Mean Oral Morphine Equivalents Research Articles

Local Infiltration Analgesia Is Superior to Regional Nerve Blocks for Total Hip Arthroplasty: Less Falls, Better Mobility, and Same-Day Discharge.

Background: Multimodal analgesia in total hip arthroplasty (THA) provides better pain control, mobility, and reduced side effects compared to monotherapies. Local infiltration analgesia (LIA) and regional nerve blocks (RNBs) are commonly used throughout these protocols. This study aimed to compare these procedures as part of a multimodal analgesia protocol for patients undergoing THA. Materials and Methods: A retrospective review of 1100 consecutive elective primary THAs was performed in 996 patients between June 2018 and December 2021. The RNB consisted of a preoperative continuous femoral nerve catheter and single-shot obturator nerve block, and LIA consisted of the intraoperative infiltration of weight-based bupivacaine. Results: A total of 579 (52.6%) patients received RNB, and 521 (47.4%) received LIA. Mean oral morphine equivalents (OMEs) during the first four hours postoperatively were significantly lower for LIA group (p < 0.001). However, the numeric pain rating scale in the post-anesthesia care unit (PACU) was similar between groups. Patients with LIA had significantly greater first ambulation distance in the PACU (p < 0.001), higher successful same-day discharge rate (p = 0.029), fewer falls (p = 0.041), and less refill OMEs post-discharge (p < 0.001) than RNB. Conclusions: In the setting of similar pain management between groups and better functional outcomes for LIA, the use of minimally invasive procedures like LIA for pain control following THA is favorable.

A comparison of opioid dose between home palliative care and hospital palliative care

ObjectiveWhile opioids are a key part of palliative care, few studies have evaluated opioid demand in the home care context. This study aims to compare opioid usage in home care and hospital care settings.MethodsThis cross-sectional study retrospectively recruited patients receiving palliative care in home care and hospital settings, between November 2018 and October 2020. Opioid prescriptions were standardized to oral morphine equivalent (OME) doses at 7 and 14 days prior to death and analyzed. Additional analysis performed multivariable linear regression on the outcome of OME at 7 days, adjusting for medical setting and confounders in patients with opioid prescriptions.ResultsAfter 21 exclusions, 209 patients (48 home care and 161 hospital care) were eligible for analysis. The home care group had a higher mean age (74.8 years) and Palliative Prognosis Score (50), than the hospital group (70.1 and 40, respectively). Mean OME at 7 and 14 days before death was numerically higher in the home care group (72.8 mg/day and 53.0 mg/day, respectively) than the hospital care group (57.7 mg/day and 35.7 mg/day). Student’s t-test produced p-values of 0.49 and 0.32, and the Wilcoxon rank sum test found p-values of 0.24 and 0.11 at 7 and 14 days, respectively. Multivariable regression analysis of the home care group found mean OME of 40.7 mg/day; 95% confidence interval [-0.62, 82.0 (mg/day)], p = 0.06. Additional analysis found a p-value of 0.06 for medical setting.ConclusionsWe did not find a statistically significant difference in opioid use between home care and hospital care. However, the numerically higher rate of use in the home care group suggests that further research is warranted.

Successful implementation of a quality improvement bundle to reduce opioid overprescribing following total hip and knee arthroplasty

BackgroundOpioid overprescribing is commonplace after total hip (THA) and total knee arthroplasty (TKA). Preliminary data demonstrated that approximately 32% of the opioids prescribed at discharge from our hospital following THA...

Interdigitation of Radiation Earlier in the Multimodal Treatment of Patients with Lymphoma: The Effect on Opiate Analgesic Requirements.

Delay in radiation therapy (RT) as part of multimodality therapy in Hodgkin (HL) and non-Hodgkin lymphoma (NHL) is associated with worse pain scores. In a heterogeneous cohort of lymphoma patients, we hypothesize that interdigitating RT before fewer (versus more) lines of chemotherapy (C) will be associated with lower opiate analgesic requirement. From 2009-2019, patients with HL or NHL received palliative (36.5%) or definitive (63.3%) RT at a single institution. An IRB approved database with baseline treatment/disease characteristics, including oral morphine equivalent (OME) requirement, was reviewed. OME was recorded for a) 3-month period prior to RT, b) the month during RT, and c) 3 months after RT. Post-RT change in OME was calculated as the difference in "b" and "c" such that greater or less OME use post-RT was defined as positive or negative value respectively. We performed one-tailed t-test analyses to determine differences in OME during RT between different cohorts. Correlations between baseline characteristics and OME were performed using Spearman correlations, controlling for lymphoma subtype, stage, tumor volume, relapsed/refractory disease, duration of radiation and bulky disease. Of 180 patients, 57.8% had NHL, 40.6% were stage IV and 29.4% had bulky disease. At median of 19 days [6-80] from diagnosis, 74% of patients received C with a median of 2 lines [1-4] before RT. The median interval from diagnosis to RT was 11 months [4-36]. Pearson correlation showed a negative association between time from diagnosis to RT and postRT OME in the definitive cohort (R2 = 0.42, F = 4.54, p = 0.002) such that the longer the time to RT, the larger the decrease in OME postRT as compared to during RT. T-test showed higher mean OME during RT for those receiving > 2 lines of C preRT (148.3mg) as compared to those receiving ≤ 2 lines before RT (51.5mg, p = 0.02). In patients receiving definitive RT, the difference remained significant: those receiving >2 lines of C had higher OME during RT as compared to those receiving ≤ 2 lines (207.5mg versus 48.3mg, p = 0.02). The difference in mean OME for patients receiving >2 C lines versus ≤ 2 lines was not significantly different in the palliative cohort (75.6 vs 60.6, p = 0.33). OME use during RT was also found to be higher in patients with bulky disease as compared to non-bulky disease (175.7 versus 52.0, p = 0.04). In our single-center experience, patients who received >2 lines of C prior to RT were found to have a significantly higher mean OME requirement during RT. In patients receiving definitive RT, longer time to receipt of RT was found to be associated with a larger decrease in OME post-RT, likely related to starting with a higher OME. Interdigitation of RT early on, prior to the 3rd line of chemotherapy, may help reduce pain and improve quality of life.

Prospective evaluation of postoperative pain and opioid use after minor urologic surgery.

Filling an opioid prescription after a minor urologic procedure increases patient risk of overdose and misuse. Strategies to reduce the number of opioids reaching the community are critical. This study evaluates opioid use after minor urologic procedures at a Canadian academic center and guides future prescribing recommendations. We prospectively evaluated patients over 18 years old undergoing minor urologic procedures (penile, scrotal, urethral, etc.) from September 2020 to May 2022. Consenting participants were given a pain diary and postoperative pain questionnaire. Patients on chronic pain medications or those who had major surgery within six months were excluded. Response rate, pain on visual analog scale, pain control satisfaction, quantity of opioids prescribed, and consumption of opioid and non-opioid medication were collected and analyzed. Ninety-five patients met the inclusion criteria. The mean age was 61.7 years (range 20- 87) and 96% of patients identified as male. The response rate for the opioid diary and pain questionnaire was 57%. Forty-two patients (78%) were offered an opioid prescription following their surgery, but only 12 of those patients (22%) filled and consumed any opioids analgesics. Forty-two patients (78%) used no postoperative opioids, and the mean oral morphine equivalents (OME) consumed was 5.87 (standard deviation 16.7). There was a total of 259 OME unused from post-procedure prescriptions. The mean overall pain score for patients who did and did not fill opioid prescriptions were 3.18/10 and 1.79/10 (p<0.01), respectively, with mean overall pain management satisfaction score of 8.63/10 and 8.58/10 (p=0.94), respectively. Most patients undergoing minor urologic procedures do not require opioids to manage postoperative pain. Based on our data, we suggest that a prescription for 39 OME would adequately treat postoperative pain in 95% of patients undergoing minor urologic procedures. Education around pain management with non-narcotic modalities is imperative, and practice changes are warranted to address the opioid crisis within our specialty.

Analysis of Opioid Use in Patients Undergoing Open Versus Robotic Gastrectomy.

Minimally invasive, robotic gastrectomy is associated with better short-term outcomes and quicker functional recovery. However, the degree to which the robotic approach influences postoperative pain and opioid use after gastrectomy is unknown. Our primary aim was to determine whether the robotic approach to gastrectomy reduces postoperative opioid use compared with the open approach. Patients who underwent gastrectomy (November 2018 to September 2021) were identified retrospectively. Clinical characteristics, short-term surgical outcomes, oral morphine equivalent (OME) use, and pain scores were collected. Both groups were managed through an enhanced recovery program in the perioperative period. Of 81 patients, 50 underwent open and 31 underwent robotic gastrectomy. Compared with open gastrectomy patients, robotic gastrectomy patients had longer surgery time (360 vs. 288min), less blood loss (50 vs. 138mL), and shorter hospital stay (4 vs. 6days) (all medians, P<0.001). Robotic gastrectomy patients used lower OMEs on postoperative days 0-4 (all P<0.05) and in total for days 0-4 (total mean dose 65.0 vs. 169.5mg; P<0.001) than did open gastrectomy patients. The robotic gastrectomy patients were prescribed a lower mean OME dose than the open gastrectomy patients (19.0 vs. 29.0mg, respectively; P=0.001). Multivariable analysis showed that robotic approach was associated with lower opioid use (odds ratio 3.70; 95% CI 1.01-14.3; P=0.049). Compared with open gastrectomy, robotic gastrectomy reduces opioid use in the early postoperative period and is associated with fewer OME discharge prescriptions and shorter hospital stay.

PD38-02 INTERNATIONAL PRESCRIBING RATES OF OPIOIDS AFTER ROBOTIC PROSTATECTOMY

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety III (PD38)1 Sep 2021PD38-02 INTERNATIONAL PRESCRIBING RATES OF OPIOIDS AFTER ROBOTIC PROSTATECTOMY Emily C. Hacker, Michelle Yu, Maria M. Pere, Bruce L. Jacobs, and Benjamin J. Davies Emily C. HackerEmily C. Hacker More articles by this author , Michelle YuMichelle Yu More articles by this author , Maria M. PereMaria M. Pere More articles by this author , Bruce L. JacobsBruce L. Jacobs More articles by this author , and Benjamin J. DaviesBenjamin J. Davies More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002048.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The purpose of this study is to compare international opioid prescribing patterns for patients undergoing robotic assisted laparoscopic prostatectomy (RALP). To our knowledge, this is the first study to assess international opioid prescribing trends among urologists. METHODS: An anonymous Web-based survey assessing the frequency and quantity of opioid prescriptions for RALP was designed using Qualtrics software. The survey was distributed to urologists internationally via Twitter and email in early 2021. Prescribing patterns were analyzed based on country of practice in three groups: USA, Canada, and all other countries under the assumption that response rates would be lower in these countries. RESULTS: 145 participants from 21 countries completed the survey including the USA (56%), Greece (16%), Canada (9%), Israel (3.4%), Brazil (2%), the United Kingdom (2%), Germany (1.4%), and India (1.4%). 57% of respondents were attendings/consultants 32% residents, 10% fellows, and 2% advanced practice providers. The percentage of providers prescribing post-discharge opioids significantly differed between Canada, the United States, and other countries (85%, 63%, and 8%, respectively, p <0.0001). There was a significant difference between years of experience in those who provide opioids compared to those who do not (6.5 years vs 9.9 years, p=0.001). The average oral morphine equivalents (OME) provided in those who did prescribe opioids was greatest in Canada but was not significantly different between groups (mean OME: Canada 41mg, USA 35mg, all others 33mg; p=0.82). Attending physicians prescribed more OME than trainees (residents, fellows) on average (attending mean OME = 46 mg, trainee mean OME = 29 mg, p=0.0012). The most prescribed medication in the United States was oxycodone, hydromorphone in Canada, and tramadol in the rest of the world. CONCLUSIONS: Opioid prescriptions after prostatectomy are common in North America and uncommon in the rest of the world. Narcotic-free prostatectomies are still rare in North America and offer an opportunity for surgeons to decrease the pool of narcotics, and thus, reduce the risk of narcotic abuse. Source of Funding: Bruce L. Jacobs, MD MPH is supported in part by the Shadyside Hospital Foundation © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e661-e662 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily C. Hacker More articles by this author Michelle Yu More articles by this author Maria M. Pere More articles by this author Bruce L. Jacobs More articles by this author Benjamin J. Davies More articles by this author Expand All Advertisement Loading ...

Inequity in discharge pain management for trauma patients with limited English proficiency.

Pain management is critical for optimal recovery after trauma. Previous work at our institution revealed differences in pain assessment by patient language, which may impact management. This study aimed to understand differences in discharge opioid prescribing for trauma patients with limited English proficiency (LEP). We conducted a cross-sectional study of adult trauma patients discharged to the community from a diverse, urban level 1 trauma center in 2018. Opioid prescriptions were obtained from discharge pharmacy records and converted to standard oral morphine equivalents (OMEs). Multivariable logistic and quantile regression was used to examine the relationship between LEP, opioid prescriptions, and OMEs at discharge, controlling for demographic and clinical characteristics. Of 1,419 patients included in this study, 83% were English proficient (EP) and 17% were LEP. At discharge, 56% of EP patients received an opioid prescription, compared with 41% of LEP patients. In multivariable models, EP patients were 1.63 times more likely to receive any opioid prescription (95% CI, 1.17-2.25; p = 0.003). Mean OME was 147 for EP and 94 for LEP patients. In multivariable models, the difference between EP and LEP patients was 40 OMEs (95% CI, 21.10-84.22; p = 0.004). In adjusted quantile regression models, differences in total OMEs increased with the amount of OMEs prescribed. There was no difference in OMEs at the 20th and 40th percentile of total OMEs, but LEP patients received 26 fewer OMEs on average at the 60th percentile (95% CI, -3.23 to 54.90; p = 0.081) and 45 fewer OMEs at the 80th percentile (95% CI, 5.48-84.48; p = 0.026). Limited English proficiency patients with traumatic injuries were less likely to receive any opioid prescription and were prescribed lower quantities of opiates, which could contribute to suboptimal pain management and recovery. Addressing these disparities is an important focus for future quality improvement efforts. Care Management, level IV.

An Evaluation of the Effect of Catheter-Directed Continuous Infusion of Local Anesthetic by Elastomeric Pump on Opioid Usage Following Donor Kidney Nephrectomy.

Postoperative pain management following donor nephrectomy can prove challenging for immediate discharge on postoperative day 1 or 2. Although the standard for pain control is utilization of opioids, this increases the risk of postoperative ileus and, if continued inappropriately, increases excess opioids circulating in the community. One strategy that proposes to limit postoperative opioids in kidney donors is the continuous infusion of local anesthetics (CILA), though the effect on patient outcomes is unclear. The purpose of this study was to evaluate the effectiveness of postoperative CILA to decrease opioid usage in kidney donors who undergo laparoscopic nephrectomy. A retrospective analysis was conducted of kidney donors who underwent laparoscopic nephrectomy and received CILA (CILA group) compared with kidney donors who received standard-of-care (SOC) postoperative analgesia. The primary outcome was the mean total oral morphine equivalents (OMEs) administered following surgery. A total of 176 kidney donors were evaluated, 88 in each group. The mean OME administered in the CILA group was significantly higher than in the SOC group: 194.8 versus 133.5 mg (P = 0.003). Mean total postoperative administration of acetaminophen was also increased in the CILA group: 3736.9 versus 2611.6 mg (P = 0.0041). Mean length of stay following surgery was higher in the kidney donors who received CILA, whereas return to bowel function, time to ambulation, and pain scores were not significantly different. This report demonstrated that CILA is not an effective modality to reduce opioid utilization or improve recovery in kidney donors following laparoscopic nephrectomy.

Morphologic Severity of Acute Pancreatitis on Imaging Is Independently Associated with Opioid Dose Requirements in Hospitalized Patients.

Prior studies have evaluated clinical characteristics associated with opioid dose requirements in hospitalized patients with acute pancreatitis (AP) but did not incorporate morphologic findings on CT imaging. We sought to determine whether morphologic severity on imaging is independently associated with opioid dose requirements in AP. Adult inpatients with a diagnosis of AP from 2006 to 2017 were reviewed. The highest modified CT severity index (MCTSI) score and the daily oral morphine equivalent (OME) for each patient over the first 7days of hospitalization were used to grade the morphologic severity of AP and calculate mean OME per day(s) of treatment (MOME), respectively. Multiple regression analysis was used to evaluate the association of MOME with MCSTI. There were 249 patients with AP, of whom 196 underwent contrast-enhanced CT. The mean age was 46 ± 13.6years, 57.9% were male, and 60% were black. The mean MOME for the patient cohort was 60 ± 52.8mg/day. MCTSI (β = 3.5 [95% CI 0.3, 6.7], p = 0.03), early hemoconcentration (β = 21[95% CI 4.6, 39], p = 0.01) and first episode ofAP (β = - 17 [95% CI - 32, - 2.7], p = 0.027) were independently associated with MOME. Amongthe 19 patients undergoing ≥ 2 CT scans, no significant differences in MOME were seen between those whose MCTSI score increased (n = 12) versus decreased/remained the same (n = 7). The morphologic severity of AP positively correlated with opioid dose requirements. No difference in opioid dose requirements were seen between those who did versus those who did not experience changes in their morphologic severity.

Effect of epidural analgesia on postoperative opioid requirements following elective laparotomies performed at Vancouver General Hospital

BackgroundEnhanced recovery pathways aim to reduce postoperative opioid use and opioid-related complications. These pathways often include epidural analgesia (EA). This study examines postoperative opioid use after elective laparotomy with and without EA. MethodsRetrospective chart review of elective laparotomies performed by General Surgery at a tertiary academic center during 2017 was completed. Primary outcome was postoperative opioid usage. Secondary outcomes were time to mobilization, duration of urinary catheterization and postoperative ileus. ResultsAmong 236 patients, 213 (90%) received EA. There was no significant difference in mean total oral morphine equivalent (OME) usage between EA and non-EA groups. Mean OME use on postoperative day three was higher in the EA group (38.0 vs 22.4 mg, p = 0.02). On multivariate analysis, preoperative opioid use was associated with increased postoperative OME consumption (regression coefficient 147.5, p < 0.001). ConclusionsIn this cohort, epidural analgesia did not reduce postoperative opioid consumption.

The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain.

Simple SummaryThe aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.

Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer

Pain is common in cancer, affecting more than 70% of patients with advanced disease. Intrathecal drug delivery systems (IDDS) are a well-established treatment for patients with refractory cancer pain, improving pain control and reducing associated side effects. To date, details of systemic opioid use before and after IDDS implant have not been reported. We conducted a retrospective review of patients at Huntsman Cancer Institute-University of Utah treated with IDDS for cancer pain from May 2014 to May 2018. Oral, transdermal, and parenteral opioid use before IDDS implant was compared to use 30 days postoperatively. A total of 173 patients were included, 93% with stage IV disease. The pre-implant median daily oral morphine equivalent (OME) was 240 mg (interquartile range 130-390, range 0-2616 mg). OME doses >200 mg/day were required by 57% of patients, and >500 mg OME by 19% of patients. The post-implant median OME was 0 mg (interquartile range 0-0, range 0-480 mg) and 82.6% of patients discontinued systemic opioids completely. 11.0% of patients used <100 mg OME, and only 1.7% of patients used >200 mg OME. Mean OME decreased by 94% following IDDS implant (p < 0.0001) and all patients who continued to use systemic opioids required a lower OME compared to pre-implant. In the largest cohort of patients with advanced cancer and refractory pain treated with IDDS, implantation was associated with a dramatic reduction in systemic opioid use 30 days postoperatively, with a large majority of patients discontinuing systemic opioids. Those patients that continued systemic opioids utilized significantly lower doses as compared to their pre-implant dose.

2 Impact of Multimodal Analgesia on Critically Ill Burn Patients

Abstract Introduction Opioids are considered the cornerstone of treatment for post-operative burn pain. However, detrimental adverse effects of opioid use include over-sedation, respiratory depression and dependence. Multimodal analgesia is an alternative method of pain control that utilizes a combination of opioid and non-opioid medications. Multimodal analgesia offers different mechanisms of action which may be beneficial in burn-injured patients. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit (BICU). Methods This retrospective cohort study was performed at an academic burn center between 2012 and 2018. Consecutively admitted patients with burns greater than or equal to 10% total body surface area (TBSA) and BICU length of stay (LOS) greater than seven days were eligible for inclusion. Patients were excluded if they received an opioid continuous infusion greater than 48 hours. Patients treated with multimodal analgesia were compared to those treated with opioids alone. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period for 5 days after a grafting surgery. Secondary endpoints included pain scores, BICU LOS, and ventilator days. Data analysis was performed with descriptive statistics. A power calculation determined that 60 patients per group were needed to detect a 30% difference in the primary endpoint. Results There were 100 patients in the non-multimodal group and 100 patients in the multimodal group. Mean cumulative OME dose was significantly lower in the multimodal group (1,028 mg vs. 1,438 mg, P &amp;lt; 0.002). Patients with over 20% TBSA burns had a larger reduction in mean OME doses in the multimodal group (1,097 mg vs. 1,624 mg, P = 0.0049) compared to patients with 10% to 20% TBSA burns (949 mg vs 1,282 mg, P = 0.057). Utilizing more multimodal agents was not associated with lower OME doses. There was no difference in pain score on post-operative day 5 (5.5 + 2.3 vs. 6.2 + 2.2, P=0.07) or at ICU discharge (4.7 + 2.4 vs 4.7 + 2.8, P = 0.99). There was no difference in other secondary outcomes. Conclusions The use of multimodal analgesia significantly reduced cumulative OME doses without compromising pain control. Applicability of Research to Practice Multimodal analgesia may be a beneficial adjunct to burn pain management to mitigate opioid use without compromising pain control.

More opioids, more constipation? Evaluation of longitudinal total oral opioid consumption and self-reported constipation in patients with cancer.

Opioid-induced constipation (OIC) is a distressing physical symptom for patients with cancer taking opioids. Total opioid consumption may contribute to developing worsening OIC-related symptoms. We completed a retrospective analysis examining the association of total daily opioid consumption on self-reported constipation in patients with cancer. In over 5 clinic visits, we collected self-reported constipation scores and 24-h oral morphine equivalents (OME). We examined the association between OME and the presence of constipation (i.e., score >3) and the relationship of OME between patients with or without constipation. Of 297 patients with cancer, we observed 57.8% with constipation and 42.4% without constipation at the first clinic visit. Age was similar in both groups (54.2 ± 14.5 vs. 56.4 ± 14.8years [mean ± SD]) and the majority of patients were women (63.7% vs. 61.1%). The most common cancer type in patients with constipation was non-colorectal gastrointestinal (n = 25, 14.6%), while in patients without constipation was colorectal gastrointestinal (n = 25; 19.8%). Across visits, we observed weak or no association between OME and self-reported constipation (r = 0.01-0.27). At the first visit, higher mean OME was seen in patients who self-reported constipation (133.4 vs 76; p < 0.05). Age, sex, metastatic disease, and stimulant laxative use were not associated with constipation. We observed weak to no association between OME and constipation in patients with cancer. These results suggest a lack of a clear association between total opioid consumption and self-reported constipation.

Characterization of opioid consumption and disposal patterns after total knee arthroplasty.

The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA). In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform. Overall, 103 of 109 patients (94.5%) completed the daily short message service (SMS) surveys. The mean oral morphine equivalents (OME) consumed during the six weeks post-surgery were 639.6 mg (sd 323.7; 20 to 1616) corresponding to 85.3 tablets of 5 mg oxycodone per patient. A total of 66 patients (64.1%) had stopped taking opioids within six weeks of surgery and had the mean equivalent of 18 oxycodone 5 mg tablets remaining. Only 17 patients (25.7%) appropriately disposed of leftover medications. These prospectively collected data provide a benchmark for general opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and leftover medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Cite this article: Bone Joint J 2019;101-B(7 Supple C):98-103.

Success of Hospital Intervention and State Legislation on Decreasing and Standardizing Postoperative Opioid Prescribing Practices

We sought to evaluate change in postoperative prescription practices in an independent community-based hospital after hospital interventions and a state legislation change. This is a retrospective review of opioid-naïve adult subjects who underwent 5 common general surgical procedures between 2015 and 2017, including cholecystectomy, appendectomy, minimally invasive inguinal hernia repair, open inguinal hernia repair, and breast lumpectomy. Educational interventions were introduced, new statewide legislation was passed, and 129 subsequent cases were reviewed. Mean ± SD oral morphine equivalent (OME) prescribed for all procedures on retrospective review was 218.8 ± 113.7 (n= 722), cholecystectomy 235.3 ± 133.8 (n= 248), appendectomy 220.2 ± 103.2 (n= 175), open inguinal hernia repair 214.4 ± 97.2 (n= 119), minimally invasive inguinal hernia repair 187.7 ± 87.8 (n= 117), and lumpectomy 212.5 ± 114.5 (n= 63). There was significant variation in OME prescribed by procedure and by surgeon (p= 0.006 and p= 0.008, respectively). Review of post-intervention cases showed a significant reduction in the OME prescribed each year (mean OME 197.6 in 2015 to 2017 vs 72.3 in 2018; p < 0.005), and a 60% to 70% reduction in mean OME per procedure. Post-intervention data also revealed resolution of previously seen variation in prescription practices, and a significant increase in the percentage of patients prescribed multimodal pain therapy (23.5% in 2015 to 2017 to 31.5% in 2018; p < 0.05). We achieved a 60% to 70% decrease in postoperative opioid prescription at our community hospital for 5 common surgical procedures, and resolution of variation in opioid prescription practices after a hospital-wide intervention and statewide legislation.

Early Hemoconcentration Is Associated With Increased Opioid Use in Hospitalized Patients With Acute Pancreatitis.

Opioids are commonly required for abdominal pain in hospitalized patients with acute pancreatitis (AP). The factors associated with increased opioid requirements are unknown. The medical records of adult inpatients with AP from 2006 to 2016 were reviewed. Patients with chronic pancreatitis, psychiatric comorbidities, intubation, chronic opioid, and illicit drug use were excluded. The total quantity of opioids required during the first 7 days of hospitalization was converted to oral morphine equivalents (OME), divided by the number of days opioids were required to obtain the mean OME per day(s) of treatment (MOME). Multiple regression analysis was performed to identify factors associated with MOME. A total of 267 patients were included. The mean (standard deviation) age was 46.9 (13.9) years and 56% were males. The most common etiology was alcohol (55.4%). The mean (standard deviation) MOME was 59.1 (54.5) mg. Although age (P = 0.008), black race (P = 0.004), and first episode of AP (P = 0.049) were associated with a lower MOME, early hemoconcentration (hematocrit ≥44%) (P < 0.001) was associated with an increased MOME. Early hemoconcentration is associated with an increased opioid requirement in hospitalized patients with AP. The impact of fluid therapy in these patients merits prospective study.

More opioids, more constipation? Evaluation of longitudinal total oral opioid consumption and self-reported constipation in patients with cancer.

211 Background: Constipation is a distressing physical symptom inadequately assessed in patients with cancer. Total opioid consumption may impact opioid-induced constipation (OIC) prevalence. This study examined total daily opioid consumption on self-reported constipation in patients with cancer. Methods: We performed a retrospective analysis in patients who had a histologically-confirmed cancer diagnosis and completed at least 2 outpatient PC visits at an academic palliative care (PC) clinic. At each PC visit, we collected self-reported constipation scores (11-point scale, 0 [no symptom] to 10 [worst symptom]) and 24-hour oral morphine equivalents (OME) for up to 5 visits. Spearman correlation examined the association between OME and presence of constipation rated ≥3 and Wilcoxan-Mann-Whitney examined OME between patients with or without constipation. Univariable logistic regression examined associations of independent variables on constipation. Results: We identified 404 patients with cancer (mean age 55.5±14.3 years, 61.9% women, 89% metastatic disease). The most common cancer types were gastrointestinal (n = 115; 31%) and gynecologic (n = 47; 13%). Stimulant laxative use was observed in 172 (44.9%) patients. Across all visits, we observed a weak association between OME and patient-reported constipation score (r = 0.16-0.24, p &lt; 0.05 for 4 of 5 visits). Mean OME increased, while mean constipation score decreased across visits. At the first visit, higher mean OME was seen in patients who self-reported constipation (128.8 vs 92.3; p &lt; 0.05). In contrast, for each subsequent clinic visit there was no difference in mean OME in patients with or without constipation. Age, sex, metastatic disease, and stimulant laxative use were not associated with constipation. Conclusions: A weak association was observed between OME and self-reported constipation in cancer patients across multiple palliative care visits. Except for the first clinic visit, there was no difference in OME and self-reported constipation scores. These results suggest a lack of a clear association between total opioid consumption and patient-reported constipation.

Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty

Postoperative pain control, short-term and long-term narcotic consumption, complication rates, and costs of indwelling interscalene catheter (ISC) were compared with a liposomal bupivacaine (LBC) mixture in patients undergoing primary total elbow arthroplasty. Forty-four consecutive patients were identified, the first 28 with an ISC and the later 16 with intraoperative LBC injection that also included ketorolac and 0.5% bupivacaine. Medical records were reviewed for visual analog scale scores for pain, oral morphine equivalent (OME) use, complications, and facility charges. Average visual analog scale scores at 24 hours, 2 weeks, 6 weeks, and 12 weeks were not significantly different. Mean OME use was significantly greater in the LBC group at 24 hours but less at 12 weeks, although this difference was not statistically significant. Twelve anesthetic-related complications occurred in the ISC group (1 major and 11 minor); 10 patients (36%) had at least 1 complication. The major complication was respiratory failure requiring emergent tracheostomy. Minor complications included leaking pump/catheters, catheters inadvertently pulled out early, global hand paresthesias, forearm paresthesias, and pain at the catheter site. There were no anesthetic-related complications in the LBC group. The average charge for the LBC mixture was $327.10; charges for ISC, including equipment and anesthesia fees, were $1472.42. An LBC mixture provides similar pain relief with fewer complications at a lower cost than indwelling ISC after total elbow arthroplasty. Although the OME use in the LBC group was almost double that of the ISC group at 24 hours, there was no difference at later time points.