Nonopioid Pain Medications Research Articles

270. Patterns of opioid and other prescription medication use in lumbar surgery for spinal stenosis: a national claims database analysis

BACKGROUND CONTEXT Low back pain is one of the most common chronic pain conditions and pain medication use is common among lumbar spine surgery patients. Patients undergoing spine surgery have an increased risk for chronic opioid dependence, which is associated with poorer outcomes and increased surgical costs. However, details of specific patterns of opioid and non-opioid pain medication use pre- and postsurgery and how these might relate to chronic use are not well understood. PURPOSE 1) Characterize patterns in prescription medication use before and after surgery for lumbar spinal stenosis; 2) Identify phenotypes of patients that have similar patterns of medication utilization. STUDY DESIGN/SETTING Retrospective analysis of national claims data (Marketscan® 2007—2015). PATIENT SAMPLE Adult patients undergoing primary single level lumbar surgery for a diagnosis of stenosis (n=17,466, age 58.5±12.8 years, 49.9% female). Patients were required to have continuous enrollment in a health plan providing outpatient pharmacy data for at least 2 years before and after surgery to track medication usage and costs. OUTCOME MEASURES Percentage of patients using each class of pain medication pre- and postoperatively, median morphine milligram equivalents (MME), and medication costs (2015 US$). METHODS We conducted a retrospective analysis of national claims data (Marketscan® 2007—2015)Adult patients undergoing primary single level lumbar surgery for a diagnosis of stenosis (n=17,466, age 58.5±12.8 years, 49.9% female). Patients were required to have continuous enrollment in a health plan providing outpatient pharmacy data for at least 2 years before and after surgery to track medication usage and costs. RESULTS Median annual prescription costs were $1,810 (IQR: $410, $4,423) 2 years prior to surgery and $2,125 (IQR: $604, $4,908) in the year prior to surgery. Postoperatively, annual prescription costs were $2,021 (IQR: $553, $4,826) in the first year and $1,656 (IQR: $286, $4,697) in the second year. The percentage of patients taking opioids prior to surgery increased dramatically leading up to surgery and remained elevated 2 years postsurgery. To a lesser degree, the percentage of patients taking anxiolytics, muscle relaxants, and anticonvulsants also increased prior to surgery and remained elevated 2 years post-surgery. 84.3% of patients used opioids in the two years preoperatively, while 95.2% used opioids in the 2 years postoperatively. Of all prescriptions filed, the 3 most common opioid medications were hydrocodone bitartrate-acetaminophen (54.3%), oxycodone HCl-acetaminophen (15.6%), and oxycodone-HCl (5.5%). While the number of users increased dramatically leading up to surgery, in opioid users, the median dose of opioids taken remained relatively stable. However, the median MME taken per patient per month remained elevated 2 years after surgery (720 MME/month 2 years postop vs 492 MME 2 years preop). CONCLUSIONS The proportion of patients taking prescription drugs increased in the months leading up to spine surgery, and in many cases remained elevated 2 years postsurgery. In particular, the proportion of patients using opioids never dropped to levels observed 2 years preoperatively and opioid users were taking greater quantities of opioids 2 years postoperatively than they were 2 years preoperatively. Spine surgery has a lasting impact on medication use patterns. However, we hope that with greater attention paid to medication use, better progress can be made in the future to reverse these patterns. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Reducing Opioid Use in Endocrine Surgery Through Patient Education and Provider Prescribing Patterns

BackgroundPostoperative opioid use can lead to dependence, contributing to the opioid epidemic in the United States. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increased documentation of persistent opioid use postoperatively, surgeons must pursue interventions to reduce opioid use perioperatively. MethodsWe performed a prospective cohort study to assess the feasibility of a preoperative intervention via patient education or counseling and changes in provider prescribing patterns to reduce postoperative opioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from January 22, 2019 to February 28, 2019 at a tertiary referral, academic endocrine surgery practice. Surveys were administered to assess pain and patient satisfaction postoperatively. Prescription, demographic, and comorbidity data were collected from the electronic health record. ResultsSixty six patients (74.2% women, mean age 58.6 [SD 14.9] y) underwent thyroidectomy (n = 35), parathyroidectomy (n = 24), and other cervical endocrine operations (n = 7). All patients received a preoperative educational intervention in the form of a paper handout. 90.9% of patients were discharged with prescriptions for nonopioid pain medications, and 7.6% were given an opioid prescription on discharge. Among those who received an opioid prescription, the median quantity of opioids prescribed was 135 (IQR 120-150) oral morphine equivalents. On survey, four patients (6.1%) reported any postoperative opioid use, and 94.6% of patients expressed satisfaction with their preoperative education and postoperative pain management. ConclusionsClear and standardized education regarding postoperative pain management is feasible and associated with high patient satisfaction. Initiation of such education may support efforts to minimize unnecessary opioid prescriptions in the population undergoing endocrine surgery.

Decreasing Opioid Use in Pediatric Lower Extremity Trauma: A Quality Improvement Project.

Perioperative anxiety increases postoperative pain and the risk of complications in hospitalized children. Nonpharmacologic pain resources provided by Certified Child Life Specialists (CCLS) are a viable adjunct for pain management. A routine CCLS consult was implemented for patients admitted to the orthopedic service with traumatic lower extremity injuries requiring surgery. A retrospective chart review compared patients who did not receive a CCLS consult. Daily pain rating scores, total doses of opioid and nonopioid pain medication, number of physical therapy attempts, length of stay, and demographics were compared for both groups. A clinically significant improvement was seen for decreased pain rating scores and opioid use after a routine CCLS consult was implemented. Adopting a routine CCLS consult for children with unplanned admissions because of trauma reduces the number of opioids used, provides children with pain management resources, and promotes coping skills that may be used in the future.

A Real-World Study Using Claims Data to Evaluate Possible Failure of Opioid Treatment Regimens Among Patients with Hip and/or Knee Osteoarthritis in the US.

BackgroundAlthough opioids may be used in the management of pain in patients with osteoarthritis (OA), there is a dearth of real-world data characterizing opioid regimen failure in these patients.ObjectiveUsing claims data, this study explored measures that may be potentially indicative of opioid treatment failure and the association of such potential failure with health care resource utilization (HRU) and costs.Patients and MethodsUsing a national employer-sponsored insurance claims database covering the years 2011–2016, this retrospective longitudinal study identified adults with hip/knee osteoarthritis who filled ≥1 opioid prescription (index event) and had continuous health plan enrollment 6 months pre- and ≥12 months post-index. Index opioid regimen intensity was defined in the 3-month post-index period by frequency, average daily dose, and duration of action. Possible index opioid regimen failure was defined as an increase in opioid regimen intensity, addition of a non-opioid pain medication, joint surgery, or opioid-abuse-related events. One-year follow-up HRU and costs were compared between those with possible treatment failure and those without.ResultsAmong 271,512 OA patients (61.5% knee; 11.1% hip; 27.4% both), 34.9% met the definition of possible index opioid regimen failure within a year: increased regimen intensity (16.1%), joint surgery (14.0%), addition of non-opioid pain medication (11.4%), and opioid-abuse-related events (1.9%). Rates of possible failure generally increased with higher index regimen intensity. Compared with those who did not fail, those who potentially failed their index treatment regimen had significantly higher HRU (P<0.001), and all-cause ($36,699 vs $15,114) and osteoarthritis-related costs ($17,298 vs $1,967) (both P<0.0001).ConclusionAmong OA patients treated with opioids, approximately one-third may fail their index opioid regimen within a year and incur significantly higher HRU and costs than those without. Further research is needed to validate these findings with clinical outcomes.

Underutilization of Nonopioid Pain Medication in Patients Undergoing Abdominal Aortic Aneurysm Repair

With increased focus on the opioid crisis, it was our goal to describe rates and risk factors for postoperative use of opioids in patients undergoing abdominal aortic aneurysm (AAA) repair as well as identify pain modalities that are underutilized. We retrospectively analyzed perioperative analgesic prescriptions for endovascular (EVAR) and open AAA repair between January 1, 2010 and January 1, 2018. Patients' baseline opioid use, demographics, and medical comorbidities were obtained. The EVAR group was further subdivided into percutaneous (pEVAR) and cutdown (cEVAR) groups. Primary outcomes were postoperative and discharge pain medication prescriptions. Relative rates of opioid prescribing were obtained through the electronic medical record and normalized into morphine milligram equivalents (MMEs). Of the 128 patients analyzed in the entire cohort, 21.8% (n=28) underwent open repair and 78.12% (n=100) underwent EVAR (46 pEVAR, 54 cEVAR). As expected, open repair had increased postoperative pain reported compared to EVAR (2.67±0.75 vs. 0.96±0.19, P<0.01). Adjunctive epidural reduced postoperative pain for open repair (0.77±0.48 vs. 3.50±0.96, P<0.01). EVAR had less postoperative opioid prescriptions compared to open repair (35.0% vs. 77.3%, P<0.01). In the endovascular group, there was no difference between postoperative opioid prescription based on access, pEVAR versus cEVAR (65.8% vs. 80.1%, P=0.11). When stratifying patients by number of cutdowns, patients with bilateral cutdown as opposed to a single cutdown received more opioid prescriptions than pEVAR patients (84.44% vs. 65.8%, P=0.036). Of those receiving opioids, the average MME for open repair was 320.94mg compared to 28.82mg for EVAR (P<0.01). Those undergoing percutaneous repair had significantly less MME use during hospitalization compared to femoral cutdown (17±3.52 vs. 31.90±5.43mg, P<0.01). Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketorolac, were rarely used in the postoperative period for open or EVAR (8.3% vs 1.1%). Percutaneous EVAR patients reported less pain at discharge compared to cEVAR patients (0.18±0.12 vs. 0.88±0.29, P=0.036). Open and EVAR had comparable low rates of NSAID and acetaminophen prescriptions at discharge. Open patients had longer postoperative length of stay compared to EVAR patients (9.82±1.27 vs. 3.86±0.47, P<0.01). pEVAR had a shorter length of postoperative course compared to cEVAR (3.2±0.26 vs. 4.12±0.30, P<0.01). Patients undergoing EVAR with use of pain medications amounting to <20 MME had a significantly shorter length of stay. This single institutional retrospective study evaluated pain prescription patterns for patients undergoing AAA repair. AAA patients are predominantly treated with opioid pain medications with few adjunctive therapies. Intraoperative epidural and pEVAR may aid in decreasing the total MME used; however, the total number of opioids prescribed is similar for pEVAR and cEVAR despite the difference in approach. Clinicians must consider alternative nonopioid based pain management strategies.

Pre-emptive pain management program is associated with reduction of opioid prescription after minimally invasive pulmonary resection.

BackgroundWe developed and implemented a pre-emptive pain management program wherein providers agreed to have non-opioid pain medication as a standard pain management strategy at discharge accompanied by patient education about the program.MethodsA retrospective case-control study of prospectively collected data of patients who underwent minimally invasive pulmonary resection. We compared the outcomes among patients who were managed with pre-emptive pain management program with enhanced recovery after surgery (Pre-emptive), enhanced recovery program after surgery alone (ERAS) and standard care (control).ResultsOf the 443 patients, 132 patients (30%) were in the pre-emptive pain management group, 90 (20%) patients were in the ERAS only group and 221 (50%) in the control group. There were significantly fewer complications (15.9% vs. 23.3% vs. 38%, P<0.001), shorter median length of hospital stay (2 vs. 3 vs. 3 days, P<0.001), lower 30-day readmission rates (2.3% vs. 3.3% vs. 11.3%, P=0.002), and fewer opioid prescriptions at discharge (17.4% vs. 76.7% vs. 83.7%, P<0.001) in the pre-emptive pain management group compared to the ERAS and control groups. Multivariate logistic regression analyses showed that the pre-emptive pain management program (OR 0.06; 95% CI, 0.03, 0.11, P<0.001) and robotic surgery (OR 0.52; 95% CI, 0.3, 0.88, P=0.02) were associated with lower odds of patients being discharged to home with opioid prescriptions. The median pain score in the pre-emptive pain group at 30 days after surgery was 1.5 on a pain scale of 1–10.ConclusionsThe pre-emptive pain management program was associated with a decrease in opioid prescriptions after elective pulmonary resections. Successful implementation of this program can lead to significant decreases in the amount of prescription opioids in the community.

PMS35 REAL-WORLD HEALTHCARE RESOURCE UTILIZATION AND ECONOMIC BURDEN IN PARTIAL TEAR PATIENTS MANAGED ON CONSERVATIVE THERAPY

First-line conservative treatment (e.g: physiotherapy and/or pain medications) for partial thickness rotator cuff tears (pRCT) often fails to control symptoms or prevent disease progression. This study aims to understand healthcare resource utilization (HRU) and direct and indirect economic burden in pRCT non-repair patients. Adult (aged ≥18 years) conservatively managed (without mention of surgical repair) pRCT patients from 2013-2017 with at least 12-months of continuous enrollment prior to and following the index date were identified from the IBM Watson Health MarketScan® Commercial healthcare claims database using ICD-9/10-CM codes. Total and RCT-related healthcare costs (plan paid and patient out-of-pocket payment) and HRU information were reported descriptively within 12 months of pRCT diagnosis. Mean days missed from work, and absenteeism (ABS) or short-term disability (STD) attributable productivity costs (indirect costs) were also estimated. 29,774 patients were included, representing 64% of pRCT patients. On average, 75.7% of the patients had at least one physiotherapy visit (average visits: all-cause:26, RCT-related:11.4). 14.2% and 9.1% of the patients had at least one claim for physician administered opioid and non-opioid pain medications and 53.9% and 44.3% of the patients had at least one claim for opioid and non-opioid pain medicine prescription for management of RCT symptoms. 42% of the patients received at least one cortisone injection (average: 0.8 (±1.1.) injections). RCT-related cost accounted for around 13% of all-cause spending per patient [Total Healthcare costs: $22,693.67 (±$48,682.30); RCT-related costs: $2,841.16 (±6,180.12)]. Physiotherapy and outpatient pharmacy accounted for 21% and 9% of the RCT-related spending. Patients had more ABS days (33 days ±24) than STD days (13 days ±35) resulting in higher indirect costs (ABS:$5,559 ±$4,179, STD:$1,574 ±$4,138). Conservative management of pRCT patients represents a significant direct and indirect healthcare burden. Given that these patients are managed and not repaired, studies with longer-term cost-implication are warranted.

Patients' Experiences With an Opioid-Sparing Protocol Following Cesarean Delivery [28E

INTRODUCTION: Overprescribing of opioids after cesarean delivery may lead to overconsumption and opioid diversion. Opioid-sparing protocols have reduced post-cesarean inpatient opioid use by over half, but how they affect post-discharge opioid use has not been explored. This study describes the impact of a post-discharge opioid-sparing protocol on home opioid use for women undergoing cesarean delivery. METHODS: At our academic institution, all patients undergoing cesarean delivery receive an opioid-sparing protocol, including scheduled (not as needed) acetaminophen and ibuprofen at discharge. Patients are prescribed ≤20 tabs of oxycodone for breakthrough pain. We conducted a telephone survey of post-cesarean women, 4–12 weeks after discharge on utilization of opioid and non-opioid pain medication and pain control. Data were analyzed using descriptive statistics. RESULTS: Of the 394 women contacted, 205 agreed to participate (52%). Most patients were multiparous (average parity=2) and had an unplanned cesarean delivery (67%). Most patients utilized ≥1 opioid alternative (75% Tylenol and ibuprofen, 14% Tylenol only, 9% ibuprofen only). Overall, 80% of patients received an opioid prescription, and 62% consumed opioids. Patients received on average 17 pills (range 0–20) and consumed 9 pills (range 0–20). Only 7% of patients received a refill. Of the 121/205 (63%) patients who reported good pain control with opioid alternatives, 56/205 (27%) still reported using opioids. CONCLUSION: Most patients report good pain control after cesarean with non-opioid medication and use fewer opioids than prescribed. Still, education is needed to help patients match pain needs to appropriate medication and limit unnecessary opioid exposure.

Reducing the Use of Opioids in the Peripartum Period—A Quality Improvement Initiative [34E

INTRODUCTION: The aim of this quality improvement initiative was to reduce the use of oral opioids in the inpatient postpartum period. METHODS: A systematic approach to pain management during the postpartum hospitalization was employed. A step-wise approach was implemented that included non-pharmacologic interventions, scheduled non-opioid pain medications, and oral opioids for breakthrough pain. Outcomes for the first 8 months were compared to baseline data from all patients delivered in 2017. RESULTS: In the vaginal delivery group 2889 patients were evaluated. The average number of opioid tablets taken was 0.53 per patient compared to 1.64 per patient in the baseline group, a 68% reduction. The average number of patients who received any opioid during their postpartum hospitalization was 12.4% compared to 33.6% in the baseline group, a 63% reduction. In the Cesarean section group 1162 patients were evaluated. The average number of opioid tablets taken was 6.5 per patient compared to 10.2 per patient in the baseline group, a 36% reduction. The average number of patients who received any opioid during their postpartum hospitalization was 78.4% compared to 95.3% in the baseline group, an 18% reduction. CONCLUSION: This quality improvement project evaluated a systematic approach to pain management in the postpartum period that includes a scheduled non-opioid pharmacologic, non-pharmacologic pain interventions, and oral opioids for breakthrough pain. The results demonstrate a clear reduction in oral opioid pain medication consumption during the postpartum hospitalization.

A physician-pharmacist collaborative care model to prevent opioid misuse.

Clinical pharmacists in primary care clinics can potentially help manage chronic pain and opioid prescriptions by providing services similar to those provided within their scope of practice to patients with diabetes and hypertension. We evaluated the feasibility and acceptability of a pharmacist-physician collaborative care model for patients with chronic pain. The program consisted of an in-person pharmacist consultation and optional follow-up visits over 4 months in 2 primary care practices. Eligible patients had chronic pain and a long-term prescription for opioids or buprenorphine or were referred by their primary care physician (PCP). Pharmacist recommendations were communicated to PCPs via the electronic medical record (EMR) and direct communication. Mixed-methods evaluation included baseline and follow-up surveys with patients, EMR review of opioid-related clinical encounters, and provider interviews. Between January and October 2018, 47 of the 182 eligible patients enrolled, with 46 completing all follow-up; 43 patients (91%) had received opioids over the past 6 months. The pharmacist recommended adding or switching to a nonopioid pain medication for 30 patients, switching to buprenorphine for pain and complex persistent opioid dependence for 20 patients, and tapering opioids for 3 patients. All physicians found the intervention acceptable but wanted more guidance on prescribing buprenorphine for pain. Most patients found the intervention helpful, but some reported a lack of physician follow-up on recommended changes. The study demonstrated that comanagement of patients with chronic pain is feasible and acceptable. Policy changes to increase pharmacists' authority to prescribe may increase physician willingness and confidence to carry out opioid tapers and prescribe buprenorphine for pain.

What Explains Poor Health-related Quality of Life Associated With Opioid Use Among Adults With Chronic Noncancer Pain Conditions? A Blinder-Oaxaca Decomposition

Objectives: The objective of this study was to estimate the extent to which differences in person-level characteristics between opioid users and nonusers contribute to poor health-related quality of life (HRQoL) of long-term opioid users with chronic noncancer pain condition (CNCP). Materials and Methods: We conducted a retrospective cohort study of adults (n=5917) using longitudinal data from multiple years of Medical Expenditure Panel Survey. Adults with CNCP were classified into short-term, long-term, and opioid nonusers. We measured HRQoL with physical component summary (PCS) and mental component summary (MCS) scores from the Short-Form 12 Questionnaire. A regression decomposition analysis of results from linear regression was performed. Results: Among adults with CNCP, 17.8% and 17.2% reported long-term and short-term opioid use, respectively. Long-term opioid users had lower PCS scores (β=−4.48; P&lt;0.001) as compared with nonusers, even after adjusting for other independent variables. There were no statistically significant associations of long-term opioid use to MCS and short-term opioid use to both PCS and MCS scores. Postlinear regression decomposition analyses revealed that 44.8% of the difference in PCS scores (−3.76 of −8.41) was explained by differences in employment, physical activity, number of CNCP, and other chronic conditions, and use of nonopioid pain medications between long-term opioid users and nonusers. Conclusions: Long-term opioid use was associated with lower HRQoL. The difference in HRQoL between long-term opioid users and nonusers was explained by both modifiable and nonmodifiable patient characteristics. Our findings suggest that improving HRQoL among long-term opioid users may require interventions and policies both within and beyond health care.

A Thermal Place Preference Test for Discovery of Neuropathic Pain Drugs

Developing potent non-opioid pain medications is an integral part of the battle to conquer both chronic pain and the current opioid crisis. Although most screening approaches use in vitro surrogate targets, in vivo screening of analgesic candidates is a necessary preclinical step in drug discovery. Here, we report the design of a new automated behavioral testing apparatus based on the principle of a thermal place preference test (TPPT). This new design can detect, quantify, and differentiate behavioral responses to cold stimuli between sham and chronic constriction injury (CCI) rodents with up to 12 animals tested simultaneously. At an optimized temperature pair of 12.5 °C vs 30.0 °C (±0.5 °C), the TPPT design has captured the antinociceptive effects of morphine and pregabalin on CCI rats in individual 10 min tests. Moreover, it can differentiate analgesic effects by morphine or pregabalin from anxiolytic effects by diazepam. The results, along with the relatively low cost to construct the apparatus and moderately high throughput, make our TPPT design applicable for behavioral studies of chronic pain in rodents and for high-throughput in vivo screening of the next generation of pain medications.

125 Management of Acute Pain in the Burn Patient: Reaching a New Guideline

Abstract Introduction The most recent ABA pain guidelines were developed over 13 years ago and have not been revised despite the changing practice of burn care. Coupled with the nationwide opioid epidemic there is a need to examine the available literature and revise the ABA practice guidelines for pain management. Methods A committee of a professional association was created to revise the previously published pain guidelines and consisted of a wide range of burn care providers including burn surgeons, burn nurses, anesthesiologists, a pharmacist, and a psychologist. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords “burn pain,” “treatment,” and “assessment”. Selected other references were also used based on our evaluation of the greater pain literature. Studies were graded by 2 members of the committee using Oxford Centre for Evidence-based Medicine – Levels of Evidence (level 1 being the highest and level 5 the lowest). When there was a disagreement, a third member of the committee was used to resolve the disagreement. Our next step was to meet as a group and determine what our expert consensus was on a variety of topics related to treating pain in burn-injured patients. Finally, we assessed gaps in the knowledge that was available and determined research questions that would aid us in providing better recommendations for the care of the burn-injured patient. Results The literature search produced 189 papers, of which 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature, 115 references were included so a total of 210 papers were analyzed. The greatest number of papers were level 5 evidence (62, 29.5%) while only 30 (14.3%) were level 1. Following the review of the literature and meeting to establish consensus, 18 guidelines were established in the areas of pain assessment, opioid pain medications, non-opioid pain medications, regional anesthesia, and non-pharmacologic treatments. Conclusions While there is increasing research on various pain management modalities, the available studies are inadequate to create a true standard of care. Despite this, our committee reached a consensus using available literature from burn or other areas, expert experience and knowledge of pain physiology. Moving forward we call for more burn specific research into all modalities for burn pain control as well as research on multimodal pain control. Applicability of Research to Practice Burn pain is particularly difficult to manage and further study is needed to develop a standard of care for burn pain management.

The Effects of Adjunctive Pain Medications on Postoperative Inpatient Opioid Use in Abdominally Based Microsurgical Breast Reconstruction.

The purposes of this study were to quantify the amount of opioid medication used postoperatively in the hospital setting after abdominally based microsurgical breast reconstruction, to determine factors that are associated with increased opioid use, and to identify other adjunctive medications that may contribute to decreased opioid use. An electronic medical record data pull was performed at the University of Pennsylvania from November 2016 to October 2018. Cases were identified using Current Procedural Terminology code 19364. Only traditional recovery after surgery protocol patients were included. Patient comorbidities, surgical details, and pain scores were captured. Postoperative medications including non-patient-controlled analgesia opioid use and adjunctive nonopioid pain medications were recorded. Non-patient-controlled analgesia total opioid use was calculated and converted to oral morphine milligram equivalents (mme). Statistical analysis was performed using t test analyses and linear regression. A total of 328 patients satisfied our inclusion criteria. Five hundred forty free flaps were performed (212 bilateral vs 116 unilateral, 239 immediate vs 89 delayed). Bilateral patients used on average 115.2 mme (95% confidence interval [CI], 103.4-127.0 mme) compared with 89.0 mme in unilateral patients (95% CI, 70.0-108.0 mme; P = 0.015). Patients with abdominal mesh placement (n = 249) required 113.0 mme (95% CI, 100.5-125.5 mme) compared with 83.8 mme (95% CI, 68.8-98.7 mme) for patients without mesh (n = 79; P = 0.016). Each additional hour of surgery increased postoperative mme by 9.4 (P < 0.01). Patients with a nonzero preoperative pain score required 100.3 mme (95% CI, 90.2-110.4 mme) compared with 141.1 mme (95% CI, 102.7-179.7 mme) for patients with preoperative pain score greater than 0/10 (P < 0.01). Patients with postoperative index pain score ≤5/10 required 89.2 mme (95% CI, 78.6-99.8 mme) compared with 141.1 mme (95% CI, 119.9-162.2 mme) for patients with postoperative index pain score >5/10 (P < 0.01). After regression analysis, a dose of intravenous acetaminophen 1000 mg was found to decrease postoperative mme by 11.7 (P = 0.024). A dose of oral ibuprofen 600 mg was found to decrease postoperative mme by 8.3 (P < 0.01). Bilateral reconstruction and longer surgery resulted in increased postoperative mme. Patients with no preoperative pain required less opioids than did patients with preexisting pain. Patients with good initial postoperative pain control required less opioids than did patients with poor initial postoperative pain control. Intravenous acetaminophen and oral ibuprofen were found to significantly decrease postoperative mme.

Association Between Vaso-Occlusive Crises and Opioid Prescriptions Among Patients with Sickle Cell Disease: A Retrospective Claims-Based Study.

Background/Objectives: Among sickle cell disease (SCD) patients, vaso-occlusive crises (VOCs) are recurrent and unpredictable attacks of acute pain. These pain crises are often treated with analgesics, including opioids, which have been associated with misuse and overdose. The aim of this study was to examine the association between VOC events and opioid use and assess the association between opioid prescriptions and health care resource utilization among SCD patients. Methods: This was a retrospective cohort study using Texas Medicaid medical and prescription claims between September 2011 and August 2016. The index date was the first SCD diagnosis. Patients (2-63 years) with at least one inpatient or two outpatient SCD diagnoses, who were continuously enrolled during 12 months postindex, were included in the study. The primary outcome was number of opioid prescriptions, while the independent variable was number of VOC events. Covariates included age, gender, nonopioid medication use, nonstudy SCD-related medication (penicillin and folic acid) use, evidence of blood transfusions, number of SCD-related complications, number of SCD-related comorbid conditions, and Charlson Comorbidity Index score. Negative binomial regression analysis was used to address study objectives. Results: Of 3368 included patients, 1978 (58.7%) had at least one opioid prescription with a mean of 4.2 (SD=7.2). Overall, 2071 (61.5%) had at least one VOC event with an average of 2.9 (SD=4.4). The results from the negative binomial regression showed that for every increase in VOC events, the number of opioid prescriptions increased by 9.5% (Incidence rate ratio=1.095, 95% CI: 1.078-1.111; P ≤ 0.0001). Other significant covariates associated with higher opioid use included age (13 and older compared to 2-12) and increase in the number of nonopioid pain medications, nonstudy SCD-related medications, and SCD-related complications. Conclusions: The majority of SCD patients had at least one VOC event and were prescribed opioids during the 12-month study period. We found that each VOC event was associated with a 9.5% increase in the use of opioids. SCD guidelines recommend opioids for the treatment of VOC-related pain. Payers and providers should be aware of opioid use in this population, consider appropriate VOC prevention measures, and provide SCD patients with access to appropriate pain management.

Factors Associated With Frequent Opioid Use in Children With Acute Recurrent and Chronic Pancreatitis.

The aim of the study was to understand the association of frequent opioid use with disease phenotype and pain pattern and burden in children and adolescents with acute recurrent (ARP) or chronic pancreatitis (CP). Cross-sectional study of children <19 years with ARP or CP, at enrollment into the INSPPIRE cohort. We categorized patients as opioid "frequent use" (daily/weekly) or "nonfrequent use" (monthly or less, or no opioids), based on patient and parent self-report. Of 427 children with ARP or CP, 17% reported frequent opioid use. More children with CP (65%) reported frequent opioid use than with ARP (41%, P = 0.0002). In multivariate analysis, frequent opioid use was associated with older age at diagnosis (odds ratio [OR] 1.67 per 5 years, 95% confidence interval [CI] 1.13-2.47, P = 0.01), exocrine insufficiency (OR 2.44, 95% CI 1.13-5.24, P = 0.02), constant/severe pain (OR 4.14, 95% CI 2.06-8.34, P < 0.0001), and higher average pain impact score across all 6 functional domains (OR 1.62 per 1-point increase, 95% CI 1.28-2.06, P < 0.0001). Children with frequent opioid use also reported more missed school days, hospitalizations, and emergency room visits in the past year than children with no frequent use (P < 0.0002 for each). Participants in the US West and Midwest accounted for 83% of frequent opioid users but only 56% of the total cohort. In children with CP or ARP, frequent opioid use is associated with constant pain, more healthcare use, and higher levels of pain interference with functioning. Longitudinal and prospective research is needed to identify risk factors for frequent opioid use and to evaluate nonopioid interventions for reducing pain and disability in these children.

305: The effect of standardized discharge prescriptions on opioid use and pain experience after cesarean delivery

To evaluate opioid use following cesarean delivery (CD) and determine the effect of standardized discharge prescriptions as part of an Enhanced Recovery After Surgery (ERAS) pathway on patients’ pain experience and opioid use. We conducted a baseline survey of women who underwent CD from Jan- March 2017 at an urban academic hospital. Patients were called after discharge to assess their pain and opioid use. In July 2017, we implemented an ERAS pathway, including consistent use of non-opioid pain medications and standardization of opioid prescriptions on discharge to ≤25 tabs of oxycodone. From Nov-Jan 2019, a post-implementation survey was conducted. Data was obtained from 102 women pre-implementation (PRE) and 104 women post-implementation (POST). On a 0-10 scale, mean reported pain scores at discharge were significantly lower in the POST group (PRE 6.61 vs POST 4.84, p=0.0001). 90% of discharge prescriptions were combined oxycodone/acetaminophen PRE, compared to 90% oxycodone alone POST. In the PRE group, 96% of patients were prescribed ≥30 pills, whereas POST, 97% were prescribed ≤25 pills. The mean number of pills consumed was significantly lower PRE vs. POST (24 vs 16, p=0.001). The number of patients who consumed all pills prescribed (43% vs 40%, p=0.691) and the mean number of leftover pills (7 vs 7, p=0.832) were not different between groups. Number of pills consumed was not associated with any patient factors, but was associated with pills prescribed. For each additional pill prescribed, 0.467 more pills were consumed (p< 0.05). Refills did not differ between groups (6% vs 3%, p=0.786). Mean pain scores the week after discharge were lower in the POST group, at 4.0 vs 3.3, p=0.02. Implementing an ERAS pathway with standardized discharge prescriptions after CD led to a significant decrease in the mean number of opioid pills taken while also improving patients’ reported pain. The similar number of unused pills in both groups suggests that even fewer pills could be prescribed. Standardized discharge prescriptions should be incorporated into ERAS protocols.

Management of Patients with a Musculoskeletal Pain Condition that is Likely Chronic: Results from a National Cross Sectional Survey

The purpose of the study was to explore clinical management for new cases of musculoskeletal pain that are likely chronic. We used data from the National Ambulatory Medical Care Survey, 2007-2015, identifying visits with a new chronic musculoskeletal pain condition using predetermined ICD-9 codes. We documented prescribing of nonopioid pain medication, opioids, physical therapy (PT), counseling, and other nonpharmacologic treatments and explored associations between patient and provider factors for each of these treatments. There were 11,994 visits over the 9-year period for a new case of chronic musculoskeletal pain, representing an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions that were prescribed nonopioid medication, opioids, PT, counseling and other nonpharmacologic treatments were: 40.2, 21.5, 10.0, 15.2 and 14.3 respectively. Patient age was associated with type of treatment with a young to old gradient for other nonpharmacologic treatments, PT, opioids, counseling and other medications. Orthopedists were less likely to prescribe pharmacological treatments than family practice physicians and more likely to prescribe PT. Physicians who used the electronic medical record were more likely to prescribe opioids. Contrary to practice guidelines for managing musculoskeletal pain, many patients are prescribed opioids for a new chronic musculoskeletal problem. PerspectiveWe outlined in a representative sample of Americans what treatments are being prescribed for new cases of likely chronic musculoskeletal pain. Opioid prescription was double that of physical therapy. Using the electronic medical record was associated with more opioid prescription– a novel finding that should be corroborated by future research.

Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study

ObjectivesThis prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing. MethodsData analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use. ResultsAmong 14 221 patients, 9% had prescriptions with an average MEDD ≥90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD ≥90 (high-dose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P < .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change. ConclusionsEMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.

Impact of Preoperative Acetaminophen and Carbohydrate Loading on Pain and Functional Status in Patients Undergoing Mohs Micrographic Surgery for Nonmelanoma Skin Cancers.

Preoperative acetaminophen and carbohydrate loading has been shown to improve the functional recovery of surgical patients. To determine the effects of preoperative acetaminophen and carbohydrates on functional outcomes and the use of pain medications after surgery in patients undergoing Mohs Micrographic Surgery (MMS) for nonmelanoma skin cancer (NMSC). One hundred patients treated with MMS for NMSC at an academic center were randomized into a control group receiving standard preoperative care or an intervention group receiving acetaminophen and carbohydrate drinks immediately before surgery. Patients rated levels of pain, thirst, hunger, anxiety, and fatigue on the day of surgery on a scale of 0 to 100, and reported through a phone interview the use of pain medications within 48 hours of surgery. There was no significant difference between intervention and control groups in maximum pain score on the day of surgery; maximum pain score 48 hours after surgery; use of nonopioid pain medications; and use of opioids. However, the intervention group had lower anxiety levels during and at the end of surgery. Patients undergoing MMS for NMSC reported very low levels of pain during and after surgery. Preoperative acetaminophen and carbohydrate loading had no impact on pain levels or the use of pain medications but did reduce levels of anxiety.