Prescriptions For Opioid Medications Research Articles

Pain-management protocol aimed at reducing opioids following total knee arthroplasty does not negatively impact patient satisfaction

BackgroundPrior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. MethodThis study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. ResultsOf the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in “top box” percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). ConclusionsProtocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOEIII. Clinical RelevanceThis study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Strain and sex-related behavioral variability of oxycodone dependence in rats

Over the past two decades, the escalating prescription of opioid medications for pain management has culminated in a widespread opioid epidemic, significantly impacting public health, social dynamics, and economic stability. The urgent need for improved treatments for opioid addiction necessitates a deeper understanding of its biological underpinnings, with genetic variations playing a crucial role in individual susceptibility to opioid use disorder (OUD) and influencing clinical practices.In this study, we leverage the genetic diversity of four rat strains (ACI/N, BN/NHsd, WKY/N, and F344/N) to examine the contribution of genetic factors to oxycodone metabolism and addiction-like behaviors. We used the extended access to intravenous oxycodone self-administration procedure (12 h/day, 0.15 mg/kg/injection) to comprehensively characterize oxycodone-related behaviors and pharmacokinetics. We measured escalation of oxycodone self-administration, motivation for drug consumption, tolerance to the analgesic effects of oxycodone, withdrawal-induced hyperalgesia, and oxycodone-induced respiratory depression. Additionally, we examined oxycodone-seeking behavior after four weeks of withdrawal by reintroducing the animals to environmental and cue stimuli previously associated with oxycodone self-administration.The findings revealed notable strain differences in several behavioral measures, including oxycodone metabolism. Intriguingly, BN/NHsd and WKY/N strains exhibited similar drug intake and escalation patterns but displayed significant disparities in oxycodone and oxymorphone metabolism. Minimal sex differences were observed within strains, primarily relating to oxycodone metabolism.In conclusion, this study identifies strain differences in the behavioral responses and pharmacokinetics associated with oxycodone self-administration in rats, providing a robust foundation for identifying genetic and molecular variants associated with various facets of the opioid addiction process.

The Impact of Opioid Prescribing Limits on Drug Usage in South Carolina: A Novel Geospatial and Time Series Data Analysis.

The opioid crisis in the United States has had devastating effects on communities across the country, leading many states to pass legislation that limits the prescription of opioid medications in an effort to reduce the number of overdose deaths. This study investigates the impact of South Carolina's prescription limit law (S.C. Code Ann. 44-53-360), which aims to reduce opioid overdose deaths, on opioid prescription rates. The study utilizes South Carolina Reporting and Identification Prescription Tracking System (SCRIPTS) data and proposes a distance classification system to group records based on proximity and evaluates prescription volumes in each distance class. Prescription volumes were found to be highest in classes with pharmacies located further away from the patient. An Interrupted Time Series (ITS) model is utilized to assess the policy impact, with benzodiazepine prescriptions as a control group. The ITS models indicate an overall decrease in prescription volume, but with varying impacts across the different distance classes. While the policy effectively reduced opioid prescription volumes overall, an unintended consequence was observed as prescription volume increased in areas where prescribers were located at far distances from patients, highlighting the limitations of state-level policies on doctors. These findings contribute to the understanding of the effects of prescription limit laws on opioid prescription rates and the importance of considering location and distance in policy design and implementation.

Evaluating State-Level Prescription Drug Monitoring Program (PDMP) and Pill Mill Effects on Opioid Consumption in Pharmaceutical Supply Chain.

The opioid crisis in the United States has had devastating effects on communities across the country, leading many states to pass legislation that limits the prescription of opioid medications in an effort to reduce the number of overdose deaths. This study evaluates the impact of two categories of PDMP and Pill Mill regulations on the supply of opioid prescriptions at the level of dispensers and distributors (excluding manufacturers) using ARCOS data. The study uses a difference-in-difference method with a two-way fixed design to analyze the data. The study finds that both of the regulations are associated with reductions in the volume of opioid distribution. However, the study reveals that these regulations may have unintended consequences, such as shifting the distribution of controlled substances to neighboring states. For example, in Tennessee, the implementation of Operational PDMP regulations reduces the in-state distribution of opioid drugs by 3.36% (95% CI, 2.37 to 4.3), while the out-of-state distribution to Georgia, which did not have effective PDMP regulations in place, increases by 16.93% (95% CI, 16.42 to 17.44). Our studies emphasize that policymakers should consider the potential for unintended distribution shifts of opioid drugs to neighboring states with laxer regulations as well as varying impacts on different dispenser types.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated. To assess the interventions and patient factors associated with ED return following an initial ED visit for HS. This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022. Factors analyzed included those associated with the ED visit and patient characteristics. Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit. This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days). This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Variations in Postpartum Opioid Prescribing Practices among Obstetrician-Gynecologists.

There have been many efforts to combat the United States opioid crisis that has been occurring for the past two decades, specifically with postpartum patients that often were prescribed opioids. Prior studies described how accounting for usage of inpatient opioids on the day prior to discharge had an impact on how much discharge opioids were prescribed on the day of discharge. These studies provided a guideline to use the inpatient opioid amount from the day before discharge to determine discharge opioid quantity and minimize how much was being prescribed. In July 2018, the American College of Obstetrics and Gynecologists (ACOG) published Committee Opinion 742, guidelines for obstetricians-gynecologists about post-partum pain management. Prescription pain medications (including opioids, if necessary) require a shared decision-making approach between the physician and patient to determine the medication type and quantity. This study aimed to determine if there were differences in prescribing practices based on the specific post-operative day that opioid prescriptions were written, and if there were differences in the prescribing practices for cesarean deliveries following the publication of ACOG Committee Opinion 742. This retrospective chart review included patients who had a live cesarean birth at one rural Midwest facility anytime between July 1, 2017 and February 28, 2021. This study excluded those with chorioamnionitis and those discharged after more than four days. Opioid amounts were converted to oral morphine milligram equivalents (MME) for comparison, and total MME was calculated for each prescription. Patients were stratified into two groups based on the day that their discharge opioid medication prescriptions were written (i.e., a day prior to discharge or the day of discharge). Patients were also stratified based on date of delivery, before or after the publication of ACOG Committee Opinion 742. Of 411 cesarean patients, 93.9% (n = 386) had opioids prescribed at discharge, 86% (n = 330) of whom received a prescription written on the day of discharge. There was no difference in the quantity of MMEs, doses per day, or dosage from discharge prescriptions between those written on the day of discharge and those written on a prior day. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 (63.9%, n = 263) received discharge prescriptions with fewer average MMEs (159.53 ± 61.64) than those whose deliveries occurred before the publication (36%, n = 148; 187.35 ± 53.42; χ2 (1, N = 411) = 17.71; p < 0.001), and they were prescribed fewer doses per day. After cesarean sections, the specific post-operative day did not seem to impact the prescribing trends as there were no differences in MMEs, doses per day, or dosage between prescriptions that were written on the day of discharge and before the day of discharge. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 received discharge prescriptions with fewer MMEs, fewer doses per day, and the same dosage than those whose deliveries occurred before the publication, reflecting the overall national trend of decreasing prescription opioids over these years.

Opioid Use Increases the Rate of Pseudarthrosis and Revision Surgery in Patients Undergoing Anterior Cervical Discectomy and Fusion.

Retrospective Cohort. To (1) quantify the risk opioids impart on pseudarthrosis development, (2) analyze the effect of pseudarthrosis on clinical outcomes, and (3) identify if the amount of opioids prescribed are predictive of pseudarthrosis revision. Patients who underwent ACDF at a single institution between 2017-2019 were retrospectively identified. Postoperative dynamic cervical spine radiographs were reviewed to assess fusion status. Logistic regression models measured the effect of morphine milligram equivalents (MME) prescribed on the likelihood of pseudarthrosis development. Receiver operating characteristic (ROC) curves were generated to predict the probability of surgical revision based on MME prescribed. Of 298 included patients, an average of 2.01 ± 0.82 levels were included in the construct and 121 (40.9%) patients were diagnosed with a pseudarthrosis. However, only 14 (4.7%) required a pseudarthrosis revision. Patients requiring pseudarthrosis revision had worse one-year postoperative Δ PCS-12 (-1.70 vs. 7.58, P = 0.004), Δ NDI (3.33 vs. -15.26, P = 0.002), and Δ VAS Arm (2.33 vs. -2.48, P = .047). Multivariate logistic regression analyses found the three-month postoperative (OR=1.00, P = .010), one-year postoperative (OR=1.001, P = 0.025), and combined pre- and postoperative MME (OR=1.000, P = .035) increased the risk of pseudarthrosis. ROC analysis identified cutoff values to predict pseudarthrosis revision at 90.00 (area under the curve (AUC): 0.693, confidence interval (CI): 0.554-0.832), 132.86 (0.710, CI: 0.589-0.840), 224.76 (0.687, CI: 0.558-0.817) and 285.00 (0.711, CI: 0.585-0.837) MME in the preoperative, three-month postoperative, one-year postoperative, and combined pre-and postoperative period. Increased prescription of opioid medications following ACDF procedures may increase the risk of pseudarthrosis development and revision surgery. Therapeutic Level III.

Opioid prescribing patterns after arthroplasty of the knee and hip: a Dutch nationwide cohort study from 2013 to 2018.

Background and purposeNumbers on opioid prescriptions over time in arthroplasty patients are currently lacking. Therefore we determined the annual opioid prescribing rate in patients who received a hip/knee arthroplasty (HA/KA) between 2013 and 2018.Patients and methodsThe Dutch Foundation for Pharmaceutical Statistics, which provides national coverage of medication prescriptions, was linked to the Dutch Arthroplasty Register, which provides arthroplasty procedures. The opioid prescription rates were expressed as the number of defined daily dosages (DDD) and morphine milligram equivalent (MME) per person year (PY) and stratified for primary and revision arthroplasty. Amongst subgroups for age (< 75; ≥ 75 years) and sex for primary osteoarthritis arthroplasties, prescription rates stratified for opioid type (weak/strong) and prevalent preoperative opioid prescriptions (yes/no) were assessed.Results48,051 primary KAs and 53,964 HAs were included, and 3,540 revision KAs and 4,118 HAs. In 2013, after primary KA 58% were dispensed ≥ 1 opioid within the first year; this increased to 89% in 2018. For primary HA these numbers increased from 38% to 75%. In KAs the prescription rates increased from 13.1 DDD/PY to 14.4 DDD/PY, mainly due to oxycodone prescriptions (2.9 DDD/PY to 7.3 DDD/PY), while tramadol decreased (7.3 DDD/PY to 4.6 DDD/PY). The number of MME/PY also increased (888 MME/PY to 1224 MME/PY). Similar changes were observed for HA and revision arthroplasties. Irrespective of joint, prescription of opioid medication increased over time, with highest levels in groups with preoperative opioid prescriptions while weak opioid prescriptions decreased.InterpretationIn the Netherlands, between 2013 and 2018 postoperative opioid prescriptions after KA and HA increased, mainly due to increased oxycodone prescriptions with highest levels after surgeries with preoperative prescriptions.

Real-World Reductions in Healthcare Resource Utilization over 6Months in Patients with Substance Use Disorders Treated with a Prescription Digital Therapeutic.

Background and AimsSubstance use disorders (SUDs) affect approximately 40.3 million people in the USA, yet only approximately 19% receive evidence-based treatment each year. reSET® is a prescription digital therapeutic (PDT) and the only FDA-authorized treatment for patients with cocaine, cannabis, and stimulant use disorders. This study evaluated real-world healthcare resource utilization (HCRU) and associated costs 6 months after initiation of reSET in patients with SUD.MethodsA retrospective analysis of HealthVerity PrivateSource20 data compared the 6-month incidence of all-cause hospital facility encounters and clinician services in patients treated with reSET (re-SET cohort) before (pre-index period) and after (post-index period) reSET initiation (index). Incidence was compared using incidence rate ratios (IRR). HCRU-related costs were also assessed.ResultsThe sample included 101 patients (median age 37 years, 50.5% female, 54.5% Medicaid-insured). A statistically significant decrease of 50% was observed in overall hospital encounters from pre-index to post-index (IRR 0.50; 95% CI 0.37–0.67; P < 0.001), which included inpatient stays (56% decrease; IRR 0.44; 95% CI 0.26–0.76; P = 0.003), partial hospitalizations (57% decrease; IRR 0.43; 95% CI 0.21–0.88; P = 0.021), and emergency department visits (45% decrease; IRR 0.55; 95% CI 0.38–0.80; P < 0.004). Additionally, some clinician services declined significantly including pathology and laboratory services: other (54% decrease; IRR 0.46; 95% CI 0.28–0.76; P = 0.003); pathology and laboratory services: drug assays prior to opioid medication prescription (37% decrease; IRR 0.63; 95% CI 0.41–0.96; P = 0.031); and alcohol and drug abuse: medication services (46% decrease; IRR 0.54; 95% CI 0.41–0.70; P < 0.001). Reductions in facility-encounters drove 6-month reSET per-patient cost reductions of $3591 post-index compared to pre-index.ConclusionsUse of reSET by patients with SUD is associated with durable reductions in HCRU and lower healthcare costs over 6 months compared to the 6 months before PDT treatment, after adjusting for covariates, providing an economic benefit to the healthcare system.Graphical abstract Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-022-02215-0.

Paper 04: The effect of prescribing patterns on utilization of opioid medication in ACL reconstruction: A randomized, prospective trial

Objectives:During the 21st century, opioid medication prescription and consumption has increased, which has led to an increase in opioid abuse, dependence, and fatal overdoses. Health care providers, particularly surgeons, have recently focused on decreasing the amount of opioids prescribed, as overprescribing is a known cause contributing to the opioid epidemic. Patients undergoing anterior cruciate ligament reconstruction (ACLR) would especially benefit for the identification of an ideal opioid prescription amount for post-op pain, as the average age of patients undergoing ACLR is 29.8 years old, which falls within the age group that experienced the largest increase in opioid related deaths between 2001 and 2016. It is unknown if prescribing patterns change patient behavior related to opioid consumption. The purpose of this randomized, prospective trial was to evaluate the effects of different quantities of prescribed opioid tablets on opioid utilization by patients, post-operative pain, and patient satisfaction following ACL reconstruction.Methods:This study was a prospective, randomized trial enrolling patients undergoing primary ACLR following ACL tear. Patients were randomly assigned to one of 3 prescription groups pre-operatively: 15 tablets, 25 tablets, or 35 tablets of oxycodone-5mg. Standard of care nerve blocks were utilized in all patients in addition to general anesthesia for the surgical procedure. Patients were instructed to take acetaminophen and NSAIDs as needed with the opioid medication to be used for “breakthrough” pain. Exclusion criteria included concomitant procedure other than meniscectomy or meniscal repair, ACL revision, history of chronic pre-operative opioid use, history of substance abuse, pregnancy, or workman’s compensation claims. Patients in all 3 groups were asked to complete pain and medication logs 2 times a day for the first 14 days post-operatively, along with an opioid medication satisfaction survey at 2 weeks, and IKDC questionnaires before surgery and up to 6 months post-operatively. Demographics and complication information were gathered from the medical record. Requests for prescription refills were recorded as well. Analysis assessed for statistical differences in post-op pain and medication usage. All usage of narcotics was verified with the state database monitoring system for narcotic pain medication.Results:One hundred thirty patients were included in the analysis (41 who received 15 oxycodone tablets, 40 who received 25 oxycodone tablets, and 49 who received 35 oxycodone tablets). There were no significant differences between the two groups in mean age at surgery (33.6 vs. 31.6 vs 33.3; P=0.328), BMI (27.7 vs 26.1 vs 25.7; P=0.525), or sex ratio (24M/17F, 20M/19F, 25M/24F; P=0.735). There were also no significant preoperative differences in subjective pain and function, as measured by IKDC scores (46.8 vs 48.7 vs 46.5; P=0.794).There were no significant differences in mean total morphine milligram equivalents (MME) consumed between the three groups (72.3 in the 15 tablet group, 61.9 in the 25 tablet group, 78.1 in the 35 tablet group; P>0.05). There was a significant difference between those who received 15 tablets and those who received 25 and 35 tablets when asked if they thought they were prescribed too few/too many narcotics, with a greater percentage of the 15 tablet group reporting that they felt they received too few at 20.6%, (P=0.05) as depicted in Figure 1. Despite this difference, there was no significant difference between the three groups on subjective morning or afternoon pain for the first 14 days after surgery, total opioid pills consumed, patient satisfaction on ability of the narcotic to treat their condition, patient satisfaction on amount of pain relief they experienced since surgery, or patient satisfaction regarding the amount of narcotics initially prescribed after surgery. Finally, there was no difference between the three groups on postoperative function at 2 weeks, 6 weeks, 3 months, and 6 months, as measured by IKDC scores (Figure 2).Conclusions:Despite a significantly larger portion of the group who received 15 oxycodone tablets reporting that they felt they received too few opioid tablets, there was no difference between those who received 15, 25, or 35 oxycodone-5mg tablets in reported pain levels, opioid consumption, or any satisfaction metrics. In addition, there was no difference between the three groups in pain and function as reported in the IKDC surveys. Given these results, giving lower quantities of opioid medication appears to be as effective in appropriately controlling post-operative pain as higher quantities, and may help to limit amount of opioids prescribed and possible diversion of unused prescription opioid medication.

Narcotic use and pain control after cesarean section

Opioid use and dependence have markedly increased in recent years which has led to an opioid epidemic. Various factors that have contributed to this crisis, one being the over prescription of opioid medication to post-surgery patients. In the United States cesarean section deliveries accounted for 31.8% of all births in 2020. Therefore, it is necessary to evaluate pain control and narcotic use in the postpartum period. Most studies on postpartum pain control focus primarily on the immediate inpatient postoperative period. This study investigates pain control and Percocet use in the 3-day post-discharge period of women who underwent Cesarean delivery at The Brooklyn Hospital Center (TBHC) from January to June 2021. This study evaluated 100 women; the data shows that patients took on average 4 out of 36 Percocet pills; only 11% of the total prescribed dose. Additional factors were taken into consideration including pain scale up to 3 days post-discharge, pain management alternatives, home childcare, family size, and prior opioid use. This study concludes that post cesarean delivery patients were overprescribed narcotics upon discharge from the hospital. Considerations should be made for smaller doses, spaced-out hourly doses, and shorter interval of days. Patients should be advised that if additional pain medication is required to contact their provider and be educated on the importance of properly disposing unused opioid medications.

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery

BackgroundEnhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. MethodsA pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017–2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. ResultsThere was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. ConclusionsThe use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. Levels of evidenceLevel III.

Cervical medial branch radiofrequency ablation and opioid usage: Cross sectional views at six months prior to and six months following procedure

BackgroundZygapophysial joint pain has a prevalence of up to 55% in patients suffering from neck pain. Interventional pain procedures are commonly used to treat facetogenic neck pain including cervical medial branch radiofrequency ablation (CMBRFA), which has been shown to effectively reduce pain. However, there is little research regarding its impact on opioid medication usage. ObjectiveWe aimed to evaluate changes in opioid medication usage after CMBRFA and impact of comorbid conditions on noted changes. DesignRetrospective observational study. MethodsFor patients undergoing CMBRFA between May 01, 2017 and May 31, 2020, the following data were collected: demographics, spinal level of procedure, history of prior neck surgery or pain procedures, presence of comorbid conditions, and opioid medication prescription data at 6 months before and after the procedure. Fisher’s exact tests were used for continuous variables due to inadequate sample for parametric tests. Multivariable analysis was used to assess independent predictive factors. ResultsA total of 140 patients underwent RFA during the 3-year study period. Fifteen percent (N = 21) of the cohort were on opioid medication pre-procedurally – of these, 71 % (N = 15) decreased opioid use post-procedurally which includes the 43 % (N = 9) who ceased opioid use completely. However, no statistically significant difference was noted between pre- and post-procedural MME. Of the 119 opioid-naïve patients, 16 % (N = 19) started opioids by 6 months following CMBRFA; this group was noted to have higher prevalence of anxiety and depression. ConclusionOpioid use, studied in isolation, is not a reliable measure to assess CMBRFA effectiveness. Psychologic considerations such as history of anxiety or depression are significant factors in opioid use and may influence procedure effectiveness. Opioid use patterns are multifaceted. Larger, future studies are needed to analyze post-procedure opioid use in the context of other factors such as pre-procedure opioid use, psychiatric comorbidities, and presence of multiple pain generators.

Opioid Prescriptions in Women: Is the Data Accurate?

Background: In 2012, U.S. health care providers wrote more than 259 million opioid prescriptions, which is twice as many as in 1998. Approximately 1 in 10 women report the use of opioids for pain management during pregnancy. The Centers for Disease Control and Prevention (CDC) estimated that between 2008 and 2012, 39% of reproductive-aged women on Medicaid had filled a prescription for opioid medication each year, as did 28% of women with private insurance. The opioid epidemic extends to the state of New Jersey (NJ); however, limited data is available regarding opioid prescriptions among Medicaid and private insurance patients within the state. Objective: Evaluate opioid prescriptions filled in reproductive-aged women presenting in labor at a community teaching hospital in suburban New Jersey. Methods: We performed a retrospective cohort study using data obtained from patient records and the New Jersey Prescription Monitoring Program (NJPMP) database. We enrolled 200 patients that were admitted in labor between May 2015 and May 2016. Data was collected from reproductive-aged women during the one year preceding labor admission. We compared our findings to national data reported by the CDC using Chi-square analysis. Maternal demographic data were extracted from patient records and included age, insurance status (private insurance, Medicaid, and no insurance), race, and ethnicity. The primary outcome was opioid prescriptions filled. Results: Of the 200 women admitted in labor, 129 had private insurance, 63 had Medicaid, and 8 had no insurance. We found that 5.4% (7/129) of patients with private insurance, 4.8% (3/63) of patients with Medicaid, and 12.5% (1/8) of patients with no insurance filled opioid prescriptions. Overall, 5.5% (11/200) of women filled opioid prescriptions during the study period. Opioid prescriptions confirmed via NJPMP were significantly lower than rates reported by the CDC in Medicaid (4.8% vs. 41.4%, p-value 0.001) and private insurance (5.4% vs. 29.1%, p-value Conclusion: Rates of opioid prescriptions filled were lower among our suburban cohort of women in New Jersey than national rates reported by the CDC. We did not confirm that patients with Medicaid filled more prescriptions than patients with private insurance. These discrepancies raise the question of whether a federal prescription monitoring program would better capture data than state-wide programs. Further research is needed to ensure that prescription monitoring programs are actually capturing accurate data.

Post-Operative Prescription of Opioid Medications and Patient Education: A Pilot Study

Introduction: Opioid medications are essential in the management of pain. 80-85% of surgical patients and 51% of inpatients are discharged with opioid prescriptions. With increased prescriptions, an increase in opioid abuse and overdose was identified. In 2018, nearly 47,000 deaths were reported secondary to opioids. Also, in 2015, 504 billion dollars were spent on the opioid crisis. Our aim was to determine if our division, urology, was prescribing opioids appropriately in the post-operative setting. We sought to identify gaps in patient knowledge of opioid risks, storage, and disposal. Methods: Our institution initiated an after-visit summary (AVS) detailing opioid abuse, storage, and disposal. This AVS was given to all patients that were discharged, inpatient and outpatient, with an opioid prescription. Our group analyzed patient use of opioids and knowledge before and after AVS initiation in 2019-2020. This was done using surveys at initial follow up of post-operative patients. Only completed surveys were analyzed, 50 pre-protocol and 44 post-protocol. Results: While no statistically significance difference was noted for patient knowledge, we observed a clinical difference in usage of entire opioid prescription, 20% pre-protocol vs 11% post-protocol. More patients disposed of narcotics, 60% pre-protocol vs 91% post-protocol. Pre-protocol, zero patients identified addiction as a risk of opioid use while four post-protocol. Additionally, areas of improvement were identified within the AVS. Conclusion: The survey was not statistical significance, it suggested clinical differences. Opioid prescribing is important in medicine but requires continued learning of best practices and understanding of opioid risks.

Practitioner counseling associated with improved opioid disposal among families of postoperative pediatric patients

Death from opioid-related overdose has doubled in recent years. Interestingly, there has been a similar increase in the number of opioid prescriptions. Medical providers, unfortunately, have contributed towards this rise in prescriptions. To combat the opioid epidemic, numerous efforts have been made to focus on the medical field and its role in the opioid epidemic. Proposed solutions for reduction of circulating opioids have included such measures as education, monitoring programs, alternative pain management strategies, and improved opioid disposal. We aimed to assess if counseling is associated with proper opioid disposal among families of post-operative pediatric patients. We conducted a cross-sectional, convenience sample study of families of post-surgical, pediatric patients at a single academic institution. Participants completed a survey during their postoperative visit assessing opioid requirements, storage and disposal during and after the postoperative period, and if they were counseled by any medical professional on proper disposal methods. We used multivariable logistic regression to evaluate the association between the independent variables and the primary outcome. We enrolled 180 participants, mean age of 8 years. Thirty-four percent reported having no opioid medication remaining at follow up because the medication was either consumed or the prescription was not filled. Sixty-six percent had leftover medication at the time of follow up. Sixty-six percent of participants knew the proper opioid disposal methods. However, only 22% of patients with leftover medication properly disposed of the medication. Patients who were counseled about proper opioid disposal were 3 times more likely to practice proper disposal practices than those who were not (p<0.01). Our study uniquely look at opioid consumption, disposal rates, and the effect of counseling in a diverse post-surgical pediatric population. Our findings confirm similar observations in the literature with regards to low opioid consumption, but in a larger, more surgically diverse cohort with a 100% response rate. Limitations included a lack of demographic diversity and lack of data measuring the impact of timing or frequency of counseling on opioid disposal practices. Further research goals would be to evaluate the effectiveness of counseling on proper opioid disposal, and the influence of timing and various counseling methods. Most patients do not use all of their opioid medication prescription. Proper opioid disposal counseling by a medical professional may play an important role in adherence to recommended opioid disposal practices.

Patient Preference and Risk Assessment in Opioid Prescribing Disparities

Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. ClinicalTrials.gov Identifier: NCT03134092.

The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty.

BackgroundOrthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty.MethodsA retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences.ResultsPreoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043).ConclusionsState-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.

Quality Improvement Efforts to Reduce Opioid Prescribing From a Pediatric Emergency Department.

Since the early 1990s, the United States has been fighting the epidemic of opioid addiction. Increases in the prescription of over-the-counter opioid pain medications were correlated with a notable rise in overdose deaths as early as 1999.1 These trends may have been driven in part by national efforts to improve the assessment and management of pain among patients and the “pain as a fifth vital sign” culture.2 In this issue of Pediatrics, Bryl et al3 describe their quality improvement (QI) initiative to decrease prescription of opioid medications at discharge from their urban pediatric emergency department. Evaluation of data showing that nearly half of the opioid-related deaths among patients 0 to 21 years in the San Diego area involved patients seen at their institution prompted a call to action. As the largest pediatric provider in that region, achieving a decrease in the group’s prescription of opioid medications could have a significant impact on this population.The team used rigorous QI methods to guide their initiative. These included developing a specific aim; defining outcome, process, and balancing measures; and implementing interventions by using plan-do-study-act cycles. Statistical process control charts were used to track and analyze their data. Their results were dramatic: they achieved >90% reductions in their primary outcome measures of opioid doses prescribed per week and per visit in the emergency department. Importantly, they did not see any concerning trends in their balancing measures of return visits or poor pain control assessed on follow-up phone calls.First, among their interventions, the strongest appeared to be the use of clinical decision support as a “nudge” in the form of fixed discharge dosage limits within the electronic medical record (EMR).4 First described in 2008, clinical nudges represent low-cost, highly effective strategies for changing behaviors by limiting choice, leading to decreased variation. These types of interventions are often instrumental in sustaining change long-term.Second, any effort to reduce opioid prescriptions must use a balanced approach to achieve safe prescribing while adequately treating pain. Bryl et al3 used several balancing measures, including follow-up phone calls to discharged patients, and found no evidence of undertreatment. It is notable, however, that the group only reached 17% of patients, making it difficult to assess the impact of this project’s dosage choice on pain management at this time.Third, although the overall QI methods used were robust, their QI team did not include patients and families. When developing initiatives involving direct patient care, it is important to consider inclusion of patients and families, because these stakeholders can provide pivotal information related to patient adherence and preferences.The work of Bryl et al3 should be considered in the larger context of opioid reduction efforts. With their study, they support the current literature that leftover opioid medication can be a major source of misuse, abuse, and diversion.5 It is evident that reducing overall opioid doses prescribed may be an important avenue toward addressing the opioid crisis. However, opioid prescribing for children and adolescents accounts for only a fraction of the overall opioids prescribed.6,7 This highlights the critical need for partnering with general emergency medicine colleagues and adult health care providers to ensure improved stewardship of opioid prescribing. Groenewald et al8 suggest best practices include: “1) create guidelines to guide responsible opioid prescribing and reduce leftover medications, 2) educate adolescents about risks of opioids and how to safely dispose of opioids, and 3) reduce illicit prescriptions by using state Prescription Drug Monitoring Programs (PMPs).” The study by Bryl et al3 demonstrates how use of QI methodology can bring these strategies to front line providers in the pediatric emergency department.Initiatives involving guideline development, EMR modifications, and education have broad applicability and are easily implemented, making them ideal interventions for most emergency departments. The dramatic overall opioid reduction achieved by Bryl et al3 is not surprising. In a previous study, Guarisco et al9 used similar interventions in a general emergency department setting and demonstrated a 70% reduction in prescription rates for some physicians, without negatively impacting patient satisfaction scores. This suggests that such opioid reduction outcomes could be successfully replicated in other institutions and interventions are generalizable to all age groups. Another impressive achievement with this study is the sustainability of the initiative. Although strategies such as education have been shown to wane over time, fixed function changes, such as EMR dosing limits, are neither time-bound nor provider-dependent and are easily tracked for data collection.This initiative provides a wonderful example of a project which can be undertaken within other emergency departments to decrease opioid prescribing in the pediatric population. Thoughtful QI efforts and a commitment to change can have broad implications in the care we provide to our patients.

Determining the influence of the Workers Compensation Board of Manitoba's opioid policy on prescription opioid use amongst WCB recipients.

BackgroundOpioid medications are commonly used by Workers Compensation Board (WCB) claimants following workplace injuries. The purpose of this study is to describe the impact of an opioid management policy on opioid prescriptions amongst a WCB‐covered population compared to changes in the use of these medications in the general population of a Canadian province.MethodsWe linked WCB claims data from 2006 to 2016 (13,155 claims, 11,905 individuals) to Manitoba provincial health records and compared opioid use amongst this group to 478,606 individuals aged 18–65. Linear regression was performed to examine the change over time in number of individuals being prescribed opioids for various durations and dosages of 50 or more, and 120 or more morphine equivalents (ME)/day for both the WCB and Manitoba population.ResultsWCB claimants totaled 2.5% of Manitoba residents aged 18–65 who were prescribed opioids for non‐cancer pain. After the introduction of the opioid use policy for the WCB population in November 2011, the number of people prescribed opioids declined 49.4% in the WCB group, while increasing 10.8% in the province as a whole. The number of individuals using 50 ME/day or more declined 43.1% in the WCB group and increased 5.8% in the province.ConclusionsOpioid management programs organized by a compensation board can lead to a substantial reduction in the prescription of opioid medications to a WCB client population, including individuals who were prescribed higher doses of these medications when compared with general trends in the community.