Opioid Pills Research Articles

Opioid use patterns following discharge from elective colorectal surgery: a prospective cohort study.

Opioid overprescription after colorectal surgery can lead to adverse events, persistent opioid use, and diversion of unused pills. This study aims to assess the extent to which opioids prescribed at discharge after elective colorectal surgery are consumed by patients. This prospective cohort study included adult patients (≥ 18yo) undergoing elective colorectal surgery at two academic hospitals in Montreal, Canada. Patients completed preoperative questionnaires and data concerning demographics, surgical details, and perioperative care characteristics (including discharge prescriptions) were extracted from electronic medical records. Self-reported opioid consumption was assessed weekly up to 1-month post-discharge. The total number of opioid pills prescribed and consumed after discharge were compared using the Wilcoxon signed-rank test. Negative binomial regression was used to identify predictors of opioid consumption. We analyzed 344 patients (58 ± 15years, 47% female, 65% laparoscopic, 31% rectal resection, median hospital stay 3days [IQR 1-5], 18% same-day discharge). Most patients received a TAP block (67%). Analgesia prescription at discharge included acetaminophen (92%), NSAIDs (38%), and opioids (92%). The quantity of opioids prescribed at discharge (median 13 pills [IQR 7-20]) was significantly higher than patient-reported consumption at one month (median 0 pills [IQR 0-7]) (p < 0.001). Overall, 51% of patients did not consume any opioids post-discharge, and 63% of the prescribed pills were not used. Increased opioid consumption was associated with younger age (IRR 0.99 [95%CI 0.98-0.99]), higher preoperative anxiety (1.02 [95%CI 1.00-1.04]), rectal resections (IRR 1.45 [95%CI 1.09-1.94]), and number of pills prescribed (1.02 [95%CI 1.01-1.03]). A considerable number of opioid pills prescribed at discharge after elective colorectal surgery are left unused by patients. Certain patient and care characteristics were associated with increased opioid consumption. Our findings indicate that post-discharge analgesia with minimal or no opioids may be feasible and warrants further investigation.

Multimodal Analgesia and Small Opioid Prescriptions are the New Standard in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership

BackgroundThe purpose of this survey study was to assess the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS) as well as identify changes in practice made by AAHKS members over time. MethodsA survey of 37 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 3,243 practicing adult reconstruction surgeon members of AAHKS in May 2023. Results were compared to a nearly identical survey sent out to all board-certified adult reconstruction surgeon members of AAHKS 5 years previously in November 2018. ResultsThere were 527 responses (16%) to the survey. Since 2018, the mean number of opioid pills prescribed after total joint arthroplasty has declined significantly from 49 to 32 pills after total knee arthroplasty (TKA) and from 44 to 18 pills after total hip arthroplasty (THA). The use of multimodal analgesics in addition to opioids has also increased over the past 5 years from 74 to 93%. The most common medications utilized include nonsteroidal anti-inflammatories (98%), acetaminophen (80%), and gabapentinoids (32%). A majority of surgeons (78%) still use a spinal for TKA and THA. However, there has been an increase in the number of surgeons using peripheral nerve blocks for TKA from 69% in 2018 to 84% in 2023. The routine use of periarticular injection or local infiltration anesthesia in THA and TKA has also increased over the past 5 years from 80 to 86%. ConclusionsSince 2018, there has been increased adoption of multimodal analgesia and anesthesia, and improved consensus regarding the optimal regimen among surveyed arthroplasty surgeon members of AAHKS. The number of opioid pills prescribed after THA and TKA has declined significantly over the past 5 years.

Patient reported opioid usage following vulvar surgery in gynecologic oncology

BackgroundThere remains a paucity of data for vulvar surgery outcomes in gynecologic oncology in the era of Enhanced Recovery After Surgery (ERAS) ®. As such, the primary objective is to assess the impact of patient and procedural factors on patient reported postoperative opioid usage following vulvar surgery. Secondary objective is to create a tailored opioid prescribing algorithm for this population. MethodsA retrospective cohort study was performed of patients who underwent vulvar surgery for a gynecologic malignancy between 3/2019–7/2022. Covariates of interest included a history of risk factors for opioid usage, age, anatomic location of the vulvar resection, radicality of surgery, groin dissection, use of postoperative non-steroidal anti-inflammatory drugs (NSAIDs), and complications. Logistic regression models evaluated the effects that sociodemographic characteristics and procedural factors have on opioid usage. Linear regression models were created to determine prescribing guidelines. ResultsA total of 100 patients were included. Following surgery, 35 patients (35 %) were not sent home with an opioid prescription, 39 patients (39 %) reported using at least one opioid pill from their prescription, and 26 patients (26 %) reported not using any opioid pills from their prescription. In the regression models, patient age (p < 0.006) had a significant impact on opioid use, while all other factors did not. Contraindications to NSAIDs did not have a statistically significant impact (p = 0.1) but was deemed clinically meaningful and included in the final model. Proposed opioid prescribing guidelines were created. ConclusionIn conclusion, most patients after vulvar surgery require little to no opioids. Identifiable preoperative factors can aid providers to manage postoperative pain while minimizing unnecessary opioid prescriptions.

The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review.

Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.

Curbing the Opioid Crisis: Optimal Dynamic Policies for Preventive and Mitigating Interventions

Problem statement: This paper addresses the challenge of effectively responding to the opioid epidemic stemming from prescription pills through a public health lens. It centers on the strategic distribution of resources across diverse interventions aimed at preventing and mitigating the consequences of opioid use disorder (OUD) and overdose occurrences. Methodology: This paper proposes a decision aid tool built on the expected utility theory that leverages a Susceptible-Infected-Removed compartmental model to simulate the dynamics of the epidemic in a population. This model then feeds into a Markov Decision Process (MDP) model to generate optimal policies upon the current state of the epidemic. The optimal policies allocate the intervention budget to primary preventive and mitigating interventions in each decision period by minimizing the cost of fatal overdoses relative to the population’s number of individuals with OUD, considering the impact magnitude of each intervention, based on the current state of the epidemic. A 10-year simulation of the epidemic’s progression is conducted to assess the dynamic efficacy of the proposed decision tool. Results: The findings reveal an average reduction of 29% in total costs compared to the scenario without interventions and a decrease of 12% in total costs on average compared to the scenario with a 50-50 allocation. The extensive sensitivity analysis of key parameters validates the decision aid tool. We observe that it is optimal to allocate a significant portion of the budget to prevention when the rate of opioid pill acquisition rises. Even with a heightened rate of fatal overdoses, it remains optimal to mostly invest in preventive interventions, as long as fatal overdose rates are lower than opioid access rates. Practical implications: This study provides practitioners with a tool to effectively address the opioid epidemic and enhance public health by deciding how to allocate their budget to various levels of intervention.

The persistent benefits of decreasing default pill counts for postoperative narcotic prescriptions.

In 2017, a university-based academic healthcare system changed the opioid default pill count from 30 to 12 pills. Modifying the electronic default pill count influences short-term clinician prescribing practices. We sought to understand the long-term impact on postoperative opioid prescribing habits after an opioid default pill count reduction. A retrospective electronic medical record system (EMRS) review was conducted in a healthcare system comprised of seven affiliated hospitals. Patients who underwent a surgical procedure and were prescribed an opioid on discharge between 2017-2021 were evaluated. All prescriptions were converted into morphine equivalents (MME). Analyses were performed with the chi-square test and Bonferonni adjusted t-test. 191,379 surgical procedures were studied. The average quantity of opioids prescribed decreased from 32 oxycodone 5 mg tablets in 2017 to 21 oxycodone 5 mg tablets in 2021 (236 MME to 154 MME, p<0.001). The percentage of patients obtaining a refill within 90 days of surgery varied between 18.3% and 19.9% (p<0.001). Patients with a pre-existing opioid prescription and opioid-naïve patients both had significant reductions in prescription quantities above the default MME (79.7% to 60.6% vs. 65.3% to 36.9%, p<0.001). There was no significant change in refills for both groups (pre-existing 36.7% to 38.3% (p = 0.1) vs naïve 15.0% to 15.3% (p = 0.29)). The benefits of decreasing the default opioid pill count continue to accumulate long after the original change. Physician uptake of small changes to default EMRS practices represents a sustainable and effective intervention to reduce the quantities of postoperative opioids prescribed without deleterious effects on outpatient opiate requirements.

Enhanced recovery after cesarean (ERAC) versus conventional care: An expanded systematic review and meta-analysis of 18,368 subjects

Abstract Background and Aims: Enhanced recovery after cesarean (ERAC) is an interdisciplinary approach to improve patient outcomes following cesarean section. ERAC’s execution must be constantly evaluated. Thus, we aimed to analyze parameters associated with ERAC adoption for clinical care in this expanded systematic review. Material and Methods: A systematic literature search using Epistemonikos, Google Scholar, PubMed, and Scopus was done until February 2023. The appropriate observational and experimental research comparing the effects of ERAC protocols with conventional care on postoperative adverse events, operation-related characteristics, time to first (oral intake, mobilization, bowel movement, and urinary catheter removal), and opioid use. Meta-analyses were conducted using the RevMan 5.4.1. and Comprehensive Meta-Analysis version 3.3 software. Results: In total, 23 studies were included in this systematic review. ERAC implementation was found to be associated with improvement in terms of shorter postoperative hospital stays and faster time to first liquid intake, first solid diet, urinary catheter removal, and mobilization. Furthermore, the rate of opioid-free treatment, total in-hospital morphine milligram equivalent (MME), daily in-hospital MME, and total prescribed opioid pills at discharge (all parameters, P &lt; 0.01) were significantly better in the ERAC group than in the conventional care group. However, no significant difference was observed regarding postoperative adverse events, blood loss, operation duration, and total prescribed MME at discharge parameters between the two observed groups. Conclusion: ERAC implementation is associated with better healthcare delivery, as determined by shorter time to first, lower opioid consumption, and shorter postoperative length of stay compared with conventional care. However, it is not associated with a lower dosage of opioid prescription at discharge. Key Message: ERAC has demonstrated immense advantages and appears to be the future of cesarean delivery methods worldwide. However, based on our analysis, it is not associated with a lower dosage of opioid prescription at discharge.

Prescription Opioid Diversion Sources Among African Americans: Implications for Overdose Prevention

Recent data show that African Americans (AAs) experienced a greater increase in overdose deaths involving prescription opioids relative to other racial/ethnic groups. One possible mechanism through which elevated risk for overdose is conferred to AAs could be due to greater exposure to contaminated counterfeit pills. Unfortunately, prescription opioid diversion is understudied among AAs and less is known regarding which sources AAs use to access pharmaceutical opioids. The objective of this study, therefore, was to identify and describe the most commonly used diversion sources for prescription opioids among AAs. Qualitative interview data are also presented to contextualize the most prevalent sources. This study used data from the Florida Minority Health Study, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of AAs. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. Analyses revealed that the most widely used sources for prescription opioids were dealers (33.0%) and friends/relatives (34.7%). Additionally, interview data indicated that dealers are the access point where larger volume acquisitions are made and high potency formulations are accessed. These findings suggest that AAs may utilize nonhealthcare related sources at higher rates than healthcare related sources to acquire prescription opioids. This is concerning because opioid pills acquired through nonhealthcare related sources are especially susceptible to fentanyl adulteration. These findings invite further study using nationally representative data to determine if AAs disproportionately use nonhealthcare related sources compared to persons from other racial/ethnic groups.

Association Of Opioid Prescribing And Consumption With Patient-Reported Experiences And Satisfaction Following Emergency Surgery In Michigan.

To investigate the relationships between opioid prescribing, consumption, and patient reported outcomes (PROs) in emergency surgery patients. Overprescribing of opioids for pain management after surgery has become a public health concern and major contributor to opioid misuse and dependency. Current guidelines do not address opioid prescribing following emergency surgical procedures, highlighting the importance of understanding the relationship between opioid prescribing and consumption in this setting. Retrospective analysis of the quantity of opioids prescribed and patient-reported outcomes (PROs) in a population-based setting. The sample included adults 18 years and older undergoing emergency surgery across 69 hospitals in Michigan. Patients were included if they received a discharge opioid prescription and had valid data for opioid consumption and PROs. Surgical procedures took place between January 1, 2018 and December 31, 2020. During the study period, a total of 3,742 patients underwent an emergency operation. The mean number of opioid pills prescribed was 9.6 and the mean number of opioid pills consumed was 4.6. In a two-model with logit in the first part and a linear regression in the second, prescription size was significantly associated with both the probability of consumption (aOR 1.02, 95% CI 1.01-1.04) and the amount of consumption conditional on any consumption (coefficient 0.70 95% CI 0.54-0.86). Patients only consumed half of the opioids they were prescribed after undergoing emergency surgery. Additionally, patients who were given larger prescriptions consumed more opioids, but did not experience less pain, higher satisfaction, better quality of life, or less regret to undergo surgery. Overall, this suggests that opioids may be excessively prescribed to patients undergoing emergency surgical procedures, and that larger prescriptions do not improve the patient experience after surgery.

How low can we go? A randomized controlled trial of low-quantity initial opioid prescriptions for shoulder surgery

Orthopedic surgeons are the third most frequent prescribers of opioid medications. Given the current opioid addiction crisis, it is critical to limit opioid prescriptions to the lowest effective dose. In this study, we investigated how the initial opioid prescription after shoulder surgery affects maximum possible opioid consumption. We hypothesized that fewer pills in the initial opioid prescription would lead to less opioid consumption, a lower refill request rate, and fewer post-surgery office contacts for pain. In this single-center, prospective, randomized controlled clinical trial, 74 adults who underwent shoulder arthroplasty, rotator cuff repair, or other arthroscopic shoulder procedures were enrolled from December 2020 to July 2022. Follow-up was completed by February 2023. Participants were randomly assigned to receive postoperative prescriptions of seven 5-mg oxycodone pills (n=20), 15 pills (n=29), or 23 pills (n=25). The primary outcome was maximum possible opioid consumption within 2weeks after surgery, calculated by assuming consumption of all pills in the initial prescription, as well as any refills. Secondary outcomes were the opioid prescription refill request rates, post-surgery pain-related telephone calls or messages to the provider's office ("office contacts") within 2weeks after surgery, and American Shoulder and Elbow Surgeons pain scores 2weeks after surgery. Baseline characteristics did not differ among groups except for mean age, which was younger in the 7-pill group (P=.047). Maximum possible opioid consumption increased with the number of pills initially prescribed, with means of 78 morphine milligram equivalents (MME) for the 7-pill group, 118 MME for the 15-pill group, and 199 MME for the 23-pill group (P<.001). None of the secondary outcome measures differed among groups. Refill request rates were 20% for the 7-pill group, 3.4% for the 15-pill group, and 12% for the 23-pill group (P=.20). The proportions of patients with at least 1 office contact were 35% in the 7-pill group, 45% in the 15-pill group, and 28% in the 23-pill group (P=.43). Mean American Shoulder and Elbow Surgeons pain scores were 49 in the 7-pill group, 44 in the 15-pill group, and 40 in the 23-pill group (P=.20). After shoulder surgery, an initial prescription of fewer opioid pills was associated with less maximum possible opioid consumption without an increase in the percentage of patients requesting opioid refills or contacting the provider's office for pain-related concerns. An initial postoperative prescription of fewer 5-mg oxycodone pills may be equally or more effective compared with larger quantities for most patients.

The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States

BackgroundCo-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality.MethodWe recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant.ResultsA clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand.ConclusionTransformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs’ market dominance at this location and possible interventions.

Predictors of adequate pain control after outpatient hand and upper extremity surgery.

The opioid epidemic has changed practice, though there remains a paucity of data regarding prescribing habits and pain control following outpatient hand surgery. We sought to evaluate patient-related predictors of adequate postoperative pain control. A retrospective review was performed of a single-center prospectively collected database of elective outpatient surgery on the elbow, forearm, wrist, and/or hand. Patients were asked to complete preoperative and postoperative questionnaires to capture their perception of anticipated pain levels, expected prescription quantity/duration, additional medications used, and overall pain satisfaction. Patient demographics collected included, sex, age, race, tobacco use, and recreational drug use. Further, the questionnaire included the Brief Resilience Score (BRS), EuroQol 5-dimension health-related QOL measure (EQ-5D), and an assessment of patient-reported limitations secondary to their pain. Ninety-six patients completed the pre/postoperative questionnaires and were eligible for analysis. Of these patients, 80% reported adequate pain control. The sex, age, and race of those who reported adequate pain control and inadequate control were not significantly different. BRS scores were not found to be significantly different between groups, although EQ-5D QOL scores were significantly lower in the inadequately controlled group. Tobacco use was more prevalent in the inadequately controlled group. Marijuana use and the presence of a chronic pain diagnosis were not significantly different between groups. Preoperative self-reported quality of life measures and tobacco use appear to have significant effects on postoperative opioid use, suggesting further areas of optimization which may ensure patients are safe and minimize the number of opioid pills required.

Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter.

The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.

Discharge Opioid Prescription and Consumption Following Surgery: The POPCORN Observational Study.

Few studies have evaluated opioid consumption after various inpatient surgical procedures. To describe opioid prescription patterns and to characterize patient-reported use of opioids after surgery. This single-centre prospective observational study was conducted between February and October 2021 at the Jewish General Hospital in Montréal, Quebec. Patients 18 years of age or older who underwent a surgical procedure, were hospitalized for 24 hours or longer after the procedure, and had an opioid prescription at the time of discharge were included. Data were collected for the quantity of opioids prescribed, as documented in hospital records, and the quantity consumed, as reported by participants. Various potential predictors of opioid consumption were explored, and data were also collected on patients' use of non-opioid coanalgesia, scores on the Numeric Rating Scale for pain, opioid renewal requests, and proper opioid disposal during the 30-day follow-up period. A total of 150 participants completed the study. The median dose prescribed was 10 opioid pills (75.0 morphine milligram equivalents). By the end of the follow-up period, a median of 1 pill (7.5 morphine milligram equivalents) had been consumed from the total amount in the discharge prescription. Overall, 66 participants (44.0%) did not consume any of the opioids prescribed at discharge. Of the total number of pills prescribed, 58.2% (1193/2050) were unused, and 7.0% (5/71) of participants with unused pills disposed of them properly. Following discharge from hospital, postoperative patients consumed a median proportion of only 10% of prescribed opioid pills. More than half of all prescribed pills were unused. Protocols implementing specific prescribing strategies warrant further investigation to evaluate their potential impact on opioid prescription and consumption.

Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial

Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown. This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine. This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test. Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar. Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.

A Resident-Driven Quality Initiative for Reducing Opioid Prescribing in Patients Undergoing Elective General Surgery Procedures, With Long-Term Follow-Up

Background The opioid epidemic has been declared a public health emergency in the United States—and major news outlets have labeled operating rooms as “unintended gateways.” In response to this emergency, our academic institution sought to decrease our contribution to the potential diversion pool—the opioids surgeons prescribe to patients which go unused. Methods Patients undergoing common surgical procedures between August 2017 and March 2018 were identified. Patients were contacted by phone and consented, and opioid use data was collected. The potential diversion pool was calculated as pills prescribed minus pills consumed for each patient and procedure, and subgroup analysis was performed to correlate the number of opioid pills taken within 24 hours before hospital discharge to the number taken after discharge. Results Surveys were completed for 357 patients. Overall, 6,831 of the 12,061 tablets prescribed were unused (57%). Patients who took 7 or more doses of oral opioids in the last 24 hours before discharge had significantly fewer (30%) pills remaining compared to patients who took 0–6 doses (68% remaining). Ninety-nine of 111 patients (89%) who took 0 tablets 24 hours prior to discharge left with an opioid prescription, creating a diversion pool of 2,419 pills remaining out of 3,353 prescribed (72%). Based on a 95% confidence interval of procedural opioid consumption, prescribing guidelines were created within a toolkit designed to set preoperative expectations, promote use of nonopioid analgesics, and provide opioid disposal information. We have continued to track our data, with low opioid prescribing patterns. Conclusion Surgical departments can develop opioid reduction toolkits aimed at reducing the potential diversion pool of opioids in our communities. Such toolkits have a sustained positive impact.

Factors Associated with Postoperative Opioid Use in Adolescents

BackgroundWe aimed to identify factors associated with postoperative prescription opioid use in adolescents. MethodsAdolescents aged 13–20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge. ResultsWe enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5–8). Adolescents reported using a median of 7 (IQR:2–15) opioid pills, with 20 (IQR:7–30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5–29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0–7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%–23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%–31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%–22 %). ConclusionsOlder age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing. Level of evidenceII.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

The Association of Cannabis Use After Discharge From Surgery With Opioid Consumption and Patient-reported Outcomes.

To compare outcomes of patients using versus not using cannabis as a treatment for pain after discharge from surgery. Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes. Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing 16 procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included postdischarge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life, and regret to undergo surgery (secondary). Of 11,314 included patients (58% females, mean age: 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI: 0.4-1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (adjusted odds ratio: 1.7, 95% CIL 1.4-2.1) and 1 month (adjusted odds ratio: 2.1, 95% CI: 1.7-2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs 82.6%), best quality of life (46.7% vs 63.0%), and no regret (87.6% vs 92.7%) (all P < 0.001). Patient-reported cannabis use, to treat postoperative pain, was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes.

The Influence of Community Disadvantage and Opioid Pill Prescriptions on Overdose Deaths in American Counties

The Influence of Community Disadvantage and Opioid Pill Prescriptions on Overdose Deaths in American Counties