Nonopioid Medications Research Articles

Prescription opioids are commonly unused after ambulatory head and neck surgeries: Opioids prescription presence and size has no effect on patient satisfaction with pain control

PurposeTo explore the opioid prescribing practices after common ambulatory head and neck surgeries in a large academic institution; and to examine the association between opioid prescription and the patient's satisfaction with pain control. MethodsThis retrospective cohort study conducted in a tertiary academic medical center. Phone interviews of patients who underwent ambulatory head and neck surgeries one month after their procedures were conducted. The interview included, among several questions, the amount of opioid prescribed and consumed, the use of non-opioid pain medications, and the patient's satisfaction with pain control. Logistic regression models were used to investigate the significant factors affecting the patient's satisfaction with pain control. ResultsMost patients were prescribed opioids at discharge (84%). Of those, 17% did not use their prescriptions. The median of leftover opioid was 76.50 morphine milligram equivalents (MMEs) with IQR (45–130.95). Patient satisfaction with pain control is not associated with opioid prescription at discharge (OR 0.195 [95% CL, 0.036–1.036], p = 0.059) or the amount of the prescribed opioid (OR 1.001 [95% CL, 0.997–1.004], p = 0.717) after controlling for other patient and procedural factors. ConclusionA significant portion of ambulatory head and neck surgery patients were discharged with opioid prescriptions they may not use. Patient satisfaction with pain control is not associated with the presence or the amount of opioid prescribed.

Underutilization of Acetaminophen in Older Adult Trauma Patients.

Older adults are more vulnerable to opioid-associated morbidity. The purpose of this study was to determine the frequency and timing of acetaminophen and opioid use in the postoperative period. Older adult trauma patients (≥65years) with hip fractures requiring femur or hip fixation were reviewed (Premier Database 2008-2014). We examined rates of acetaminophen use on the day of surgery and prior to receipt of oral opioids. Mixed-effects linear regression models were used to examine the effects of an acetaminophen-first approach on opioid use the day prior to and on the day of discharge. Of the 192768 patients, 81.6% were Caucasian; 74.0% were female; and the mean age was 82.0years [± 7.0]. Only 16.8% (32291) of patients received acetaminophen prior to being prescribed opioids. 27.4% (52779) received an acetaminophen-opioid combination, and 9.2% (17730) received opioids without acetaminophen first. Acetaminophen first was associated with reduced opioid use on the day prior to and on the day of discharge (3.52 parenteral morphine equivalent doses (PMEs) less [95% CI: 3.33, 3.70]; P < .0001). A statistically but not clinically significant reduction in length of stay was observed in the acetaminophen-first group. Nearly 37% of older adult patients did not receive acetaminophen as first-line analgesia after hip surgery. Multimodal analgesia, including non-opioid medications as first-line, should be encouraged.

Reduction of opioid utilization after vaginal delivery with an electronic health record intervention

The national epidemic of opioid misuse has focused its attention on postpartum analgesic usage. Adequate pain control achieved with nonopioid pain medications and conservative measures could reduce the number of opioid pain medications available for misuse and diversion. Interventions that decrease inpatient opioid use after delivery could reduce the potential for chronic dependence in postpartum women. Modification of preloaded electronic order sets to decrease opioid administration has successfully reduced opioid use following a major abdominal surgery, including cesarean delivery. However, interventions to reduce opioid use following vaginal delivery are not well described. We aimed to evaluate the effect of removing opioid medications from postpartum order sets on medication usage following vaginal delivery. We performed a retrospective cohort study of women undergoing a singleton vaginal delivery at an academic tertiary care center. Our institution removed opioid medications from postpartum order sets in April 2018. We compared the following 2 delivery cohorts: the "preintervention" cohort (April 2016-March 2018) and the "postintervention" cohort (June 2018-July 2018). The primary outcome was postpartum opioid use. The secondary outcomes were nonopioid analgesic use and discharge with an opioid prescription. We compared the demographic and obstetrical data, self-reported pain scores, and postpartum analgesic usage between groups. We determined that a minimum of 138 patients would be needed in each group to identify a 20% decrease in opioid usage (α=.05; β=.2). We analyzed 276 subjects: 138 in the preintervention group and 138 in the postintervention group. The postintervention group was older and more likely to have an operative vaginal delivery. Otherwise, groups had similar demographic and obstetrical characteristics. Postpartum opioid use decreased from 56% in the preintervention group to 16% in the postintervention group, a 71% reduction (P<.001). The incidence of severe pain score (>7) was similar between groups with a median occurrence of 1 (interquartile range, 0-4) for both (P=.7). The number of opioid discharge prescriptions among those receiving inpatient opioids was significantly lower in the postintervention group than in the preintervention group (18% vs 38%, respectively), a 53% decrease (P<.001). Removal of opioids from the postpartum order set was associated with lower rates of opiate usage following vaginal delivery in a single center without changing the frequency of severe pain scores. This simple intervention has the potential to reduce opioid exposure.

A Randomized Controlled Trial of Liposomal Bupivacaine for Pain Following Obstetrical Laceration

(Am J Obstet Gynecol MFM. 2020;2:100115) Following a second-, third-, or fourth-degree laceration in a vaginal delivery, pain management is important. Correct pain management methods can positively impact the postpartum recovery period and the desire to decrease use of opioids has led to the search for long-acting non-opioid medications. Liposomal bupivacaine is bound by liposomes, allowing for a slow release of bupivacaine (and therefore prolonged analgesia). While studies exist referencing the effectiveness of bupivacaine as a postoperative pain management treatment, its use as a treatment following lacerations after vaginal delivery have yet to be documented. The primary aim of this study was to assess the effectiveness of liposomal bupivacaine as a pain control method following vaginal deliveries involving a second-, third-, or fourth-degree obstetric laceration on postpartum day (PPD) 3.

Care for chronic musculoskeletal pain varies across age

An increasing prevalence of chronic musculoskeletal (MSK) pain conditions has been documented for children, adolescents, and young adults. Despite this increase, there has been scarce literature examining treatment modalities for MSK and, in particular, differences in treatments across ages. In this volume of The Journal, Feldman and Nahin reported treatment trends for children and young adults who had received care for MSK. The results indicated that non-opioid medication use was the most commonly prescribed intervention, relative to other interventions such as counseling and physical therapy, and that the primary mode of therapy changed across age groups. One of the more interesting features of this report was the finding that the prescription of opioids increased in the older cohort (ages 18 to 24) and was similar to opioid prescription rates among adults. This finding is noteworthy given that medication-based treatments for MSK have not been subject to clinical trials, and the long-term use of pain medication is problematic. For pediatricians, the results of this study are informative for several reasons. First, the topic of opioid use is a relevant topic of study in healthcare, and a reliance on opioids to manage pain earlier in life could lead to increased dependency in adulthood. Second, these data reveal the type of MSK referred at given age ranges, which sheds some light on relative symptom presentation that has been lacking in the literature. Third, the authors highlight the need for multidisciplinary care to address the biopsychosocial impact of MSK. Finally, these results support the need for additional research on the identification and management of MSK in the pediatric population. Article page 212 ▸ National Estimates of Chronic Musculoskeletal Pain and Its Treatment in Children, Adolescents, and Young Adults in the United States: Data From the 2007-2015 National Ambulatory Medical Care SurveyThe Journal of PediatricsVol. 233PreviewTo portray physician office visits by young Americans with chronic musculoskeletal pain; to describe clinical management in this group; and to explore factors associated with prescribed treatments. Full-Text PDF

530 Restless Legs Syndrome Prevalence and Severity Among Patients Treated with Buprenorphine and Naloxone for Opioid Use Disorder

Abstract Introduction Restless Legs Syndrome (RLS) is a sensory-motor neurological disorder which is associated with sleep disturbance and emotional distress. Opioid medications are effective treatments for RLS, and a high percentage of patients undergoing opioid withdrawal exhibit symptoms of RLS. Despite the known connection between RLS and opioids, there has been no assessment of RLS in patients actively treated with buprenorphine and naloxone for opioid use disorder (OUD). Methods We conducted a study to determine the prevalence of RLS among patients with OUD at an outpatient buprenorphine and naloxone clinic at Lemuel Shattuck Hospital in Jamaica Plain, Massachusetts. With the help of nurses, participants completed questionnaires which inquired about demographic information, previous opioid use, current medications, and RLS. Patients were categorized as having RLS if, according to the Cambridge-Hopkins Questionnaire, they answered positively to the four essential RLS criteria and if common mimics were not endorsed. A final determination of RLS status in those with ambiguous answers to RLS mimics was made by a trained sleep medicine physician (JWW). Results Participants (n=129) were primarily male (n=86; 66.7%), white (n=101; 78.3%), and the median age was 37.5 years. Approximately half of the sample (n=59; 45.7%) used medications for depression and/or anxiety. The median duration of buprenorphine and naloxone use was 3 years. 13.2% were judged to have RLS. RLS symptoms tended to be of moderate severity, disturb sleep to a moderate degree, and occur 5–15 days per month. There were no significant demographic or clinical differences in those with and without RLS. Of the 103 participants without suspected RLS, 15.5% (n=16) were taking a non-opioid medication known to treat RLS symptoms (e.g. gabapentin). Only 1/17 people (5.9%) with RLS were taking a treatment that would control such symptoms. Conclusion Approximately 13% of this sample currently taking buprenorphine and naloxone for OUD had RLS. RLS can greatly interfere with sleep and quality of life, and those with untreated or partially treated symptoms may be motivated to use unprescribed opioids to control them. With this in mind, clinicians treating OUD should be aware that there are effective non-opioid medications that can treat RLS. Support (if any):

532 Two-Year Longitudinal Data From the National Restless Legs Syndrome Opioid Registry

Abstract Introduction Restless Legs Syndrome (RLS) is a sensory-motor neurological disorder which is associated with sleep disturbance and emotional distress. Low dose opioid medications are prescribed for treatment-refractory RLS. We now report two-year longitudinal data from the National RLS Opioid Registry, a national sample of patients using opioids for RLS. Methods Individuals (n=500) taking a prescribed opioid for diagnosed RLS were enrolled in the registry from 12/2017–9/2019. Information on initial and current opioid dosages, side effects, past and current RLS treatments, and RLS severity was collected by interview at baseline. Follow-up online surveys were performed at six-month intervals for two years. Results At the time of analysis, 325 participants had reached two years since enrollment and completed the two-year survey (retention rate=95.3%). There were no mean changes from baseline in RLS symptom severity, sleep, or mood measures. Opioid dose changes from baseline to one- and two-year follow-up were: unchanged (51.2%, 43.1%), increased dose (29.7%, 36.7%), decreased dose (19.1%, 20.2%). Only 7.9% of participants increased dose from baseline at both one and two years. The median dose increase from baseline to two-years was just 10 morphine milligram equivalents (MME). Dose increases of &amp;gt;25 MME occurred in 7.3% of participants (vs 5.2% at one-year) and were independently associated with use of an opioid for a comorbid pain condition in addition to RLS (OR 5.91, p=0.02), discontinuing a non-opioid RLS medication (OR 4.26, p=0.01), and age of 55 or younger at baseline (OR 3.60, p=0.01). Being on an opioid medication for &amp;lt;1 year at baseline was a predictor at one-year follow-up but not during year two of participation. Conclusion Prescribed opioid doses remained relatively stable over the two years following enrollment into the registry. Of the 37% of participants that increased dose, over half increased by 10 MME or less. Individuals at the start of opioid treatment for RLS do not see elevated rates of dose increase past the first year of use. Future longitudinal data will improve our understanding of the efficacy and tolerability of opioids for RLS. Support (if any) The RLS Foundation, Baszucki Brain Research Fund, Florence Petrlik Family Foundation, Diane and Richard Brainerd, and Steven Silin

A covalent poly(lactic acid) naloxone nanoparticle reduces fentanyl‐induced poisoning in rats

Accidental and deliberate exposure to fentanyl and related synthetic opioid analogs are the primary catalysts behind the exponential rise in opioid-related fatal overdose in the US and worldwide. These synthetic opioids are either misused or added as adulterants in counterfeit prescription opioid and non-opioid medications. Although the opioid antagonist naloxone (NLX) is very effective at reversing opioid overdose, multiple doses of NLX may need to be administered to avoid renarcotization and death due to the apparent rapid metabolism of NLX compared to synthetic opioids. To circumvent this shortcoming of NLX and provide greater protection against overdose, this study developed covalent poly(lactic acid-co-glycolic acid) naloxone nanoparticle (NP-NLX) as a delivery platform for sustained-release of naloxone. In the current study, rats were exposed to repeated subcutaneous challenges of fentanyl at 0, 4, 24, and 48 hr timepoints and tested for respiratory depression via oximetry and antinociception via the hotplate test of central analgesia. Immediately following testing only after the t=0 hr timepoint, rats were rescued using either NLX or NP-NLX and tested 15 minutes later on the oximeter and hotplate. During all subsequent timepoints, rats did not receive NLX or NP-NLX. Data showed that NP-NLX was as effective as NLX at reversing fentanyl-induced effects 15 minutes after the initial fentanyl exposure. However, no effect of fentanyl was seen during subsequent fentanyl treatments due to the establishment of tolerance. To circumvent fentanyl-induced tolerance and to demonstrate efficacy at later timepoints, an independent follow-up study involved rats receiving NLX or NP-NLX 0 hr, but not fentanyl. Fentanyl challenges at subsequent timepoints showed that NP-NLX protected against fentanyl effects during the 4 and 24 hr timepoints, while NLX did not. These results suggest that NP-NLX could be an effective alternative to NLX to reverse fentanyl-induced overdose and prevent renarcotization, and that covalent poly(lactic acid-co-glycolic acid) nanoparticles are an attractive delivery platform for opioid antagonists or other small molecules used in treatment of toxicity.

Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population.

BACKGROUND: More than 30% of Medicare beneficiaries and 40% of patients dually eligible for Medicare and Medicaid use opioids. With an estimated 8%-12% of patients developing an opioid use disorder (OUD) after initiating opioids, opioid misuse is a significant public health challenge, especially among high-risk Medicare populations. Medication-assisted treatment (MAT) is the use of medications for the treatment of OUD and to prevent relapse to opioid use. MAT is the most effective treatment for OUD. There are a variety of barriers to MAT therapy that may delay access to treatment. OBJECTIVE: To study the impact of the removal of prior authorization requirements for MAT medications on MAT utilization, opioid utilization, and clinical outcomes, including emergency department visits, inpatient admission, relapse rates, behavioral health services, and nonopioid pain medication utilization, among opioid-using individuals with Medicare Advantage Prescription Drug (MAPD) coverage. METHODS: This retrospective, cross-sectional study used administrative medical, pharmacy, and enrollment data to identify chronic opioid users and a subset cohort initiating MAT use in 2017, when prior authorization requirements were in effect, and 2018 after removal of prior authorization requirements. Opioid and MAT utilization and clinical outcomes from emergency department visits were also examined before and after prior authorization requirements. A logistic regression analysis was conducted to examine the impact of the policy change on relapse rates, comparing relapse rates in 2017 and 2018, after controlling for potentially confounding demographic and clinical factors. RESULTS: This policy change was followed by a decrease in opioid utilization, an increase in MAT initiation, and a 4% decline in relapse rates. Patients initiating MAT after removal of prior authorizations had a 19% decrease in likelihood of relapse, and those with an OUD diagnosis were 47% less likely to relapse. The majority of MAT recipients were aged younger than 65 years, had a mental or behavioral health disorder diagnosis, and initially used relatively low doses (< 90 MME) of prescription opioids. There were no statistically significant differences in the use of behavioral health services or the use of nonopioid medications from 2017 to 2018. CONCLUSIONS: Utilization management policies should ensure appropriate MAT use, while minimizing impediments to access. Providing patients with evidence-based therapy effective for the treatment of OUD is essential to patient recovery and combating the consequences of the opioid epidemic. Further strides are needed to eliminate additional obstacles to OUD care. DISCLOSURES: No outside funding supported this study. All authors are or were employees of Humana, Inc., at the time of the study and have no other potential conflicts of interest to disclose.

Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care

ContextThere are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life. ObjectiveWe assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care. MethodsThis was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients’ electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care). ResultsAmong 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%–94.1%) in 2010 to 79.3% (95% CI = 74.3%–83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period. ConclusionsWe observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.

Postoperative Opioid Prescription and Use After Outpatient Vascular Access Surgery

BackgroundLarger opioid prescriptions are associated with increased consumption without improvements in pain, and the majority of opioids prescribed go unused. We examined postoperative opioid prescription and use in patients undergoing vascular access surgery, where preoperative opioid exposure is common. MethodsA retrospective analysis was conducted in adult CKD patients who underwent outpatient vascular access surgery. Patients were surveyed by telephone >2 weeks after surgery to assess pain level and opioid and non-opioid medication use. ResultsOf 117 patients contacted, 76 responded (65% response rate), with a median (interquartile range) age of 56 (42-69) years. Sixty-three patients (83%) were prescribed an opioid postoperatively. Respondents were prescribed 60 (38-75) oral morphine equivalents (OMEs) and consumed 0 (0-15) OMEs over 1 day with a pain score of 5 out of 10. Thirty-nine patients (>50%) used no opioids. There were no differences in postoperative opioid prescribing or use in patients with recent opioid exposure compared to patients without. Patients who underwent arteriovenous fistula (AVF) creation (short surgical incision procedure) were prescribed 60 (38-75) OMEs, compared with 75 (56-111) OMEs for patients who underwent AVF superficialization, AVG, or BVT (long surgical incision procedure; P < 0.01) and consumed 0 (0-15) OMEs compared with 10 (0-43) OMEs, respectively (P = 0.07). ConclusionRegardless of preoperative opioid exposure, CKD patients undergoing vascular access surgery consumed fewer opioids than prescribed, with a median of <10% of opioids used. Therefore, we've reduced our institutional prescribing recommendations to 4 and 6 oxycodone 5mg pills for short and long surgical incision procedures, respectively.

Editors' Note: Characterizing Opioid Use in a US Population With Migraine: Results From the CaMEO Study

Editors' Note: Characterizing Opioid Use in a US Population With Migraine: Results From the CaMEO Study

In the Arms of Morpheus without Morphia; Mitigating the United States Opioid Epidemic by Decreasing the Surgical Use of Opioids.

The opioid epidemic is a major public health issue in the United States. Exposure of opioid naïve-patients to opioids in the perioperative period is a well-documented source of continued use with one in 20 opioid-naïve surgical patients continuing to use opioids beyond 90 days. There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure. Causal factors include over reliance on opioids for intraoperative and postoperative analgesia and excessive ambulatory opioid prescribing. Opioid-induced hyperalgesia can paradoxically result from intraoperative (anesthesia controlled) opioid administration. Increasing size of initial prescription is a strong predictor of continued use necessitating procedure specific supplies limited to under 3-days. Alternative multimodal pain management (non-opioid medications and regional anesthesia) that limit opioid use must be a high priority with opioids reserved for severe breakthrough pain. Barriers to implementation of opioid-sparing pathways include reluctance to adopt protocols and apprehension about opioid elimination. Considering the number of surgeries performed annually in the United States, perioperative physicians must aggressively address modifiable factors in surgical patients. Patient care pathways need to be constructed collaboratively by surgeons and anesthesiologists with continuing feedback to optimize patient outcomes including iatrogenic opioid dependence.

“That’s what we call the cocktail”: Non-Opioid medication and supplement misuse among opioid users

Background Recent evidence suggests that the practice of combining opioid use with non-opioid substances is common, though little is known about this phenomenon and how best to address it. Methods: We recruited adults in Boston, Massachusetts, with recent opioid use. We conducted semi-structured interviews to explore the practice of combining non-opioid substances with opioids and analyzed transcripts to identify themes. Results: Twenty-nine individuals completed interviews. Combining other substances with opioids was a well-known practice: “that’s what we call the cocktail.” Participants reported the use of clonidine, gabapentin, benzodiazepines, promethazine, amphetamine salts, quetiapine, barbiturates, cough and cold medications, as well as alcohol and candy in combination with opioids. Participants reported purchasing these substances on the street, stealing them, or getting them from a prescriber. Augmenting the opioid high was a common reason for combining substances. Importantly, participants also reported combining substances to treat psychiatric symptoms. Individuals commonly reported learning about combining substances “from people on the street” but also reported learning from the internet and television. Perceived benefits outweighed safety concerns. Participants also felt that using over-the-counter or prescription medications would be safe. Conclusions: Combining a variety of substances with opioids is common and driven by diverse motives. Clinicians caring for opioid-involved patients should consider screening for concurrent use of other substances and discussing the risks of this practice.

589 Methadone in Procedural Care for Burn Injuries of 20–30% Total Burn Surface Area: A Retrospective Chart Review

Abstract Introduction Prolonged opioid usage remains a concern in pain management in procedural care. Recent evidence also suggests that a considerable number of patients who were prescribed opioids struggle with transitioning to non-opioid pain medications. As a continuous effort to reduce opioid consumption following burn surgical procedures, our institution recently evaluated methadone administration for burn procedural care in patients with 20–30% total burn surface area (TBSA) requiring excision and grafting. Methods After IRB approval, we performed a retrospective chart review of patients who underwent excision and grafting procedure for 20–30% TBSA burn injuries between January 1, 2019 and June 30, 2020. The following data was evaluated: postoperative opioid consumption, postoperative pain intensity (rated as “No Pain” [NRS=0], “Minor Pain” [NRS 1 to 3], “Moderate Pain” [NRS 4 to 6], “Severe Pain” [NRS 7 to 10]), time to physical therapy and time to hospital discharge. Data was analyzed using chi square/Fisher exact test for categorical variables and t-test/Wilcoxon rank sum test for continuous variables. Results Our preliminary data included 12 patients who met inclusion criteria, of which two patients received methadone administration. Our patient sample consisted of average age of 43 years, 75% male, and 24% TBSA (92% were flame burns). Patients in both methadone and non-methadone groups had no significant differences in medical histories and TBSA (23% TBSA in methadone, 25% TBSA in non-methadone). There was no significant difference in reported preoperative pain intensity between the two groups, rating moderate to severe. Postoperative pain intensity remained the same, rating moderate to severe and controlled with fentanyl, oxycodone, morphine and non-opioid analgesics. While there was no difference in postoperative fentanyl, opioid and non-opioid analgesic consumptions between the two groups, morphine consumption was significantly lower in the methadone group compared to non-methadone group (2±2 mg vs 51±54 mg, respectively, p=0.02). There was no significant difference between average time from surgery to first physical therapy session and time to hospital discharge (about 21 days after surgery) between the two groups. Conclusions This evaluation shows a potential trend in reduction of inpatient postoperative opioid consumption with the conjunctive administration of methadone, although a bigger sample size is needed for further assessment.

110 Pain Medication Prescription Patterns and the American Burn Association 2020 Guidelines on the Management of Acute Pain in the Adult Burn Patient

Abstract Introduction In September 2020, the American Burn Association released new pain guidelines following a rigorous literature review and input from experts. These guidelines were last updated 14 years ago and represent a multitude of changes including increased importance for non-opioid pain medication use and non-pharmacologic adjuncts given the current opioid crisis. Specifically, the main recommendations were to use opioid medication sparingly and always with adjuncts; acetaminophen utilized in all patients; NSAID use depending on baseline comorbidities and kidney function; neuropathic pain therapy for those with such pain/refractory to standard therapy; and ketamine for procedural sedation/adjunct for opioid consumption. Further, nonpharmacologic treatments include cognitive-behavioural therapy (‘CBT’), hypnosis, and virtual reality should be considered. The objective of this study is to describe current pain medication prescription habits at one ABA-verified centre and how well they are in compliance with these new guidelines. Methods We conducted phase one of a quality improvement retrospective study of 514 patients admitted to an ABA-verified centre over a two-year period. Data included demographics and pain medication use which was compared against the new ABA American Burn Association 2020 Guidelines on the Management of Acute Pain in the Adult Burn Patient. Pain medication contraindications were defined using UpToDate Drug Information. Statistical analysis was descriptive in nature. Results 422 patients were admitted for acute burns. 65.9% were male with an average age of 46.4 (st dev 17.6,range 15–96). Flame burns were most common(n=209,49.5%) with average TBSA of 11.9%(st dev 16.5,range 0–98%) and 54 inhalation injuries(12.8%) covering an average length of stay of 15.6 days in the burn centre (st dev 16.8,range 1–146 days). A total of 3549 pain medications were prescribed: 1792 opioid(50.5%) and 1757 non-opioid(49.5%). Of those admitted, 93.8% were prescribed opioids, 72.5% NSAIDs, 87.2% acetaminophen, 74.4% nerve pain medications, and 25.3% ketamine. Opioids were not prescribed in 26 patients(6.2%) and only prescribed in 29 patients(6.9%). Regarding adjuncts, 4(0.94%) had documented contraindications to NSAIDs and 3(0.71%) to acetaminophen. No referrals were completed for CBT. Virtual reality and hypnosis are not available at this centre. Conclusions This work represents the first known study examining compliance to the new pain guidelines in an ABA-verified burn centre. There is significant room for improvement for the use of adjuncts specifically NSAIDs and acetaminophen as both were under prescribed. In addition, nonpharmacologic treatments are largely not available or not used and may be an untapped resource for better pain control.

Implementing the Use of Non-Opioid Medications for Treating Pain in the Hospital Setting

Implementing the Use of Non-Opioid Medications for Treating Pain in the Hospital Setting

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations.

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge

To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors. We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α= 0.05). Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95). Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.

In-hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway?

Intraoperative methadone has been shown to decrease opioid medication requirement following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). No study to date has investigated the effect of methadone on opioid medication requirement when used in conjunction with an enhanced recovery after surgery (ERAS) protocol following PSF. A retrospective cohort study was performed at a single, tertiary care pediatric hospital. Patients with AIS undergoing PSF were consecutively given a single intra-operative methadone dose and matched 1:2 to a AIS control group without methadone. Patients were matched for age, curve magnitude, levels fused, blood loss, and operating time. All children followed a standard ERAS protocol with methadone being the only change in the post-operative regimen. In-hospital data for opioid and non-opioid medication use, surgical, and patient variables were recorded and compared between cohorts. Twenty-six patients received methadone (average 15.1 ± 1.9years) and were matched with 52 control patients without methadone (average 14.7 ± 2.2years). There were no significant differences in total opioid usage at any time-interval prior to hospital discharge or in cumulative opioid usage. Additionally, patients had a similar VAS pain level at discharge (methadone: 4.0 ± 2.3 vs control: 3.8 ± 1.9; P = 0.572). Total opioid usage was correlated with LOS. There were no opioid-related medication complications in either cohort. There was no decrease of in-hospital opioid usage when methadone was used with an ERAS protocol. Total opioid usage is correlated with hospital LOS following PSF.