High-dose Opioids Research Articles

Trends in naloxone co-prescriptions.

The opioid epidemic remains a significant public health crisis in the United States. Naloxone has been identified as a critical component in combating this crisis. However, co-prescription rates among patients receiving opioids remain suboptimal, especially among certain high-risk populations. The purpose of the current study is to update and analyze recent trends in naloxone co-prescription rates in Iowa. A retrospective analysis of de-identified prescription data from the Iowa Prescription Monitoring Program (PMP) was performed. Naloxone co-prescription rates per 1000 patients receiving opioids in the state of Iowa were calculated in 2019, 2020, 2021, and 2022 for nine categories, stratified by opioid dose, concurrent benzodiazepine use, and patient demographics. Exclusion criteria consisted of patients in a hospice or a non-ambulatory setting. The study found a year-over-year increase in naloxone co-prescriptions from 2019 to 2022 across all examined categories. High-risk groups, including patients on higher opioid doses and those prescribed opioids and benzodiazepines concurrently, showed substantial increases in naloxone co-prescriptions. Geographical and age-related disparities in naloxone co-prescribing rates were also observed, with rural areas and older patient groups less likely to receive naloxone. The observed increases in naloxone co-prescribing rates indicate progress in opioid overdose prevention efforts. Nonetheless, co-prescription rates remain suboptimal among high-risk groups, underscoring the need for continued education and policy efforts to enhance naloxone accessibility and encourage its co-prescription with opioids, particularly among older patients and geographical areas with lower co-prescription rates.

Personalizing Prediction of High Opioid Use in the Neurointensive Care Unit: Development and Validation of a Stratified Risk Model for Acute Brain Injury Due to Stroke or Traumatic Brain Injury.

Background/Objectives: This study aimed to develop and validate a stratified risk model for predicting high opioid use in patients with acute brain injury due to stroke or traumatic brain injury (TBI) admitted to a neurocritical care intensive care unit. Methods: We examined the factors associated with the use of high-opioids (≥75th quartile, ≥17.5 oral morphine equivalent/ICU day) in a retrospective cohort study including patients with acute ischemic stroke, spontaneous intracerebral hemorrhage, spontaneous subarachnoid hemorrhage, and TBI. We then developed, trained, and validated a risk model to predict high-dose opioids. Results: Among 2490 patients aged 45-64 years (β = -0.25), aged 65-80 years (β = -0.97), and aged ≥80 years (β = -1.17), a history of anxiety/depression (β = 0.57), a history of illicit drug use (β = 0.79), admission diagnosis (β = 1.21), lowest Glasgow Coma Scale Score (GCSL) [GCSL 3-8 (β = -0.90], {GCS L 9-12 ((β = -0.34)], mechanical ventilation (β = 1.21), intracranial pressure monitoring (β = 0.69), craniotomy/craniectomy (β = 0.6), and paroxysmal sympathetic hyperactivity (β = 1.12) were found to be significant predictors of high-dose opioid use. When validated, the model demonstrated an area under the curve ranging from 0.72 to 0.82, accuracy ranging from 0.68 to 0.91, precision ranging from 0.71 to 0.94, recall ranging from 0.75 to 1, and F1 ranging from 0.74 to 0.95. Conclusions: A personalized stratified risk model may allow clinicians to predict the risk of high opioid use in patients with acute brain injury due to stroke or TBI. Findings need validation in multi-center cohorts.

Perioperative pain management for cardiac surgery.

Acute postsurgical pain after cardiac surgery is challenging to treat. Adverse effects related to the high dose opioids which have traditionally been used perioperatively in cardiac surgery have led to the adoption of alternative analgesic strategies. This review aims to highlight current evidence-based approaches to managing pain after cardiac surgery. Current evidence and international guidelines support the use of multimodal analgesics for managing perioperative pain after cardiac surgery. Regional anaesthesia in the form of fascial plane blocks, such as the erector spinae plane and parasternal intercostal plane blocks, are effective and safe techniques for anticoagulated cardiac surgery patients. Transitional pain services are multidisciplinary programmes that bridge the gap between inpatient and outpatient care for these patients. This paper reviews advancements in perioperative pain management for cardiac surgery patients, emphasising the shift from high-dose opioids to multimodal analgesia and regional anaesthetic techniques, and highlighting the role of multidisciplinary transitional pain services.

Experience of using multimodal opioid-saving anesthesia in children: single-center prospective randomized study

BACKGROUND: In the protocols of rapid recovery after surgery, it is recommended to avoid long-term administration and/ or high doses of opioids in order to reduce the severity of their adverse reactions in the postoperative period. In this regard, opioid-sparing anesthesia (OSA) may become a promising approach to the treatment of cancer patients. AIM. To evaluate the effectiveness of multimodal OSA in the scheme "dexmedetomidine+ketamine (in subanesthetic doses)+lidocaine (intravenous infusion)" in pediatric oncosurgery. MATERIALS AND METHODS: A single-center prospective randomized study involved 40 children aged 12 to 18 years. Patients were divided into 2 groups depending on the method of anesthesia: in group I (n=20), combined endotracheal anesthesia with opioids was performed, in group II (n=20) — multimodal OCA based on intravenous infusion of lidocaine, dexmedetomidine and subanesthetic doses of ketamine. The patients underwent extended operations in the head and neck area in the volume of thyroidectomy with fascial-sheath lymph dissection and excision of the central tissue of the neck from 2 sides. RESULTS: With stable intraoperative hemodynamic parameters, the median total intraoperative need for analgesics in group II was: for lidocaine— 351 (289.6; 418.5) mg (which is 1.75mg/kg per hour), for dexmedetomidine— 88.2 (38.5; 119.7) µg, for ketamine — 21.6 (17.4; 27.3mg. In group I, the median total intraoperative need for fentanyl was 273.7 (406; 240.9)µg. In addition, in group I, the median amount required for postoperative analgesia of the synthetic opioid analgesic tramadol was 419 (365.6; 479)mg (which is 7.8mg/kg; p=0.01). In group II, the median amount of lidocaine required for postoperative analgesia (1 mg/kg per hour) turned out to be 1377.3 (735.7; 1894)mg, while additional tramadol administration at a dose of 57.3 (28.5; 107.7)mg was required in only 7(35%) patients. CONCLUSION: Multimodal OSA based on dexmedetomidine, lidocaine, ketamine and sevoflurane is an effective and safe method of anesthesia in children from 12 to 18 years old, which is not inferior to opioid analgesics in the treatment of perioperative pain during surgical interventions on the thyroid and parathyroid glands in cancer patients, and also reduces the number of adverse reactions characteristic of opioids.

Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ∆PES in ventilated children.

Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆PES) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆PES in children. We sought to identify risk factors for P0.1 over or underestimating ∆PES in ventilated children. Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆PES (∆PES-REAL), P0.1 and predicted ∆PES (∆PES-PRED = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆PES-REAL and ∆PES-PRED were aligned (low, normal, and high effort and drive), two where ∆PES-REAL and ∆PES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes. We analyzed 953 patient days (222 patients). ∆PES-REAL and ∆PES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017). In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome. NCT03266016; August 23, 2017.

Chronic Opioid Use Following Implementation of Oregon's Medicaid Back Pain Policy

IntroductionIn 2016, Oregon developed an innovative policy to improve care for Medicaid patients with back pain. The objective of this study was to identify factors associated with dose reduction and discontinuation among Medicaid patients using chronic opioid therapy following implementation of this policy. MethodsUsing Medicaid administrative claims data, this was a retrospective cohort of patients on chronic stable opioid therapy between July and December 2016. Outcomes assessed were 1) 30% reduction in opioid dose and 2) an absolute discontinuation between January to December 2017. Multivariable logistic regressions evaluated association between dose reduction outcomes and clinical and demographic factors. ResultsOf 4,643 Medicaid patients on chronic opioid therapy, 3853 (83%) had a dose reduction and 651 (14%) discontinued opioids; patients with back pain were more likely to have a dose reduction (adjusted odds ratio [aOR] 1.19; 95% 1.01 to 1.41). Factors associated with discontinuation included having a mental health diagnosis (aOR 1.30; 95% CI 1.08 to 1.56), substance use disorder (aOR 1.90; 95% CI 1.41 to 2.56), opioid use disorder (aOR 1.55; 95% CI 1.21 to 1.99), and receipt of buprenorphine (aOR 2.82; 95% CI 1.30 to 6.15). Discontinuation was less likely in Black patients (aOR 0.50; 95% CI 0.29 to 0.85), in older age groups, and in those with a higher opioid dose at baseline. ConclusionsMost Medicaid beneficiaries had a dose reduction following implementation of Oregon's back pain policy. Opioid discontinuation was associated with factors that suggest providers pursue this strategy for patients at higher overdose risk.

Adoption of clinical pharmacist roles in primary care: Longitudinal evidence from English general practice.

Over the last decade, the number of clinical pharmacists working within multidisciplinary teams in English general practice has expanded Aim: This study examines changes in quality of prescribing after the adoption of clinical pharmacists in English general practices. Two-way fixed effects regression was used to compare differences in prescribing indicators in general practices in England with and without pharmacists following implementation between September 2015 and December 2019 Results: Between September 2015 and December 2019, the proportion of practices employing a clinical pharmacist increased from 236/ 7,623 (3.10%) to 1,402/ 6,836 (20.51%). Clinical pharmacist implementation resulted in statistically significant reductions in total costs of medicines per 1,000 patients (-0.85% ,95% CI -1.50%, -0.21%), the total number of opioid prescriptions per 1,000 patients (- 1.06%, 95% CI -1.82%, -0.29%), and the average daily quantity (ADQs) of anxiolytics per 1,000 patients (-1.26%, 95% CI -2.40%, -0.12%). Clinical pharmacist implementation also resulted in reductions in the total number of prescriptions per 1,000 patients (-0.58%, 95% CI -1.30%, 0.13%), and the total number of antibiotic prescriptions per 1,000 patients (-0.51%, 95% CI -1.30%, 0.27%) that trended towards statistical significance. There were no statistically significant differences in the share of broad-spectrum versus narrow-spectrum antibiotics (0.02%, 95% CI -0.07%, 0.11%) and the oral morphine equivalence of high-dose opioids (>120mg per 24 hours) per 1,000 patients (1.19%, 95% CI -0.46%, 2.85%). Our analysis is limited by aggregate data at the practice-level but supports the hypothesis that clinical pharmacist implementation results in improvements in prescribing quality.

Buprenorphine: Opioid Agonist-Antagonist for Refractory Pain of Sickle Cell Disease Patients During Hematopoietic Stem Cell Transplant, Uncontrolled By Full-Agonist Opioids.

Bone marrow transplant (BMT) offers potential cure for cancer and a spectrum of otherwise incur- able diseases. The BMT process can cause multi-systemic pain in patients with sickle cell disease (SCD) refractory to high-dose opioid analgesics during BMT because of their pre-existing opioid-tolerance. Because of frequent pain resulting in hyperalgesia and chronic opioid use, SCD patients undergoing BMT often experience excruciating pain uncontrolled by exceedingly high-dose opioids with severe and intolerable adverse effects. There is a small but growing body of literature about the successful buprenorphine effect for SCD's chronic pain management that had failed sufficient pain relief by the traditional full-agonist opioids in the outpatient setting. However, the buprenorphine use for acute inpatient pain management has not been previously researched. Pilot prospective clinical trial with buprenorphine-based pain management for acute BMT-related pain was initiated for SCD patients' pain uncontrolled by full-agonist opioids. Procedures/data/observations: Buprenorphine was started as scheduled and as-needed analgesics, supplemented by full-agonist opioids upon consultation for uncontrolled BMT-related pain of SCD patients. Patients' 24-hour opioid requirement by morphine equivalent daily doses (MEDD) were assessed at 3 time points: 1)immediately before pain escalation; 2)consultation; 3)discharge. MEDDs were compared to those of patients treated with full-agonist opioids only. Cases treated by full-agonist opioids (morphine/hydromorphone/fentanyl/methadone/oxycodone) had MEDD escalation by 1230-16300% by discharge compared to immediately before BMT-related pain escalation. Buprenorphine-supported cases had significantly smaller MEDD increase by 220-317%. Our case series suggests superior pain control by adding Buprenorphine prior to opioid dose escalation during BMT for SCD. Buprenorphine may provide the advantageous effect for other patients with complex pain background and experiencing difficult pain management during BMT due to pre-existing hyperalgesia and high opioid-tolerance. The evidence for buprenorphine's analgesic effect is moderate but growing, and more randomized controlled trials comparing the buprenorphine and other standard opioids are needed.

Relationships between the qNOX, qCON, burst suppression ratio, and muscle activity index of the CONOX monitor during total intravenous anesthesia: a pilot study

Background: Processed electroencephalographic (EEG) indices can help to navigate general anesthesia. The CONOX (Fresenius Kabi) calculates two indices, the qCON (hypnotic level) and the qNOX (nociception). The CONOX also calculates indices for electromyographic (EMG) activity and EEG burst suppression (BSR). Because all EEG parameters seem to influence each other, our goal was a detailed description of parameter relationships. Methods: We used qCON, qNOX, EMG, and BSR information from 14 patients receiving propofol anesthesia. We described index relationships with linear models, heat maps, and box plot representations. We also evaluated associations between qCON/qNOX and propofol/remifentanil effect site concentrations (ceP/ceR). Results: qNOX and qCON (qCON = 0.79*qNOX + 5.8; p < 0.001; R2 = 0.84) had a strong linear association. We further confirmed the strong relationship between qCON/qNOX and BSR for qCON/qNOX < 25: qCON=-0.19*BSR + 25.6 (p < 0.001; R2 = 0.72); qNOX=-0.20*BSR + 26.2 (p < 0.001; R2 = 0.72). The relationship between qCON and EMG was strong at higher indices: qCON = 0.55*EMG + 33.0 (p < 0.001; R2 = 0.68). There was no qCON > 80 without EMG > 0. The relationship between ceP and qCON was qCON=-3.8*ceP + 70.6 (p < 0.001; R2 = 0.11). The heat maps also suggest that the qCON and qNOX can at least partially separate the hypnotic and analgetic components of anesthesia. Conclusion: We could describe relationships between qCON, qNOX, EMG, BSR, ceP, and ceR, which may help the anaesthesiologist better interpret the information provided. One major finding is the dependence of qCON > 80 on EMG activity. This may limit the possibility of detecting wakefulness in the absence of EMG. Further, qNOX seems generally higher than qCON, but high opioid doses may lead to higher qCON than qNOX indices.

Efficacy of perioperative pain management in paediatric cardiac surgery: a protocol for a network meta-analysis

IntroductionCongenital heart disease is a common birth defect, but advancements in diagnosis and treatment have improved survival rates. Enhanced recovery after surgery (ERAS) programmes have emerged in paediatric cardiac surgery....

Predictive Model for Opioid Use Disorder in Chronic Pain: A Development and Validation Study.

There are several questionnaires for the challenge of anticipating opioid use disorder (OUD). However, many are not specific for chronic non-cancer pain (CNCP) or have been developed in the American population, whose sociodemographic factors are very different from the Spanish population, leading to scarce translation into clinical practice. Thus, the aim of this study is to prospectively validate a predictive model for OUD in Spanish patients under long-term opioids. An innovative two-stage predictive model was developed from retrospective (n = 129) and non-overlapping prospective (n = 100) cohorts of real-world CNCP outpatients. All subjects used prescribed opioids for 6 or more months. Sociodemographic, clinical and pharmacological covariates were registered. Mu-opioid receptor 1 (OPRM1, A118G, rs1799971) and catechol-O-methyltransferase (COMT, G472A, rs4680) genetic variants plus cytochrome P450 2D6 (CYP2D6) liver enzyme phenotypes were also analyzed. The model performance and diagnostic accuracy were calculated. The two-stage model comprised risk factors related to OUD (younger age, work disability and high daily opioid dose) and provided new useful information about other risk factors (low quality of life, OPRM-G allele and CYP2D6 extreme phenotypes). The validation showed a satisfactory accuracy (70% specificity and 75% sensitivity) for our predictive model with acceptable discrimination and goodness of fit. Our study presents the results of an innovative model for predicting OUD in our setting. After external validation, it could represent a change in the paradigm of opioid treatment, helping clinicians to better identify and manage the risks and reduce the side effects and complications.

Understanding the role of intraoperative hypothermia in perioperative opioid requirements in immediate implant-based breast reconstruction

BackgroundThe relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction. MethodsA retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019-2023. Patients were classified into the hypothermic group (majority of procedure < 36.0 °C) or normothermic group (majority of procedure ≥ 36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring “high-dose opioids” (≥ 100 MMEs) were collected and compared between groups. ResultsIn total, 536 patients (835 breasts) were included, of which 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs 99.1 MMEs, P = 0.007) and postoperative (44.2 vs 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = -27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007). ConclusionHypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain.

Opioid Dose Variation in Cardiac Surgery: A Multicenter Study of Practice.

Although high-opioid anesthesia was long the standard for cardiac surgery, some anesthesiologists now favor multimodal analgesia and low-opioid anesthetic techniques. The typical cardiac surgery opioid dose is unclear, and the degree to which patients, anesthesiologists, and institutions influence this opioid dose is unknown. We reviewed data from nonemergency adult cardiac surgeries requiring cardiopulmonary bypass performed at 30 academic and community hospitals within the Multicenter Perioperative Outcomes Group registry from 2014 through 2021. Intraoperative opioid administration was measured in fentanyl equivalents. We used hierarchical linear modeling to attribute opioid dose variation to the institution where each surgery took place, the primary attending anesthesiologist, and the specifics of the surgical patient and case. Across 30 hospitals, 794 anesthesiologists, and 59,463 cardiac cases, patients received a mean of 1139 (95% confidence interval [CI], 1132-1146) fentanyl mcg equivalents of opioid, and doses varied widely (standard deviation [SD], 872 µg). The most frequently used opioids were fentanyl (86% of cases), sufentanil (16% of cases), hydromorphone (12% of cases), and morphine (3% of cases). 0.6% of cases were opioid-free. 60% of dose variation was explainable by institution and anesthesiologist. The median difference in opioid dose between 2 randomly selected anesthesiologists across all institutions was 600 µg of fentanyl (interquartile range [IQR], 283-1023 µg). An anesthesiologist's intraoperative opioid dose was strongly correlated with their frequency of using a sufentanil infusion (r = 0.81), but largely uncorrelated with their use of nonopioid analgesic techniques (|r| < 0.3). High-dose opioids predominate in cardiac surgery, with substantial dose variation from case to case. Much of this variation is attributable to practice variability rather than patient or surgical differences. This suggests an opportunity to optimize opioid use in cardiac surgery.

Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial.

High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors. Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions. Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA. Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls. EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management. Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation. Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants. Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain. ClinicalTrials.gov ID NCT03889418.

Pain Predictors in Patients in the Postanesthesia Care Unit

To analyze the effects of pain-predicting factors on patients in the postanesthesia care unit (PACU). This is an observational and prospective study. This study was conducted at a University Hospital in the state of Minas Gerais (Brazil). To collect data on demographic, clinical, and surgical factors, a collection instrument was devised. The verbal numerical scale was employed to measure pain levels before and after surgery in the PACU. A path analysis was used to assess a predictive model. A total of 226 patients were included in this study. The incidence of pain in the PACU was 31.9%. A model with demographic, clinical, and surgical variables was tested. The final model, after including modification indices, obtained results that indicated an acceptable data fit (comparative fit index=0.996; root mean square error of approximation=0.08). Age (being young), sex (being a woman), oncological diagnosis as an indication for the surgical procedure, type of surgery (surgery of the digestive system), duration of surgery (longer surgeries), and high intraoperative doses of opioids were predictive variables for pain in the PACU. This study's findings provide support for pain management in the PACU. Furthermore, the results of this research can be used to anticipate the occurrence of acute postoperative pain and personalized perioperative analgesia needs.

High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies.

How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown. To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing. A county-level multiple-policy difference-in-difference event study framework. A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019. The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions. Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found. State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series

BackgroundSurgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population.Case presentationA total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 μg/kg was administered within 10 minutes, and a maintenance dose of 1.5 μg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients.ConclusionDexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

Fall Risk Screening in Older Adult Patients on Chronic Opioid Therapy: A Quality Improvement Project.

Many older adults prescribed opioid pain medications may be at increased risk of falls. As a quality improvement (QI) initiative, the University of Utah Sugar House clinic initiated a 9-month fall risk screening pilot for older adult patients on chronic opioids. This QI project sought to determine the feasibility of adding screening to a busy clinical practice, examine risk of falls in this patient cohort, and examine whether there were significant clinical and demographic differences between the patients who did or did not receive screening. We observed whether conventionally understood fall risk factors, including higher opioid doses, concurrent benzodiazepine prescription, and age, correlate with high fall risk. After the screening initiative, we determined that it was possible to significantly increase fall risk screening rates with prompts in Electronic Health Record (EHR). This cohort's fall risk screening increased from 18% to 33%. In the patients who were screened, 43% were found to be at high risk of falls. We did not see a correlation with high fall risk and patients taking higher doses of opioids or concurrent benzodiazepine prescriptions. These findings emphasize the need for consistent screening in primary care because review of the medication list alone is not a reliable predictor of fall risk.

Subpectineal obturator nerve block reduces opioid consumption after hip arthroscopy: a triple-blind, randomized, placebo-controlled trial

BackgroundHip arthroscopy causes severe pain during the first few hours in the postoperative care unit. This is probably due to the intraoperative stretching of the hip joint capsule. Pain relief...

Data-Driven Identification of Potentially Successful Intervention Implementations Using 5 Years of Opioid Prescribing Data: Retrospective Database Study.

We have previously demonstrated that opioid prescribing increased by 127% between 1998 and 2016. New policies aimed at tackling this increasing trend have been recommended by public health bodies, and there is some evidence that progress is being made. We sought to extend our previous work and develop a data-driven approach to identify general practices and clinical commissioning groups (CCGs) whose prescribing data suggest that interventions to reduce the prescribing of opioids may have been successfully implemented. We analyzed 5 years of prescribing data (December 2014 to November 2019) for 3 opioid prescribing measures-total opioid prescribing as oral morphine equivalent per 1000 registered population, the number of high-dose opioids prescribed per 1000 registered population, and the number of high-dose opioids as a percentage of total opioids prescribed. Using a data-driven approach, we applied a modified version of our change detection Python library to identify reductions in these measures over time, which may be consistent with the successful implementation of an intervention to reduce opioid prescribing. This analysis was carried out for general practices and CCGs, and organizations were ranked according to the change in prescribing rate. We identified a reduction in total opioid prescribing in 94 (49.2%) out of 191 CCGs, with a median reduction of 15.1 (IQR 11.8-18.7; range 9.0-32.8) in total oral morphine equivalence per 1000 patients. We present data for the 3 CCGs and practices demonstrating the biggest reduction in opioid prescribing for each of the 3 opioid prescribing measures. We observed a 40% proportional drop (8.9% absolute reduction) in the regular prescribing of high-dose opioids (measured as a percentage of regular opioids) in the highest-ranked CCG (North Tyneside); a 99% drop in this same measure was found in several practices (44%-95% absolute reduction). Decile plots demonstrate that CCGs exhibiting large reductions in opioid prescribing do so via slow and gradual reductions over a long period of time (typically over a period of 2 years); in contrast, practices exhibiting large reductions do so rapidly over a much shorter period of time. By applying 1 of our existing analysis tools to a national data set, we were able to identify rapid and maintained changes in opioid prescribing within practices and CCGs and rank organizations by the magnitude of reduction. Highly ranked organizations are candidates for further qualitative research into intervention design and implementation.