Discharge Opioid Prescriptions Research Articles

A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service.

To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.

Perioperative Opioid Stewardship Program: Barriers and Promotors of Implementation and Sustainability

AbstractPerioperative opioid stewardship programs aim to harness the benefits of opioid analgesia for managing acute post-surgical pain whilst mitigating potential harm. Healthcare worker stakeholders are vital for the effective program introduction and continuation. However, their perceptions of program barriers and promotors are underexplored. We conducted twenty semi-structured interviews with healthcare workers across three health services that introduced a perioperative opioid stewardship program. The participants included specialist pain medicine physicians, anaesthetist managers, pain nurses, pharmacists and Junior Medical Officers. Interviews were transcribed and coded both inductively and deductively against the Consolidated Framework of Implementation Research. Key themes from the data were reviewed, refined and reported. Participants were generally aware of perioperative opioid stewardship principles but senior clinicians reported greater specific program knowledge. Adherence to the discharge opioid prescription guideline was promoted by hospital leadership endorsement and workflow integration. A universal barrier to program adherence was inadequate resourcing. Lack of role clarity was a barrier to patient discharge opioid education. Hospital-community prescriber communication was variable but generally limited to written discharge summaries rather than a comprehensive, personalised approach. Introducing an Electronic Medical Record was universally seen as an opportunity to promote better program integration and sustainment. This study deepens our current understanding of the drivers of observed perioperative opioid stewardship program outcomes from the perspective of healthcare worker stakeholders. The findings could be used to optimise existing programs or to guide the implementation of new programs to achieve effective clinical change.

Sex concordance between physicians and patients and discharge opioid prescribing.

Inpatient pain management is challenging for clinicians and inequities are prevalent. We examined sex concordance between physicians and patients to determine if discordance was associated with disparate opioid prescribing on hospital discharge. We examined 15,339 hospitalizations from 2013 to 2021. Adjusting for patient, clinical, and hospitalization-level characteristics, we calculated the odds of a patient receiving an opioid on discharge and the days of opioids prescribed across all hospitalizations and for patients admitted with a common pain diagnosis. We did not find an overall association between physician-patient sex concordance and discharge opioid prescriptions. Compared to concordant sex pairs, patients in discordant pairs were not significantly less likely to receive an opioid prescription (odds ratio: 1.04; 95% confidence interval [CI]: 0.95, 1.15) and did not receive significantly fewer days of opioids (2.1 fewer days of opioids; 95% CI: -4.4, 0.4). Better understanding relationships between physician and patient characteristics is essential to achieve more equitable prescribing.

Use-Based Opioid Prescribing Protocol Reduces Opioid Prescriptions After Cesarean Section [ID 2683514

INTRODUCTION: Up to 75% of post-cesarean patients report having up to 50% of their discharge opioid prescription left over. We assessed an institutional standardized post-cesarean section pain management and opioid prescribing protocol implemented to decrease unused opioids entering the community while still adequately managing pain. METHODS: This was an IRB-approved single-center retrospective comparative cohort study in patients aged 18 years or older, who underwent cesarean section before or after implementation of standardized pain management and opioid prescribing protocol. The intervention group received scheduled acetaminophen and NSAIDs with oxycodone 5 to 10 mg as needed postoperatively. Opioid consumption during the 24 hours prior to discharge was used with set ranges determine the quantity of opioid to prescribe for discharge. Outcomes included opioid prescription receipt, quantity of opioid prescribed, and supplementary opioid prescription within 30 days of discharge. RESULTS: Four hundred thirty-three patients were included, with 255 in the intervention group and 208 in the control group. The intervention group used less oxycodone postoperatively (75.1%, 17.8%, and 7.1% of patients using 45 mg, respectively, versus 52.4%, 30.3%, and 17.3%; P&lt;.001), received fewer opioid prescriptions (79.1% versus 89.4%; P=.041), and fewer oxycodone tablets if prescribed (median [interquartile range]: 15 [5–20] versus 30 [20–30]; P&lt;.001). There was no significant difference in number of supplemental post-discharge opioid prescriptions received. CONCLUSION: A standardized post-cesarean section pain management and opioid prescribing protocol significantly reduced the number of both opioid prescriptions written and number of tablets prescribed without increasing patients seeking opioid refills in the 30 days following discharge.

Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample.

Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes. In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis. Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14. Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.

Surgeons’ views of peer comparison and guideline-based feedback on postsurgery opioid prescriptions: a qualitative investigation

BackgroundExcess 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...

Association Of Opioid Prescribing And Consumption With Patient-Reported Experiences And Satisfaction Following Emergency Surgery In Michigan.

To investigate the relationships between opioid prescribing, consumption, and patient reported outcomes (PROs) in emergency surgery patients. Overprescribing of opioids for pain management after surgery has become a public health concern and major contributor to opioid misuse and dependency. Current guidelines do not address opioid prescribing following emergency surgical procedures, highlighting the importance of understanding the relationship between opioid prescribing and consumption in this setting. Retrospective analysis of the quantity of opioids prescribed and patient-reported outcomes (PROs) in a population-based setting. The sample included adults 18 years and older undergoing emergency surgery across 69 hospitals in Michigan. Patients were included if they received a discharge opioid prescription and had valid data for opioid consumption and PROs. Surgical procedures took place between January 1, 2018 and December 31, 2020. During the study period, a total of 3,742 patients underwent an emergency operation. The mean number of opioid pills prescribed was 9.6 and the mean number of opioid pills consumed was 4.6. In a two-model with logit in the first part and a linear regression in the second, prescription size was significantly associated with both the probability of consumption (aOR 1.02, 95% CI 1.01-1.04) and the amount of consumption conditional on any consumption (coefficient 0.70 95% CI 0.54-0.86). Patients only consumed half of the opioids they were prescribed after undergoing emergency surgery. Additionally, patients who were given larger prescriptions consumed more opioids, but did not experience less pain, higher satisfaction, better quality of life, or less regret to undergo surgery. Overall, this suggests that opioids may be excessively prescribed to patients undergoing emergency surgical procedures, and that larger prescriptions do not improve the patient experience after surgery.

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.

Opioid Consumption After Discharge From Total Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundPain is challenging after recovery from total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures, and patients often receive prescription opioids. However, opioid consumption by patients remains unclear, and unused opioids may lead to risks including misuse and diversion. The objective of this systematic review and meta-analysis was to compare prescription size versus patient-reported consumption of opioids after discharge following TKA and THA. MethodsPubMed and Embase were systematically searched for publications published between 2015 and 2022 on patient-reported consumption of opioids after TKA and THA. The primary outcome was opioid use in oxycodone 5-mg equivalents. Team members independently reviewed studies for screening, inclusion, data extraction, and risk of bias. ResultsAmong the 17 included studies (15 TKA and 11 THA), discharge opioid prescribing exceeded consumption for both TKA (88.4 versus 65.0 pills at 6 weeks) and THA (64.0 versus 29.8 pills at 12 weeks). For both TKA and THA, the range of opioids prescribed varied significantly, by 1.6-fold for TKA and 2.8-fold for THA. Most studies reported pain outcomes (89%) and the use of nonopioid medications (72%). Of the 4 studies offering prescribing recommendations, the amounts ranged from 50 to 104 pills for TKA and 30 to 45 pills for THA. ConclusionsOpioid prescribing exceeds the amount consumed following TKA and THA. These findings serve as a call to action to tailor prescribing guidelines to how much patients actually consume while emphasizing the use of nonopioid medications to better optimize recovery from surgery.

Mismatched Postsurgical Opioid Prescription to Liver Transplant Patients: A Retrospective Cohort Study From a Single High-volume Transplant Center.

Improper opioid prescription after surgery is a well-documented iatrogenic contributor to the current opioid epidemic in North America. In fact, opioids are known to be overprescribed to liver transplant patients, and liver transplant patients with high doses or prolonged postsurgical opioid use have higher risks of graft failure and death. This is a retrospective cohort study of 552 opioid-naive patients undergoing liver transplant at an academic center between 2012 and 2019. The primary outcome was the discrepancy between the prescribed discharge opioid daily dose and each patient's own inpatient opioid consumption 24 h before discharge. Variables were analyzed with Wilcoxon and chi-square tests and logistic regression. Opioids were overprescribed in 65.9% of patients, and 54.3% of patients who required no opioids the day before discharge were discharged with opioid prescriptions. In contrast, opioids were underprescribed in 13.4% of patients, among whom 27.0% consumed inpatient opioids but received no discharge opioid prescription. The median prescribed opioid daily dose was 333.3% and 56.3% of the median inpatient opioid daily dose in opioid overprescribed and underprescribed patients, respectively. Importantly, opioid underprescribed patients had higher rates of opioid refill 1 to 30 and 31 to 90 d after discharge, and the rate of opioid underprescription more than doubled from 2016 to 2019. Opioids are both over- and underprescribed to liver transplant patients, and opioid underprescribed patients had higher rates of opioid refill. Therefore, we proposed to prescribe discharge opioid prescriptions based on liver transplant patients' inpatient opioid consumption to provide patient-centered opioid prescriptions.

Patient Interaction With the Health Care System Following a Nonopioid Discharge Strategy for Anterior Urethroplasty.

Continued efforts have been made to minimize postoperative opioids following urologic interventions. Studies show that patient-reported pain outcomes are similar between those patients discharged with and without opioids following anterior urethroplasty, but we do not know what impact this has on health care utilization. We aim to show that a nonopioid discharge following anterior urethroplasty does not increase postoperative health care utilization. Five hundred patients who underwent anterior urethroplasty from January 2016 to October 2022 were identified from retrospective chart review. Patient demographic information, surgical characteristics, and postoperative interactions with the health care system were extracted from the electronic medical record. We then compared these outcomes by discharge opioid prescription status. A total of 253 patients were discharged without an opioid prescription. Patients who received an opioid were more likely to have had a perineal incision (73% vs 64%, P = .02), more likely to have had an overnight hospital stay (30% vs 14%, P < .01), and were more likely to have been prescribed an opioid preoperatively (13% vs 7%, P = .03). There were overall low rates of interaction with the health system in both groups with no significant difference in 30-day unplanned office visits, emergency department visits, or office phone calls. Overall, by the end of our study period 97% were discharged without an opioid and 94% of patients were discharged the same day. Patients undergoing anterior urethroplasty can safely be discharged home without opioids following surgery without undue postoperative burden on the health care system.

Hospital Discharge Opioid Prescribing Trends in a Multistate Institution Following the Introduction of Opioid Prescribing Guidelines and Key Metrics Dashboard

Background Despite the introduction of the Centers for Disease Control and Prevention's opioid prescribing guidelines, studies indicate that a significant proportion of opioids prescribed at hospital discharge remains unused. Little is known if improved provider awareness of guidelines and metrics would facilitate rightsizing opioid prescriptions at hospital discharge. Our institution created opioid prescribing guidelines and a key metrics dashboard and subsequently disseminated these tools to our institution's leadership and prescribers. We aim to evaluate the effectiveness of these efforts in reducing hospital discharge opioid prescriptions, especially those for acute pain exceeding 100 morphine milligram equivalents (MME). Methods Following the development of practice-specific opioid prescribing guidelines in 2017, a key metrics dashboard was created in 2021 to display the percentage of hospital discharges with opioids prescribed and the percentage of discharges with opioids prescribed for acute pain exceeding 100 MME. These metrics were broken down into calendar years between 2018 and 2022, and by the 7 major practice regions across our institution spanning 5 U.S. States. Results From 2018 to 2022, all regions showed a decline in the percentage of hospital discharges with opioids prescribed (range 2.7%-9.4%). In the same period, 5 of 7 regions showed a decline in discharge opioid prescriptions exceeding 100 MME for acute pain (range 8.8%-23.2%). Two sites showed an increase of 2.4% and 2.7%. Conclusion Downward trends in hospital discharge opioid prescriptions were observed for most practice regions following the introduction of our institution's opioid prescribing guidelines and key metrics dashboard.

Postdischarge Opioid Prescription after Cesarean: A Quality Improvement Initiative.

This study aims to determine if adoption of a user-friendly algorithm for individualized opioid prescribing at discharge would decrease the number of opioids prescribed after cesarean delivery. As part of a quality initiative, we developed and implemented an algorithm for opioid prescribing at discharge for patients after cesarean delivery. The intervention group comprised patients delivering by cesarean in the 6 months following initiation of the intervention. The intervention group was divided into three groups based on inpatient opioid needs 24 to 48 hours after delivery. Oxycodone tablets were prescribed at discharge based on inpatient group. The control group comprised patients delivering at the same institution in the 6 months prior to initiation of the intervention. The primary outcome was number of oxycodone tablets prescribed at discharge. The secondary outcome was the proportion of patients with a pain-related encounter or additional oxycodone prescription up to 6 weeks after delivery. From July to December 2020, a total of 382 subjects met criteria for the intervention. The comparison group consisted of 391 subjects discharged from January to June 30, 2020, after cesarean. Baseline characteristics and inpatient opioid use 24 to 48 hours after delivery did not differ between the groups. Compared with the control group, subjects in the intervention group had fewer oxycodone tablets prescribed at discharge (11.1 vs. 15.8, p < 0.001). The number of pain-related encounters within 6 weeks of delivery did not differ between the intervention and comparison groups (10.5 vs. 10.3%, p = 0.82). There was no increase in the additional number of oxycodone prescriptions after discharge (4.7% in the intervention group vs. 4.3% in the control group, p = 0.81). Discharge opioid prescribing based on inpatient use after cesarean reduces the number of opioids prescribed without increasing the number of pain-related encounters after discharge. A simple algorithm may ensure compliance from prescribers. · Previous research has shown that most opioids prescribed after cesarean delivery are unused after discharge. We implemented an algorithm for opioid discharge prescribing after cesarean delivery based on inpatient opioid consumption.. · Implementing an individualized approach to opioid prescribing reduced the number of tablets prescribed at discharge after cesarean delivery. The decrease in discharge prescribing did not correspond to an increase in pain-related encounters or additional narcotic prescriptions in the 6 weeks following delivery.. · The overprescription of opioids at discharge after cesarean delivery is well-established, and previous authors have found success in prescribing opioids at discharge based on inpatient use. Our study proposes a simple, reproducible algorithm for opioid prescribing at discharge after cesarean..

Retrospective study of disparities in regional anesthesia and discharge opioid prescriptions at a veterans affairs medical center

Background: Abundant literature acknowledges healthcare disparities exist in medicine, especially in pain management, but disparities related to peri-operative pain management in veterans undergoing total knee arthroplasties (TKA) has not been previously described. TKAs are becoming increasingly common, and evidence suggests that perioperative regional anesthesia improves post TKA outcomes. This study aimed to determine if healthcare disparities exist pertaining to the use of regional anesthesia and the prescribing of discharge opioids for TKAs in the Veterans Affairs Health Care System (VAHCS). We hypothesized that race-based disparities would be present in the use of regional anesthesia and discharge opioid prescribing at our institution. Our secondary hypothesis was that older patients would be more likely to receive regional anesthesia and lower quantities of opioids at discharge. Methods: This was a retrospective analysis of Atlanta VAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. A total of 653 patients were included. Multivariate logistic regression was used to model the impact of patient demographics on nerve block use and multivariate linear regression was used to model the impact of patient demographics on total oral morphine equivalents prescribed. Results: Our results showed that Black patients were as likely to receive regional anesthesia for their TKAs (p=0.85) but did receive less opioid pain medications at discharge (p&lt;0.001) than White patients. We also found that older patients (&gt; 50 years old) had significantly lower odds ratio of receiving regional anesthesia and received less opioid pain medications post TKA discharge. Conclusions: Our study showed age-based disparities in regional anesthesia utilization and discharge opioid prescriptions. It also showed race-based disparities in discharge opioid prescriptions. Our results demonstrate the need to better understand why these differences exist within this open access system and suggests solutions based on the socioecological model to diminish them.

Appendectomy Pain Medication Prescribing Variation inthe U.S. Military Health System.

Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System. This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED). Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only. Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.

Changes in Surgical Opioid Prescribing and Patient-Reported Outcomes After Implementation of an Insurer Opioid Prescribing Limit

Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain. To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan. This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019. Policy limiting opioid prescriptions to a 5-day supply in February 2018. Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume. Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone. This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.

Comparing Rationale for Opioid Prescribing Decisions after Surgery with Subsequent Patient Consumption: A Survey of the Highest Quartile of Prescribers.

Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions-from nudges to reminders-have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown. Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure-as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption. During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%). The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients.

The Tailored Opioid Reduction Strategy (TORS): A Quality Improvement Initiative to Reduce Opioid Prescription Following Hysterectomy

ObjectiveTo evaluate a tailored opioid reduction strategy (TORS) in minimizing opioid prescriptions for patients undergoing hysterectomy. MethodsThis quality improvement initiative was developed by multiple stakeholders at an academic hospital in a Canadian urban centre. The intervention consisted of a three-pronged approach: (1) patient and provider education, (2) perioperative multimodal analgesia, and (3) a targeted opioid reduction strategy. All eligible patients were asked to fill pre- and postoperative questionnaires. Analysis of outcomes pre- and post-TORS implementation as well as intervention compliance was performed. ResultsFrom September 2020 to April 2021, 133 patients who underwent hysterectomy were included in the study, 69 in the pre-intervention group and 64 in the post-intervention group. Of 133 hysterectomies, 78 (58.6%) were performed laparoscopically, 16 (12%) open, 14 (10.5%) vaginally, and 25 (18.8%) robotically. The rate of discharge opioid prescriptions was significantly reduced in the post-intervention group compared with the pre-intervention group (37/64, 58% versus 62/69, 90%, respectively, P < 0.001), as well as the amount of opioid prescribed in oral morphine equivalents (OME) (mean 47 mg pre-intervention, 28 mg post-intervention, P < 0.001). There was no significant difference in patient satisfaction or postoperative pain scores between groups. Overall, compliance with 2 or more components of TORS intervention was seen in 64/64 (100%) cases. ConclusionTORS implementation was successful in reducing the rate of discharge opioid prescriptions and the total amount of opiates prescribed in patients undergoing hysterectomy with no decrease in patient satisfaction or change in postoperative pain scores. We believe it can be applied more broadly across different surgical patient populations to prevent opioid abuse.

Variability in Opioid Prescribing Among Plastic Surgery Residents After Bilateral Breast Reduction.

Prescription opioid misuse in the United States accounts for significant avoidable morbidity and mortality. Over one third of all prescriptions written by surgeons are for opioids. Although opioids continue to provide needed analgesia for surgical patients, there are few guidelines in the plastic surgery literature for their safe and appropriate use after surgery. The consequence is wide variability and excessive opioid prescriptions. Understanding patterns of prescribing among plastic surgery residents is a crucial step toward developing safer practice models for managing postoperative pain. The authors performed a retrospective analysis of discharge opioid prescriptions after bilateral breast reduction at a single academic medical center from 2018 to 2021. Single factor 1-way analysis of variance was used to evaluate prescribing patterns by resident, postgraduate year, attending of record, and patient characteristics for 126 patients. A multivariate analysis was performed to determine the degree to which these factors predicted opioid prescriptions. This analysis revealed significant variability among residents prescribing opioids after bilateral breast reductions (P < 0.001) irrespective of patient comorbidities and demographics. Residents were found to be the main predictor of opioid prescriptions after surgery (P < 0.001) with a greater number of morphine milligram equivalents prescribed by the more junior residents (P < 0.001). Excessive and variable opioid prescriptions among plastic surgery residents highlight the need for opioid prescribing education early in surgical training and improved oversight and communication with attending surgeons. Furthermore, implementation of evidence-based opioid-conscious analgesic protocols after common surgical procedures may improve patient safety by standardizing postoperative analgesic prescriptions.

Effect of Alternatives to Opiates Program on Discharge Opioid Prescribing in Trauma Patients.

Opioid overdose deaths have increased over the last two decades, despite efforts to reduce prescribing. This study aimed to determine if a hospital-wide Alternatives to Opiates (ALTOSM) program reduced opioid prescribing in hospital and upon discharge after trauma. The primary outcome was incidence of opioid prescribing at hospital discharge Pre- and Post-ALTO. Secondary outcomes were the percent of patients with in-hospital opioid, non-opioid and multimodal analgesia, and hospital and intensive care unit (ICU) length of stay (LOS). This is a single-center, retrospective analysis of patients >/ = 18years old admitted for >24hours with the primary diagnosis of traumatic injury between August 2018 - October 2019. Patients with alcohol or polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. A total of 703 patients were included, 471 in Pre-ALTO and 232 in Post-ALTO groups. The mean age was 59 ± 22years and most were male (58.7%). Mean initial Injury Severity Score (ISS) was 9.1 ± 7.7. Opioid prescribing at hospital discharge occurred more in the Post-ALTO group (132/332, 39.4% vs 90/203, 43.8%; P = .1237). Most patients were prescribed in-hospital opioid (332/471, 70.4% vs 203/232, 87.5%, P < .0001) and non-opioid (441/471, 93.6% vs 229/232, 98.7%; P = .0027) analgesics, or multimodal analgesia (397/471, 84.3% vs 203/232, 87.5%; P = .2591). Median hospital and ICU LOS were also similar between groups [5 (3-9) vs 4(3-7), P = .3427] and ICU [2(0-4) vs 3(2-5), P = .3461]. Opioids remain mainstay for trauma-related pain treatment. ALTOSM was not associated with less in-hospital or discharge opioid prescribing.