Initial Opioid Prescription Research Articles

Influence of Anxiety and Depression on Opioid Use Following Lumbar Spine Fusion: A Large Database Study.

Retrospective database. The purpose of this study was to understand how a mental health disorder, specifically anxiety and depression, influences a patient's postoperative opioid needs following single-level lumbar spine fusion. Patients with spine pathology commonly demonstrate symptoms of an active psychiatric disorder. Mental health significantly influences how a patient perceives pain and a patient's opioid pain control needs after surgery. The Pearldiver Patient Claims Database was used to identify patients undergoing single-level posterior spine fusion within the United States between 2010 and 2020. Patients were placed into 1 of 4 groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. χ 2 tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days following their fusion. The control group filled significantly more initial opioid prescriptions within the first 90 days following their spine fusion ( P <0.001). However, there was no difference among the study groups in regard to the additional need for prescriptions. Patients with mental health diagnoses may present as complex patients to spine surgeons; however, this study suggests they do not require additional opioid pain control following a single-level lumbar fusion.

Diagnostic profiles associated with long-term opioid therapy in active duty servicemembers.

Over-prescription of opioids has diminished in recent years; however, certain populations remain at high risk. There is a dearth of research evaluating prescription rates using specific multimorbidity patterns. To identify distinct clinical profiles associated with opioid prescription and evaluate their relative odds of receiving long-term opioid therapy. Retrospective analysis of the complete military electronic health record. We assessed demographics and 26 physiological, psychological, and pain conditions present during initial opioid prescription. Latent class analysis (LCA) identified unique clinical profiles using diagnostic data. Logistic regression measured the odds of these classes receiving long-term opioid therapy. All electronic health data under the TRICARE network. All servicemembers on active duty during fiscal years 2016 through 2019 who filled at least one opioid prescription. Number and qualitative characteristics of LCA classes; odds ratios (ORs) from logistic regression. We hypothesized that LCA classes characterized by high-risk contraindications would have significantly higher odds of long-term opioid therapy. A total of N = 714,446 active duty servicemembers were prescribed an opioid during the study window, with 12,940 (1.8%) receiving long-term opioid therapy. LCA identified five classes: Relatively Healthy (82%); Musculoskeletal Acute Pain and Substance Use Disorders (6%); High Pain, Low Mental Health Burden (9%); Low Pain, High Mental Health Burden (2%), and Multisystem Multimorbid (1%). Logistic regression found that, compared to the Relatively Healthy reference, the Multisystem Multimorbid class, characterized by multiple opioid contraindications, had the highest odds of receiving long-term opioid therapy (OR = 9.24; p < .001; 95% confidence interval [CI]: 8.56, 9.98). Analyses demonstrated that classes with greater multimorbidity at the time of prescription, particularly co-occurring psychiatric and pain disorders, had higher likelihood of long-term opioid therapy. Overall, this study helps identify patients most at risk for long-term opioid therapy and has implications for health care policy and patient care.

Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021.

Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.

O128 Time trends in opioid prescribing after discharge following colectomy in england: a cross-sectional study

Abstract Introduction Opioid prescribing patterns after discharge following colectomy within a population from England are not well characterised. This study aimed to report changes in opioid prescribing prevalence, formulation choices and opioid analgesics over time. Methods This cross-sectional analysis included people undergoing colectomy between 2010 and 2019 using primary (Clinical Practice Research Datalink) and linked secondary care (Hospital Episode Statistics) data. The prevalence of initial opioid prescription within 90 days of surgical discharge was calculated, and prescription characteristics in terms of analgesics and formulation were described. Trend analysis was performed using the Cochran Armitage test, and percentage change between 2010 and 2019 was tested using univariate logistic regression. Results Of the 95,155 individuals undergoing colectomy within the study period, 15,503 (16.3%) received opioid prescriptions. There was a decreasing trend in the prevalence of post-discharge opioids for opioid naïve people (P&amp;lt;0.001), with a decrease from 11.4% in 2010 to 6.7% in 2019 (-41.3%, p&amp;lt;0.001). Whereas the prevalence remained stable for patients prescribed opioids prior to surgery (p=0.637). The prescribing of immediate release formulations decreased from 86% in 2010 to 82% in 2019 (-4.65%). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Moreover, morphine and oxycodone prescriptions rose significantly by 76.6% and 131%, respectively, while tramadol prescribing dropped by 48%. Conclusion This study identified a changing pattern of opioid prescribing following colectomy, with prescribing prevalence decreasing for opioid naïve people. Trends suggested decreased tramadol prescribing, but a shift toward increasing codeine, oxycodone and morphine prescriptions.

Association between Initial Opioid Prescription and Patient Pain with Continued Opioid Use among Opioid-Naïve Patients Undergoing Elective Surgery in a Large American Health System.

There is growing concern about the over-prescription of opioids and the risks of long-term use. This study examined the relationship between initial need (pre-operative, post-operative, and discharge pain) and dosage of opioids in the first prescription after surgery with continued opioid use through opioid refills over 12 months, while considering patient-level characteristics. A total of 9262 opioid-naïve patients underwent elective surgery, 7219 of whom were prescribed opioids following surgery. The results showed that 17% of patients received at least one opioid refill within one year post-surgery. Higher initial opioid doses, measured in morphine milligram equivalent (MME), were associated with a greater likelihood of continued use. Patients receiving a dose greater than 90 MME were 1.57 times more likely to receive a refill compared to those receiving less than 90 MME (95% confidence interval: 1.30-1.90, p < 0.001). Additionally, patients who experienced pain before or after surgery were more likely to receive opioid refills. Those experiencing moderate or severe pain were 1.66 times more likely to receive a refill (95% confidence interval: 1.45-1.91, p < 0.001). The findings highlight the need to consider surgery-related factors when prescribing opioids and the importance of developing strategies to balance the optimization of pain management with the risk of opioid-related harms.

The Diabetic Foot-Pain-Depression Cycle.

More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days. We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The outcome was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P < .1 in the univariate analysis were included in the multiple logistic regression model. Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001-0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation. Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those without antidepressant use. We proposed an underlying diabetic foot-pain-depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams.

OA10 Factors associated with long-term opioid use in fibromyalgia patients newly started on an opioid: results from Clinical Practice Research Datalink

Abstract Background/Aims The impact of the opioid epidemic in North America has caused concern in the United Kingdom. Long-term opioid use is associated with several opioid-related harms and adverse outcomes. Fibromyalgia is frequently treated with opioids due to limited therapeutic options. Understanding what factors are associated with long-term opioid use in such patients is the first step in helping to develop targeted interventions for deprescribing. Therefore, the objective of this study was to (i) quantify the proportion of new opioid users with fibromyalgia who become long-term opioid users; and (ii) identify risk factors associated with long-term opioid use in fibromyalgia. Methods A retrospective cohort study was conducted using data from the Clinical Practice Research Datalink (CPRD). CPRD is a national database of electronic health records within primary care, representation of the general population. Fibromyalgia patients without prior cancer who were new opioid users between 01/Jan/2006 and 31/Aug/2021 were included. Long-term opioid use was defined as at least 3 opioid prescriptions issued within a 90-day period, or ≥ 1 opioid prescription lasting at least 90 days, in the first year of follow-up. Logistic regression analysis and a random forest model were used to identify risk factors related to long-term opioid use. Compared to logistic regression, random forest variable importance measures covered both the effects of individual predictor variables as well as multivariate interactions with other predictor variables. In the random forest model, the mean decrease accuracy (MDA) index to measure the variables’ importance was used; the larger the value of the mean decrease accuracy, the more important the variable is. Results Of the 28,552 fibromyalgia patients who were new opioids users, 7,375 (26%) became long-term opioid users in the first year. In the fully adjusted logistic regression model, suicide and self-harm (adjusted odds ratio [aOR]: 1.98, 95% confidence interval (CI): 1.72-2.27, p &amp;lt; 0.001), substance use disorder (aOR: 2.07, 95%CI: 1.62-2.66, p &amp;lt; 0.001), most deprived (Index of Multiple Deprivation (IMD) quintile 5/most deprived, aOR: 1.98, 95%CI: 1.69-2.33, p &amp;lt; 0.001, compared with quintile 1/least deprived), obesity (aOR: very severely obese, OR: 2.35, 95%CI: 1.76-3.18, p &amp;lt; 0.001) and mean daily morphine milligram equivalents (MME) at the initiation (High (120-199 MME/day): aOR: 34.81, 95%CI: 18.00-78.05, p &amp;lt; 0.001 compared to mean daily MME: Low (&amp;lt;50 MME/day)) were associated with higher risk of long-term opioid use. The three most important variables using the random forest model were mean MME/day at initiation (MDA 140), history of suicide and self-harm (MDA 40) and IMD (MDA 30). Conclusion Almost 1 in 4 patients with fibromyalgia starting opioids became a long-term opioid user in this nationally representative dataset within the first year. The dose of initial opioid prescription, high deprivation score, history of suicide and self-harm, substance use disorder and obesity were associated with long-term opioid use. Disclosure M. Feng: None. C. Ramirez Medina: None. Y. Huang: None. D. Jenkins: None. M. Jani: None.

Prolonged Opioid Use Following Bladder Tumor Resection for Opioid-Naïve Patients.

Bladder cancer patients represent a high-risk group for opioid dependence due to the frequency of surgical procedures. Using MarketScan insurance commercial claims (CC) and Medicare-eligible (ME) databases, we sought to identify whether filling an opioid prescription following initial TURBT resulted in increased odds of prolonged opioid use. We analyzed 43,741 CC and 45,828 ME opioid-naïve patients with a new diagnosis of bladder cancer from 2009 to 2019. Multivariable analyses were completed to assess the odds of prolonged opioid use at 3-6 months based on initial exposure to opioids and initial opioid dose quartile. We performed subgroup analyses by sex and eventual treatment modality. Those who filled an opioid prescription following initial TURBT had greater odds of persistent opioid use (CC: 27% vs 12%, OR 2.14, 95% CI (1.84-2.45), ME: 24% vs 12%, OR 1.95, 95% CI (1.70-2.22). Increasing dosage quartile of opioids was associated with increased odds of prolonged opioid use. Those going on to radical therapy had the highest rates of an initial opioid prescription (31% (CC) and 23% (ME)). Men and women had similar rates of initial prescriptions, but female sex was associated with higher odds of persistent opioid use at 3-6 months in the ME group: OR 1.08, 95% CI (1.01-1.16). Opioids following initial TURBT increase the odds of continued use at 3-6 months, with the greatest odds in those prescribed the highest initial doses. These data suggest that short-term prescriptions have long-term effects, and additional research on opioid use and bladder cancer outcomes is merited.

MP54-15 ASSOCIATION BETWEEN PRE-OPERATIVE OPIOID EXPOSURE AND POST-OPERATIVE OPIOID PRESCRIBING PATTERNS FOLLOWING MAJOR CANCER SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP54-15 ASSOCIATION BETWEEN PRE-OPERATIVE OPIOID EXPOSURE AND POST-OPERATIVE OPIOID PRESCRIBING PATTERNS FOLLOWING MAJOR CANCER SURGERY Emily Serrell, Jessica Schumacher, Manasa Venkatesh, Randi Cartmill, Robert Tyllo, Daniel Shapiro, Kyle Richards, E. Jason Abel, David Jarrard, and Tudor Borza Emily SerrellEmily Serrell More articles by this author , Jessica SchumacherJessica Schumacher More articles by this author , Manasa VenkateshManasa Venkatesh More articles by this author , Randi CartmillRandi Cartmill More articles by this author , Robert TylloRobert Tyllo More articles by this author , Daniel ShapiroDaniel Shapiro More articles by this author , Kyle RichardsKyle Richards More articles by this author , E. Jason AbelE. Jason Abel More articles by this author , David JarrardDavid Jarrard More articles by this author , and Tudor BorzaTudor Borza More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most post-operative opioid prescribing guidelines are restricted to opioid naïve populations due to a dearth of data regarding pre-operative opioid use. We aim to quantify pre- and post-operative opioid prescribing patterns among patients undergoing a major cancer surgery and measure the association between pre-operative opioid exposure and post-operative prescribing. METHODS: We used the Wisconsin Health Information Organization database, which includes commercial-payer, Medicare Advantage and Medicaid claims and captures over 75% of Wisconsin’s population. We collected demographic data on adult patients undergoing radical prostatectomy and partial or radical nephrectomy between 1/1/2017 and 12/31/2021. We evaluated pre- and post-operative opioid prescriptions, quantified opioid exposure in morphine milligram equivalents (MME), and compared prescribing characteristics between opioid naïve and opioid exposed patients (defined as those with a filled prescription in 6 months before surgery). RESULTS: We identified 3,693 patients (2,306 prostatectomy; 1,387 partial or radical nephrectomy). 23% of patients were exposed to opioids prior to surgery (18% prostatectomy, 30% nephrectomy). The median pre-operative dose was 202 MME (IQR 100-600), and fills occurred at a median time of 42 days (IQR 18-91), with increasing frequency in the weeks prior to surgery (Figure 1). After surgery, 55% of patients filled an initial opioid prescription, with a median first dose of 171 MME (IQR 100-334), equivalent to 23 oxycodone 5mg tablets. Opioid exposed patients had a significantly higher two-week post-operative dose (238 vs 142 MME, p<0.001) and number of prescriptions filled (1.46 vs 1.23, p<0.001). CONCLUSIONS: Nearly one quarter of prostatectomy and partial or radical nephrectomy patients are exposed to opioids prior to surgery. Post-operative prescribing remains at levels twice the guideline recommendations for all patients, even higher in patients with prior exposure. Understanding the implications of prior opioid exposure on the management of postoperative pain and opioid use is imperative to inform real-world care and guideline recommendations. Source of Funding: AHRQ K08HS028474 award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e759 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily Serrell More articles by this author Jessica Schumacher More articles by this author Manasa Venkatesh More articles by this author Randi Cartmill More articles by this author Robert Tyllo More articles by this author Daniel Shapiro More articles by this author Kyle Richards More articles by this author E. Jason Abel More articles by this author David Jarrard More articles by this author Tudor Borza More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients.

To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals. A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated. A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone. Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.

Association Between Initial Opioid Prescription Duration and 30-Day Risk of Receiving Repeat Opioid Among Children.

Our study evaluated the association between initial opioid prescription duration and receipt of a repeat opioid prescription in children. Eligible individuals were children between 1 and 17 years of age who enrolled in a Medicaid Managed Care plan and filled an incident opioid prescription during 2013 to 2018. An incident prescription was defined as receipt of an opioid analgesic without a prior use for 12 months. A repeat opioid prescription was defined as receipt of a subsequent opioid prescription within 30 days since the end of incident opioid prescription. A hierarchical multivariable logistic regression model was fitted to test the association between incident opioid prescription duration and the likelihood of receiving a repeat prescription. The cohort consisted of 17,086 children receiving an incident opioid prescription in which 6272 (36.7%) received 1 to 3 days' supply, 8442 (49.4%) received 4 to 7 days' supply, 1434 (8.4%) received 8 to 10 days' supply, and 938 (5.5%) received >10 days' supply. Of these incident opioid recipients, 1780 (10.4%) filled a repeat opioid prescription. The multilevel model results indicated that, children receiving 4 to 7 days' supply (adjusted odds ratio [aOR]: 0.98 {0.9-1.1}), 8 to 10 days' supply (aOR: 1.03 [0.8-1.3]), and >10 days' supply (aOR: 0.85 [0.7-1.1]) had comparable likelihoods of receiving a repeat prescription as those receiving 1 to 3 days' supply. Nearly 10% of children who filled an opioid prescription for acute pain received a repeat prescription. Initial prescription duration was not associated with the risk of receiving a repeat prescription.

Opioid Represcriptions After ACL Reconstruction in Adolescents Are Associated With Subsequent Opioid Use Disorder.

Postoperative opioid prescriptions may confer a risk for subsequent opioid use disorders (OUDs). For many children, postoperative analgesia is often the first opioid exposure. The rates of anterior cruciate ligament (ACL) reconstruction in pediatric populations are rising. Here, we use an administrative claims database to describe opioid prescription patterns after ACL reconstruction and their effect on subsequent risk of OUD. Using International Classification of Diseases (ICD)-9, ICD-10, and CPT codes, we identified patients, with ages 10 to 18, undergoing primary ACL reconstruction between 2014 and 2016 with minimum 1 year follow-up in the Optum Clinformatics Data Mart, which is a nationally representative administrative claims database. Demographic variables and prescription patterns (in morphine milligram equivalents [MMEs]) were analyzed using univariate tests and multivariable logistic regression to determine any potential association with the appearance of anew an ICD-9 or ICD-10 code for OUD within 1 year of the initial procedure. A total of 4459 cases were included and 29 (0.7%) of these patients were diagnosed with an OUD within 1 year of surgery. Upon univariate analysis, opioid represcriptions within 6 weeks were significantly more common among patients with OUD; 27.6% vs. 9.7% of patients that did not develop a new diagnosis of OUD ( P =0.005). Multivariable logistic regression indicated an independent significant relationship between total MMEs initially prescribed and the odds of a subsequent OUD diagnosis: for each additional 100 MMEs prescribed in total, the odds of OUD increased by 13% ( P =0.002). Patients with a represcription within 6 weeks of surgery had an average increase in the odds of OUD by 161% ( P =0.027). In this cohort of patient ages 10 to 18 undergoing primary isolated ACL reconstruction, we found substantial variability in opiate prescribing patterns and higher initial opioid prescription volume, as well as opioid represcription within 6 weeks were predictive of the subsequent development of OUD. Level III.

CDC Issues New Opioid Prescribing Guideline

Back to table of contents Previous article Next article Clinical & ResearchFull AccessCDC Issues New Opioid Prescribing GuidelineTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:12 Jan 2023https://doi.org/10.1176/appi.pn.2023.02.2.12AbstractThe new guideline emphasizes flexibility and addresses challenges that arose after the 2016 guideline was released.Late last year the Centers for Disease Control and Prevention (CDC) released a new guideline for prescribing opioids that includes updated and expanded recommendations for health professionals who provide pain care for adult outpatients with short- and long-term pain.The guideline is meant to address challenges that developed in the wake of the 2016 guideline and to add more flexibility in opioid prescribing.“Of particular concern, some policies purportedly drawn from the 2016 CDC Opioid Prescribing Guideline have been notably inconsistent with it and have gone well beyond its clinical recommendations,” the 2022 guideline states. “Such misapplication includes extension to patient populations not covered in the 2016 CDC Opioid Prescribing Guideline (e.g., cancer and palliative care patients), rapid opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment (previously referred to as medication assisted treatment), duration limits by insurers and pharmacies, and patient dismissal and abandonment.”The 2022 guideline addresses the following:Determining whether to initiate opioids for pain.Selecting opioids and determining opioid dosages.Deciding duration of initial opioid prescription and conducting follow-up.Assessing risk and addressing potential harms of opioid use.The guideline also supports the development and promotion of evidence-based treatments to manage pain and expands recommendations for tapering opioids for patients already receiving opioid therapy.The guideline should not be used as an inflexible standard of care or rigid policy or law, says Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H.According to Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H., acting director of CDC’s National Center for Injury Prevention and Control, the guideline includes new structural elements that make it very clear that the guideline is a clinical tool to support individualized care and should not be used as an inflexible standard of care or rigid policy or law.Patients who have been taking opioids long term for chronic pain who appear unstable or show a decrease in function should be thoroughly evaluated for opioid use disorder, says Andrew J. Saxon, M.D.“To emphasize flexibility and encourage individualized care in using the new guideline, we have highlighted overarching principles of safe and effective pain treatment rather than focusing on specific dosage thresholds,” Jones told Psychiatric News. “For example, we do not include a specific days supply recommendation or morphine milligram equivalent dose … like was done with the 2016 guideline.”The guideline also addresses opioid prescribing for various populations that are often represented in psychiatric practice.“Of particular note for addiction psychiatrists, general psychiatrists, and others working with patients who have substance use disorders or mental disorders, we have expanded the evidence base around the use of opioid pain medication and other pain treatments and risk mitigation and treatment strategies in certain groups, like older adults and pregnant people, and in people with conditions posing special risks, such as those with a history of substance use disorder and mental health issues,” Jones said.Andrew J. Saxon, M.D., the director of the Center of Excellence in Substance Addiction Treatment and Education at the VA Puget Sound Health Care System and a former member of APA’s Council on Addiction Psychiatry, stressed the importance of evaluating patients who have been taking opioids long term (prescribed opioids continuously for more than 90 days).“Patients currently on long-term opioid therapy for chronic pain who appear unstable or show a decrement in function should be thoroughly evaluated for opioid use disorder,” Saxon said. “If they have opioid use disorder, they should be transitioned from opioid therapy to medication for opioid use disorder, typically buprenorphine, though it could be methadone if an Opioid Treatment Program is available and the patient is amenable. If the patient does not have opioid use disorder or refuses medication for opioid use disorder, a careful clinical decision will need to be made regarding continuation of opioids versus tapering, with very careful monitoring in either case.” ■Resource“CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022” ISSUES NewArchived

Association of a State Prescribing Limits Policy with Opioid Prescribing and Long-term Use: an Interrupted Time Series Analysis.

Prescription opioids were a major initial driver of the opioid crisis. States have attempted to reduce overprescribing by enacting policies that limit opioid prescriptions, but the impacts of such policies on new prescribing and subsequent transitions to long-term use are not fully understood. To examine the association of implementation of a state prescribing limits policy with opioid prescribing and transitions to long-term opioid use. Interrupted time series analyses assessing trends in new opioid prescriptions and long-term use before and after policy implementation. A total of 130,591 New Jersey Medicaid enrollees ages 18-64 who received an initial opioid prescription from January 2014 to December 2019. New Jersey's opioid prescribing limit policy implemented in March 2017. Total new opioid prescriptions, percentage of new prescriptions with >5 days' supply, and transition to long-term opioid use, defined as having opioid supply on day 90 after the initial prescription. Policy implementation was associated with a significant monthly increase in new opioid prescriptions of 0.86 per 10,000 enrollees, halving the pre-policy decline in the prescribing rate. Among new opioid prescriptions, the percentage with >5 days' supply decreased by about 1 percentage point (-0.76 percentage points, 95% CI -0.89, -0.62) following policy implementation. However, policy implementation was associated with a significant monthly increase in the rate of initial prescriptions with supply on day 90 (9.95 per 10,000 new prescriptions, 95% CI 4.80, 15.11) that reversed the downward pre-implementation trend. The New Jersey policy was associated with a reduction in initial prescriptions with >5 days' supply, but not with an overall decline in new opioid prescriptions or in the rate at which initial prescriptions led to long-term use. Given their only modest benefits, policymakers and clinicians should carefully weigh potential unintended consequences of strict prescribing limits.

Opioid Legislation Decreases Opioid Prescribing in Total Knee Arthroplasty.

The purpose of this study was to evaluate the impact of opioid-limiting legislation on perioperative opioid prescriptions in total knee arthroplasty. The hypothesis was that opioid legislation has reduced opioid prescription filling above levels anticipated by national trends. This study retrospectively evaluated opioid prescription filling for all patients undergoing total knee arthroplasty in a commercially available insurance database between 2010 and 2018 (n=1,068,764). Initial discharge and 90-day cumulative oxycodone 5-mg equivalents filled were tabulated. Opioid prescription filling was evaluated over time and between states with and without opioid-limiting legislation using analysis of variance and multivariable linear and logistic regression. States with and without opioid legislation had significant reductions in initial and cumulative opioid prescription filling volume (all P<.001). However, the magnitude of this reduction was larger in states with opioid legislation. Legislation targeting duration and volume had the largest impact on initial post-act opioid prescription filling volume compared with states without legislation in an estimated "pre-act" time frame. Legislation targeting duration and volume and no specific target had the largest impact on cumulative post-act opioid prescription filling volume. States without legislation still had large, significant reductions in filling volume, but the magnitude was not as great as in states with opioid legislation. States with and without opioid legislation had significant decreases in initial and cumulative opioid prescription filling volume. However, the magnitude of reduction was larger in states that enacted legislation. Younger age, pre-operative opioid use, and higher comorbidity burden were associated with greater opioid use postoperatively. [Orthopedics. 2023;46(3):142-150.].

Intended and unintended consequences: Changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012–2018 – Controlled and single-series interrupted time series analyses

BackgroundThe potential misapplication of current opioid prescribing policies remains understudied and may have substantial adverse implications for patient safety. MethodsWe used autoregressive integrated moving average models to assess level and trend changes in monthly 1) prescribing rates, 2) days’ supply, and 3) daily morphine milligram equivalents (MME) of incident opioid prescriptions relative to 1) a state medical board initiative to reduce high-dose and -volume opioid prescribing and 2) legislation to limit initial opioid prescriptions for acute and postsurgical pain. We examined outcomes by pain indication overall and by cancer history, using prescribing patterns for benzodiazepines to control for temporal trends. We used large private health insurance claims data to include North Carolina residents, aged 18–64, insured at any point between January 2012 and August 2018. ResultsAfter the medical board initiative, prescribing patterns for chronic pain patients did not change; conversely, acute and postsurgical pain patients experienced immediate declines in daily MME. Post-legislation prescription rates did not decline for those with acute, postsurgical, and non-cancer pain, but instead declined among cancer patients with chronic pain. Chronic pain patients experienced the largest days’ supply declines post-legislation, instead of acute and postsurgical pain patients. ConclusionsWe found mixed evidence on the potential impact of two opioid prescribing policies, with some observed declines in a group not intended to be impacted by the policy. This study provides evidence of the need for clearer opioid prescribing policies to ensure impacts on intended populations and avoid unintended consequences.

Association Between Initial Prescription Size and Likelihood of Opioid Refill After Total Knee and Hip Arthroplasty

BackgroundThe present study was designed to test the hypothesis that there was no association between initial opioid prescription size and the likelihood of refill after elective primary total knee (TKA) and hip arthroplasty (THA). MethodsWe retrospectively analyzed large national datasets of commercial and Medicare insurance claims to identify a weighted cohort of 120,889 primary total joint arthroplasties (76,900 TKA and 43,989 THA) comprised of opioid-naive patients aged 18 to 75 years who had surgery between January 2015 and November 2019. The primary outcome was refill of any prescription opioid medication within 30 days after discharge, and the primary predictor variable was the total amount of opioid filled in the initial discharge prescription measured in oral morphine equivalents (OMEs). Logistic regressions were used to estimate the likelihood of refill, given a particular prescription size while adjusting for multiple patient factors, including age, sex, comorbidities, and year of surgery. ResultsThe 30-day refill rate was 59.6% following TKA and 26.1% for THA. Adjusted odds of refill decreased by 2% for every 75 OME (10 tablets of 5 mg oxycodone) increase to the initial prescription size among the THA cohort (adjusted odds ratio [OR] = 0.98; 95% CI 0.97-0.99), and decreased by 3% for the TKA cohort (aOR = 0.97; 95% CI 0.97-0.98). ConclusionThese nationally representative data demonstrated that larger initial opioid prescription size was associated with small but clinically insignificant decreases in 30-day refill after total joint arthroplasty. This finding should allay concerns about efforts to decrease postsurgical opioid prescribing.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022.

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Predictors of High-Dose Initial Opioid Prescriptions in Primary Osteoarthritis: A Single Institution Analysis

Category: Ankle Arthritis; Other Introduction/Purpose: High-dose opioid prescriptions in osteoarthritis (OA) increase the risk of overdose and chronic opioid dependence, which is associated with worse perioperative outcomes in total joint arthroplasty (TJA). The purpose of this study was to determine the (1) incidence and (2) identify independent risk factors for receiving high-dose initial opioid prescriptions in OA patients. Methods: A retrospective chart review was performed to evaluate initial outpatient opioid prescriptions for OA in opioid-naïve adult patients at a single academic institution between 2013 and 2020. Patients with prior surgery or opioid prescriptions were excluded. Patient demographic data, medical comorbidities, Charlson Comorbidity Index (CCI) scores, and prescription metadata were recorded. High-dose prescriptions were defined as daily oral morphine equivalents (OME/d) &gt;=50. Univariate analysis and multivariate logistic regression were used to identify independent predictors for high-risk opioid prescriptions. Results: A total of 1,527 patients were identified with an initial opioid prescription for OA, with 21.5% of patients receiving high- dose prescriptions. The majority of high-dose prescriptions (&gt;=50 OME/d) were given oxycodone (56.1%), while low-dose prescriptions (&lt;50 OME/d) were more commonly prescribed hydrocodone-acetaminophen (34.2%) and tramadol (32.5%). Using multivariate logistic regression, patient factors that are independently associated with high-dose prescriptions include decreased age, decreased BMI, white race, and non-orthopaedic encounters. Comorbid factors that were independently predictive of high- dose prescriptions include hip OA, higher CCI scores, and depression. (Table 1) Conclusion: Independent predictors for high-dose initial opioid prescriptions in OA include younger age, decreased BMI, white race, non-orthopaedic encounters, hip OA, higher CCI scores, and depression.

The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness.

Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. Investigators searched publicly available laws ("[state]+opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.