Narcotic Prescriptions Research Articles

ED treatment of migraine patients has changed

Study objectivesNumerous studies have shown benefits of nonnarcotic treatments for emergency department (ED) migraine patients. Our goal was to determine if ED treatment of migraine patients and the rate of return within 72 h have changed. MethodsDesign: Multi-hospital retrospective cohort. Population: Consecutive ED patients from 1-1-1999 to 9-31-2014. Protocol: For determining treatments, we examined charts at the beginning (1999–2000) and end (2014) of the time period. We combined similar medications into the following groups: parenteral narcotics, oral narcotics, antihistamines and dopamine receptor antagonists prochlorperazine/metoclopramide (DRA). We calculated the percent of migraine patients given each treatment in each time period. We identified those who returned to the same ED within 72 h, and calculated the difference in annual return rates between 1999–2000 and 2014. ResultsOf the 2,824,710 total visits, 8046 (0.28%) were for migraine. We reviewed 290 charts (147 in 1999–2000 and 143 in 2014) to determine migraine treatments. The use of IV fluids, DRA, ketorolac and dexamethasone increased from 1999–2000 to 2014, whereas narcotic use and discharge prescriptions for narcotics decreased. Of the 8046 migraine patients, 624 (8%) returned within 72 h. The return rate decreased from 1999–2000 to 2014 from 12% to 4% (difference = 8%, 95% CI 5%–11%). ConclusionFor ED migraine patients, the use of IV fluids, DRA, ketorolac and dexamethasone increased whereas the use of narcotics and discharge prescriptions for narcotics decreased. The return rates for migraines decreased. We speculate that the increased use of non-narcotic medications contributed to this decrease.

Celecoxib versus ketorolac following robotic hysterectomy for the management of postoperative pain: An open-label randomized control trial

ObjectiveCompare postoperative pain scores following hysterectomy in patients receiving perioperative celecoxib versus postoperative ketorolac as part of a multimodal pain regimen. MethodsPatients undergoing hysterectomy were randomized to receive scheduled intravenous ketorolac in the immediate postoperative period or oral celecoxib prior to surgery and continued for a total seven days. All patients received a common multimodal pain protocol consisting of scheduled acetaminophen, gabapentin, and opioids as needed. Inpatient pain scores and postoperative opioid use were analyzed. A questionnaire regarding outpatient opioid use and return to normal activities of daily living (ADLs) was returned two weeks postoperatively. Results192 patients were assessed for eligibility and 170 patients were randomized. Enrollment of patients undergoing open hysterectomy was closed prematurely for poor accruement (n = 32). 138 patients undergoing robotic hysterectomy were included were analyzed. There were no differences for inpatient pain scores (2.7 ± 1.9 v. 2.4 ± 1.6, p = 0.21). Average length of stay was similar between the two arms (11.6 ± 8.1 h v. 11.9 ± 7.6 h, p = 0.41). Patients in the celecoxib arm used less prescription opioids (6.0 ± 3.6 v. 8.1 ± 4.0, p = 0.001) and stopped using oral opioids earlier (3.8 ± 2.6 days v. 5.7 ± 2.8 days, p < 0.001). No differences were seen in inpatient opioid or anti-emetic usage, perioperative complications, or days to return to ADLs. ConclusionsThere was no difference in inpatient pain scores between patients who received celecoxib or ketorolac as part of multimodal pain control following robotic hysterectomy. Patients who received scheduled celecoxib for seven days after surgery used less prescription narcotics.

Perioperative Narcotic Use and Carpal Tunnel Release: Trends, Risk Factors, and Complications.

Background: The goals of the study were to: (1) evaluate trends in preoperative and prolonged postoperative narcotic use in carpal tunnel release (CTR); (2) characterize risks for prolonged narcotic use; and (3) evaluate narcotic use as an independent risk factor for complications following CTR. Methods: A query of a large insurance database from 2007-2016 was conducted. Patients undergoing open or endoscopic CTR were included. Revision surgeries or patients undergoing median nerve repair at the forearm, upper extremity fasciotomies, or with distal radius fractures were excluded. Preoperative use was defined as narcotic use between 1 to 4 months prior to CTR. A narcotic prescription between 1 and 4 months after surgery was considered prolonged postoperative use. Demographics, comorbidities, and other risk factors for prolonged postoperative use were assessed using a regression analysis. Subgroup analysis was performed according to the number of preoperative narcotic prescriptions. Narcotic use as a risk factor for complications, including chronic regional pain syndrome (CRPS) and revision CTR, was assessed. Results: In total, 66 077 patients were included. A decrease in prescribing of perioperative narcotics was noted. Risk factors for prolonged narcotic use included preoperative narcotic use, drug and substance use, lumbago, and depression. Preoperative narcotics were associated with increased emergency room visits, readmissions, CRPS, and infection. Prolonged postoperative narcotic use was linked to CRPS and revision surgery. Conclusions: Preoperative narcotic use is strongly associated with prolonged postoperative use. Both preoperative and prolonged postoperative prescriptions narcotic use correlated with increased risk of complications. Preoperative narcotic use is associated with a higher risk of postoperative CRPS.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Surgery and Opioids: 75. Opioid utilization following lumbar arthrodesis: trends and factors associated with long-term use

BACKGROUND CONTEXT Opioid therapy is one of the most effective and commonly practiced methods to control acute postoperative pain. Concerns relating to the overwhelming use of prescription narcotics including an inherent risk of abuse and tolerance has been a contentious issue. In patients undergoing lumbar spine surgery, limited or no data exist on potential risk factors for prolonged postoperative opioid use. In the context of national concern, it is pertinent to define epidemiological trends and risk factors of opioids use in spine patients for practice surveillance, preventive strategies, and patient counseling and welfare. PURPOSE To investigate trends in postoperative narcotic use amongst preoperative opioid users (OU) versus opioid-naive (ON) patients, and identify factors associated with postoperative narcotic use at one year following lumbar arthrodesis. STUDY DESIGN/SETTING Retrospective, observational cohort study. PATIENT SAMPLE A total of 26,553 patients (OU: 58.3%) registered in the Humana Inc. claims dataset (2007 through 2016Q3) that underwent either anterior (ALIF), posterior or transforaminal lumbar interbody fusions (P/TLIFs), postero-lateral fusion (PLF) or a combination of ALIF and PLF. OUTCOME MEASURES Postoperative monthly opioid prescription filling rates up to one year in OUs and ON patients, and risk factors associated with prolonged opioid usage. Prolonged opioid use was defined as narcotic prescription filling at one year following lumbar arthrodesis. METHODS Using the Humana Inc. claims dataset (2007 through 2016Q3), we identified patients undergoing lumbar arthrodesis. Based on preoperative opioid use, patients were identified as an OU (history of the narcotic prescription filled within three months before surgery) or ON (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and longitudinally tracked up to one year postoperatively for both OU and ON patients. Using log-binomial multivariable regression techniques, factors associated with opioid use at one year following lumbar arthrodesis. In an observational cohort study, we identified patients registered in the Humana Inc. claims dataset (2007 through 2016Q3) who underwent anterior (ALIF) or posterior/transforaminal lumbar interbody fusions (P/TLIFs), or postero-lateral fusion (PLF) or a combination of ALIF and PLF. Based on preoperative opioid use, patients were identified as an OU (history of the narcotic prescription filled within three months before surgery) or an ON (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and trended for one year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at one year following lumbar surgery. RESULTS Overall, 26,553 patients (OU: 58.3%) underwent lumbar surgery (ALIF:8.5%; P/TLIF:43.8%; PLF:41.5%; ALIF+PLF:6.2%). At one month following surgery, 60.2% NOU and 82.9% OUs had a filled opioid prescription. At three months, rates of prescription opioids declined significantly to 13.9% in NOUs versus 53.8% in OUs, while plateauing at 6-12-month postoperative period (NOU:8.4-9.6%; OU:42.1-45.3%). At one year, significantly higher narcotic prescription filling rates was observed in OUs compared to NOUs (42.4% vs. 8.6%; p CONCLUSIONS Approximately one-third of patients used opioids prior to lumbar spine surgery. Postoperative opioid use fell dramatically during the first three months in ON patients, but nearly half of the preop opioid users will remain on narcotics at one year after primary lumbar arthrodesis. Our findings serve as a baseline in identifying patients at risk for chronic use and encourage discontinuation of opioids prior to lumbar spinal surgery owing to the risks associated with it. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Surgery and Opioids: 74. Opioid utilization following cervical spine surgery: trends and factors associated with long-term use

BACKGROUND CONTEXT Limited or no data exist evaluating risk-factors associated with prolonged opioid use following cervical arthrodesis. PURPOSE To assess trends in postoperative narcotic use amongst preoperative opioid users (OU) versus nonopioid users (NOU), and identify factors associated with postoperative narcotic use at one year following cervical arthrodesis. STUDY DESIGN/SETTING Retrospective, observational cohort study with longitudinal follow-up. PATIENT SAMPLE A total of 17,391 patients (OU: 52.4%) registered in the Humana Inc. claims dataset that underwent anterior (ACF) or posterior cervical fusions (PCF) between 2007 and 2015. OUTCOME MEASURES Prolonged opioid usage defined as narcotic prescription filling at one year following cervical arthrodesis. METHODS Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3-months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU, and trended for 1-year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at one year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis: https://www.neurosurgerycost.com/opioid/opioid_use RESULTS Overall, 87.4% patients (n=15,204) underwent ACF while 12.6% (n=2,187) underwent PCF. At one month following surgery, 47.7% NOU and 82% OUs had a filled opioid prescription. At three months, rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs, while plateauing at 6-12 month postoperative period (NOU:5.7-6.7%; OU:44.9-46.9%). At one year, significantly higher narcotic prescription filling rates were observed in OUs compared to NOUs (45.3% vs. 6.3%;p CONCLUSIONS Over 50% patients used opioids prior to cervical arthrodesis. Postoperative opioid-use fell dramatically during the first three months in NOU, but nearly half of the preop opioid users will remain on narcotics at one year postop. Our findings serve as a baseline in identifying patients at risk for chronic use and encourage discontinuation of opioids prior to cervical spinal surgery FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

A Prospective Evaluation of Opioid Consumption Following Orthopaedic Foot and Ankle Surgery

Category: Other Introduction/Purpose: The purpose of our study was to assess opioid consumption patterns following outpatient orthopaedic foot and ankle procedures in order to develop a pragmatic approach to narcotic drug prescription. Methods: Patients undergoing outpatient orthopaedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history and Visual Analog Scale (VAS), anesthesia type, procedural details, and opioid prescription and consumption details. Utilization rates were compared using the Man-Whitney Test or the Kruskall-Wallis analysis of variance test with post-hoc Dunn’s multiple comparison test. Results: A total of 1,009 of 1,027 patients were included in this study (mean age: 49 years). Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 51% and nearly 21,196 pills left unused. Patients who received forefoot surgery used 6 pills less than those receiving hindfoot/ankle surgery (p=0.002). Patients between the ages of 60-79 consumed significantly less than those between 18-59 years old (p&lt;0.012). Patients with preoperative VAS score =77 (p=0.002) or self-reported anxiety (p=0.070) a had an increase in opioid consumption compared to those who did not. Conclusion: Our study demonstrates that patients who undergo orthopaedic foot and ankle procedures are overprescribed narcotic medication by nearly twice the amount that is actually consumed. This leads to a significant surplus of narcotics available for potential diversion. We recommend that surgeons judiciously administer opioid prescriptions based on their patients’ consumption patterns and anatomic location of surgery.

Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed ( scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 ( P = .034) as well as use regional nerve blocks for scenario 2 ( P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

335 Preoperative administration of a long-acting local anesthetic block to limit narcotic use after inflatable penile prosthesis insertion

With the growing epidemic of opioid abuse, surgeons must consider ways to limit prescribing narcotics when possible. Placement of an inflatable penile prosthesis (IPP) for refractory erectile dysfunction (ED) is associated with postoperative pain commonly requiring narcotics. We evaluated the feasibility of a long acting, easy-to-administer preoperative local anesthetic block in discharging patients on postoperative day (POD) 0 after IPP placement without a narcotic prescription. 85 men underwent IPP placement for refractory ED with a local penoscrotal block. A mixture of 0.5% ropivacaine 20cc, 1% lidocaine 20cc, sodium bicarbonate 1cc, and dexamethasone 4mg was prepared and administered using a 22-gauge needle into the pudendal space bilaterally, subcutaneous penile ring, and the external inguinal ring. The IPP was placed using a modified no-touch technique through a subcoronal (88%), infrapubic (11%), or penoscrotal (1%) approach. In addition to local penoscrotal block, 27 (32%) and 58 (68%) patients received general anesthesia and monitored anesthesia care, respectively. The Wong-Baker FACES Visual Analog Scale was used to evaluate pain in the recovery room with an average score of 4.4 (range 0-6). All patients were discharged home on POD 0 with a prescription for Acetaminophen or NSAIDs; none were prescribed narcotics. When evaluated on POD 2, 9 (11%) patients required a narcotic prescription. However, at POD 7-10 days, no patients were taking narcotics.

A pilot study of a breast surgery Enhanced Recovery After Surgery (ERAS) protocol to eliminate narcotic prescription at discharge.

The evolving conceptualization of the management of surgical pain was a major contributor to the supply of narcotics that led to the opioid crisis. We designed and implemented a breast surgery-specific Enhanced Recovery After Surgery (ERAS) protocol using opioid-sparing techniques to eliminate narcotic prescription at discharge without sacrificing perioperative pain control. A pilot observational study included patients with and without cancer undergoing lumpectomy. The convenience sample consisted of an ERAS group and a control usual care (UC) group who underwent surgery during the same time period. Discharge narcotic prescriptions were compared after converting to oral morphine milligram equivalents (MME's). Postoperative day one and week one pain scores were also compared between the two groups. Ninety ERAS and 67 UC patients were enrolled. Most lumpectomies were wire-localized, and half of the patients in each group had breast cancer. There were more obese patients in the ERAS group. UC lumpectomy patients were discharged with a median of 54.5 MMEs (range 0-120), while the ERAS lumpectomy patients were discharged with none (p < 0.001). Postoperative pain scores were not significantly different between groups, and there were few complications. A breast surgery-specific ERAS protocol employing opioid-sparing techniques successfully eliminated postoperative narcotic prescription without sacrificing perioperative pain control or increasing postoperative complications. By promoting the adoption of similar protocols, surgeons can continue to improve patient outcomes while decreasing the quantity of narcotics available for diversion within our patients' communities.

Food and Drug Administration upscheduling of hydrocodone and the effects on nurse practitioner pain management practices.

In 2013, the Advisory Committee of the Food and Drug Administration determined hydrocodone combination medications (HCMs) needed tighter regulation due to high abuse potential; they recommended upscheduling HCMs from Schedule III to II. The purpose of this study was to examine the effect of upscheduling of HCMs on pain management practices of advanced practiced registered nurses (APRNs) in Oklahoma. In this qualitative study, 25 participants described their primary care experiences after the upscheduling. A thematic analysis was used to understand the effects on APRN pain management practices. The upscheduling of HCMs has greatly affected the pain management practices of APRNs in a state where Schedule II narcotic prescribing is forbidden. Findings will assist APRNs with improving patient access to care, implementing practice regulations, and exploring options for alternative pain therapies in primary care. Upscheduling of HCMs has had a severe impact on APRNs, affecting their prescribing practices and leading to increased referrals. They noted limited treatment options, increased health care costs, and decreased access to care. The APRNs understand the problem of prescription opioid abuse, diversion, and misuse. A consensus model could standardize the regulatory process for APRNs, increase interstate mobility for practice, and increase access to APRN care nationwide.

How much is enough? Narcotic prescribing practices and patient-reported outcomes from a single institution quality improvement project

Objective: To ascertain whether the postoperative narcotic-prescribing practices of gynecologic surgeons is in alignment with outpatient patient narcotic usage and to evaluate patient-reported prescription storage and disposal patterns.

Patients With Hip or Knee Arthritis Underreport Narcotic Usage

BackgroundPatients taking narcotics chronically are more likely to have worse outcomes after total joint arthroplasty. These negative outcomes may be avoided when modifiable risk factors such as narcotic use are identified and improved before elective joint replacement. An accurate assessment of narcotic use is needed to identify patients before surgery. This study examines the amount of reported narcotic use in patients with hip or knee osteoarthritis and compares this with the narcotic prescriptions recorded in our state’s drug prescription monitoring database. MethodsAll new patients seen during a 1-year period by our adult reconstruction practice were identified. Patients’ electronic health records were reviewed to determine whether narcotic use was reported. A subsequent search was performed using the Arkansas Prescription Drug Monitoring Program to determine if the patient had been previously prescribed a narcotic. ResultsA total of 502 patients were included in the study. One hundred seventy patients (34%) were prescribed a narcotic within 3 months of the clinic visit according to the Arkansas Prescription Drug Monitoring Program, but only 111 (22%) reported narcotic use in their electronic health record (P < .0001). Moreover, only 92 patients (54% of 170) prescribed a narcotic within 3 months reported it. Narcotic recipients were more likely to be under the age of 65 years (P = .0081), smokers (P < .0001), and current benzodiazepine users (P < .0001). ConclusionThis study demonstrates that patients significantly underreport their narcotic use to their physician. The availability of a state prescription drug monitoring program allows physicians to check the frequency of filled narcotic prescriptions by their patients.

Opioid consumption day prior to discharge in patients undergoing open gynecologic surgery in an ERAS program: Developing a model for reduction in narcotic discharge prescriptions.

Opioid consumption day prior to discharge in patients undergoing open gynecologic surgery in an ERAS program: Developing a model for reduction in narcotic discharge prescriptions.

A 10-yr Analysis of Chronic Pelvic Pain and Chronic Opioid Therapy in the Women Veteran Population.

Chronic pelvic pain (CPP) affects an estimated 30% of women Veterans. Previous research shows high rates of narcotic abuse in the women Veteran population. Narcotics are not recommended for the treatment of CPP. Understanding how CPP impacts narcotic prescribing in the women Veteran population is critical to addressing the public health crisis of opioid abuse. Our objective was to compare chronic opioid therapy (COT) prescribed 5 yr prior to and following CPP diagnosis and to identify predictors of COT as well as adverse events associated with COT. We choose to look at 10 yr of data because we thought this time period would provide unique insight into the longitudinal associations of CPP and COT and was available in the database. Women with non-cancer CPP were included for analyses from the Veteran's Affairs Corporate Database Warehouse. COT was defined as 90 d of opiates/calendar year for each of the 5 yr proceeding and following the diagnosis of CPP. Patient characteristics and potential variables influencing COT were collected. We compared baseline demographics between the women who received COT to the women who did not receive COT to find additional demographic predictors of COT in association with CPP. Multivariable analysis identified predictors of COT in this population of women with CPP. We utilized an interrupted time series analysis to understand the impact of the diagnosis of CPP on COT. A total of 49,601 women met inclusion criteria with an average age of 40.1 ± 11.5 yr; 37.3% self-characterized as being a racial minority and 24% had a history of military sexual trauma. Chronic use increased significantly (p < 0.001) in the 5 yr preceding the diagnosis of CPP from 6.3% (n = 3124) of women at time -5 to 13.6% (n = 6746) at time 0. In the first year following the diagnosis of CPP, 16.8% (n = 8,333) of women with CPP met the criteria for COT (p < 0.001) and 15% (n = 7440) of women with CPP remained in the COT group for the remaining 5 yr following the diagnosis. On average women in the COT group had 250-292 d of opioids/year. When comparing women who received chronic narcotics following the diagnosis of CPP versus those who did not receive chronic narcotics, women who received COT were older, more likely to smoke and more frequently diagnosed with other pain conditions such as back pain, headaches, and fibromyalgia. (All p < 0.001). In the multivariable model, predictors of COT following CPP diagnosis included prior COT (OR = 10.0 (95% CI 9.4, 10.6), a positive history of military sexual trauma, smoking, and other chronic pain conditions. The distinct pattern of prescribing shown in this cohort may mean COT is prescribed for CPP and this prescribing pattern contributes to the adverse events associated with COT. As COT is not recommended for CPP, physicians need more education on the therapies available to help CPP patients.

Tamper-resistant prescription forms for narcotics in France: Should we generalize them?

In France, prescription of narcotics must be written on a tamper-resistant prescription form with specific technical particularities. Dosage and daily dose of medicines shall be written out entirely in letters. These prescription forms are also mandatory for buprenorphine, clorazepate, clonazepam, tianeptine, buccal midazolam and zolpidem owing to traffic, abuse or diversion. In 2012, to assess the use of standard and tamper-resistant prescription forms and the acceptability of the generalization of the latter to all medicines, a national opinion survey was performed, with a postal questionnaire, within three randomized samples of 1500 prescribers (physicians, dentists and midwives). Of the 403 participating prescribers (participation rate of 26.8%), 373 were physicians, 14 dentists and 16 midwives. Tamper-resistant prescription forms were used by 76.2% of prescribers, but only by 5.1% in a computerized version, whereas for standard prescription forms, 61% used computer assisted prescription software. The main reason was the inability of the prescription software to print these forms or to respect the mandatory prescription rules for narcotics. Theft and falsification of prescriptions had ever occurred (working life). Most prescribers (62.5%) were against the generalization of tamper-resistant prescription forms. Those in favour were for a generalization to all medicines (65%) and not only to psychotropic agents. Generalization of tamper-resistant prescription forms is not a consensual solution to prevent medicines' diversion. Some prescribers alluded to the possibility of dematerialization and electronic transmission of prescription forms, which could avoid theft, forgery or falsification.

MP26: An emergency department team-based quality improvement initiative reduces narcotic and benzodiazepine ‘to-go’ medication administration

Introduction: The administration of “to-go” medications in the Kelowna General Hospital Emergency Department was identified as an issue. Frequently, multiple administrations of “to-go” medication pre-packs were administered to individual patients on a frequent basis. In addition, the variability in “to-go” medication was substantial between providers. Recognizing the patient issues (addiction, dependency and diversion) and system issues (costs, risk) a team-based quality improvement initiative was instituted, utilizing a variety of quality improvement techniques. The aim was to reduce the number of “to-go” medications by half, within a year. Methods: The project began January 2015, and is ongoing. Multiple stakeholders were engaged within the emergency department; these included leaders of the physician, nursing and pharmacy teams, including an executive sponsor. Using change theory, and traditional Plan-Do-Study-Act (PDSA) cycles, an iterative methodology was proposed. The outcome measure proposed was number of “to-go” medications administered; secondary measures included number of opioid “to-go” and benzodiazepine “to-go“prescriptions. Balancing measures were the number of narcotic prescriptions written. Physician prescribing practice and nursing practice were reviewed at meetings and huddles. Individualized reports were provided to physicians for self-review. Data was collated at baseline then reviewed quarterly at meetings and huddles. Run charts were utilized along with raw data and individualized reports. Results: At baseline (January 2015), the number of “to-go” medications was 708. Over the next year, this value reduced to 459, showing a 35% reduction in “to-go”. Two years later (June 2017), this had reduced to 142, resulting in an overall reduction of 80% “to-go” medications. Secondary measures are currently under analysis. Further, no increase in prescribing of narcotics was seen during this time period. Conclusion: The administration of “to-go” medications from the emergency department has significant individual and societal impact. Frequently, these medications are diverted; meaning, sold for profit on the black market. Further, opioid prescribing is under increased scrutiny as the linkage between opioid prescriptions and addiction / dependency becomes more evident. This quality improvement initiative was successful for a number of reasons. First, we had strong engagement from the full emergency department clinical teams. The issue was first identified collaboratively, and teamwork and participation was strong from the outset. Second, we used individual and aggregate data to provide feedback on a regular basis. Third, we had strong support from our executive sponsor(s) who were able to support the efforts and champion and present the results locally, and now, throughout the Health Region.

Debates in Pain Management Testing

The annual healthcare costs associated with chronic pain are significant. Chronic pain also has important societal implications including the increasing availability of prescription narcotics. Recent literature and several professional societies have recommended urine drug testing to monitor adherence to prescription medications and to detect drug abuse and/or misuse. The technical benefits of urine drug testing using definitive testing methods such as LC-MS/MS are well documented. However, the guidelines, literature, and expert consensus on other aspects of pain management testing are sparse and/or more controversial. While many institutions and laboratories perform some form of validity and adulterant testing, the extent and utility of testing in pain management is not standardized. The benefits of point-of-care testing and the resources required to maintain a robust testing program are also not well studied. Furthermore, while urine testing is currently the gold standard in pain management, recent literature has shown some benefits of testing oral fluid and other matrices. There continue to be analytical and billing challenges with pain management testing. The utility of quantitative, definitive testing is controversial. Some laboratories only report qualitative results, while others find value in reporting some or all results quantitatively. Furthermore, the practice of laboratory professionals providing formal consultations for pain management testing and/or billing for interpretations is variable. Finally, pharmacogenomic testing is not routinely done in pain management, but some studies suggest it may be beneficial. Here we ask 7 individuals their expert opinion on different aspects of drug testing to assess compliance in pain management. Which validity and adulterant testing (e.g., observation of specimen collection, recording urine temperature immediately after collection, chain of custody, creatinine, specific gravity, pH, oxidants, nitrites) should be required? William Clarke: If there is a low suspicion for adulteration, measuring temperature, specific gravity, and creatinine should be sufficient. If tampering with the specimen …

Current State of the Opioid Epidemic as it Pertains to Pediatric Orthopaedics From the Advocacy Committee of the Pediatric Orthopaedic Society of North America.

The opioid epidemic in the United States has reached crisis proportions. Urgent response is needed. Hydrocodone in combination with acetaminophen is the most prescribed drug in the United States. The most common source of opioids available for misuse is the unused portions of postoperative prescriptions. Among high school seniors, 80% of those who reported nonmedical use of prescription opioids previously had legitimate prescriptions but recreationally used leftover doses. Roughly one-quarter of patients do not take any of their postoperatively prescribed opioids and the remainder take one-third to two-thirds of the prescribed doses. A summary of the literature is presented beginning from historical perspective to current status and pertinent strategies in dealing with this complicated problem. This review includes data from an electronic survey of the members of the Pediatric Orthopaedic Society of North America (POSNA) with regard to the prescriptions they would provide for 7 treatment scenarios. Strategies for the preoperative, intraoperative, and postoperative phases of management of pain as well as strategies for education, research, and advocacy are presented. The Pediatric Orthopaedic Society of North America survey yielded 264 respondents. The 3 most commonly used opioid medications were hydrocodone, oxycodone, and acetaminophen with codeine, in that order, for most of the scenarios. The time period covered by postoperative prescriptions varied considerably. The magnitude of this problem is overwhelming. Education of care providers, patients and families, standardization of narcotic prescribing practices which incorporate patient characteristics, and appropriate plans for disposal of unused narcotics are immediate concepts to consider in correcting this problem. Long-term issues to tackle will be changing patient a family expectations, legislation, and obtaining additional resources directed towards this issue.

Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients.

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

Opioid use following cervical spine surgery: trends and factors associated with long-term use.

Limited or no data exist evaluating risk factors associated with prolonged opioid use following cervical arthrodesis. The objectives of this study were to assess trends in postoperative narcotic use among preoperative opioid users (OUs) versus non-opioid users (NOUs) and to identify factors associated with postoperative narcotic use at 1 year following cervical arthrodesis. This is a retrospective observational study. The patient sample included 17,391 patients (OU: 52.4%) registered in the Humana Inc claims dataset who underwent anterior cervical fusion (ACF) or posterior cervical fusion (PCF) between 2007 and 2015. Prolonged opioid usage was defined as narcotic prescription filling at 1 year following cervical arthrodesis. Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3 months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and trended for 1 year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at 1 year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis (http://neuro-risk.com/opiod-use/ or https://www.neurosurgerycost.com/opioid/opioid_use). Overall, 87.4% of the patients (n=15,204) underwent ACF, whereas 12.6% (n=2187) underwent PCF. At 1 month following surgery, 47.7% of NOUs and 82% of OUs had a filled opioid prescription. Rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs at 3 months, but plateaued at the 6- to 12-month postoperative period (NOU: 5.7%-6.7%, OU: 44.9%-46.9%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs compared with NOUs (45.3% vs. 6.3%, p<.001). Preoperative opioid use was a significant driver of 1-year narcotic use following ACF (odds ratio [OR]: 7.02, p<.001) and PCF (OR: 6.98, p<.001), along with younger age (≤50 years), history of drug dependence, and lower back pain. Over 50% of the patients used opioids before cervical arthrodesis. Postoperative opioid use fell dramatically during the first 3 months in NOU, but nearly half of the preoperative OUs will remain on narcotics at 1 year postoperatively. Our findings serve as a baseline in identifying patients at risk of chronic use and encourage discontinuation of opioids before cervical spine surgery.