Discharge Opioid Prescriptions Research Articles

The Relationship Between Limited English Proficiency and Discharge Opioid Prescription Among Patients Undergoing Operation

INTRODUCTION: Barriers to effective communication may negatively impact pain assessment and the decision to prescribe opioids. In this study, we examine the relationship between limited English proficiency (LEP) and postoperative opioid prescribing. METHODS: This is a cross-sectional study of patients undergoing operation across a large healthcare delivery system between 2016 and 2020. Discharge opioid prescription was converted to morphine milligram equivalents (MME). Odds of being prescribed an MME dose below the 25th percentile and above the 75th percentile were compared between English proficient (EP) and LEP patients using multivariable logistic regression. RESULTS: Among 89,383 patients included in this study (mean age 52.13 years, 51% female), 7.4% had LEP; 21.6% (95% CI 21.3% to 21.8%) of EP patients and 28.5% (95% CI 27.4% to 29.6%) of LEP patients were not prescribed opioids. Among those who had an opioid prescription, the median (interquartile range [IQR]) MME was lower in LEP compared with EP patients (150 [75 to 225] vs 180 [96 to 315]). Median MME at discharge varied across surgical specialties (Fig. 1). Patients with LEP had higher odds of being prescribed lowest quartile MME (odds ratio [OR] 1.32, 95% CI 1.21 to 1.43) and lower odds of being prescribed highest quartile MME (OR 0.66, 95% CI 0.59 to 0.73) compared with EP patients after adjustment for clinical characteristics and surgical specialty.CONCLUSION: No opioid prescribing and less opioid prescribing occurred more often in LEP patients. If these differences result in inadequate pain management, this may be an opportunity for performance improvement. Given that larger MME prescriptions can be problematic, the clinical impact of these differences remains to be determined.

Perioperative Communication Association with Discharge Opioid Prescription in Patients with Limited English

Perioperative Communication Association with Discharge Opioid Prescription in Patients with Limited English

Factors That Influence Discharge Opioid Prescribing among Bariatric Surgeons across Michigan

Introduction: Opioid prescribing after bariatric surgery has been an area of focus due to its association with new persistent opioid use (NPOU) and worse outcomes. The development of statewide guidelines has led to a reduction in discharge opioid prescribing, but there remains variation in the number of opioids prescribed by surgeons after bariatric surgery. Understanding the factors underlying this variation may be another way to further improve practices around opioid prescribing. Methods: We conducted interviews with 20 bariatric surgeons across Michigan to explore factors that influence discharge opioid prescribing after bariatric surgery. All interviewed surgeons participate in a statewide bariatric surgery focused quality improvement collaborative. Transcripts were analyzed using descriptive content analysis. Results: Surgeons identified factors that influence their decision-making at the patient, provider, institution, and collaborative level. At the patient level, surgeons described the role of surgical history, addiction history, and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, provider reputation, workload, and involvement with research. At the institution level, surgeons discussed the influence of colleagues, variation in resources, and pressure from administration. At a collaborative level, surgeons described the role of evidence and performance measures. Notably, there was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery. Conclusion: Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices and beliefs among bariatric surgeons across Michigan. Understanding determinants that impact stakeholder alignment and proficiency is critical to the development of tailored intervention aimed at increasing adherence to guideline-concordant care.

Factors Associated With Total Discharge Opioid Prescription Morphine Milligram Equivalent Amounts Following Primary Anterior Cervical Spine Surgery.

Opioid overuse is a substantial cause of morbidity and mortality in the United States, and orthopaedic surgeons are the third highest prescribers of opioids. Postoperative prescribing patterns vary widely, and there is a paucity of data evaluating patient and surgical factors associated with discharge opioid prescribing patterns after elective anterior cervical surgery (ACS). The purpose of this study was to evaluate the volume of postoperative opioids prescribed and factors associated with discharge opioid prescription volumes after elective ACS. We retrospectively identified patients aged 18 years and older who underwent elective primary anterior cervical diskectomy and fusion (ACDF), cervical disk arthroplasty (CDA), or hybrid procedure (ACDF and CDA at separate levels) at a single institution between 2015 and 2021. Demographic, surgical, and opioid prescription data were obtained from patients' electronic medical records. Univariate and multivariate analyses were conducted to assess for independent associations with discharge opioid volumes. A total of 313 patients met inclusion criteria, including 226 (72.2%) ACDF, 69 (22.0%) CDA, and 18 (5.8%) hybrid procedure patients. Indications included radiculopathy in 63.6%, myelopathy in 19.2%, and myeloradiculopathy in 16.3%. The average age was 57.2 years, and 50.2% of patients were male. Of these, 88 (28.1%) underwent one-level, 137 (43.8%) underwent two-level, 83 (26.5%) underwent three-level, and 5 (1.6%) underwent four-level surgery. Younger age (P = 0.010), preoperative radiculopathy (P = 0.029), procedure type (ACDF, P < 0.001), preoperative opioid use (P = 0.012), and discharge prescription written by a midlevel provider (P = 0.010) were independently associated with greater discharge opioid prescription volumes. We identified wide variability in prescription opioid discharge volumes after ACS and patient, procedure, and perioperative factors associated with greater discharge opioid volumes. These factors should be considered when designing protocols and interventions to reduce and optimize postoperative opioid use after ACS.

Racial Variations in Pain Management and Outcomes in Hospitalized Patients With Acute Pancreatitis.

Acute pancreatitis (AP) is a common cause of hospitalization. Black AP patients have higher risk for alcoholic etiology and hospitalization than White patients. We evaluated outcomes and treatment disparities by race in hospitalized AP patients. We retrospectively analyzed Black and White AP patients admitted 2008-2018. Primary outcomes were length of stay, intensive care unit admission, 30-day readmissions, and mortality. Secondary outcomes included pain scores, opioid dosing, and complications. We identified 630 White and 186 Black AP patients. Alcoholic AP (P < 0.001), tobacco use (P = 0.013), and alcohol withdrawal (P < 0.001) were more common among Blacks. There were no differences in length of stay (P = 0.113), intensive care unit stay (P = 0.316), 30-day readmissions (P = 0.797), inpatient (P = 0.718) or 1-year (P = 0.071) mortality, complications (P = 0.080), or initial (P = 0.851) and discharge pain scores (P = 0.116). Discharge opioids were prescribed more frequently for Whites (P = 0.001). Hospitalized Black and White AP patients had similar treatment and outcomes. Standardized protocols used to manage care may eliminate racial biases. Disparities in discharge opioid prescriptions may be explained by higher alcohol and tobacco use by Black patients.

155. What are the risk factors for continued opioid use in patients following spine surgery?

BACKGROUND CONTEXT Although studies have explored acute opioid use within 30 days after surgery and chronic opioid use longer than 90 days after surgery, the impact of opioid use within the subacute phase of 31-90 days after surgery has not been studied. However, this subacute postoperative period has been identified as a potential predictor of chronic opioid use. PURPOSE This study aims to identify factors common in opioid-naïve patients who are at a high risk of opioid use during the subacute phase of 31-90 days after discharge. STUDY DESIGN/SETTING Retrospective analysis. PATIENT SAMPLE Adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019. OUTCOME MEASURES Opioid refills in the subacute postoperative period of 31-90 days following discharge. METHODS In this retrospective cohort study, the electronic medical record of adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019 were analyzed. Opioid refills in the subacute postoperative period of 31-90 days following discharge were the primary study outcome. RESULTS Of the study cohort consisting of 3,024 patients, 2,685 (89%) required inpatient opioids in the last 24 hours before discharge, 733 (26%) required an opioid refill 1-30 days after discharge, and 579 (19%) required opioid refill 31-90 days after discharge. Moreover, a postoperative opioid refill 1-30 days after discharge conferred the strongest risk of an opioid refill 31-90 days after discharge (OR 4.66, 95% CI 3.84-5.64). Other factors associated with the increased risk of an opioid refill 31-90 days after discharge were gabapentinoid use, discharge disposition to facilities other than home or self-care, reoperation, and female gender. Meanwhile, Asian American race was associated with the reduced risk. Those requiring opioid refills were noted to be younger, underwent longer surgeries, had extended inpatient hospital stays, required higher doses of inpatient opioids, and required higher doses of discharge opioid prescriptions for longer durations. CONCLUSIONS In opioid-naïve postoperative spine patients, opioid refills 1-30 days after discharge were strongly associated with an increased risk of opioid refills 31-90 days after discharge. Factors associated with opioid refill requirements also included longer surgeries and inpatient hospital stays as well as higher doses of inpatient opioids. Overall, this study enables physicians to identify patients at a higher risk of opioid use and to intervene early during the postoperative course. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Although studies have explored acute opioid use within 30 days after surgery and chronic opioid use longer than 90 days after surgery, the impact of opioid use within the subacute phase of 31-90 days after surgery has not been studied. However, this subacute postoperative period has been identified as a potential predictor of chronic opioid use. This study aims to identify factors common in opioid-naïve patients who are at a high risk of opioid use during the subacute phase of 31-90 days after discharge. Retrospective analysis. Adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019. Opioid refills in the subacute postoperative period of 31-90 days following discharge. In this retrospective cohort study, the electronic medical record of adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019 were analyzed. Opioid refills in the subacute postoperative period of 31-90 days following discharge were the primary study outcome. Of the study cohort consisting of 3,024 patients, 2,685 (89%) required inpatient opioids in the last 24 hours before discharge, 733 (26%) required an opioid refill 1-30 days after discharge, and 579 (19%) required opioid refill 31-90 days after discharge. Moreover, a postoperative opioid refill 1-30 days after discharge conferred the strongest risk of an opioid refill 31-90 days after discharge (OR 4.66, 95% CI 3.84-5.64). Other factors associated with the increased risk of an opioid refill 31-90 days after discharge were gabapentinoid use, discharge disposition to facilities other than home or self-care, reoperation, and female gender. Meanwhile, Asian American race was associated with the reduced risk. Those requiring opioid refills were noted to be younger, underwent longer surgeries, had extended inpatient hospital stays, required higher doses of inpatient opioids, and required higher doses of discharge opioid prescriptions for longer durations. In opioid-naïve postoperative spine patients, opioid refills 1-30 days after discharge were strongly associated with an increased risk of opioid refills 31-90 days after discharge. Factors associated with opioid refill requirements also included longer surgeries and inpatient hospital stays as well as higher doses of inpatient opioids. Overall, this study enables physicians to identify patients at a higher risk of opioid use and to intervene early during the postoperative course.

Reduction in unnecessary postoperative opioid prescription among patients undergoing inpatient gynecologic surgery by standardizing postoperative prescribing practices (499)

<b>Objectives:</b> In this quality improvement initiative, we sought to reduce the amount of unutilized and unnecessary opioid prescriptions given to patients following gynecologic surgery. <b>Methods:</b> Opioid-naïve patients over the age of 18 years who underwent inpatient gynecologic surgery at our institution were included in this quality improvement initiative. A 3-month pre-intervention evaluation of the number of opioid pills prescribed, the number of pills taken, acetaminophen and non-steroidal anti-inflammatory taken, and additional refills, were obtained by contacting patients via phone 7-10 days following discharge. After 100 consecutive patients were contacted and data collected, we standardized discharge opioid prescriptions to supply a total of 10 tablets to eligible patients. One hundred patients were contacted in this post-intervention phase, and data were collected. Appropriate statistical tests were utilized to compare between the pre- and post-intervention groups. <b>Results:</b> A total of 197 patients completed our survey when contacted following discharge (97 pre-intervention, 100 post-intervention). In the pre-intervention group, the median number of opioids prescribed was 22 pills (range: 0-60) and in the post-intervention group was 10 (range 0-60) (p< 0.001). The median number of pills consumed pre-intervention was 2 (range: 0-51) and 3 in the postintervention group (range: 0-50) (p = 0.668). Among all 197 patients, 75 patients (38.1%) took no opioids following discharge (40.6% of patients pre-intervention, 35.6% of patients post-intervention). There were no differences among the pre- and post-intervention groups with respect to age, the type of procedure performed, type of incision, post-discharge acetaminophen consumed, post-discharge NSAID consumed, or additional pain medication refill. <b>Conclusions:</b> Standardizing prescribing patterns following inpatient gynecologic surgery dramatically reduces unnecessary and unused opioids while having no effect on opioid consumption or the need for a refill. More than one-third of patients undergoing gynecologic surgery require no opioids following discharge. Efforts to individualize opioid prescriptions are needed to further reduce unnecessary opioid prescriptions.

Factors that influence discharge opioid prescribing among bariatric surgeons across Michigan

BackgroundOpioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices. MethodsWe conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis. ResultsAt the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery. ConclusionDespite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.

Decreasing opioid prescribing at discharge while maintaining adequate pain management is sustainable

Background:In 2018, using a pragmatic multimodal approach, discharge opioid prescriptions were reduced without affecting pain control management. Herein, we assessed whether this approach was sustainable and whether discharge opioid prescriptions could be further reduced.Methods:This is a single center prospective study of patients who underwent elective outpatient procedures provided by our institution‘s Acute Care Surgery Division surgeons. Adult patients who underwent elective surgeries performed by surgeons in the Division of Acute Care Surgery from November 2018 to June 2021 and agreed to participate were included. The opioid prescriptions pre-populated in the order set at discharge were reduced from 20 pills to 10 pills in May 2020. Demographics, opioid information, non-opioid adjuncts prescribed, reported use of opioids prescribed, and patients’ satisfaction were collected. Opioids were converted to oral morphine equivalents (OME).Results:A total of 178 patients were included. Elective surgeries performed mainly included inguinal hernia repair (38.8%), laparoscopic cholecystectomy (30.3%), cyst excision (13.5%), and umbilical hernia (8.4%). One hundred twenty-five and 53 patients underwent an elective operation with a surgeon in the Acute Care Surgery Division before and after the number of opioids pre-populated in the order set at discharge was reduced from 20 pills to 10 pills, respectively. Reducing the pre-populated discharge opioid prescriptions led to a significant decrease in OME prescribed (75 [75–76.5] vs. 80 [75–150], p < 0.001) without affecting patients’ satisfaction with pain management (excellent/good: 87.8% vs. 84%; p = 0.305)Conclusions:Our pragmatic multimodal approach is sustainable and allows for additional opioid prescription reduction without affecting patients’ satisfaction with pain management.

Variation by default: cesarean section discharge opioid prescription patterns and outcomes in Military Health System hospitals: a retrospective longitudinal cohort study

BackgroundTo examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid naïve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30 days) across a large healthcare system.MethodsThe Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was “female,” age was 18 years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home < 4 days after the Cesarean section.ResultsAcross 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225 mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts.ConclusionSignificant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation.

Association Between Default Number of Opioid Doses in Electronic Health Record Systems and Opioid Prescribing to Adolescents and Young Adults Undergoing Tonsillectomy

In prior studies, decreasing the default number of doses in opioid prescriptions written in electronic health record systems reduced opioid prescribing. However, these studies did not rigorously assess patient-reported outcomes, and few included pediatric patients. To evaluate the association between decreasing the default number of doses in opioid prescriptions written in electronic health record systems and opioid prescribing and patient-reported outcomes among adolescents and young adults undergoing tonsillectomy. This nonrandomized clinical trial included adolescents and young adults aged 12 to 50 years undergoing tonsillectomy from October 1, 2019, through July 31, 2021, at a tertiary medical center. The treatment group comprised patients from a pediatric otolaryngology service (mostly aged 12-21 years) and the control group comprised patients from a general otolaryngology service (mostly aged 18-25 years). Data on patient-reported opioid consumption and outcomes were collected via a survey on postoperative day 14. Based on opioid consumption among pediatric otolaryngology patients before the intervention, the default number of opioid doses was decreased from 30 to 12 in a tonsillectomy order set. This change occurred only for pediatric otolaryngology patients. Proportion of patients with 12 doses in the discharge opioid prescription, number of doses in this prescription, and refills and pain-related visits within 2 weeks of surgery. In a secondary analysis of patients completing the postoperative survey, patient-reported opioid consumption, pain control, sleep disturbance, anxiety, and depression were assessed. Linear or log-linear difference-in-differences models were fitted, adjusting for patients' demographic characteristics and presence of a mental health or substance use disorder. The study included 237 patients (147 female patients [62.0%]; mean [SD] age, 17.3 [3.6] years). Among 131 pediatric otolaryngology patients, 1 of 70 (1.4%) in the preintervention period and 27 of 61 (44.3%) in the postintervention period had 12 doses in the discharge opioid prescription (differential change, 45.5 percentage points; 95% CI, 32.2-58.8 percentage points). Among pediatric otolaryngology patients, the mean (SD) number of doses prescribed in the preintervention period was 22.3 (7.4) and in the postintervention period was 16.1 (6.5) (differential percentage change, -29.2%; 95% CI, -43.2% to -11.7%). The intervention was not associated with changes in refills or pain-related visits. The secondary analysis included 150 patients. The intervention was not associated with changes in patient-reported outcomes except for a 3.5-point (95% CI, 1.5-5.5 points) differential increase in a sleep disturbance score that ranged from 4 to 20, with higher scores indicating poorer sleep quality. This nonrandomized clinical trial suggests that evidence-based default dosing settings may decrease perioperative opioid prescribing among adolescents and young adults undergoing tonsillectomy, without compromising analgesia. ClinicalTrials.gov Identifier: NCT04066829.

Opioid Prescription and Usage Patterns After Open Abdominal Aortic Aneurysm Repair in Opioid-Naive Patients

Open abdominal aortic aneurysm (oAAA) repair is a painful procedure with no discharge opioid prescription guidance available. We hypothesized that a large variation exists in discharge opioid prescribing practices. We examined the prescribing practice in a large statewide quality database and within a single institution to understand the discharge opioid prescribing practice for oAAA repairs, to quantify the usage practices in this patient population, and to develop recommendations for discharge opioid prescription.

Opioid Discharge Prescriptions After Inpatient Surgery: Risks of Rebound Refills by Length of Stay

IntroductionAs inpatient stays become shorter, one concern with standardizing discharge opioid prescriptions is the potential risk of “rebound refills.” We sought to compare opioid prescription refill rates and volumes for surgical patients discharged on postoperative day (POD) 2-3, 4-7, and 8+. MethodsIn a prospective quality improvement protocol, faculty volunteered to use either a 5x-multiplier (5x) or usual care (UC) for discharge prescriptions after inpatient (≥48 h stay) surgery from Sep-Dec 2019. The 5x-multiplier is 5-times the patient's last 24-h opioid use (by oral morphine equivalents, OME). Cohorts were compared by POD of discharge: POD 2-3 (“SHORT”), POD 4-7 (“INTERMEDIATE”), and POD 8+ (“LONG”). The primary endpoint was 30-d refill rates. Secondary endpoints included 30-d refill OME and inpatient opioid weaning/discharge metrics. ResultsFrom 22 faculty, 409 patients were included. When stratified by POD, 154 (37.7%) were discharged SHORT, 176 (43.0%) INTERMEDIATE, and 79 (19.3%) LONG. SHORT stay patients had a median last 24-h OME of 10 mg (versus 5 mg INTERMEDIATE, 5 mg LONG; P = 0.268), and a median discharge OME of 55 mg (versus 75 mg INTERMEDIATE, 100 mg LONG; P = 0.221). Patients with SHORT stays did not have higher refill rates (11.7% versus 18.2% INTERMEDIATE, 19.0% LONG; P = 0.193) or higher median refill OME (150 mg versus 300 mg INTERMEDAITE, 339 mg LONG; P = 0.154). ConclusionsDespite concerns of increased refills, patients discharged by POD 2-3 were not associated with “rebound refills.” A patient-centered 5x-multiplier standardization of discharge opioid prescriptions is feasible in all inpatient surgery patients, even those discharged following a short inpatient stay.

Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention’s 2016 opioid prescribing guideline

BackgroundThe Centers for Disease Control and Prevention’s (CDC) March 2016 opioid prescribing guideline did not include prescribing recommendations for surgical pain. Although opioid over-prescription for surgical patients has been well-documented, the potential effects of the CDC guideline on providers’ opioid prescribing practices for surgical patients in the United States remains unclear.MethodsWe conducted an interrupted time series analysis (ITSA) of 37,009 opioid-naïve adult patients undergoing inpatient surgery from 2013–2019 at an academic medical center. We assessed quarterly changes in the discharge opioid prescription days’ supply, daily and total doses in oral morphine milligram equivalents (OME), and the proportion of patients requiring opioid refills within 30 days of discharge.ResultsThe discharge opioid prescription declined by -0.021 (95% CI, -0.045 to 0.003) days per quarter pre-guideline versus -0.201 (95% CI, -0.223 to -0.179) days per quarter post-guideline (p < 0.0001). Likewise, the mean daily and total doses of the discharge opioid prescription declined by -0.387 (95% CI, -0.661 to -0.112) and -7.124 (95% CI, -9.287 to -4.962) OME per quarter pre-guideline versus -2.307 (95% CI, -2.560 to -2.055) and -20.68 (95% CI, -22.66 to -18.69) OME per quarter post-guideline, respectively (p < 0.0001). Opioid refill prescription rates remained unchanged from baseline.ConclusionsThe release of the CDC opioid guideline was associated with a significant reduction in discharge opioid prescriptions without a concomitant increase in the proportion of surgical patients requiring refills within 30 days. The mean prescription for opioid-naïve surgical patients decreased to less than 3 days’ supply and less than 50 OME per day by 2019.

Postoperative opioid prescribing, use and pain trends following general surgery procedures: a retrospective cohort study among veterans comparing non-opioid versus chronic opioid users

IntroductionUnderstanding postoperative opioid use patterns among different populations is key to developing opioid stewardship programs.MethodsWe performed a retrospective cohort study on opioid prescribing, use, and pain after general surgery procedures...

Impact of continuous infusions of opioids on discharge opioid prescriptions.

The 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guidelines from the Society of Critical Care Medicine recommend opioids as a first-line treatment option for non-neuropathic pain among critically ill adults and prioritize pain management optimization before the administration of sedatives. Although analagosedation is recommended, the downstream effects, such as intensive care unit (ICU)-acquired opioid dependence, are not well described. The purpose of this study is to determine the impact of continuous infusions of opioids for mechanically ventilated patients prescribed opioids on discharge. This was a single-center, retrospective chart review of mechanically ventilated patients admitted to the medical ICU at a tertiary medical center from July 1, 2018 to June 30, 2019. The primary objective of this study was to compare the incidence of opioid prescriptions at discharge between those who received opioid infusions versus intermittent administrations. Secondary objectives included risk factors for receiving opioid prescriptions at discharge and readmission within 90 days with an active opioid prescription and/or a diagnosis of opioid use disorder. A total of 100 patients were included. There was no statistically significant difference in the incidence of opioid prescriptions at discharge between the groups (p = 0.933). Only one patient was readmitted within 90 days with documented opioid use disorder and 11 patients with prescription opioids on their home medication list. A best-fit logistic regression model including the type of opioid administration (p = 0.275), length of stay (p = 0.018), and opioid dose (p = 0.137) showed that length of stay was the only significant predictor of discharge opioid prescribing. The incidence of opioid prescriptions at discharge for critically ill, mechanically ventilated patients did not differ based on opioid administration strategy. ICU length of stay appears to be a predictive factor of opioid discharge prescriptions.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients.

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses. In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Chemical producers facing looming uncertainty

We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care.Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates.Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742).The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.

Theoretical Concepts of Photocatalysis

We designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care.Faculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥ 48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates.Median last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742).The 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.

A prospective feasibility study evaluating the 5x-multiplier to standardize discharge prescriptions in cancer surgery patients

BackgroundWe designed a prospective feasibility study to assess the 5x-multiplier (5x) calculation (eg, 3 pills in last 24 hours × 5 = 15) to standardize discharge opioid prescriptions compared to usual care. MethodsFaculty-based surgical teams volunteered for either 5x or usual care arms. Patients undergoing inpatient (≥48 hours) surgery and discharged by surgical teams were included. The primary end point was discharge oral morphine equivalents. Secondary end points were opioid-free discharges and 30-day refill rates. ResultsMedian last 24-hour oral morphine equivalents was similar between arms (7.5 mg 5x vs 10 mg usual care, P = .830). Median discharge oral morphine equivalents were less in the 5x arm (50 mg 5x vs 75 mg usual care, P < .001). Opioid-free discharges included 33.5% 5x vs 18.0% usual care arm patients (P < .001). Thirty-day refill rates were similar (15.3% 5x vs 16.5% usual care, P = .742). ConclusionThe 5x-multiplier was associated with reduced opioid prescriptions without increased refills and can be feasibly implemented across a diverse surgical practice.