cohort of primary care patients within an interrupted time series model. Electronic medical record data for 62,776 adult (18+ years) primary care patients from a major medical center in Vermont from January 1, 2016, to June 30, 2018. State-level opioid prescription policy changes limiting dose and duration. Changes in (1) opioid overdose rate and (2) opioid-related adverse effects rate per 100,000 person-months following the July 1, 2017, prescription policy change. Among primary care patients, there was no change in opioid overdose rate following implementation of the prescribing policy (incidence rate ratio; IRR: 0.64, 95% confidence interval; CI: 0.22-1.88). There was a 78% decrease in the opioid-related adverse effects rate following the prescribing policy (IRR: 0.22, 95%CI: 0.09-0.51). This association was moderated by opioid prescription history, with decreases observed among opioid-naïve patients (IRR: 0.18, 95%CI: 0.06-0.59) and among patients receiving chronic opioid prescriptions (IRR: 0.17, 95%CI: 0.03-0.99), but not among those with intermittent opioid prescriptions (IRR: 0.51, 95%CI: 0.09-2.82). Limiting prescription opioids did not change the opioid overdose rate among primary care patients, but it reduced the rate of opioid-related adverse effects in the year following the state-level policy change, particularly among patients with chronic opioid prescription history and opioid-naïve patients. Limiting the quantity and duration of opioid prescriptions may have beneficial effects among primary care patients.

Collaborative Care Management for Community-Dwelling Older Adults Prescribed Opioids: A Summary of Pilot Program Findings

<h3>Introduction</h3> Pain is highly comorbid with mental health problems, and can lead to significant disability and loss of function. Pain is common among older adults, with approximately half of older adults nationwide reporting experiencing bothersome pain in the preceding month. The treatment of pain in later life is complicated by a variety of factors, and there are significant safety risks associated with the use of analgesics, especially opioids. Multimodal strategies and collaborative care models that employ both non-pharmacological and pharmacological methods of pain care management may be especially promising in treating pain and improving outcomes. The objective of this project was to explore preliminary results from a pilot study of a telephone-delivered collaborative care service designed for community-dwelling older adults with chronic pain receiving prescriptions for high doses of opioids. Specifically, we were interested in examining program feasibility and acceptability, the extent to which engaged patients and their prescribers achieved opioid dose reduction, and changes in patient-level symptoms (e.g., pain severity and interference, depressive symptoms). <h3>Methods</h3> Eligible participants included 82 older adults referred by the Pennsylvania Department of Aging's pharmaceutical assistance program for low-income seniors (PACE/PACENET) to the University of Pennsylvania/PACE Behavioral Health Laboratory program. Referred patients were identified as receiving chronic opioid prescriptions for > 120 mg morphine-equivalent dose (MED) per day. Upon enrollment, patients first completed a comprehensive baseline clinical assessment. Clinical data on mental health, cognition, pain and functional status, as well as self-reported daily opioid dose and biopsychosocial needs, were collected over the phone and entered into the program's informatics tool. Patients next engaged in a series of telephone sessions during which care managers offered individualized treatment planning. Program goals included opioid dose reduction to safer levels and improved pain and psychosocial outcomes. Treatment modalities offered included: (1) behavioral pain management, (2) general medication education, (3) reinforcing positive health behaviors, (4) addressing barriers to change, (5) scheduling positive activities, and (6) relaxation techniques. Following each session, summary reports were sent to prescribers with recommendations for pain care management and opioid dose reduction. <h3>Results</h3> Enrolled patients were on average 73.5 (+/-6.1) years old, and the majority were non-Hispanic white (91%) and female (70%). Seventy-seven percent of the sample met criteria for clinically significant anxiety or depressive symptomatology. Of the 82 patients completing the baseline assessment, 53 (65%) engaged in the program. Patients were considered engaged in the program if they completed the baseline assessment and two or more additional follow-up contacts with a care manager. Those who engaged in the program did not differ on sociodemographic or clinical characteristics or baseline reports of pain when compared to those who did not engage. Pre-post intervention comparisons suggest a significant reduction in medication dose at the last contact relative to baseline. Further, at their last clinical contact, 66% of engaged patients achieved dose reductions of >20%. While there were no significant changes in pain interference or pain-related self-efficacy, engaged patients did report reductions in pain severity (p=0.05) and depressive symptoms (p=0.003) at the last contact relative to baseline. Preliminary findings also suggest that patients who achieved dose reductions of >20%, compared to those who did not, showed greater reductions in depressive symptoms and pain interference at the last contact relative to baseline. Pharmacy record data comparing those who engaged versus those who did not engage in the program were also collected for analysis. <h3>Conclusions</h3> In conclusion, the findings provide preliminary support for the feasibility of a community-based, collaborative care model for pain management and suggest the potential for positive treatment outcomes. The results also support further development and evaluation of collaborative care models that aim to address opioid use in later life. <h3>Funding</h3> Pennsylvania Department of Aging, PACE/PACENET program

Association between sex and perioperative opioid prescribing for total joint arthroplasty: a retrospective population-based study

BackgroundScarce data exist on differential opioid prescribing between men and women in the pre-, peri-, and postoperative phases of care among patients undergoing total hip/knee arthroplasty (THA/TKA). MethodsIn this retrospective population-based study, Truven Health MarketScan claims data were used to establish differences between men and women in (1) opioid prescribing in the year before THA/TKA surgery, (2) the amount of opioids prescribed at discharge, and (3) chronic opioid prescribing (3–12 months after surgery). Multivariable regression models measured odds ratios (OR) with 95% confidence intervals (95% CI). ResultsAmong 29 038 THAs (42% men) and 48 523 TKAs (52% men) men (compared with women) were less likely to receive an opioid prescription in the year before surgery (54% vs 60%, and 54% vs 60% for THA and TKA, respectively); P<0.001. However, in multivariable analyses male sex was associated with higher total opioid dosages prescribed at discharge after THA (OR=1.04; 95% CI 1.03, 1.06) and TKA (OR=1.05; 95% CI 1.04, 1.06); both P<0.001. Chronic opioid prescribing was found in 10% of the cohort (THA: n=2333; TKA: n=5365). Here, men demonstrated lower odds of persistent opioid prescribing specifically after THA (OR=0.90; 95% CI 0.82, 0.99) but not TKA (OR=0.96; 95% CI 0.90, 1.02); P=0.026 and P=0.207, respectively. ConclusionsWe found sex-based differences in opioid prescribing across all phases of care for THA/TKA. The results highlight temporal opportunities for targeted interventions to improve outcomes after total joint arthroplasty, particularly for women, and to decrease chronic opioid prescribing.

Factors associated with persistent opioid use after an upper extremity fracture

AimsThe increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.MethodsA total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support.ResultsA new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001).ConclusionThis study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health.Cite this article: Bone Jt Open 2021;2(2):119–124.