Narcotic Prescriptions Research Articles

Preoperative Smoking and Narcotic, Benzodiazepine, and Tramadol Use are Risk Factors for Narcotic Use After Hip and Knee Arthroplasty

BackgroundThe use of narcotics has been found to be a modifiable risk factor for success of arthroplasty. We sought to determine the risk factors leading to increased narcotic use after total hip arthroplasty and total knee arthroplasty. MethodsA retrospective chart review was performed on new patients presenting to an orthopedic reconstructive-service clinic. New patients aged 18 years or older with osteoarthritis of the hip or knee who presented over a 1-year period and underwent total knee arthroplasty or total hip arthroplasty were included. The Arkansas prescription monitoring program was then used to determine recent narcotic and benzodiazepine prescriptions filled within 3 months of surgery, and this was converted into morphine milligram equivalents (MME). ResultsOne hundred seventy-nine patients met the inclusion criteria. When compared with patients who did not take any preoperative opioids, narcotic- and tramadol-only users filled an average of 86% and 38% more MME, respectively. Benzodiazepine users required an average of 81% more MME postoperative than nonusers, and smokers required an average of 90% more MME postoperative than nonsmokers. Subjects with body mass index >40 kg/m2 had 82% higher average postoperative MME than subjects with body mass index <25 kg/m2. Age and sex had no significant correlation with postoperative narcotic use. ConclusionThis study suggests that a patient's preoperative narcotic, tramadol, benzodiazepine, and tobacco use are correlated to the amount of postoperative narcotic prescriptions filled in the 3 months following surgery. Predisposition to substance abuse may be a characteristic which leads to increased postoperative narcotic use.

Laser Papillotomy for Chronic Flank Pain – A Reassessment of Efficacy in the Era of Automated Opioid Prescription Monitoring

ObjectiveTo determine if laser papillotomy for patients with chronic flank pain decreased narcotic pain medication usage post-surgery. Specifically the introduction of state-specific automated prescription reporting systems offers the opportunity for a more objective longitudinal assessment of outcomes in patients who often utilize multiple providers for pain management. Materials and MethodsPatients who underwent laser papillotomy for chronic flank pain at a single institution between January 2013 and January 2017 were identified. Narcotic prescription refill information for the 12 months prior to the surgery and the 12 months after was obtained through the Ohio Automated Rx Reporting System (OARRS) and the Pennsylvania Prescription Drug Monitoring Program (PA PDMP). Results10 patients underwent laser papillotomy for chronic flank pain. Preoperative outpatient narcotic prescriptions filled ranged from 0 to 23 prescriptions, with a mean of 10.5 separate prescriptions per patient. Postoperatively, 8/10 (80%) of patients were considered failures. Six patients had multiple narcotic pain medication refills, with the mean number of pills filled recorded as 993.3 in the 12 months post-surgery. One patient became a heroin addict postoperatively and another required ongoing care in the chronic pain clinic. ConclusionsLaser papillotomy for chronic flank pain has a high failure rate, especially in patients who are on narcotic pain medication preoperatively. In the era of automated opioid prescription monitoring, urologists should use such information to make surgical decisions and properly counsel patients.

Competency-based learning in an ambulatory care setting: Implementation of simulation training in the Ambulatory Care Rotation during the final year of the MaReCuM model curriculum.

Aim: As part of the MaReCuM model curriculum at Medical Faculty Mannheim Heidelberg University, a final year rotation in ambulatory care was implemented and augmented to include ambulatory care simulation. In this paper we describe this ambulatory care simulation, the designated competency-based learning objectives, and evaluate the educational effect of the ambulatory care simulation training.Method: Seventy-five final year medical students participated in the survey (response rate: 83%). The control group completed the ambulatory rotation prior to the implementation of the ambulatory care simulation. The experimental group was required to participate in the simulation at the beginning of the final year rotation in ambulatory care. A survey of both groups was conducted at the beginning and at the end of the rotation. The learning objectives were taken from the National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM).Results: The ambulatory care simulation had no measurable influence on students’ subjectively perceived learning progress, the evaluation of the ambulatory care rotation, or working in an ambulatory care setting. At the end of the rotation participants in both groups reported having gained better insight into treating outpatients. At the beginning of the rotation members of both groups assessed their competencies to be at the same level. The simulated ambulatory scenarios were evaluated by the participating students as being well structured and easy to understand. The scenarios successfully created a sense of time pressure for those confronted with them. The ability to correctly fill out a narcotic prescription form as required was rated significantly higher by those who participated in the simulation. Participation in the ambulatory care simulation had no effect on the other competencies covered by the survey.Discussion: The effect of the four instructional units comprising the ambulatory care simulation was not measurable due to the current form or the measurement point at the end of the 12-week rotation. The reasons for this could be the many and statistically elusive factors relevant to the individual and the wide variety among final year rotation placements, the late point in time of the final survey, and the selection of simulated scenarios. The course is slated to undergo specific further development and should be supplemented with additional learning opportunities to ensure that the main learning objectives are covered. The description of the teaching format is meant to contribute to the ongoing development of medical education with an emphasis on competency in the areas of ambulatory care, communication, prevention and health promotion.

Factors Affecting Long-Term Postoperative Narcotic Use in Discectomy Patients.

Long-term narcotic use has risks and potentially life-threatening opioid-related side effects. Extended narcotic use in patients undergoing discectomy raises concerns of other underlying causes of pain or overprescription and/or abuse. The goal of this study was to determine which factors have an effect on active narcotic prescription >3 months after discectomy. The PearlDiver Database was used in this study. Patients 30-55 years old undergoing discectomy without fusions were queried for active narcotic drug prescription occurring >30 days and >3 months after original surgery. Medical co-diagnoses were independently analyzed for effects on long-term active narcotic prescriptions. Prior narcotic use was defined by use within 4 months before surgery. Of 1321 patients undergoing discectomy, 621 had actively prescribed narcotics >3 months after surgery. Preoperative narcotic use had the largest effect on odds of postoperative prescription (odds ratio [OR]= 3.4). Medical comorbidities increasing odds oflong-term narcotic prescriptions included migraines (OR= 1.4), diabetes mellitus (OR= 1.4), depression (OR=1.6), and smoking (OR= 1.9). Narcotic abuse is a serious problem rooted in overprescription of these drugs, which has ultimately led to much more caution in prescribing among physicians. Because pain management and drug prescription must be balanced, identifying patients who may be susceptible to narcotic overprescription is important. Patients with co-diagnoses increasing odds of long-term narcotic prescriptions would benefit from early and continual postsurgical follow-up to ensure accurate pain management and to determine if narcotic prescriptions are justly warranted in the later postoperative period.

Changes in Primary Care Health Care Utilization after Inclusion of Epidemiologic Data in Lumbar Spine MR Imaging Reports for Uncomplicated Low Back Pain.

Purpose To determine whether inclusion of an epidemiologic statement in radiology reports of lumbar magnetic resonance (MR) imaging influences downstream health care utilization in the primary care population. Materials and Methods Beginning July 1, 2013, a validated epidemiologic statement regarding prevalence of common findings in asymptomatic patients was included in all lumbar MR imaging reports at a tertiary academic medical center. Data were collected from July 1, 2012, through June 30, 2014, and retrospective analysis was completed in September 2016. The electronic medical record was reviewed to capture health care utilization rates in patients for 1 year after index MR imaging. Of 4527 eligible adult patients with low back pain referred for lumbar spine MR imaging during the study period, 375 patients had their studies ordered by in-network primary care providers, did not have findings other than degenerative disease, and had at least one follow-up encounter within the system within 1 year of index MR imaging. In the before-and-after study design, a pre-statement-implementation cohort was compared with a post-statement-implementation cohort by using univariate and multivariate statistical models to evaluate treatment utilization rates in these groups. Results Patients in the statement group were 12% less likely to be referred to a spine specialist (137 of 187 [73%] vs 159 of 188 [85%]; P = .007) and were 7% less likely to undergo repeat imaging (seven of 187 [4%] vs 20 of 188 [11%]; P = .01) compared with patients in the nonstatement group. The intervention was not associated with any change in narcotic prescription (53 of 188 [28%] vs 54 of 187 [29%]; P = .88) or with the rate of low back surgery (24 of 188 [13%] vs 16 of 187 [9%]; P = .19). Conclusion In this study, inclusion of a simple epidemiologic statement in lumbar MR imaging reports was associated with decreased utilization in high-cost domains of low back pain management. © RSNA, 2018.

Characteristics of fibromyalgia patients prescribed opioid medications: data from the Cleveland clinic fibromyalgia registry

Objective: Determine the prevalence, socioeconomic, clinical characteristics of fibromyalgia (FM) patients and the factors associated with narcotic drug prescription. Methods: New patients with FM referred for rheumatology evaluation are compared based on narcotic drugs use. Demographic, socioeconomic, clinical, and medication data are collected. Results: Of 305 FM patients 34.8% are taking narcotic medication and these patients (p ≤ 0.05) are older, have longer duration of FM, are socioeconomically more disadvantaged by lower education and employment and higher disability rates; more are obese, and clinically report more extensive and severe pain, higher depression, more disability and higher FM severity, compared to FM patients not prescribed opioid drugs. Patients prescribed opioids are using more medical resources, they take more medications for FM and report more doctor visits and surgeries. Binomial regression analysis demonstrates that pain and stiffness severity, and functional impairment are independent predictors of being prescribed opioid medications. Taking narcotic medications is an independent predictor of FM severity along with pain and depressive symptoms. Conclusion: About one third of patients with FM seen in a tertiary care rheumatology center are taking narcotic medications to treat pain. In this environment, opioid prescription for FM identifies a group of patients with severe FM who have failed the traditional therapeutic options.

Let Me Hold the Wheel, Daddy!

Let Me Hold the Wheel, Daddy! Amos Ritter I have been in Family Practice for 30 years now, out of which 23 in the same office that used to be my grandmother's home. In spite of the rule that a doctor should not treat his family members, I do it all the time. Even before I graduated from residency, I wrote prescriptions for narcotics to help my mother who died of Multiple Myeloma at the age of 69. So when I opened my practice, in the same neighborhood where I grew up, it was only natural that other members of my family would become my patients. My father, my four children, my wife and her parents, my brother and two of my aunts, were all my patients, not to mention many friends, old and new, who live in the area. My rationale for doing so was that I felt I was able to separate between my emotions and my professional knowledge, and I made sure I treated my relatives the exact way I would treat any other patient. And even if my family was under the care of another doctor, I would anyhow be involved in the treatment they received. After my mother's death 28 years ago, my 71-year-old father continued to live the active life of a healthy man. He had been retired for 6 years from his job as a general manager of a large rubber factory. He kept a strict daily routine, maintained his home, went for walks at the beach or in mountain trails, and drove his car every day to one of his favorite restaurants for lunch. Driving his car was for him the symbol of his masculinity and independence. He owned many cars in his lifetime, starting from a 2nd hand convertible Austin 7 with a manual starter, which he loved almost as much as his children, and did all the repair work on by himself. He remembered periods in his life by the car he owned at that time. He rarely consulted me for medical problems, doing his best to avoid putting extra burden on me, since he always thought that I was under too much stress due to my work and family obligations. Luckily for both of us, he did not suffer from any major illness. Mild hypertension, benign prostate hypertrophy and biliary stones were his main medical problems. A suspicious skin lesion that I discovered on his flank turned out to be malignant melanoma, which was removed without further consequences. When my father was 80, his urologist requested a PSA test. The result was 15—which is quite high, even for his age. A rectal exam performed by the urologist revealed a hardened area in the remaining prostate, which was most likely due to cancer. I decided to discuss the options with my father in the most open and direct way—since I knew how important it was for him to make his own independent decisions about his life. We discussed the need for a transrectal biopsy in order to make a definite diagnosis, followed by possible hormonal therapy, chemotherapy or radical surgery. We also discussed the option of not doing anything, not even a biopsy. My father chose the last option—he felt well, and did not want any medical test or treatment to render his freedom and independence. I felt strongly that I acted in his best interest. He made it clear to me, in many occasions, that he would not desire any life prolonging procedures if he suffered from an untreatable disease. I knew [End Page 9] that prostate cancer at his age could be very slow growing, and that most patients die of other illnesses before the cancer spreads in their body. We checked his PSA level several times after that, but when my father noticed that it kept rising, he suggested that we stop measuring it, so we "don't get upset about it". I agreed. The years went by. At my father's 85th birthday we organized a big celebration at the nursing home where his elder sister lived. He looked handsome and sharp minded as ever. He continued...

Economics of Pain Management Testing.

Chronic pain management accounts for a significant portion of health-care costs and has important societal implications, including the increasing availability of prescription narcotics. Urine drug testing (UDT) is an effective tool to monitor adherence to prescription medications and has been recommended by several guidelines. Furthermore, the clinical and technical benefits of UDT using definitive testing methods such as LC-MS/MS are well documented. However, the cost-effectiveness is not well studied. In this article, we discuss the cost considerations associated with different UDT methodologies, including point-of-care immunoassays, laboratory-based immunoassays, and definitive testing by LC-MS/MS. The costs of reagents, consumables, instrumentation, service, and labor are described, as well as the opportunity each methodology offers in relation to test utilization and clinical cost savings. An overview of how to assess the cost-effectiveness of insourcing definitive testing and how to generate a comprehensive insourcing proposal is provided. Billing options for UDT and the recent changes in current procedural terminology codes are also discussed. Given the current health-care environment, additional studies and recommendations that incorporate the cost-effectiveness of definitive testing to monitor compliance in pain management are needed. The decreasing cost of mass spectrometry, the increasing visibility of the value of the laboratory medicine, the new prescriber regulations for opioids, and the push to change reimbursement for definitive UDT will all contribute to the cost-effectiveness of definitive LC-MS/MS to monitor patients with chronic pain.

Current pain prescribing habits for common shoulder operations: a survey of the American Shoulder and Elbow Surgeons membership

Orthopedic surgeons are among the highest prescribers of narcotic pills, and no guidelines currently exist for appropriate management of postoperative pain within this field. The purpose of this study was to gain understanding of the current pain management strategies used perioperatively and postoperatively among orthopedic shoulder surgeons. Members of the American Shoulder and Elbow Surgeons were e-mailed an online survey regarding methods for managing pain in the perioperative and postoperative setting for total shoulder arthroplasty, labral and capsular stabilization procedures, and rotator cuff repair. Postoperative narcotic prescribing amounts were converted into oral morphine equivalents. The survey response rate was 25.8% (170/658), with >90% of surgeons reporting use of a standard pain management regimen in the perioperative and postoperative periods. A regional nerve block was used on the operative day by >80% of surgeons for all 3 procedures. Short-acting narcotics are prescribed for postoperative pain control by >85% of surgeons, with long-acting narcotics provided by <14%. More than 400 oral morphine equivalents of short-acting narcotic are prescribed by shoulder surgeons. Referral to a pain specialist or primary care physician is made after 12 weeks by 92.3% of surgeons if patients continue to require narcotic painkillers. The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings. Regimens frequently include a regional nerve block, nonsteroidal anti-inflammatory drugs, and short-acting oral narcotics. Findings from this study provide guidelines on standard pain management strategies for common shoulder operations based on expert opinion.

Impact of Cystectomy With Urinary Diversion Upon Tracked Receipt of Opioid Prescriptions Among Patients With Interstitial Cystitis/Bladder Pain Syndrome

To compare opioid requirements before and after cystectomy for end-stage Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) using a statewide tracking system. Narcotic prescriptions were captured using the North Carolina Controlled Substance Reporting System for patients at a single institute undergoing cystectomy with urinary diversion (CWUD) for refractory, end-stage IC/BPS between 2010 and 2017. Values were documented for the year before and the year after surgery (excluding 30 days postoperatively to account for surgical pain) and converted to morphine equivalents (ME). Values were compared using Student t test. Following CWUD, there was a mean decrease in opioid receipt per patient of 6535 ME/year (P = .321). 8/26 (31%) had not filled any opiate prescriptions for the preceding 3 months at time of manuscript writing. In certain patients with end-stage, refractory IC/BPS, CWUD can help reduce opioid requirements.

First trimester medication abortion practice in the United States and Canada.

We conducted a cross-sectional survey of abortion facilities from professional networks in the United States (US, n = 703) and Canada (n = 94) to estimate the prevalence of medication abortion practices in these settings and to look at regional differences. Administrators responded to questions on gestational limits, while up to five clinicians per facility reported on 2012 medication abortion practice. At the time of fielding, mifepristone was not approved in Canada. 383 (54.5%) US and 78 (83.0%) Canadian facilities participated. In the US, 95.3% offered first trimester medication abortion compared to 25.6% in Canada. While 100% of providers were physicians in Canada, just under half (49.4%) were advanced practice clinicians in the US, which was more common in Eastern and Western states. All Canadian providers used misoprostol; 85.3% with methotrexate. 91.4% of US providers used 200 mg of mifepristone and 800 mcg of misoprostol, with 96.7% reporting home misoprostol administration. More than three-quarters of providers in both countries required an in-person follow-up visit, generally with ultrasound. 87.7% of US providers routinely prescribed antibiotics compared to 26.2% in Canada. Nonsteroidal anti-inflammatory drugs were the most commonly reported analgesic, with regional variation in opioid narcotic prescription. In conclusion, medication abortion practice follows evidence-based guidelines in the US and Canada. Efforts to update practice based on the latest evidence for reducing in-person visits and increasing provision by advanced practice clinicians could strengthen these services and reduce barriers to access. Research is needed on optimal antibiotic and analgesic use.

Wide Variation and Overprescription of Opioids After Elective Surgery.

We aimed to identify opioid prescribing practices across surgical specialties and institutions. In an effort to minimize the contribution of prescription narcotics to the nationwide opioid epidemic, reductions in postoperative opioid prescribing have been proposed. It has been suggested that a maximum of 7 days, or 200 mg oral morphine equivalents (OME), should be prescribed at discharge in opioid-naïve patients. Adults undergoing 25 common elective procedures from 2013 to 2015 were identified from American College of Surgeons National Surgical Quality Improvement Program data from 3 academic centers in Minnesota, Arizona, and Florida. Opioids prescribed at discharge were abstracted from pharmacy data and converted into OME. Wilcoxon Rank-Sum and Kruskal-Wallis tests assessed variations. Of 7651 patients, 93.9% received opioid prescriptions at discharge. Of 7181 patients who received opioid prescriptions, a median of 375 OME (interquartile range 225-750) were prescribed. Median OME varied by sex (375 men vs 390 women, P = 0.002) and increased with age (375 age 18-39 to 425 age 80+, P < 0.001). Patients with obesity and patients with non-cancer diagnoses received more opioids (both P < 0.001). Subset analysis of the 5756 (75.2%) opioid-naïve patients showed the majority received >200 OME (80.9%). Significant variations in opioid prescribing practices were seen within each procedure and between the 3 medical centers. The majority of patients were overprescribed opioids. Significant prescribing variation exists that was not explained by patient factors. These data will guide practices to optimize opioid prescribing after surgery.

Marijuana Utilization in Cancer Patients: A Comprehensive Analysis of National Health and Nutrition Examination Survey Data from 2005-2014

Cannabis can improve symptoms of nausea and anorexia and may even serve as an alternative to narcotic pain medication in cancer patients. Data on substance use, including marijuana utilization, in cancer patients is limited. We used a population-based dataset to examine the utilization of marijuana and other substance use among cancer patients. We hypothesized that the use of marijuana among cancer patients would be greater than non-cancer patients and that it would increase in more recent years. Publicly available population-based datasets from the National Health and Nutrition Examination Survey (NHANES) were compiled for respondents aged 20-60 for years 2005 to 2014, based on availability of data for two variables of interest - cancer diagnosis and marijuana utilization. Propensity scores were calculated for each subject based on age, sex, race, education, and self-reported health status, then cases (respondents with a cancer diagnosis) were matched 1:2 to controls (respondents with no cancer diagnosis). Behavioral characteristics (current [within past 30 days] and recent [within past 12 months] marijuana use; smoking; binge alcohol; illicit drugs; and prescription narcotics) were compared between cancer patients and propensity score matched controls. Univariable logistic regressions and two-proportion Z-tests were performed; two tailed P < 0.05 was considered significant. Of 19,604 respondents, 826 cancer patients were matched to 1,652 controls. Among cancer patients, 40.3% currently used marijuana compared with 38.0% of non-cancer patients. Cancer patients were more likely to smoke cigarettes (odds ratio [OR] = 1.26, 95% CI = 1.07-1.49; P = 0.007), and take prescription narcotics (OR = 2.36, 95% CI = 1.79-3.12; P < 0.0001), with a trend toward being more likely to currently use marijuana (OR = 1.35, 95% CI = 0.99-1.84; P = 0.056). There was no difference in binge alcohol or illicit substance use among respondents. Cancer patients using marijuana in the last 12 months were more likely to take prescribed narcotics (OR = 1.90, 95% CI = 1.28-2.82; P = 0.0015). Among cancer patients, current marijuana utilization increased significantly over 10 years (Z = 2.20; P = 0.028) but prescription narcotic use did not (Z = 1.78, P = 0.08). From 2005-2014, the proportion of cancer patients currently using marijuana increased by 20.8%, compared with 4.6% among non-cancer patients. In this population-based dataset, 40% of cancer patients reported current marijuana use, and utilization of marijuana increased significantly over the last 10 years among these patients. Cancer patients using marijuana in the last year were more likely to take prescription narcotics. This work provides insight into the evolving role of cannabis use among cancer patients and as a potential adjunct to narcotic pain medication.

Opioid Consumption Following Foot and Ankle Surgery

Category: Ankle, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Orthopaedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, the quantity of medication leftover) are unknown. Methods: All patients that underwent foot/ankle surgery during a three month period and met inclusion criteria were surveyed at their first postoperative visit (4-10 days after surgery). Information collected from the patients included gender, number of narcotic tablets remaining in the bottle, satisfaction with pain control, and willingness to surrender leftover narcotics to a Drug Enforcement Administration (DEA) disposal center. These data were collected prospectively. Additional data, including utilization of a perioperative nerve block, type of procedure (bony vs non-bony), and anatomic region of procedure, were collected by review of the medical record. All data were analyzed in a retrospective fashion. Results: A total of 47 surveys were filled out over the course of 4 weeks. Eighty-five percent of patients were either extremely satisfied or satisfied with their pain control. Ninety-six percent of patients had short acting opioids leftover, and 94% of patients had long acting opioids leftover. On average, there were 27 short acting and 11 long acting narcotic pills leftover at the first postoperative visit (4-10 days after surgery). Of those with leftover narcotic medications, 72% were willing to surrender them to a DEA disposal center. Conclusion: Most patients undergoing foot/ankle surgery had both short and long acting narcotic pain pills leftover at the first postoperative visit (4-10 days after surgery). While it is unknown how many patients continue to require narcotics after the first week from surgery, most patients said they would be willing to surrender any leftover opioid medications to a DEA disposal center. In the future, perhaps patients should be given information on the location of the nearest disposal center when given prescriptions for narcotics.

Narcotic Use and Total Knee Arthroplasty

BackgroundAlthough the United States is in the midst of a narcotic epidemic, risk factors for use and the impact of perioperative narcotic use on total knee arthroplasty (TKA) outcomes is ill-defined. MethodsA national database was queried for patients who underwent primary TKA from 2007 to 2015. Patients taking narcotics in the preoperative, and for a prolonged period of time postoperatively, were identified. The risk factors for prolonged narcotic use were analyzed with a regression analysis, in addition to evaluating preoperative and prolonged postoperative use as independent risk factors for short-term and long-term complications. ResultsIn total, 113,337 patients met inclusion criteria, of which 31,733 patients were prescribed narcotics preoperatively and 35,770 patients were prescribed narcotics more than 3 months postoperatively. There are several independent risk factors for prolonged narcotic use postoperatively, the most significant being the number of narcotic prescriptions prescribed preoperatively. Preoperative narcotic use was independently associated with an increased risk of emergency room visits, readmission, infection, stiffness, and aseptic revision. Prolonged postoperative use was also associated with significantly increased rates of infection, stiffness, and aseptic revision. ConclusionPreoperative and prolonged narcotic use following TKA was associated with an increased risk of short-term and long-term complications following TKA. The liberal use of narcotics in the perioperative period should be considered a modifiable risk factor when considering elective TKA.

Risk Factors for Prolonged Narcotic Use Following Arthroscopic Rotator Cuff Repair

Objectives:Narcotics are commonly prescribed for management of acute pain in the early postoperative period following arthroscopic rotator cuff repair (RCR), but little is known about the frequency and risk factors for persistent use. The goal of this study was to determine risk factors for prolonged narcotic use following arthroscopic RCR.Methods:A national insurance database was queried for patients undergoing arthroscopic RCR from 2007-2015 using CPT codes. Prolonged narcotic use was defined as a new prescription for a narcotic pain medication between 3 and 6 months following the procedure. Patients without minimum 6 months’ follow-up were excluded. A multivariate logistic regression analysis was utilized to evaluate risk factors for prolonged narcotic use, including a prescription for narcotics within the 3 months before surgery, age, sex, obesity, tobacco use, alcohol use, depression and inflammatory arthritis. The regression analysis was used to control for demographics and numerous medical comorbidities. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < 0.05 considered statistically significant.Results:28,331 patients met inclusion and exclusion criteria. 7,543 patients (27%) were characterized as having prolonged narcotic use. Preoperative narcotic use was the most significant risk factor for prolonged postoperative narcotic use (OR 5.4, p < 0.0001). Age < 50 years (OR 1.4), male sex (OR 1.1), obesity (OR 1.1), morbid obesity (OR 1.4), tobacco use (OR 1.8), alcohol use (OR 1.3), inflammatory arthritis (OR 1.5) and depression (OR 2.0) were also all significant risk factors for prolonged postoperative narcotic use [Table 1].Conclusion:More than a quarter of patients undergoing arthroscopic RCR continue to receive narcotic prescriptions more than 3 months postoperatively. The most significant risk factor for prolonged narcotic use is the use of preoperative narcotics. Additional risk factors include younger age, male sex, obesity, tobacco and alcohol use, depression and inflammatory arthritis.Table 1.Significant Risk Factors for Prolonged Narcotic Use after Arthroscopic Rotator Cuff RepairVariableOdds Ratio95% CIPPreoperative Narcotic Use5.43[5.22 -5.66]< 0.0001Age < 50 years1.36[1.26 - 1,46]< 0.0001Male Sex1.14[1.10 - 1.19]< 0.0001Obesity (BMI 30-40)1.09[1.04 - 1.14]< 0.0001Morbid Obesity (BMI 40+)1.36[1.28 - 1.45] < 0.0001Tobacco Use1.78[1.70 - 1.87]< 0.0001Alcohol Use1.34[1..22 - 1.46]< 0.0001Inflammatory Arthritis1.52[1.42 - 1.63]< 0.0001Depression1.99[1.91 - 2.08]< 0.0001

Opioid Demand after Anterior Cruciate Ligament Reconstruction

Objectives:Surgeons and healthcare systems have received a call to action in an effort to curtail the current opioid epidemic in the United States. Postoperative opioid demand after anterior cruciate ligament reconstruction (ACLR) is not well understood. The purpose of this study was to (1) define the natural history of opioid demand after ACLR performed with and without concomitant procedures and to (2) evaluate preoperative opioid demand as a risk factor for postoperative opioid demand.Methods:Arthroscopic ACLRs performed in the Humana Inc. database between 2007-2014 were identified using CPT code 29888. Further categorization of procedures was performed by identifying patients who underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with menisectomy, and those who underwent ACLR with microfracture. Postoperative opioid demand was trended by month following surgery for 1 year. The effect of preoperative opioid demand on postoperative opioid demand was evaluated by comparing those who had filled preoperative opioid prescriptions with those who hadn′t. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Relative risk of postoperative opioid use was calculated and 95% confidence intervals (CI) were determined.Results:Over the course of the study period, 4,946 arthroscopic ACLRs were performed. Of these, 7.24% were still filling opioid prescriptions at 2-3 months after their procedure; 4.71% of patients were filling opioid prescriptions at 1 year after surgery. Patients undergoing ACLR with microfracture were at increased risk of filling narcotic prescriptions compared to the other procedure groups. At 4-5 months postoperatively, ACLR with microfracture had increased risk of filling narcotic prescriptions compared to ACLR alone 1.96 (CI=1.32-2.92), ACL with meniscus repair 2.38 (CI=1.46-3.88), and ACL with meniscectomy 1.51 (CI=1.03-2.23). Nearly 35% of patients (1,716/4,946) were taking opioid pain medications in the 3 months prior to ACLR. Those filling preoperative opioid prescriptions were 5.34 (CI=4.12-6.94) times more likely to be filling narcotic prescriptions at 2-3 months after ACL reconstruction. Those filling preoperative opioid prescriptions were 7.54 (CI=5.32-10.71) and 6.42 (CI=4.5-9.15) times more likely to be filling opioid prescriptions at 9 and 12 months respectively after ACLR.Conclusion:Opioid demand after ACLR drops significantly in the vast majority of patients by the 3rd postoperative month. Surprisingly, 35% of patients undergoing ACLR were found to be using opioid medications preoperatively and we identify preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5 to 7 fold increased risk in this patient population. Surgeons can use this data when counseling patients on typical postoperative opioid demand. Surgeons and healthcare systems should be aware a large portion of patients undergoing ACLR are receiving preoperative opioid prescriptions which put these patients at increased risk for extended postoperative opioid demand. In the setting of preoperative care for patients who will undergo ACLR, healthcare providers should pursue non-opioid prescribing regimens in an effort to limit postoperative opioid demand.

Otolaryngology practice patterns in pediatric tonsillectomy: The impact of the codeine boxed warning.

To determine if otolaryngologists at a single children's hospital were adherent to the boxed warning for codeine use in post-tonsillectomy patients and the implications for practice patterns. Case series with chart review. Charts from all patients undergoing adenotonsillectomy at a single children's hospital from January 1, 2010 through December 31, 2015 were analyzed and stratified according to date (pre- or post-boxed warning) and practitioner type (academic otolaryngologists [AO] vs. nonacademic otolaryngologists [NAO]). Demographic data, surgical technique, method of removal, narcotic prescriptions (dosage and drug), and complications were recorded. Fisher exact test was used to determine the level of significance in prescription rates pre- and postwarning. SPSS version 22 was used for statistical analysis, with P < .05 indicating statistical significance. There were 2,749 children undergoing adenotonsillectomy during the study period, with 1,239 AOs and 1,510 NAOs. There was a distinct downward trend in codeine prescriptions before and after the warning, with the AO group reaching zero sooner than the NAO group. There was a 5% decrease in discharge narcotic prescriptions given postwarning (P < .001), but no significant difference in postoperative emergency department visits or pain-related complications when comparing the two time periods. Codeine use for management of pediatric post-tonsillectomy pain was essentially zero after issuance of the boxed warning. Total narcotic use decreased significantly without increase in pain- or medication-related complications. Future research should focus on identifying markers of increased susceptibility to adverse medication events and determining the safest options for pain management. 4. Laryngoscope, 128:264-268, 2018.

Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology

This research investigated the substances employed by and experiences of patients who come to acute treatment after self-poisoning. A retrospective search of the Toxicology Investigators Consortium Registry was performed to characterize a large cohort of patients. A detailed prospective study of one inpatient toxicology service was also conducted.Patients chose readily available agents for self-poisoning. Most cases involved at least one substance that affects the central nervous system (CNS). The majority were prescription psychotropics and narcotics. When they had access to both CNS-active and CNS-inactive medications, patients almost invariably ingested a mind-altering agent. After recovering neurocognitive function, most patients were not actively experiencing suicidal thoughts. However, more than half of patients without CNS toxicity continued to have suicidal ideation after coming to care.These findings are consistent with the hypothesis that many suicidal patients may be seeking an altered psychosomatic state rather than death per se.

Trends in Narcotic and Corticosteroid Prescriptions in Patients with Inflammatory Bowel Disease in the United States Ambulatory Care Setting from 2003 to 2011.

Before the availability of biological therapies, corticosteroids and narcotics were frequently used in patients with inflammatory bowel disease (IBD) because of a paucity of disease-modifying therapies. The increased accessibility to effective biologicals for IBD over the last decade should be leading to less use of corticosteroids and narcotic medications. This study aims to examine trends in prescriptions of corticosteroids and narcotics to patients with IBD in the United States during the period 2003 to 2011. Data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were used to examine visits of patients with IBD. Trends in corticosteroid and narcotic prescriptions were explored, and predictors of use were assessed using survey-weighted chi-square tests. From 2003 to 2011, a total of 1119 patients with IBD had visits recorded in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey databases. Although biological prescriptions significantly increased from 3.3% in 2003 to 2005 to 15.9% in 2009 to 2011 (P = 0.004), there was no significant decrease in corticosteroid or narcotic prescriptions during this same time frame. Patients with IBD were less likely to receive narcotics (odds ratio = 0.38) when seeing a medical specialist compared with primary care physicians or surgeons. Despite the availability of more effective biological therapies, prescriptions for corticosteroids and narcotics did not decline in patients with IBD visiting U.S. ambulatory clinics and emergency departments from 2003 to 2011.