In-hospital Opioid Consumption Research Articles

Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use.

Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline. We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed. A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively. Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.

A Prospective Cohort Study of Acute Pain and In-Hospital Opioid Consumption After Cardiac Surgery: Associations With Psychological and Medical Factors and Chronic Postsurgical Pain.

Understanding the association of acute pain intensity and opioid consumption after cardiac surgery with chronic postsurgical pain (CPSP) can facilitate implementation of personalized prevention measures to improve outcomes. The objectives were to (1) examine acute pain intensity and daily mg morphine equivalent dose (MME/day) trajectories after cardiac surgery, (2) identify factors associated with pain intensity and opioid consumption trajectories, and (3) assess whether pain intensity and opioid consumption trajectories are risk factors for CPSP. Prospective observational cohort study design conducted between August 2012 and June 2020 with 1-year follow-up. A total of 1115 adults undergoing cardiac surgery were recruited from the preoperative clinic. Of the 959 participants included in the analyses, 573 completed the 1-year follow-up. Main outcomes were pain intensity scores and MME/day consumption over the first 6 postoperative days (PODs) analyzed using latent growth mixture modeling (GMM). Secondary outcome was 12-month CPSP status. Participants were mostly male (76%), with a mean age of 61 ± 13 years. Three distinct linear acute postoperative pain intensity trajectories were identified: "initially moderate pain intensity remaining moderate" (n = 62), "initially mild pain intensity remaining mild" (n = 221), and "initially moderate pain intensity decreasing to mild" (n = 251). Age, sex, emotional distress in response to bodily sensations, and sensitivity to pain traumatization were significantly associated with pain intensity trajectories. Three distinct opioid consumption trajectories were identified on the log MME/day: "initially high level of MME/day gradually decreasing" (n = 89), "initially low level of MME/day remaining low" (n = 108), and "initially moderate level of MME/day decreasing to low" (n = 329). Age and emotional distress in response to bodily sensations were associated with trajectory membership. Individuals in the "initially mild pain intensity remaining mild" trajectory were less likely than those in the "initially moderate pain intensity remaining moderate" trajectory to report CPSP (odds ratio [95% confidence interval, CI], 0.23 [0.06-0.88]). No significant associations were observed between opioid consumption trajectory membership and CPSP status (odds ratio [95% CI], 0.84 [0.28-2.54] and 0.95 [0.22-4.13]). Those with moderate pain intensity right after surgery are more likely to develop CPSP suggesting that those patients should be flagged early on in their postoperative recovery to attempt to alter their trajectory and prevent CPSP. Emotional distress in response to bodily sensations is the only consistent modifiable factor associated with both pain and opioid trajectories.

Characteristics and clinical challenges in patients with substance use disorder in palliative care—experience from a tertiary center in a high-income country

BackgroundAccess to palliative care is often limited for challenging and vulnerable groups, including persons with substance use disorders. However, with optimized healthcare options and liberal substitution policies, this patient group is likely to increase over the upcoming years, and comorbidities will also influence the need for palliative support. Here, we aim at analyzing characteristics and specific challenges associated with substance use disorders (SUD) in palliative care.MethodsWe retrospectively reviewed all patients diagnosed with substance use disorder that were treated at our Competence Center Palliative Care within the University Hospital Zurich, Switzerland between 2015 and 2021. Patient characteristics, including age, gender, duration of hospitalization, as well as specific metrics like body mass index, distinct palliative care assessment scores, and in-hospital opioid consumption were retrieved from the electronic patient files. Demographics and clinical data were analyzed by descriptive statistics, and compared to those of a control group of palliative care patients without SUD. An opioid calculator was used to standardize opioid intake based on morphine equivalents for meaningful comparisons.ResultsThe primary characteristics revealed that the majority of individuals were single (56%), had no children (83%), lived alone (39%), and were either unemployed or recipients of a disability pension (in total 50%). Nicotine (89%), opioids (67%), and alcohol (67%) were the most used substances. We identified various comorbidities including psychiatric illnesses alongside SUD (56%), hepatitis A, B, or C (33%), and HIV infection (17%). Patients with SUD were significantly younger (p < 0.5), predominantly male (p < 0.05), and reported a higher prevalence of pain (p < 0.5) compared to the standard cohort of palliative patients. Regarding the challenges most frequently reported by healthcare practitioners, non-compliance, multimorbidity, challenging communication, biographical trauma, lack of social support, and unstable housing situations played a key role.ConclusionPatients with SUD represent a complex and vulnerable group dealing with multiple comorbidities that profoundly affect both their physical and psychological well-being. Understanding their unique characteristics is pivotal in providing precise and suitable palliative care.

Continuous wound infusion catheter as part of a multimodal analgesia regimen for post-Caesarean delivery pain: a quality improvement impact study

BackgroundThe role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery. MethodsAfter institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0–100%), and continuous wound infusion catheter-related complications. ResultsAll women scheduled for Caesarean delivery (n=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5–61.9] mg morphine equivalents vs control group 30.0 [11.3–48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1–3] vs 1.5 [0–3] in the continous wound infusion catheters group; P=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91–100%] vs 90% [86–100%]; P=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm. ConclusionsThe addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections.

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections. We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected. A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2- to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup {MME: 20.5 [interquartile range (IQR), 4.8-40.5] vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012} as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032]. The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use.

Opioid Sparing Anesthesia Decreases In-hospital and One Year Post-Operative Opioid Consumption compared to Traditional Anesthesia: A Propensity-matched Cohort Study.

Propensity-matched cohort. To determine if opioid-sparing anesthesia (OSA) reduces in-hospital and one-year post-operative opioid consumption. The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OS) protocol for lumbar spinal fusion surgery to mitigate opioid exposure. Patients undergoing lumbar fusion for degenerative conditions over 1 to 4 levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, BMI, ASA grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption and opioid prescriptions one year after surgery were compared. Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to Non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69y; Non-OSA: 67 males, mean age=58.94y). OSA patients had lower Blood Loss (326mL vs. 399mL, P =0.014), surgical time (201min vs. 233min, P <0.001) emergence to extubation time (9.1min vs. 14.2min, P =<0.001) and recovery room time (119min vs. 140min, P =0.0.012) compared to Non-OSA patients. Fewer OSA patients required non-home discharge (18 vs. 41, P =0.001) compared to the Non-OSA cohort, but no difference in LOS (90.3hrs vs. 98.5hrs, P =0.204). Daily opioid consumption was lower in the OSA versus the Non-OSA cohort from Post-operative Day 2 (223MME vs. 185MME, P =0.017) and maintained each day with lower total consumption (293MME vs. 225MME, P =0.003) throughout Post-operative Day 4. The number of patients with active opioid prescriptions at 1, 3, 6 and 12 months post-operative was statistically fewer in the OSA compared to the Non-OSA patients. OSA for lumbar spinal fusion surgery decreases in-hospital and one-year post-operative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays and fewer discharges to non-home facilities.

A comparison of postpartum opioid consumption and opioid discharge prescriptions among opioid-naïve patients and those with opioid use disorder

Management of patients with opioid use disorder during the acute postpartum period remains clinically challenging as obstetricians aim to mitigate postdelivery pain while optimizing recovery support. This study aimed to evaluate postpartum opioid consumption and opioids prescribed at discharge among patients with opioid use disorder treated with methadone, buprenorphine, and no medication for opioid use disorder, as compared with opioid-naïve counterparts. We conducted a retrospective cohort study of pregnant patients who underwent delivery at >20 weeks' gestation at a tertiary academic hospital between May 2014 and April 2020. The primary outcome of this analysis was the mean daily quantity of oral opioids consumed after delivery while inpatient, in milligrams of morphine equivalents. Secondary outcomes included the following: (1) quantity of oral opioids prescribed at discharge, and (2) prescription for oral opioids in the 6 weeks after hospital discharge. Multiple linear regression was used to compare differences in the primary outcome. A total of 16,140 pregnancies were included. Patients with opioid use disorder (n=553) consumed 14 milligrams of morphine equivalents per day greater quantities of opioids postpartum than opioid-naïve women (n=15,587), (95% confidence interval, 11-17). Patients with opioid use disorder undergoing cesarean delivery consumed 30 milligrams of morphine equivalents per day greater quantities of opioids than opioid-naïve counterparts (95% confidence interval, 26-35). Among patients who underwent vaginal delivery, there was no difference in opioid consumption among patients with and without opioid use disorder. Compared with patients prescribed methadone, patients prescribed buprenorphine, and those prescribed no medication for opioid use disorder consumed similar opioid quantities postpartum following both vaginal and cesarean delivery. Among patients undergoing cesarean delivery, opioid-naïve patients were more likely to receive a discharge prescription for opioids than patients with opioid use disorder (77% vs 68%; P=.002), despite lower pain scores and less inhospital opioid consumption. Patients with opioid use disorder, regardless of treatment with methadone, buprenorphine, or no medication for opioid use disorder consumed significantly greater quantities of opioids after cesarean delivery but received fewer opioid prescriptions at discharge.

In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study

(Anesth Analg. 2022;134:1280–1287) Opioid administration is a common form of analgesia for breakthrough pain following cesarean deliveries when nonopioid medication is not sufficient. Pain severity can differ from patient to patient, so an individualized approach to care can be challenging. Predicting in-hospital opioid consumption following a repeat cesarean delivery requires study. The primary aim was to identify if prior opioid consumption 48 hours postoperatively following cesarean delivery correlates with patient opioid consumption following index cesarean delivery. The hypothesis was that an associated prediction would exist. Secondary aims included whether pain scores correlated and if obstetric and demographic variables improved prediction accuracy.

In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study

(Anesth Analg. 2022;134:1280–1287. doi: 10.1213/ANE.0000000000005918) Opioid administration is a common form of analgesia for breakthrough pain following cesarean deliveries (CDs) when nonopioid medication is not sufficient. Pain severity can differ from patient to patient, so an individualized approach to care can be taken. Predicting in-hospital opioid consumption following a repeat CD has not been previously studied. The primary aim is to identify if prior opioid consumption 48 hours postoperatively following CD correlates with patient opioid consumption following index CD. The primary aim of the investigations was that an associated prediction would exist. Secondary aims included whether pain scores correlated and if obstetric and demographic variable improved prediction accuracy.

175. Opioid sparing anesthesia for adult spinal deformity surgery reduces postoperative pain, length of stay, ICU stay, opioid consumption and opioid-related complications: a propensity matched analysis

<h3>BACKGROUND CONTEXT</h3> The US opioid crisis highlights the dire need to reduce opioid exposure with alternative approaches. Prior studies report that 25% of opioid naive patients are still on opioids two years after spinal fusion surgery. Currently, opioids are a primary component of anesthesia during spinal surgery. We developed an opioid sparing anesthesia (OSA) protocol for adult spinal deformity (ASD) surgery to mitigate opioid exposure. <h3>PURPOSE</h3> The purpose of this study is to compare recovery kinematics and in-hospital opioid consumption of patients undergoing corrective surgery for ASD using OSA compared to traditional anesthesia techniques (Non-OSA). <h3>STUDY DESIGN/SETTING</h3> Retrospective, single-center propensity-matched observational cohort. <h3>PATIENT SAMPLE</h3> Opioid naive patients undergoing > 5 level lumbar fusion at a single multisurgeon tertiary level spine center. <h3>OUTCOME MEASURES</h3> Intraoperative and in-hospital opioid consumption, opioid related complications, emergence time, post-anesthesia care unit (PACU) time, pain score (0 to 10) on transfer in and transfer out of PACU, hospital length of stay (LOS), ICU admission. <h3>METHODS</h3> Opioid naive patients undergoing > 5 level lumbar fusion for were identified. Patients receiving OSA were propensity-matched to non-OSA patients based on sex, smoking status, BMI, ASA grade, surgical invasiveness, number of levels fused, and revision vs primary procedure. OSA has several components from preoperative, intraoperative and emergence. Preoperatively patients received an oral regimen of cyclobenzaprine (10 mg), gabapentin (300-600mg), acetaminophen (650mg-1gm), optional midazolam and antiemetic. Intraoperative induction with bolus doses of lidocaine, diprivan, rocuronium, succinylcholine, ketamine, magnesium, dexmedetomidine and esmolol as needed. Regional block for anterior spine fusion (transversus abdominis) when performed. Maintenance intraoperatively included inhalational and or infusion or boluses of diprivan, dexmedetomidine and esmolol. Emergence entailed reversal of muscle relaxant and antiemetics. The control arm (Non-OSA) included preoperative optional midazolam and antiemetic only. Intraoperatively induction was with bolus doses of lidocaine and fentanyl. Maintenance intraoperatively included inhalational, infusion or bolus doses of diprivan, fentanyl or hydromorphone. Emergence included reversal of muscle relaxant, antiemetics, fentanyl and/or hydromorphone. All patients (OSA and Non-OSA) had a postoperative opioid escalation protocol while in the hospital. <h3>RESULTS</h3> Of 45 OSA patients meeting inclusion criteria, 43 were successfully propensity-matched to 43 non-OSA patients. There were no differences in baseline demographic or surgical parameters. Opioid consumption was reduced intraoperatively (3.6 vs 53.2MME, p=0.000), on POD 1 (67.4 vs 111.6MME, p=0.030), and each POD with decreased total consumption (241.3 vs 453.9MME, p=0.022) in OSA patients compared to NonOSA patients. OSA patients had reduced opioid-related complications (1 vs 9, p=0.015) and less patients required blood transfusion (1 vs 28, p=0.000) despite similar EBL (570 vs 692cc, p=0.294). Emergence time (17.4 vs 14.3min, p=0.374) and PACU time (113.8 vs 142.6min, p=0.077) was similar between cohorts. There was a shorter LOS for OSA patients (4.3 vs 6.2 days, p=0.009) and less ICU admissions (4 vs 14, p=0.015). Pain score on transfer in (4.6 vs 7.6, p=0.000) and out (4.2 vs 6.2, p=0.002) of PACU was lower for OSA patients as well. <h3>CONCLUSIONS</h3> Our results show that OSA in ASD surgery improves immediate postoperative recovery kinetics by reducing the need for ICU, blood transfusion, pain scores, and LOS. Opioid-related complications and total opioid consumption were reduced as well. OSA appears to be an attractive alternative to opioid-dependent anesthesia protocols in ASD surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Who doesn’t fit? A multi-institutional study using machine learning to uncover the limits of opioid prescribing guidelines

BackgroundMany U.S. institutions have adopted postsurgical opioid-prescribing guidelines to standardize prescribing practices, and yet there is inherent variability in patients’ opioid consumption after surgery. The utility of these guidelines is limited by the fact that some patients’ needs will inevitably exceed them, and yet there are no evidence-based tools to help providers identify these patients. In this study we aimed to maximize the value of these guidelines by training machine learning models to predict patients whose needs will be met by these smaller recommended prescriptions, and patients who may require an additional degree of personalization. The aim of the present study was to develop predictive models for determining whether a surgical patient's postdischarge opioid requirement will fall above or below common opioid prescribing guidelines. MethodsWe conducted a retrospective cohort study of surgical patients at one institution from 2017 to 2018. Patients were called after discharge to collect opioid consumption data. Machine learning models were used to identify outlier opioid consumers (ie, exceeding our institutional prescribing guidelines) using diagnosis codes, medical history, in-hospital opioid use, and perioperative factors as predictors. External validation was performed on opioid consumption data collected at a second institution from 2020 to 2021, and sensitivity analysis was performed using a third institution’s prescribing guidelines. ResultsThe development and external validation cohorts included 1,867 and 498 patients, respectively. Age, body mass index, tobacco use, preoperative opioid exposure, and in-hospital opioid consumption were the strongest predictors of postdischarge consumption. A lasso regression model exhibited an area under the receiver operating characteristic curve of 0.74 (95% confidence interval 0.67–0.81) in predicting postdischarge opioid consumption. External validation of a limited lasso model yielded an area under the receiver operating characteristic curve of 0.67 (0.60–0.74). Performance was preserved when evaluated on another institution’s guidelines (area under the receiver operating characteristic curve 0.76 [0.72–0.80]). ConclusionPatient characteristics reliably predict postdischarge opioid consumption in relation to prescribing guidelines for both opioid-naive and exposed populations. This model may be used to help providers confidently follow prescribing guidelines for patients with typical opioid responsiveness and correctly pursue more personalized prescribing for others.

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.

Does In-Hospital Opioid Use Affect Opioid Consumption After Total Joint Arthroplasty?

Preoperative opioid use strongly correlates with greater postoperative opioid use and complications following total joint arthroplasty (TJA). However, there is a lack of information regarding the effect of opioid consumption during the hospital stay and within the operating room on postoperative opioid use. We retrospectively reviewed 369 consecutive patients undergoing primary TJA at an academic center over a 9-month period. Ninety-day preoperative and postoperative opioid prescriptions were obtained from the state's drug monitoring database. In-hospital opioid consumption data was obtained from the preoperative unit, operating room, postanesthesia care unit (PACU), and hospital floor. Multivariate analysis was utilized to compare patients' total in-hospital opioid consumption with their preoperative and postoperative use, along with opioid use throughout the hospitalization. Total in-hospital opioid consumption was independently associated with postoperative opioid use (rs= 0.17, P= .0010). Opioids consumed on the hospital floor correlated with opioid use in the preoperative unit (rs= 0.11, P= .0338) and PACU (rs= 0.15, P= .0032). Increased preoperative opioid consumption was the greatest risk factor for excessive postoperative use (rs= 0.44, P < .0001). A greater proportion of patients <65 years of age were high posthospital opioid consumers (P= .0146) and significantly more TKA patients were in the higher use groups (P= .0006). In-hospital opioid use is independently associated with preoperative and postoperative consumption. Preoperative opioid use remains the greatest risk factor for increased opioid consumption after TJA. Multimodal approaches to decrease reliance on opioids for pain control during hospitalization may offer hope to further decrease postoperative usage. III.

Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patientreported outcomes after manipulation under anesthesia.

Background and purposeManipulation under anesthesia (MUA) is the first-choice treatment for stiffness following total knee arthroplasty (TKA) unresponsive to pain management and physiotherapy. Some of the predisposing factors and patient-reported outcome measures (PROMs) following MUA remain poorly studied. We retrospectively investigated the etiological risk factors and the outcomes of MUA.Patients and methods391 TKA patients from a randomized trial comparing the use of a tourniquet and anesthesia (spinal or general) were analyzed, and patients needing MUA were identified (MUA group). We evaluated in-hospital opioid consumption, Oxford Knee Score (OKS), range of motion (ROM), and pain assessed by the Brief Pain Inventory-short form with a 1-year follow-up.Results39 (10%) MUA patients were identified. The MUA patients were younger (60 years vs. 64 years, difference –4, 95% CI –6 to –1) and had higher postoperative oxycodone consumption (66 mg vs. 51 mg, median difference 11, CI 1–22) than the no-MUA patients. The proportion of MUA patients who contacted the emergency department within 3 months because of pain was larger than that of non-MUA patients (41% vs. 12%, OR 5, CI 3–10). At the 1-year follow-up, the ROM was improved by 39° following MUA, but the total ROM was worse in the MUA group (115° vs. 124°, p < 0.001). No difference was found in the OKS between the MUA and no-MUA patients.InterpretationHigher postoperative pain seems to predict MUA risk. MUA performed 3 months postoperatively offers substantial ROM improvement and comparable PROMs to no-MUA patients 1 year after TKA.

In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study.

To predict opioid consumption and pain intensity after the index cesarean delivery, we tested a hypothesis that opioid consumption after the previous cesarean delivery of the same patient can predict the opioid consumption after the index cesarean delivery. We further tested a secondary hypothesis that the pain scores after the previous cesarean delivery can predict the pain scores after the index cesarean delivery. This is a retrospective cohort study of 470 women who underwent both previous and index cesarean deliveries at a single institution from January 2011 to June 2019. To predict the opioid consumption (primary outcome) and average pain scores (on 11-point numeric rating scale) after their index cesarean delivery, we used a linear regression model incorporating only the opioid consumption and average pain scores after the previous cesarean delivery, respectively (unadjusted models). Demographic and obstetric variables were then added as predictors (adjusted models). The bootstrap was used to compare these models with respect to proportion of variance of the outcome accounted for (R2). Unadjusted models were weakly predictive of opioid consumption (R2 = 0.268; 95% confidence interval [CI], 0.146-0.368) and average pain scores (R2 = 0.176; 95% CI, 0.057-0.250). An adjusted model for opioid consumption was weakly predictive (R2 = 0.363; 95% CI, 0.208-0.478), but an adjusted model for average pain scores was not predictive of the outcomes (R2 = 0.070; 95% CI, -0.143 to 0.219). Adjusted models failed to explain variances of opioid consumption and average pain scores significantly better than unadjusted models (P = .099 and P = .141, respectively). Opioid consumption and pain scores after women's previous cesarean delivery only explain 27% of variance of opioid consumption and 18% of variance of their pain after their index cesarean delivery. Therefore, previous cesarean delivery analgesic metrics are not robust enough to be used as clinically applicable predictors for index delivery.

Predictors of patient post-discharge opioid use after cesarean delivery: a prospective study

BackgroundThe opioid crisis is a public health emergency in the United States of America. It is important to understand factors associated with outpatient opioid use. Our primary aim was to assess post-cesarean outpatient opioid use. The secondary aim was to identify characteristics associated with use. MethodsWe conducted a prospective cohort analysis of women who underwent cesarean delivery at an urban academic center. Phone surveys were done on post-discharge days three, seven, and 14. The primary outcome was post-discharge opioid use. ResultsOf 205 eligible patients contacted, 190 (91%) agreed to participate and 173 (84%) participated in all three surveys. Median amount of opioid prescribed was 75 mg morphine equivalents (MME) (interquartile range 60–113) and participants used a median of 15 MME (0–53) by discharge day 14. Most patients (139/190) filled their opioid prescription but 42% (80/190) did not consume the opioids prescribed. Outpatient opioid use was associated with increased in-hospital opioid consumption (P=0.0003), gravidity (P=0.003), parity (P=0.004) and number of previous cesarean deliveries (P=0.02). Higher amounts of in-hospital opioid use (P=0.0004), higher gravidity (P=0.02), higher outpatient pain scores (>3/10, P=0.01), and poor pain control (P=0.04) were associated with consuming all prescribed opioids. Patients used opioids for a median of two days post-discharge. Use of non-opioid pain medication was not associated with opioid use. ConclusionOpioids were prescribed in excess of consumption and many patients did not use any opioids. Next steps include developing a prescribing algorithm to incorporate factors we found predictive of opioid use.

In-hospital postoperative opioid use and its trends in neurosurgery between 2007 and 2018

BackgroundPostoperative opioid use plays an important role in the global opioid crisis, but little is known about in-hospital opioid use trends of large surgical units. We investigated whether postoperative in-hospital opioid consumption changed in a large academic neurosurgical unit between 2007 and 2018.MethodsWe extracted the data of consumed opioids in the neurosurgical intensive care unit and two bed wards between 2007 and 2018. Besides overall consumption, we analyzed the trends for weak (tramadol and codeine), strong, and the most commonly used opioids. The use of various opioids was standardized using the defined daily doses (DDDs) of each opioid agent. A linear regression analysis was performed to estimate annual treatment day-adjusted changes with 95% confidence intervals.ResultsOverall, 121 361 opioid DDDs were consumed during the 196 199 treatment days. Oxycodone was the most commonly used postoperative opioid (49% of all used opioids) in neurosurgery. In the bed wards, the use of oral oxycodone increased 375% (on average 13% (9–17%) per year), and the use of transdermal buprenorphine 930% (on average 26% (9–45%) per year) over the 12-year period. Despite the increased use of strong opioids in the bed wards (on average 3% (1–4%) per year), overall opioid use decreased 39% (on average 6% (4–7%) per year) between 2007 and 2018.ConclusionsDue to the increase of strong opioid use in the surgical bed wards, we encourage other large teaching hospitals and surgical units to investigate whether their opioid use trends are similarly worrisome and whether the opioid consumption changes in the hospital setting are transferred to opioid use patterns or opioid-related harms after discharge.

Perioperative Factors Associated With Chronic Opioid Use After Spine Surgery.

Retrospective case control. The purpose of the current study is to determine risk factors associated with chronic opioid use after spine surgery. In our single institution retrospective study, 1,299 patients undergoing elective spine surgery at a tertiary academic medical center between January 2010 and August 2017 were enrolled into a prospectively collected registry. Patients were dichotomized based on renewal of, or active opioid prescription at 3-mo and 12-mo postoperatively. The primary outcome measures were risk factors for opioid renewal 3-months and 12-months postoperatively. These primarily included demographic characteristics, operative variables, and in-hospital opioid consumption via morphine milligram equivalence (MME). At the 3-month and 12-month periods, we analyzed the aforementioned covariates with multivariate followed by bivariate regression analyses. Multivariate and bivariate analyses revealed that script renewal at 3 months was associated with black race (P = 0.001), preoperative narcotic (P < 0.001) or anxiety/depression medication use (P = 0.002), and intraoperative long lumbar (P < 0.001) or thoracic spine surgery (P < 0.001). Lower patient income was also a risk factor for script renewal (P = 0.01). Script renewal at 12 months was associated with younger age (P = 0.006), preoperative narcotics use (P = 0.001), and ≥4 levels of lumbar fusion (P < 0.001). Renewals at 3-mo and 12-mo had no association with MME given during the hospital stay or with the usage of PCA (P > 0.05). The current study describes multiple patient-level factors associated with chronic opioid use. Notably, no metric of perioperative opioid utilization was directly associated with chronic opioid use after multivariate analysis.

21. Adoption of enhanced recovery after surgery (ERAS) protocol for lumbar fusion decreases in hospital postoperative opioid consumption

<h3>BACKGROUND CONTEXT</h3> Enhanced recovery after surgery (ERAS) is an evidence-based multidisciplinary perioperative protocol intended to reduce surgical morbidity and improve recovery. <h3>PURPOSE</h3> We sought to evaluate the impact of ERAS on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. <h3>STUDY DESIGN/SETTING</h3> Single center retrospective observational cohort study. <h3>PATIENT SAMPLE</h3> A total of 290 patients undergoing lumbar fusion surgery during the transition period prior to (N=174) and after (N=116) adoption of ERAS. <h3>OUTCOME MEASURES</h3> In-hospital and 90-day postop opioid consumption in morphine milligram equivalents (MME), pre- and postoperative pain scores, length of stay, urinary catheter removal and ambulation after surgery. <h3>METHODS</h3> We evaluated patients undergoing lumbar fusion surgery in the transition period prior to (N=174) and after (N=116) adoption of ERAS, comparing in-hospital and 90-day postop opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ERAS and length of stay, urinary catheter removal and ambulation after surgery. <h3>RESULTS</h3> Mean age of the cohort was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the pre-ERAS and ERAS groups. ERAS patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ERAS patients. There was no difference in 90-day opioid consumption between the two groups. Regression analysis showed that ERAS was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in MME. In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Preoperative pain sores, but not ERAS were associated with 90-day opioid consumption. Secondary analysis showed that ERAS was associated with a shorter length of stay and earlier ambulation. <h3>CONCLUSIONS</h3> This study showed ERAS has the potential to improved recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

149. Opioid sparing anesthesia for lumbar spinal fusion surgery reduces opioid consumption, blood loss and operative time: A propensity matched analysis

<h3>BACKGROUND CONTEXT</h3> The recent opioid crisis in the US highlights opioid related side-effects and the dire need to reduce opioid exposure with alternative approaches. Prior studies reported that as many as 25% of opioid naive patients undergoing lumbar fusion surgery are still consuming opioids at 2 years postoperative. Currently, opioids are a primary component of anesthesia during spinal surgery. We developed an opioid sparing anesthesia (OSA) protocol for lumbar spinal fusion surgery to mitigate opioid exposure. <h3>PURPOSE</h3> To compare surgical, peri- and postoperative process measures and in-hospital opioid consumption in patients receiving OSA vs traditional anesthesia. <h3>STUDY DESIGN/SETTING</h3> Retrospective, single center propensity-matched observational cohort study. <h3>PATIENT SAMPLE</h3> Patients who underwent 1-4 level lumbar fusion for degenerative conditions. <h3>OUTCOME MEASURES</h3> Daily and total opioid consumption in morphine milligram equivalents (MME). <h3>Methods</h3> Patients undergoing < 5-level lumbar fusion for degenerative conditions were identified. Patients taking opioids preoperatively were excluded. Patients receiving OSA were propensity-matched to non-OSA patients based on sex, smoking status, BMI, ASA grade and revision vs primary procedure. Preoperatively patients receive an oral regimen of cyclobenzaprine (10mg), gabapentin (300-600mg), acetaminophen (650-1g), Celebrex (200mg), and/or methadone (5-10mg). The intraoperative OSA protocol includes a combination of IV propofol, lidocaine, ketamine, magnesium, dexmedetomidine, and esmolol as needed. Anesthesia was maintained with inhalational agents or TIVA. Postoperatively patients received a bilateral transverse abdominis plane or erector spinae block with 0.25% Ropivacaine/4mg decadron mixture. A standard opioid escalation protocol was also utilized in the hospital postoperatively. We evaluated surgical parameters (EBL and OR Time), immediate perioperative parameters (emergence time, PACU time, pain score on transfer in/out of PACU), and length of stay (LOS). <h3>Results</h3> Of 143 OSA patients meeting inclusion criteria, 134 OSA patients were successfully propensity matched to 134 non-OSA patients. Consistent with propensity matching, there was no difference in baseline demographic parameters between cohorts. Patients undergoing OSA had reduced EBL (197mL vs 324mL, p=0.000) and OR time (153min vs 193min, p=0.000) compared to non-OSA. Emergence time (9.9min vs 11.6min, p=0.151) and PACU time (90min vs 88min, p=0.688) was similar between cohorts. There was no difference in LOS (3.3day vs 3.5 days, p=0.599). Daily opioid consumption was reduced from POD 1 (114MME vs 139MME, p=0.002) and maintained each day with decreased total consumption (195MME vs 272MME, p=0.002). Pain score on transfer out of PACU was decreased for OSA patients as well (4.8 vs 6.0, p=0.000). <h3>Conclusions</h3> In a matched comparison of OSA vs traditional anesthesia for 1-4 lumbar spinal fusions in degenerative conditions we found a reduction in EBL, OR Time, PACU pain scores, and daily/total opioid in hospital consumption. The findings of this pilot study justify ongoing efforts to optimize OSA and undertake larger prospective studies of OSA protocols. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.