Opioid Pain Medications Research Articles

Appropriateness of opioid prescribing in cancer patients.

e24129 Background: The American Cancer Society estimates 48% people with cancer and 34% of cancer survivors report issues with chronic pain and 43 and 10% report taking an opioid, respectively. We sought to further examine the indications for pain medications in people with cancer and whether they were related to cancer, treatment, or neither. Methods: Retrospective chart review was conducted on 122 cancer patients treated at a single American academic cancer center. Authors created criteria to categorize whether patients’ pain was attributable to their malignancy or treatment regimen. Two trained coders reviewed each case with a third to resolve coding differences. Pain due to disease was further subdivided into pre-determined categories (tumor site, fracture, surgery, neuropathy, disease progression). The relationship between demographic, disease and pain type were examined in relation to inappropriate opioid prescribing using Chi-square analysis and Fischer’s exact test. Results: 55% of patients were male, 39% had metastatic disease, and 33% NED. 95% had received chemotherapy 69% radiation and 43% surgery. Factors associated with inappropriate opioid prescribing included increased age and female sex. Appropriateness of opioid prescribing was not associated with a specific cancer type or pain indication subset. Conclusions: As survivorship among cancer patients increases this may result in a cohort of patients in which opioid pain medication may not be indicated and in whom the risks may outweigh the benefits.

Acute Appendicitis: Clinical Clues and Conundrums Related to the Greatest Misses.

IntroductionIn the United States (US), appendicitis is the most common acute abdominal emergency requiring surgery. Patients with appendicitis continue to display a complex and atypical range of clinical manifestations, providing a subsequent high risk for emergency physicians to miss acute abdominal pathology on a patient’s initial visits. Due to the risk of potential perforation, the proper and timely clinical identification of acute appendicitis is vital. The current study aims to identify clinical characteristics that could be useful in identifying patients at risk for having acute appendicitis that was misdiagnosed on their initial visits.MethodsMedical charts consisting of patients between the ages of 19 and 55 years on their second visit were flagged and reviewed by the emergency department quality assurance (EDQA) committee. The retrospective chart review included patients who presented to the emergency department (ED) with the chief complaint of an abdominal-related complaint, were discharged, returned within 72 hours, and were diagnosed with a pathologically confirmed appendicitis. All patients were managed operatively, with pathology results reviewed for evidence of acute appendicitis. Those with confirmed pathologic appendicitis upon return were considered to have a “misdiagnosis.” Any patients managed nonoperatively and those with negative pathology were excluded from the study and considered not to have appendicitis.ResultsFifty-five patients were identified through the EDQA committee from May 2011 to January 2014. After exclusion criteria were applied, 18 patients met the inclusion criteria for this study (7 males, 11 females). The mean age was 36.2 (range: 19-55). The most common presenting complaint on the initial visit was pain in the epigastric region of the abdomen (50%, n = 9). Twenty-two percent (n = 4) of patients had pain in the right lower quadrant documented in the physician’s note on the initial visit and 83% (n = 15) had right lower quadrant pain documented on the second visit. Two patients (11%) did not have right lower quadrant tenderness on either visit. The most common discharge diagnosis on the initial visit was undifferentiated abdominal pain (50%), followed by gastritis (28%). Opioid pain medication was administered or prescribed to 39% (n = 7) of the patients. The average return time was 23.9 hours.ConclusionThe administration of opioid pain medication is associated with many of the return visits to the emergency department for missed appendicitis. Finally, discharge diagnosis and planning are imperative, as detailed early appendicitis instructions or extended ED observation can include more cases and decrease litigation risk.

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 Risky Excess? Opioid Use, Storage, and Disposal Practices Among Post-operative Gynecologic Oncology Patients [21H

INTRODUCTION: Inappropriate storage and disposal of unused opioids presents a growing public health and safety issue. This is of special interest when caring for women undergoing surgery for gynecologic conditions, such as cancer, as there is increasing evidence of overprescribing in the post-operative period. This study investigates opioid storage and disposal practices among post-operative gynecologic oncology patients. METHODS: We developed and administered a cross-sectional survey among patients who underwent surgery for gynecologic cancer or cancer precursors between October 2017–January 2019. The survey tool assessed self-reported opioid use, storage, and disposal practices as defined according to FDA guidelines. Additional data was abstracted regarding inpatient opioid requirement prior to discharge and baseline risks factors for opioid misuse. IRB approval was obtained. RESULTS: 297 patients met inclusion criteria. The average opioid requirement on the day of discharge was 12.9 MME (morphine milligram equivalents) with average discharge amount prescribed being 180.4 MME. 70.4% reported use of 50% or less of the opioids prescribed, and 62% reported keeping their unused opioids. 75% reported unsafe storage. 26% reported personally using leftover opioid pain medication for reasons unrelated to the surgery. Only 30.4% reported using a designated drop site for opioid disposal. Only 38.3% recalled receiving information on safe opioid storage and disposal during their care. CONCLUSION: There is significant overprescribing of opioids in gynecologic oncology patients postoperatively. Increased collaborative patient and prescriber education regarding safe opioid storage and disposal is paramount for future efforts to prevent diversion, accidental ingestion, and chronic opioid use.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Association Between Intrapartum Factors and the Time to Breastfeeding Initiation.

Background/Objectives: Early breastfeeding initiation is strongly recommended. Reasons for delayed breastfeeding initiation often include intrapartum interventions such as induction of labor, opioid pain medication administration, epidural analgesia, and caesarean birth. The majority of existing studies examining the timeliness of breastfeeding initiation are from low- or middle-income countries. The objective of this study is to examine intrapartum interventions on the time to breastfeeding initiation in a cohort of mothers from a high-income country. Materials and Methods: A cohort of 1,277 new mothers was recruited within 24 hours after birth from 4 hospitals in Hong Kong from 2011 to 2012. Participants completed a self-administered questionnaire immediately after recruitment. The rates of intrapartum interventions and the time to the first breastfeed were collected from participants' hospital record. Results: Among participants, 575 (45.5%) initiated breastfeeding within 1 hour of birth and the median time to the first breastfeed was 1.5 hours. The use of opioid pain medication (adjusted hazard ratio [aHR]: 0.78, 95% confidence interval [CI]: 0.67-0.91), assisted vaginal birth (aHR: 0.74, 95% CI 0.56-0.97), and caesarean section (aHR: 0.30, 95% CI 0.25-0.36) were associated with delayed breastfeeding, whereas epidural analgesia and induction of labor had no effect on breastfeeding initiation. Natural birth (i.e., no intrapartum interventions) was also significantly associated with early breastfeeding initiation (aHR: 1.75, 95% CI 1.54-1.99). Conclusions: Breastfeeding initiation was delayed in participants who had a caesarean birth and who received opioid pain medication. These women may require additional support to initiate breastfeeding soon after birth.

Stimulation of the Gasserian Ganglion for the Treatment of Refractory Trigeminal Neuralgia. Two Case Reports

Background: Treatment of trigeminal neuralgia (TN) can be challenging for many physicians; patients who do not respond to conventional treatments and traditional surgical approaches often continue to suffer with pain. The peripheral nerve stimulator has been used to treat many chronic pain conditions, but few reports exist about its use to treat refractory TN through the stimulation of the Gasserian ganglion (GG). Case Report: We present 2 cases of patients with refractory TN who failed conventional medical and surgical management. Both patients were suitable candidates for a trial of peripheral nerve stimulation of the GG, both patients had positive results with the trials, and proceeded with permanent placement of the GG stimulator. In both cases we used deep brain stimulator leads, which were placed under fluoroscopy guidance through the foramen ovale onto the GG, and tunneled through the postauricular area to a pocket in the upper chest wall under the clavicle for the implantable pulse generator. Both of our patients experienced a significant symptomatic and functional improvement in their symptoms. The second patient was successfully weaned off her opioid pain medications after 6 months of treatment. Conclusion: Percutaneous stimulation of the GG is a promising technique for the treatment of refractory trigeminal neuropathic pain. More studies and experiences with this technique are needed to better demonstrate the efficacy and the safety profile, which potentially could allow this procedure to be considered ahead of the more invasive neurodestructive surgical treatments. Key words: Trigeminal neuralgia, Gasserian ganglion, peripheral nerve stimulator

MP03-12 CONTINUED FEASIBILITY AND SUCCESS OF A NON-OPIOID PATHWAY FOR POSTOPERATIVE PAIN AFTER URETEROSCOPY

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation I (MP03)1 Apr 2020MP03-12 CONTINUED FEASIBILITY AND SUCCESS OF A NON-OPIOID PATHWAY FOR POSTOPERATIVE PAIN AFTER URETEROSCOPY Mohannad Awad*, David Sobel, Nikolas Moring, and Kevan Sternberg Mohannad Awad*Mohannad Awad* More articles by this author , David SobelDavid Sobel More articles by this author , Nikolas MoringNikolas Moring More articles by this author , and Kevan SternbergKevan Sternberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000817.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Physician prescribing patterns in the United States are a known factor contributing to the opioid crisis. Our initial short-term experience demonstrated the ability to avoid opioids after ureteroscopy (URS) through patient counseling, use of non-steroidal anti-inflammatory drugs (NSAIDs) and adjunct medications, and making a concerted effort to avoid opioid prescriptions. In this study, we report our extended experience over a 3 year period. METHODS: Charts of patients who underwent URS with stent placement by a single surgeon from November 2016 to November 2019 were retrospectively reviewed. Efforts were made to substitute opioid pain medications on discharge for either no prescription or NSAIDs. All patients received similar adjunct medications including Tamsulosin, Tylenol, and Pyridium. Patients unable to receive NSAIDs were excluded (Allergy or CKD). Frequency of postoperative adverse events including visits to the emergency department (ED) for stent-related symptoms, stent-related clinic telephone calls including prescription refills for pain medication were measured. RESULTS: 464 patients underwent URS with stent placement over the 3 year period. 38 patients were excluded due to NSAIDs allergy, or CKD and an additional 35 for having other concurrent procedures such as cystolitholapaxy. 391 patients were included in the final analysis. 357 patients were discharged without opioid medications (91.3%). 34 patients received opioids (8.7%). Of those discharged without an opioid, 276 received NSAIDs and 81 received no pain medication (opioid or NSAIDs). There was a low number of postoperative visits to the ED for genitourinary-related concerns (3 patients receiving opioids [8.8%] and 26 patients without opioids [7.3%]). Telephone calls made to the urology clinic for concerning symptoms and prescription refills were made by 11 patients receiving opioids (32.4%) and 45 patients without opioids (12.6%). CONCLUSIONS: More than 90 % of patients were able to be discharged without opioids after URS and stent placement over a 3 year period without impact on ED visits, or clinic telephone calls. This was achieved through patient counseling and commitment to change practice patterns. We hope our experience will encourage others to take similar measures to decrease opioid prescriptions in this setting. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e26-e26 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohannad Awad* More articles by this author David Sobel More articles by this author Nikolas Moring More articles by this author Kevan Sternberg More articles by this author Expand All Advertisement PDF downloadLoading ...

Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures

PurposeSupracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation.MethodsWe performed an institutional review board–approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale–Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated.ResultsComparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale–Revised Survey results. No hematoma block-associated complications were reported.ConclusionsThe result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF.Type of study/level of evidenceTherapeutic II.

869 Opioid Utilization in Pediatric Burn Patients

Abstract Introduction Childhood burns are extremely common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, disrupting care and increasing the risk of post-traumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of burns in pediatric patients. We sought to evaluate the current use of multimodal therapy as well as the use, storage, and disposal of opioids in this patient population. Methods We prospectively surveyed parents of pediatric burn patients (0–18 years old) who presented to the burn clinic within two weeks of burn injury. Parents were surveyed regarding over-the-counter pain medication use and opioid medication use, storage, and disposal in the treatment of their child. Medians and interquartile ranges were used to describe continuous variables and frequencies and percentages were used for categorical variables. Results A total of 92 parents of burn-injured children were surveyed at a single institution in the outpatient burn clinic. The median age of burn-injured children was 3.1 years old, and 50% of patients were male. The majority had a TBSA of 1%. The hand was the most frequently burned location (45.7%). Acetaminophen (58.7%) and ibuprofen (69.6%) were the most common treatments for both constant and breakthrough pain. Approximately 28% (26/92) of patients were prescribed opioids, of which 18.5% (17/92) filled their prescription. Only 29% of patients (5/17) consumed their entire prescription, and a median of 3 doses of opioids remained for those who did not finish the entire prescription. Parents most commonly decided to give their children opioid pain medications because “my child is in severe pain” or “I give my child pain medications as scheduled (written on prescription).” Approximately 40% (7/17) of patients who filled opioid prescriptions stored them in a locked area, and only 35.3% (6/17) were educated on how to dispose of excess opioid pain medication. Conclusions Presently, multimodal therapy with over-the-counter pain medications is used to treat the majority of pediatric burns. This study demonstrates an increased need for education on opioid administration, storage, and disposal for parents of burn-injured children. Applicability of Research to Practice We aimed to evaluate what current trends in opioid use are in pediatric burn patients and areas for improvement in parent education for over-the-counter pain medication use, opioid use, opioid storage, and disposal. From the study, we were able to glean that the majority of patients are successfully managed with over-the-counter pain medications. However, parents and patients managed with opioids need additional education on appropriate administration of opioid pain medications, safe locked storage of opioids, and opioid disposal. This demonstrates an area for quality improvement inpatient and outpatient.

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.

Patterns of opioid use in dialysis access procedures

BackgroundOverprescription of opioids after surgical procedures is recognized as an important contributor to opioid misuse. Dialysis access procedures are commonly performed outpatient operations with few data or guidelines to inform prescription pain management practices. We sought to characterize opioid pain medication use after dialysis access surgery to promote a conservative approach to postoperative opioid prescriptions. MethodsWe performed a retrospective review of patients who underwent surgical dialysis access procedures from August 2018 through January 2019. Patient-reported opioid use information was captured in a brief questionnaire administered during routine follow-up appointments or phone calls and recorded in the electronic medical record. The procedure, type of intraoperative anesthesia or analgesia, postoperative prescription provided, and patient factors (including age, sex, dialysis type, history of chronic pain, and preoperative opioid or benzodiazepine use) were recorded. All procedures were classified by type (arteriovenous fistula or graft with a short incision [AVF-S], arteriovenous fistula or graft with a long incision [AVF-L], or peritoneal dialysis [PD] catheter), and descriptive statistics were performed using R (R Foundation for Statistical Computing, Vienna, Austria). ResultsEighty-six patients underwent dialysis access procedures in the study time frame, of whom 63 were administered the pain questionnaire and 58 quantified opioid use; 85% of patients received a prescription, but 31% took no opioids and 71% used opioids for ≤2 days. Interquartile ranges (25th-75th percentile) of prescription and consumption quantities for patients who underwent AVF-L procedures were 10 to 28 pills and 2.5 to 20 pills; for patients who underwent AVF-S, quantities were 4.0 to 8.4 pills and 0 to 4.3 pills; and PD quantities were 10 pills and 3.3 to 9 pills. Thirty-one patients (53%) reported receiving more pain medication than they used, which resulted in a median of 8 excess pills per patient with an unused pill interquartile range of 0 to 22 pills for AVF-L procedures, 0 to 4.2 pills for AVF-S procedures, and 1.3 to 6.7 pills for PD procedures. Patients who were prescribed oxycodone or had a repeated operation had significantly increased opioid use. ConclusionsThis investigation of opioid use after surgical dialysis access procedures suggests that most patients use relatively few opioid pills after surgery, which translates into overprescription and leftover medication for >50% of patients. A conservative approach to postoperative prescription guidelines using lower prescription quantities would encourage opioid-related risk reduction while providing adequate postoperative analgesia. Recommended quantities for postoperative prescriptions were generated using the 80th percentile consumed and were 0 to 6 pills for brachiobasilic or brachiocephalic fistulas, 0 to 5 pills for basilic vein transposition, 0 to 5 pills for radiocephalic AVF, 0 to 15 pills for upper arm grafts, and 0 to 10 pills for PD catheter placement.

Plastic Surgery Patient Expectations for Postoperative Opioid Prescriptions.

The opioid epidemic is a healthcare crisis perpetuated by analgesic overprescribing. Despite public health attention on this issue, expectations for pain management and opioid use by plastic surgery patients are poorly understood. This study aimed to evaluate patient expectations of postoperative pain, concern for opioid dependence, and anticipated analgesic plan after plastic surgery. New patients presenting to an academic plastic surgery clinic were prospectively enrolled from November 2017 to September 2018. These patients completed a preconsultation survey regarding their pain history and anticipated postoperative pain and analgesics regimens. Responses between cohorts expecting and not expecting postoperative opioids were compared using descriptive and univariate analyses. A total of 168 patients (63.9% female, 36.1% male; mean ± SD age 46 ± 17 years) completed the survey before breast (21.9%), cosmetic (5.3%), craniofacial (3.0%), general reconstruction (13.0%), hand (3.0%), and skin and soft tissue (49.1%) surgeries. Twenty-eight percent of patients expected opioid prescriptions. On a standard visual analog scale, patients who expected opioids anticipated greater postoperative pain (6.9 vs 4.6, P < 0.05). They were more concerned about experiencing pain (5.8 vs 4.9, P < 0.05), expected a longer duration of opioid use (63.0% vs 37.0%, P < 0.05), and were less interested in nonnarcotic analgesic alternatives (57.9% vs 19.8%, P < 0.05). Less than one-third of plastic surgery patients in this study expect opioid pain medications after surgery. This supports broader use of nonopioid, multimodal pain regimens. Identification and management of patient pain expectations, especially among those anticipating a need for opioids, provide a critical opportunity for preoperative education on the benefits of nonopioid analgesics, thus minimizing opiate prescribing.

Objective Quantification of Opioid Usage After Thyroid Surgery.

Introduction It is well established that America is in the midst of an opioid crisis with 46 people dying every day from overdoses involving prescription opioids. In the last 2 years, multiple articles have been published indicating that the amount of opioid pain medication needed after discharge from thyroid and parathyroid surgery is low. Objective To objectively examine the amount of opioid pain medication required by patients in our practice after thyroid surgery. Methods Patients were given a standardized discharge prescription of 30 pills with a combination of 7.5 mg of hydrocodone and 325 mg of acetaminophen after thyroid surgery. They were asked to log the number of pills consumed per day and the level of pain per day using the Wong-Baker faces pain scale. We used in-office pill counts to ensure accuracy of the logs. Results While reaching a similar conclusion, the present study is the first to objectively examine the quantity of opioid pain medication consumed between postoperative discharge and office follow-up. Our study objectively demonstrates that 85% of patients consumed less than 75.0 morphine milligram equivalent (MME) after thyroid surgery using in-office pill counts. Conclusion Recent multimodality anesthesia research appears promising to dramatically reduce or even eliminate the need for opioid prescriptions upon postoperative discharge.

Pain in older survivors of hematologic malignancies after blood or marrow transplantation: A BMTSS report.

Blood or marrow transplantation (BMT) is increasingly offered to older adults with hematologic malignancies; however, their risk for severe pain is poorly understood. Using the Bone Marrow Transplant Survivor Study, the current study investigated the prevalence and predictors of pain after BMT (allogeneic or autologous) as well as its association with physical performance impairments and frailty. The cohort included 736 patients with hematologic malignancies who underwent BMT at an age≥60years at 1 of 3 transplant centers between 1974 and 2014 and survived ≥2years after BMT; 183 unaffected siblings also participated. Study participants reported on 4 pain domains (nonminor everyday pain, moderate to severe bodily pain, prolonged pain, and moderate to extreme pain interference), and the presence of 1 or more domains was indicative of a severe and/or life-interfering pain composite variable. Overall, 39.4% of the BMT survivors reported severe pain with 2.6-fold greater odds of reporting pain in comparison with sibling controls. Among BMT recipients, those with less education, lower incomes, and active chronic graft-versus-host disease had higher odds of reporting pain. In multivariable analyses, BMT survivors with pain were more likely to have impaired physical performance and were more likely to meet the frailty criteria. BMT survivors reported higher use of pain medications (17.8% vs 9.3%) and opioid pain medications (6.5% vs 2.2%) in comparison with sibling controls. Nearly 40% of older BMT survivors who were followed for a median of 5years after BMT reported pain, and BMT survivors had 2.6-fold higher odds of reporting severe, nonminor or life-interfering pain in comparison with siblings.

Patterns of Storage, Use, and Disposal of Prescription Opioids by Parents of Children with Cancer (FR460D)

•Discuss the results of our study.•Recommend strategies for health care providers to provide knowledge about the safe storage, use, and disposal of opioids. Multiple studies have demonstrated that adults do not store prescription opioids safely. Increased prescription opioid rates have led to an increased incidence of opioid poisonings in children and adolescents. We investigated whether parents of children with cancer that were prescribed opioids practiced safe storage, use, and disposal techniques. We conducted a prospective cross-sectional survey of parents whose children were prescribed opioids and asked them about their patterns of storage, use, and disposal of prescription opioids. Virtually all parents (106/109, 97%) completed the survey. Most parents (95/106, 90%) did not store opioids safely. Six of 106 parents (6%) gave their child's opioid pain medication to someone else with pain, and 3 of 106 parents (3%) personally took some of their child's opioid. Parents who personally took their child's opioid (P = .01) or gave it to another person (P < .001) were more likely to use opioids unsafely in their child. A minority of parents (22/106, 21%) did not use opioids safely in their child. A small number of parents (3/22, 14%) did not dispose of opioids safely. Universal education about the safe, use, and disposal of opioids should be adopted when prescribing opioids. Pediatricians need to maintain vigilance about the nonmedical use of prescription opioid use by parents of children.

Implementation and assessment of a pilot, community pharmacy–based, opioid pain medication management program

ObjectivesThis study aimed to evaluate care gaps in risk- and harm-reduction strategies for patients prescribed opioids and to describe the implementation of a community pharmacy–based, pilot pain-management program. SettingThe pilot program was established in a community pharmacy within an academic medical center. Patients enrolled were prescribed opioids for chronic pain by a rheumatology clinic. Practice descriptionThe patients enrolled met 1 or more of the following criteria: they were prescribed more than 1 short-acting opioid; more than 90 morphine milligram equivalents/d; and more than 7 days’ supply of medications for acute pain, including high-risk medication combinations. Comprehensive pain-medication assessments and pharmacist interventions were communicated to providers and implemented at follow-up. Data were analyzed using descriptive statistics. Practice innovationA gap analysis was conducted by including 23 patients seen at the clinic over a 22-month period. The care gaps identified served as the basis for the pilot-program design. EvaluationPatients referred to the program were seen over a span of 1 to 2 visits; a total of 19 visits were documented. Pharmacists identified unaddressed issues with mood (68%). Recommendations made to the providers included additional adjuvant therapy (84%), dose adjustment (58%), and laboratory tests (74%). Naloxone was provided (58%), and education on naloxone use was provided at every visit. DiscussionUntreated depression, anxiety, and insomnia were the most common problems identified by pharmacists. Pharmacists implemented and documented risk-reduction strategies and coprescribed naloxone more frequently compared with clinic providers. The program enhanced the pharmacists’ ability to make safe and clinically appropriate decisions with regard to filling opioid prescriptions. ConclusionThe pilot program identified care gaps and provided an approach for engaging with patients and providers to optimize pain management, implement opioid risk-reduction strategies, and expand naloxone access.

Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study.

Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. Adults aged 23-25years old and 27-29years old who presented to the ED or died prior to reaching the hospital from opioid overdose. Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.