Mg Of Morphine Equivalents Research Articles

High-risk use of prescription opioids among patients treated for alcohol problems in New York State. A repeated cross-sectional study, 2005–2018

BackgroundPatients with alcohol use disorder (AUD) and high-risk opioid use are at risk of serious complications. The purpose of this study was to estimate the prevalence of and factors associated with high-risk opioid use in patients with an alcohol use problem from 2005 to 2018. MethodsThis repeated cross-sectional study analyzed data from first admissions for alcohol treatment (2005–2018) to the NYS Office of Addiction Services and Supports merged with Medicaid Claims Data. High-risk opioid use was defined as opioid dose ≥50 morphine mg equivalents (MME) per day; opioid prescriptions overlapping ≥7 days; opioids for chronic pain >90 days or opioids for acute pain >7 days. ResultsPatients receiving ≥50 MME increased from 690 to 3226 from 2005 to 2010; then decreased to 2330 in 2018. From 2005–2011, patients with opioid prescriptions overlapping ≥7 days increased from 226 to 1594 then decreased to 892 in 2018. From 2005–2010, opioid use >7 days for acute pain increased from 133 to 970 and plateaued after 2010. From 2005–2018, patients who received opioids >90 days for chronic pain trended from 186 to 1655. White patients, females, age 36–55, patients with chronic and acute pain diagnoses had the highest rates of high-risk use. ConclusionsThe prevalence of high-risk opioid use in patients with alcohol use problems increased from 2005 to 2011, and generally decreased after 2010. However, prevalence of opioids >90 days for chronic pain trended up from 2005 to 2018. High-risk opioid use among patients with AUD emphasizes the need to develop interventional strategies to improve patient care.

A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service.

To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.

Comparing Postoperative Pain With Laparoscopic Versus Robotic Sacrocolpopexy

Study ObjectiveTo compare postoperative pain and pain-related outcomes following laparoscopic (LS-MISC) versus robotic minimally invasive sacrocolpopexy (R-MISC). DesignA secondary analysis of an original placebo-controlled randomized-controlled trial (RCT) examining preoperative IV acetaminophen on postoperative pain following MISC. SettingPlanned secondary analysis of multicenter RCT. Patients or ParticipantsWomen undergoing MISC. InterventionsCo-primary outcomes at 24 hours were total opioid use in morphine mg equivalents (MME) and visual analog scale (VAS) pain scores comparing LS-MISC and R-MISC. The secondary outcome was pain scores using a pain diary through seven days post-procedure. Measurements and Main ResultsThe original study was a double blind, multi-center, RCT comparing intravenous acetaminophen to placebo that took place between 2014 and 2017. Given that the original trial was unable to show an impact from the use of intravenous acetaminophen, our analysis focused on the impact of surgical modality. We included 90 subjects undergoing MISC: 65 LS-MISC and 25 R-MISC. Most were Caucasian (97.8%) and postmenopausal (88.9%) with mean age 61.2±7.2 years and BMI 27.6±4.4 kg/m2. IV acetaminophen did not impact pain in the original study and was not different between LS-MISC and R-MISC. Concomitant hysterectomy was performed in 67% (LS-MISC) vs. 60% (R-MISC, p=0.49). LS-MISC underwent more perineorrhaphies (15.4% vs 0%, p=0.04) and posterior repairs (18.5% vs 0%, p=0.02). Operative time was longer with LS-MISC (208.5±57.3 vs 143.6±21.0 minutes, p=<0.01). Length of stay was longer with LS-MISC (0.9±0.4 vs 0.7±0.4 days, p=0.02). Women undergoing LS-MISC consumed more opioid MMEs through 24 hours when including intraoperative opioid's (48.5±25.5 vs 35.1±14.6 MME, p=<0.01). Using linear regression correcting for operative time and concomitant vaginal repairs, this difference disappeared. Likewise, when intraoperative opioids were excluded, there was no difference. There were no differences in 24-hour post-operative VAS scores, opioid use in first week, or quality of life (PROMIS PI-SF, all p<0.05). ConclusionWhen comparing VAS pain scores, MME opioid usage, and quality of life between LS-MISC and R-MISC, there was either no difference or differences disappeared after adjusting for confounders. Overall, opioid use, pain scores, and opioid side effects were low.

Opioid Prescribing and Suicide Risk in the United States.

This study estimates associations of regional change in opioid prescribing with total suicide deaths and suicide overdose deaths involving opioids. A panel analysis was performed with 2009-2017 U.S. national IQVIA Longitudinal Prescription Database data and National Center for Health Statistics mortality data aggregated into commuting zones (N=886), which together span the United States. Opioid prescription exposures included opioid prescriptions per capita and percentages of patients with any opioid prescription, with high-dose prescriptions (>120 mg of morphine equivalents), with long-term prescriptions (≥60 consecutive days), and with prescriptions from three or more prescribers. Linear regression models were used with year and commuting zone fixed effects. Suicide deaths were significantly positively associated with opioid prescriptions per capita (β=0.045), having any opioid prescription (β=0.069), having high-dose prescriptions (β=0.024), having long-term prescriptions (β=0.028), and having three or more opioid prescribers (β=0.046). Similar significant associations were observed between each of the five opioid prescription measures and suicide overdose deaths involving opioids (β range, 0.029-0.042). However, opioid prescriptions per capita, having any opioid prescription, and having three or more opioid prescribers were each negatively associated with unintentional opioid-related deaths in people in the 10- to 24-year and 25- to 44-year age groups. In this retrospective study of U.S. commuting zone-level opioid prescriptions and mortality, regional decreases in opioid prescriptions were consistently associated with declines in total suicide deaths, including suicide overdose deaths involving opioids. For some opioid prescribing measures, negative associations were observed with unintentional overdose deaths involving opioids among younger people. Individual-level inferences are limited by the ecological nature of the analysis.

Predictive Validity and Patterns of Change Over Time of the Sensitivity to Pain Traumatization Scale: A Trajectory Analysis of Patients Seen by the Transitional Pain Service Up to Two Years After Surgery.

PurposeThe Sensitivity to Pain Traumatization Scale (SPTS-12) was developed to assess the propensity to develop a traumatic stress response to pain. The SPTS-12 is a reliable and valid scale with a one-factor structure. The aim of the present study is to further examine the psychometric properties of the SPTS-12 by evaluating its criterion validity and how scores change over time in a sample of postsurgical patients at the Toronto General Hospital Transitional Pain Service.Participants and Methods361 adults (55% male; Mage = 50.6 years, SDage = 14.3) completed questionnaires assessing symptoms of pain, anxiety, depression, and trauma at multiple visits to the Transitional Pain Service after surgery. Latent-class growth mixture modeling defined prototypical longitudinal patterns (latent trajectories) of SPTS-12 scores up to two years after surgery. One-way ANOVAs examined how trajectory classes differed over time on measures of daily opioid use (mg morphine equivalents (MME)), average pain intensity, pain interference, and depressive symptoms.ResultsThe final model consisted of five SPTS-12 trajectory groups; two characterized by a flat and unchanging pattern and three showing a small but statistically significant decrease over time. Analysis of pain-related outcomes predicted by SPTS-12 trajectories provided evidence of criterion validity of the SPTS-12. SPTS-12 trajectories did not significantly differ on daily MME at any time. Average pain, pain interference, and depression scores significantly differed across SPTS-12 trajectory groups at two or more postsurgical visits (all p < 0.05).ConclusionThe SPTS-12 shows fairly stable patterns and predicts important pain-related and psychosocial outcomes over time. Two SPTS-12 trajectories (#2 and #5) with high scores, comprising ~28% of the total sample, are associated with problematic outcomes on several pain and psychosocial measures. Targeting patients with high SPTS-12 scores for presurgical psychological treatment may prove beneficial in reducing the impact of CPSP.

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.

Opioid Prescribing Patterns After Skull Base Surgery for Vestibular Schwannoma.

Excessive opioid prescription is a source of prescription diversion and could contribute to chronic opioid abuse. This study describes the opioid prescribing patterns and risk factors for additional opioid prescription after surgical resection of vestibular schwannoma (VS). Retrospective chart review. Single tertiary referral center. Adult VS patients undergoing surgical resection between May 2019 and March 2020. Opioid use postoperatively and up to 60 days following surgery were characterized from medical records and by querying the state-wide Controlled Substance Utilization Review and Evaluation System. The presence of additional opioid prescriptions within 60 days of surgery. A total of 109 patients (mean age 50 yrs, 65.5% female) were prescribed an average of 138.2 ± 117.8 mg of morphine equivalents (MME). Twenty-two (20.9%) required additional prescriptions of 163.2 ± 103.2 MME. Age, gender, tumor size, or surgical approach (translabyrinthine, retrosigmoid, versus middle fossa) were not associated with additional prescriptions. Patients with additional prescriptions had higher body mass index (BMI 28.8 vs. 25.8 kg/m2, p = 0.015) and required more opioid medications during hospitalization (51.8 vs. 29.1 MME, p = 0.002). On multivariate logistic regression, higher BMI (odds ratio [OR] 1.32; p = 0.001), history of headaches (OR 11.9, p = 0.011), and history of opioid use (OR 29.3, p = 0.008) were associated with additional prescription. Additional opioid prescriptions may be necessary in a portion of VS patients undergoing surgery. The choice of surgical approach is not associated with excess opioid requirements. Patients with higher BMI, history of headaches, or preoperative opioid use may require additional prescriptions.

Perioperative Oral Pregabalin Results in Postoperative Pain Scores Equivalent to Those of Interscalene Brachial Plexus Block After Arthroscopic Rotator Cuff Repair: A Randomized Clinical Trial

To compare the analgesic effects of pregabalin to those of single-shot interscalene brachial plexus block (ISBPB) in adults having arthroscopic rotator cuff (RC) repair, as well as ISBPB's effect on postoperative opioid consumption, patient satisfaction, and opioid-related adverse effects. In this randomized trial, 79 adults having arthroscopic RC repair were randomized to receive perioperative oral pregabalin (Lyrica, twice daily starting the evening before surgery, for a total of 4 doses) or single-shot ISBPB (20 ml of bupivacaine 0.25%). Intra- and postoperative management was standardized. The primary outcome was median self-reported pain score (on a visual analog scale of 0 to 100) at rest during the initial 10 postoperative days. Other outcomes included pain during activity, postoperative opioid consumption, opioid-related adverse effects, quality of recovery, and pain satisfaction score. Of 71 eligible patients, 59 were analyzed, of whom 29 received pregabalin and 30 received ISBPB. Groups were similar regarding demographic, baseline, and intraoperative variables. Median pain score at rest over the 10 postoperative days was 51 (interquartile range 26, 76) in the pregabalin group and 52 (22, 74) in the ISBPB group (difference 0.5 points; 95% confidence interval [CI] -3.2 to 6.3; P= .53). Opioid consumption during the initial 10 postoperative days was also similar (difference in median 90 mg of morphine equivalents; 95% CI -32 to 177.5; P= .12). No differences were found in any other outcome. Perioperative use of pregabalin in adults undergoing arthroscopic RC repair provided analgesia comparable to that of ISBPB for 10 days after surgery. II, randomized controlled trial (high dropout rate).

Opioid use after cesarean: a cohort study comparing combined versus separate oxycodone and acetaminophen regimens

Objective To determine whether an inpatient post-cesarean analgesic regimen which separated oxycodone and acetaminophen resulted in less inpatient opioid use, when compared to a regimen using combination medications containing both acetaminophen and oxycodone in a cohort including patients of all gestational ages, acuity levels, and modes of operative anesthesia. Methods This is a retrospective cohort study which was conducted at a single tertiary care center Labor and Delivery unit. Data were collected via retrospective chart review, and a total of 170 records were examined with a final N = 150. Inclusion criteria were all patients over the age of 18, and >23.0 weeks gestational age, who had a singleton or twin cesarean delivery regardless of their mode of operative anesthesia and whether or not they received intrathecal opioid at time of delivery. Exclusion criteria were pregnancies of higher-level multiples (triplets or greater), prolonged intensive care unit (ICU) stay, and patients who received both combination oxycodone-acetaminophen and separately administered oxycodone. For analysis patients were classified into two groups: the “Combined Medication” group representing patients who received combination oxycodone-acetaminophen medication only (n = 83) and the “Separate Medication” group representing patients who received oxycodone and acetaminophen separately (n = 67). Differences between the groups with respect to opioid use and acetaminophen use were assessed. Results The primary outcome was inpatient opioid medication use per 12-h period in intravenous morphine mg equivalents (MME). Patients received an average of 4.6 ± 3.5 MME IV morphine per 12 h in the Separate Medication group and 5.7 ± 3.7 MME IV morphine per 12 h in the Combined Medication group. When controlled for several covariates, the Separate Medication group took significantly fewer MME per 12-h period (mean difference = −1.2, 95% CI: (−2.3, −0.1), p = .04). There was no appreciable difference in acetaminophen utilization between groups. Conclusions An analgesic regimen where oxycodone is ordered separately from acetaminophen is associated with reduced inpatient opioid medication use in patients of all gestational ages, acuity levels, and modes of operative anesthesia.

Concordance between high antibiotic prescribing and high opioid prescribing among primary care physicians: a cross-sectional study.

Background:Antimicrobial resistance and opioid misuse both present major public health challenges, and identifying high prescribers of both of these agents can help provide a common target for intervention. We sought to determine the association between being a high prescriber of antibiotics and being a high prescriber of opioids in the primary care setting.Methods:We performed a cross-sectional study of the antibiotic- and opioid-prescribing habits of primary care physicians in Ontario, Canada between Mar. 1, 2017, and Feb. 28, 2018, using administrative databases. We defined high prescribers as the top quartile of antibiotic or opioid prescribers using 3 antibiotic-prescribing metrics (prescriptions per patient visit, proportion of prescriptions that were broad spectrum and proportion of prescriptions > 8 d) and 3 opioid-prescribing metrics (prescriptions per patients seen, proportion of prescriptions > 90 mg of morphine equivalents and proportion of prescriptions > 28 d). We tabulated agreement between prescribing metrics using the κ statistic.Results:We included 9994 physicians. We observed minimal overlap between high antibiotic initiation and high opioid initiation (618 physicians [6.2%]) (κ = 0.00, 95% confidence interval −0.02 to 0.02). There was slight agreement between the antibiotic-prescribing indices and between the opioid-prescribing indices (within-class, range of κ 0.05 to 0.18). There was slight disagreement to slight agreement across antibiotic- and opioid-prescribing metrics (between-class, range of κ −0.09 to 0.16).Interpretation:Among primary care physicians, there was a lack of association between high antibiotic prescribing and high opioid prescribing. Our findings suggest that separate tailored approaches to antibiotic and opioid stewardship strategies are needed.

Use of Tramadol or Other Analgesics in Patients Treated in the Emergency Department as a Risk Factor for Opioid Use.

The objective of this cohort study was to determine the association between the use of tramadol in emergency departments and the later consumption of opioids at the outpatient level in a group of patients from Colombia. Based on a medication dispensation database, patients over 18 years of age treated in different clinics in Colombia who for the first time received tramadol, dipyrone, or a nonsteroidal anti-inflammatory drug (NSAID) in the emergency room between January and December 2018 were identified. Three mutually exclusive cohorts were created, and each patient was followed up for 12 months after the administration of the analgesic to identify new formulations of any opioid. A Cox proportional-hazards regression model was constructed to identify variables associated with receiving a new opioid. A total of 12,783 patients were identified: 6020 treated with dipyrone, 5309 treated with NSAIDs, and 1454 treated with tramadol. The mean age was 47.1 ± 20.4 years, and 61.6% were women. A total of 17.3% (n = 2207) of all patients received an opioid during follow-up. Those treated with tramadol received a new opioid with a higher frequency (n = 346, 23.8%) than the other cohorts (14.7% NSAIDs and 17.9% dipyrone, both p < 0.001). In the tramadol group, using more than 10 mg of morphine equivalents was associated with a greater use of new opioids (HR:1.47, 95%CI:1.12–1.93). Patients treated with tramadol in emergency departments have a higher risk of opioid use at the one-year follow-up than those treated with NSAIDs or dipyrone.

Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study

ObjectivesTo examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. DesignRetrospective cohort study using population-level administrative data. SettingOntario, Canada. ParticipantsIndividuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. InterventionsNot applicable. Main Outcome MeasuresProportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). ResultsA total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. ConclusionsA large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.

Comparison of intravenous lidocaine versus epidural anesthesia for traumatic rib fracture pain: a retrospective cohort study

BackgroundEffective analgesia is essential in managing traumatic rib fractures. Intravenous lidocaine (IVL) is effective in treating perioperative pain, acute pain in the emergency department, cancer pain in hospice, and outpatient...

Opioid Requirement following Arthroscopic Knee Surgery: Are There Predictive Factors Associated with Long-Term Use.

The purpose of this study is to identify patterns of postoperative narcotic use and determine the impact of psychosocial and perioperative factors on postoperative opioid consumption following arthroscopic knee surgery. Fifty consecutive patients undergoing arthroscopic knee surgery were prospectively enrolled. Patients were contacted via telephone at 1 week postoperatively to report their pain level and opioid consumption. The patient was contacted again at 2 weeks, 4 weeks, and 90 days as necessary until opioid cessation, at which time the patient's plan for unused pills was inquired. Opioid consumption was compared using t-tests and one-way analysis of variance for demographic and surgical factors. Linear regression was used to determine whether the Pain Catastrophizing Scale (PCS), Resilience Scale (RS-11), International Knee Documentation Committee questionnaire, or patient-reported pain at 1 week predicted higher opioid consumption. The average morphine equivalent dose of opioid consumption was 142 mg. Sixty-four percent consumed less than 100 mg, and 68% discontinued opioid use by 1 week postoperatively. Seventy-four percent reported surplus pills, and 49% of those patients plans for pill disposal. Factors associated with higher consumption included undergoing a major procedure, having a regional anesthesia block, and higher area deprivation index score (p < 0.05). Higher PCS scores and reported average pain level at 1 week were predictive of higher opioid consumption (p < 0.05). In conclusion, a majority of patients undergoing outpatient knee surgery did not require the entirety of their narcotic prescription. The majority of patients consumed less than 100 mg of morphine equivalents and discontinued opioid use by 1 week postoperatively. Ligament reconstruction, living in an area with a higher index of deprivation, and higher score on the PCS were associated with greater opioid consumption. Overall, patient knowledge regarding opioid disposal was poor, and patients would likely benefit from additional education prior to surgery.

Association of trainee involvement in an acute pain service with postoperative opioid use in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

BackgroundSeveral hospitals have implemented a multidisciplinary Acute Pain Service (APS) to execute surgery-specific opioid sparing analgesic pathways. Implementation of an anesthesia attending-only APS has been associated with decreased postoperative opioid consumption, time to ambulation, and time to solid food intake for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. In this study, we evaluated the impact of introducing an APS trainee on postoperative opioid consumption in patients undergoing hyperthermic intraperitoneal chemotherapy during postoperative day (POD) 0–3. MethodsWe performed a retrospective propensity-matched cohort study where we compared opioid consumption and hospital length of stay among two historical cohorts: attending-only APS service versus service involving a regional anesthesia fellow.ResultsIn the matched cohorts, POD 0–3 opioid use [25%, 75% quartile] for the single attending and trainee involvement cohort were 38.5 mg morphine equivalents (MEQ) [14.1 mg, 106.3 mg] and 50.4 mg MEQ [28.4 mg, 91.2 mg], respectively. The median difference was –9.8 mg MEQ (95% CI –30.7 to 16.5 mg; P = 0.43). There was no difference in hospital length of stay between both cohorts (P = 0.67).ConclusionsWe found that the addition of a regional anesthesia fellow to the APS team was not associated with statistically significant differences in total opioid consumption or hospital length of stay in this surgical population. The addition of trainees to the infrastructure, with vigilant supervision, is not associated with change in outcomes.

2738 Comparing Postoperative Pain with Laparoscopic Versus Robotic Sacrocolpopexy

Study Objective To compare postoperative pain and pain-related outcomes following laparoscopic (LS-MISC) versus robotic minimally invasive sacrocolpopexy (R-MISC). Design Secondary analysis of placebo-controlled RCT examining preoperative IV acetaminophen on postoperative pain following MISC. Setting Planned secondary analysis of multicenter RCT. Patients or Participants Women undergoing MISC. Interventions Primary outcome was total narcotics within 24 hours in morphine mg equivalents (MME) comparing LS-MISC and R-MISC. Measurements and Main Results We included 90 subjects undergoing MISC: 65 LS-MISC and 25 R-MISC. Most were Caucasian (97.8%) and postmenopausal (88.9%) with mean age 61.2±7.2 years and BMI 27.6±4.4 kg/m2. IV acetaminophen did not impact pain in the original study and was similar between LS-MISC and R-MISC. Baseline POP-Q stage was similar between groups. Concomitant hysterectomy was performed in 67% with LS-MISC, 60% with R-MISC (p=0.49). LS-MISC underwent more concomitant perineorrhaphies (15.4% vs 0%, p=0.04) and posterior repairs (18.5% vs 0%, p=0.02). Operative time was longer with LS-MISC (208.5±57.3 vs 143.6±21.0 minutes, p= Conclusion L-MISC showed increased length of stay and drowsiness. Most other outcomes showed either no difference or differences disappeared once adjusting for confounders as with primary outcome. Overall, MME narcotic use and VAS pain scales were low as were narcotic medication side effects.

A Prospective Evaluation of Postoperative Opioid Use in Otologic Surgery.

To prospectively evaluate opioid consumption following adult outpatient otologic surgery. Prospective observational. Single-tertiary referral center. Patients scheduled for otologic surgery who did not have a history of chronic opioid use were recruited between February 2018 and February 2019. Opioid consumption was queried using telephone or in-person surveys administered between postoperative days 5 and 15. Patient demographics, surgical details, and opioid prescription patterns were abstracted from medical records. Opioid distribution was determined by querying records maintained by the California Department of Justice through a state-wide prescription drug monitoring program mandated since 2016. Seventy patients were prescribed an average of 68.9 ± 31.8 mg of morphine equivalents (MME) and consumed 47.3 ± 42.9 MME over 2.4 ± 2.3 days postoperatively. Patients who received a postauricular incision were prescribed significantly more than those who underwent transcanal procedures (86.2 vs 55.9 MME; t test, p < 0.001), consumed significantly more (72.2 vs 28.6 MME; t test, p < 0.001), and for a significantly longer duration (3.4 vs 1.6 days; t test, p = 0.001). In the postauricular group, there was no significant difference in consumption between mastoidectomy and nonmastoidectomy subgroups (64.9 vs 89.2 MME; t test, p = 0.151). Eighty percent of transcanal patients consumed 50 MME (10 pills) or less, while 80% of postauricular patients consumed 80 MME (16 pills) or less. Patients in our cohort consumed approximately 3/4 of the prescribed opioids. Those with postauricular incisions used significantly more than those with transcanal incisions. Postoperative opioid prescription recommendations should be tailored according to the extent of surgery.

Association Between Obesity and Opioid Usage for Pain Management in Postpartum Women [05D

INTRODUCTION: The objective was to assess the relationship between obesity and opioid usage for women postpartum. METHODS: This study was a secondary data analysis of an RCT (NCT02909582), limited to women with a BMI ≥35 kg/m2 at delivery. A standard order set for postpartum pain medications was utilized inpatient. Opioids consumed postpartum were converted to milligrams of oral morphine equivalents. Outcomes included milligrams of morphine equivalent used in the first 48 hours of delivery and the highest pain score within the first 48 hours post-delivery. Relationships were explored with correlation and linear regression (accounting for demographic factors). RESULTS: BMI at delivery does not correlate with the mg of morphine equivalents utilized (n=273 women, Pearson r 0.034, P=.579) or the highest pain score (r 0.028, p 0.643) in the first 48 hours postpartum. Pain scores and opioid consumption were correlated (r=0.445, P&lt;.001). Age (RR 6.13; 95% CI 0.65, 11.61; P=.029) and race (RR -12.8; 95% CI -20.93, -4.66; P=.002) were significantly associated with opioids consumed when accounting for demographics, including mental health diagnosis. Both black and white patients had similar mean highest pain scores in the first 48 hours postpartum (6.5 vs 6.3). However, black patients used almost 1/3 less milligrams of opioids (mean 29.4 mg vs 41.1). CONCLUSION: The relationship between obesity and pain postpartum is complex, and includes mediating factors such as ethnicity, age, and presence of a mental health disorder. Despite a standardized pain medication order set and similar pain scores, there are racial differences in utilization of pain medications postpartum.

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

BackgroundDespite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions. MethodsAn ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ). ResultsWe included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P <0.001), lower peak pain scores (7 [5–9] vs 8 [7–9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P <0.001) were found after the introduction of the ERAS protocol. ConclusionsImplementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

Time trends in opioid prescribing among Ontario long-term care residents: a repeated cross-sectional study.

Opioids are an important pain therapy, but their use may be associated with adverse events in frail and cognitively impaired long-term care residents. The objective of this study was to investigate trends in opioid prescribing among Ontario long-term care residents over time, given the paucity of data for this setting. We used linked clinical and health administrative databases to conduct a population-based, repeated cross-sectional study of opioid use among Ontario long-term care residents between Apr. 1, 2009, and Mar. 31, 2017. We identified prevalent opioid use by drug type, dosage and coprescription with benzodiazepines, and within certain vulnerable subgroups. We used log-binomial regression to quantify the percent change between 2009/10 and 2016/17. Among an average of 76 147 long-term care residents per year, the prevalence of opioid use increased from 15.8% in 2009/10 to 19.6% in 2016/17 (p < 0.001). Over the study period, the use of hydromorphone increased by 233.2%, whereas the use of all other opioid agents decreased. The use of high-dose opioids (> 90 mg of morphine equivalents) and the coprescription of opioids with benzodiazepines decreased significantly, by 17.7% (p < 0.001) and 23.8% (p < 0.001), respectively. Increases in opioid prevalence were more notable among frail residents (37.6% v. 18.8% among nonfrail residents, p < 0.001) and those with dementia (38.6% v. 21.6% among those without dementia, p < 0.001). Within Ontario long-term care, trends suggest a shift toward increased use of hydromorphone but reduced prevalence of use of other opioid agents and potentially inappropriate opioid prescribing. Further investigation is needed on the impact of these trends on resident outcomes.