Opioid Prescribing Patterns Research Articles

The Effect of Antiopioid State Laws on Prescribing Patterns in an Oculoplastic Practice

This study aimed to find out whether three Texas state policies restricting opioid prescriptions have influenced the prescribing patterns of the oculoplastic department at the University of Texas Medical Branch (UTMB). This is a retrospective chart review of 520 patients at UTMB between 2019 and 2021, reporting the amount of morphine milliequivalents (MMEs) prescribed to patients undergoing one of eight oculoplastic procedures before and after passage of each state policy. Of 520 patients, 218 received opioids. There were no changes in MMEs/month after the first policy (95% CI: −0.1531–0.1256, p = 0.85), second policy (95% CI: −0.000997–0.00093, p = 0.97), or third policy (95% CI: −0.001431–0.00164, p = 0.096). The passage and implementation of three Texas state antiopioid policies were not associated with significant changes in opioid prescribing patterns following oculoplastic and orbital surgeries at UTMB. Average MMEs/month were driven by orbital-floor fractures, which composed most procedures overall. Limitations included the small population and that only a single provider was reviewed. Future studies would be beneficial in further evaluating the role of state legislation on opioid prescribing patterns and usage among patients.

Describing the decision process of post-operative opioid and pain prescribing patterns in orthopedic and general surgeons.

To describe the post-operative opioid prescribing behaviors of orthopedic and general surgeons through the use of the Integrated Behavioral Model (IBM), and subsequently the steps and logic used by providers in determining post-operative pain prescriptions. This study was a prospective, cross-sectional, cohort study utilizing qualitative methods consisting of semistructured interviews. Data were analyzed using thematic analysis to categorize and identify themes to describe prescriber behavior. All participants were from a regional health system in central Appalachia. Mixed population of orthopedic and general surgeons who completed residency training and performed nontraumatic procedures. Categorization and identification of themes within the constructs of the IBM that described surgeon opioid prescribing. Fifteen surgeons participated in this study. Themes were identified within the context of the IBM. Attitudes by surgeons consisted of blame toward the government, a lack of personal screening of patients, and a theme of the abusing population of patients only being a small group. Norms were identified that included prescribing based on a standard prescribing set, realization of patient fear, and the idea of past mentality. Surgeons believed in their ability to prescribe responsibly and conservatively. The prescribing patterns of surgeons and their keenness to assess patients for opioid abuse vary. Most surgeons did not actively participate in screening activities but rely on ancillary staff. Surgeons utilize federal and state laws to back prescribing patterns and thwart patient attempts for additional medications. Prescribers maintain a sense of self-confidence with their own knowledge and ability to taper and keep patients from becoming reliant on opioid prescribing.

Opioid Prescription Trends for Isolated Diaphyseal Femur Fractures in Pediatric Patients

Purpose: Despite the ongoing opioid epidemic, there is a lack of research on narcotic prescribing in the pediatric orthopaedic population. The Pediatric Orthopaedic Society of North America (POSNA) therefore published a survey on pain management to provide recommendations for opioid dosing. The goal of this study was to characterize opioid prescribing patterns for pediatric femur fractures in the context of the opioid epidemic and emerging national studies/guidelines.Methods: A retrospective review of 128 pediatric patients (age < 16) with isolated diaphyseal femur fractures was conducted between 2003-2019 at a level I pediatric trauma center. Comparison groups included before distribution of the POSNA survey (pre-POSNA = 01/01/2016 or earlier, N = 85) and after the survey (post-POSNA, N = 43).Results: Median total hospital postoperative opioids prescribed was 27.2 morphine milligram equivalents (MME). The two groups differed in age (pre-POSNA = 9.0 years, post-POSNA = 3.7 years, P = 0.0381), hospital length of stay (LOS) (pre-POSNA = 2 days, post-POSNA = 1 day, P < 0.0001), and procedural incision required for fracture reduction (pre-POSNA = 28.3%, post-POSNA = 58.1%, P = 0.0019). Adjusted postoperative opioid dosing was significantly lower post-POSNA (median reduction of 18.351 MME per year, P = 0.0408).Conclusions: The period following the POSNA survey was associated with a significant decline in postoperative narcotic prescriptions for pediatric femur fractures. The timing of the survey likely represents an increased concern for pediatric opioid use and a shift in clinical practice. Further work is needed to optimize injury and patient-specific narcotic prescribing.Level of Evidence: Therapeutic Level III Key Concepts•The 2016 POSNA survey identified a lack of consensus on opioid prescribing practices for common orthopaedic procedures in the United States.•The 2016 POSNA survey and subsequent 2019 published narcotic prescription recommendations represent a shift in the specialty of orthopaedic surgery regarding opioid usage in the pediatric population.•Postoperative morphine milligram equivalents significantly decreased for the treatment of pediatric diaphyseal femur fractures at a single-level I pediatric trauma center following administration of the 2016 POSNA survey.

Opioid prescription patterns in the province of Las Palmas, Canary Islands, Spain (2016-2020): differences between urban and rural areas.

Introduction: The use of opioids has increased markedly in the past decades in European countries, especially for treatment of non-cancer pain including painful chronic musculoskeletal conditions. However, there are some notable differences in the relative levels of use between geographical areas and some distinct, context-specific patterns of weak and strong opioid use. The aim of this work is to describe real world trends in dosage forms and population exposure in the prescription opioid use on isolated geographically area: The Canary Islands of Gran Canaria, Lanzarote and Fuerteventura, Spain. For this, several factors such as living in a rural or urban area, population over 65years of age, population density or socioeconomic status were analyzed. Methods: Data were extracted from the wholesalers who supply the community pharmacies at the population level. Prescription opioid use was measured as defined daily doses (DDD) per 1,000 inhabitants per day. A model based on covariance analysis with two nested fixed factors and one co-variable was used for contrast analysis at different level. Results: The overall DDD per 1000 inhabitants per day and year variation rate in Spain was very similar to that obtained for Gran Canaria and Fuerteventura (0.967 vs. 1.006), although the levels of dispensation were different (14.75 versus 18.24 for Gran Canaria and 12.7 for Fuerteventura, respectively). Lanzarote is completely different in all issues, where the opioid consumption rate remained stable during the study period, but with a decreasing tendency. The dispensation level of strong opioids varied between islands, from 56.41% for Fuerteventura vs. 17.61% for Gran Canaria, although these values remained stable. Tramadol with acetaminophen and Tramadol in monotherapy were the most consumed forms of the weak opioids, whereas Buprenorphine was the most used strong opioid followed by Fentanyl, although demand for it varied between islands, the transdermal formulations were the most frequent pharmaceutical preparation. Conclusion: The differences in prescription opioid use are most likely explained by the opioid prescribing practices in each island, whereas factors such urbanicity level, population age, population density and status socioeconomic does not help to explain the differences in prescription opioid use across rural and urban areas.

Poster 211: Prolonged Opioid Use Following Distal Radius Fracture Fixation: Who is at Risk?

Objectives: Opioid pain medication is most commonly prescribed after distal radius fracture fixation, and there is high variability in the quantity and duration prescribed. Comorbidities including substance use and depression have been associated with higher consumption habits and increased sizes of postoperative opioid prescriptions has been previously linked to increasing risk of chronic opioid use and opioid use disorder. The purpose of this study was to investigate opioid prescription patterns after distal radius fracture fixation and identify patient specific risk factors for increased postoperative opioid consumption. Methods: A retrospective review of 34,629 opioid-naïve patients was conducted. Demographic, comorbidity, complication data and prescription pharmacy claims were analyzed. Patients were sorted according to the number of postoperative prescription refills of opioid pain medication. Results: Seventy-three percent of patients required no additional refills outside the perioperative window. Twenty percent required additional refill prescriptions and 6.4% of patients continued to fill opioid medication beyond 6-months postoperatively. Multiple factors increased the risk for increased opioid use including medical and surgical complications, substance use, diabetes,cardiovascular disease, and obesity. Patients with longer duration of opioid use postoperatively had higher rates of medical and surgical complications. Perioperative prescription quantities were 62.9, 78.6, 83.3 tablets for No Refill, Refill, and Prolonged Use groups, respectively. Conclusions: Many patient-specific factors for prolonged opioid consumption after distal radius fracture fixation can be identified prior to prescribing postoperative pain management. Patients most at risk for prolonged opioid use can be targeted for alternative pain management options. Surgeons should take a more patient specific approach in prescribing opioid medication after distal radius fracture fixation. [Table: see text][Table: see text][Table: see text][Table: see text]

Republication of "How Will the Foot and Ankle Orthopedic Community Respond to the Growing Opioid Epidemic?"

In the midst of the current opioid crisis, it has become critically important to properly manage opioid-prescribing patterns for the treatment of postoperative pain. There is currently a scarcity of literature specifying prescription and consumption patterns following orthopedic surgery and specifically foot and ankle surgery. Clinical guidelines for postoperative pain management are deficient.

Postoperative Pain Following Coblation of Sinonasal Hereditary Hemorrhagic Telangiectasias.

Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease and epistaxis is the most common symptom. This can be treated conservatively but severe cases may require operative interventions. Endoscopic endonasal coblation of HHT lesions has been used successfully but postoperative pain management has not been well described. This study aimed to assess levels of postoperative pain and opioid use among patients with HHT who underwent coblation of sinonasal lesions. This is a longitudinal, prospective cohort study of adult patients undergoing endoscopic endonasal coblation for treatment of HHT lesions with or without bevacizumab injection between November 2019 and March 2020 at a single academic university hospital. Patients were given preoperative questionnaires and contacted via telephone 48 hours after surgery. If they reported using opioids for pain control, they were called every 2 days until they no longer used these medications. Fourteen cases, including 13 unique patients, were included in this study. Opioids were ordered on discharge in 4 cases and the average morphine milligram equivalent prescribed on discharge was 41. The median pain score on postoperative day (POD) 2 was 4 of 10. Twelve patients reported using acetaminophen and 4 were using opioid pain medications. Of those using opioid pain medications, only 1 patient was using opioid pain medication by POD 4 and denied any use after POD 10. This study is the first to analyze postoperative pain management and opioid prescribing patterns in HHT patients undergoing endonasal coblation of telangiectasias. Postoperative pain was mild to moderate and most patients stopped using opioid medications by POD 4, although the majority of patients solely used acetaminophen. Future studies with increased sample size will be useful to further identify predictors of need for analgesics postoperatively and other non-opioid adjuncts for pain control.

Detecting Anomalous Networks of Opioid Prescribers and Dispensers in Prescription Drug Data

The opioid overdose epidemic represents a serious public health crisis, with fatality rates rising considerably over the past several years. To help address the abuse of prescription opioids, state governments collect data on dispensed prescriptions, yet the use of these data is typically limited to manual searches. In this paper, we propose a novel graph-based framework for detecting anomalous opioid prescribing patterns in state Prescription Drug Monitoring Program (PDMP) data, which could aid governments in deterring opioid diversion and abuse. Specifically, we seek to identify connected networks of opioid prescribers and dispensers who engage in high-risk and possibly illicit activity. We develop and apply a novel extension of the Non-Parametric Heterogeneous Graph Scan (NPHGS) to two years of de-identified PDMP data from the state of Kansas, and find that NPHGS identifies subgraphs that are significantly more anomalous than those detected by other graph-based methods. NPHGS also reveals clusters of potentially illicit activity, which may strengthen state law enforcement and regulatory capabilities. Our paper is the first to demonstrate how prescription data can systematically identify anomalous opioid prescribers and dispensers, as well as illustrating the efficacy of a network-based approach. Additionally, our technical extensions to NPHGS offer both improved flexibility and graph density reduction, enabling the framework to be replicated across jurisdictions and extended to other problem domains.

Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents.

The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].

Neighborhood disadvantage and pediatric inpatient opioid prescription patterns

BackgroundTo explore the role of children's residential environment on opioid prescribing patterns in a predominantly Latinx sample. MethodsWe connected geocoded data from electronic medical records in a diverse sample of pediatric patients to neighborhood environments constructed using latent profile modeling techniques. We then estimated a series of multilevel models to determine whether opioid prescribing patterns vary by residential context. ResultsA stepwise pattern exists between neighborhood disadvantage and pediatric opioid prescription patterns, such that higher levels of disadvantage associate with a greater likelihood of opioid prescription, independent of the patient's individual profile. ConclusionIn a largely Latinx sample of children, the neighborhood in which a child lives influences whether or not they will receive opioids. Considering the differences in patient residential environment may reduce variation in opioid dispensing rates among pediatric patients.

PRESTO: Promoting Engagement for the Safe Tapering of Opioids.

Twenty-four percent of all U.S. opioid overdose deaths involve a prescription opioid. Changing prescribing practices is considered a key step in reducing opioid overdoses. Primary care providers (PCPs) commonly lack the patient engagement skills needed to address patient resistance to taper or end opioid prescriptions. We developed and evaluated a protocol aimed at improving PCP opioid-prescribing patterns and modeled on the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. We conducted a time series trial comparing provider opioid prescribing 8 months before and 8 months after training with the PRomoting Engagement for Safe Tapering of Opioids (PRESTO) protocol. The 148 Ohio PCPs who completed PRESTO training gained confidence in their ability to engage their patients on the topics of opioid overdose risk and potential opioid tapering. Promoting Engagement for Safe Tapering of Opioids participants had decreased opioid-prescribing over time, but this was not significantly different from Ohio PCPs who had not received PRESTO training. Participants completing PRESTO training had small, but significant increased buprenorphine prescribing over time compared with Ohio PCPs who had not received PRESTO training. The PRESTO approach and opioid risk pyramid warrant further study and validation.

Reducing daily dosing in opioid prescriptions in 11 safety net emergency departments

BackgroundThe United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US. MeasuresThe primary outcome measure was the rates of oxycodone-acetaminophen 5–325 mg prescriptions exceeding 50 morphine milligram equivalents per day (MMED) pre- vs. post-intervention; and stratified by individual hospitals and provider type. InterventionThe defaults for dose and frequency were uniformly changed to ‘every 6 hours as needed’ and ‘1 tablet’, respectively, across 11 EDs. OutcomesThe percentage of prescriptions greater than or equal to 50 MMED decreased from 46.0% (1624 of 3530 prescriptions) to 1.6% (52 of 3165 prescriptions) (96.4% relative reduction; p < 0.001). All 11 hospitals had a significant reduction in prescriptions exceeding 50 MMED. Nurse practitioners had the highest relative reduction of prescriptions exceeding 50 MMED at 100% (p < 0.001), and the attendings/fellows had the lowest relative reduction at 95.6% (p < 0.001). Conclusions/Lessons LearnedDefault nudges are a simple yet powerful intervention that can strongly influence opioid prescribing patterns.

Opioid prescribing patterns for head and neck cancer radiation patients, with a comparison to breast cancer radiation patients.

e18051 Background: Curative-intent radiation treatment for head and neck cancer (HNC) is painful and often requires opioids. Opioid prescribing patterns and duration are not known for these patients. Identifying patients using high amounts of opioids may permit targeted interventions to reduce overall opioid usage. Methods: This retrospective observational study collected EMR prescription data on 10755 patients with a diagnosis of HNC, along with 15664 patients with a diagnosis of breast cancer (BC), between 2008-2022 at Stanford. We identified every non-IV opioid and adjunctive medicine (e.g. gabapentin) prescription using the Stanford Research Repository (STARR). We analyzed opioid prescriptions in 894 HNC and 1100 BC patients who received definitive or adjuvant radiation for 4-6 weeks, and compared usage by age, gender, and ethnicity. A multivariate logistic regression was used to estimate the odds ratio of prescribing opioids, adjusting for age, gender, race, ethnicity, insurance type, and substance use history. Results: HNC patients prescribed opioids were 69% male; 66% white, 17% Asian; median age of 65.9 years (IQR: 56.9-73.9); 48% prior smokers and 2% reported prior heavy drinking. 774 of 894 HNC radiation patients were ever prescribed opioids. Relative to the start of radiation, the numbers of HNC radiation patients prescribed opioids were: 259 (29%) within &lt; 30 days prior; 355 (40%) within 30 days after; 329 (37%) within 30-60 days after; 142 (16%) within 60-90 days after; 86 (10%) within 90-120 after; 67 (7%) within 120-150 days after; 56 (6%) within 150-180 days after; 53 (6%) within 80-210 days after; 43 (5%) within 210-240 days after. Across all time periods for HNC radiation patients fentanyl (72-83%) and oxycodone (79-85%) were the most common opioid prescriptions, while morphine (14-24%) and hydromorphone (22-27%) were the least common opioid prescriptions. Concurrent gabapentin prescriptions were given to &gt; 80% of HNC patients with opioid prescriptions at every time period, peaking at 91% at the end of radiation. Compared to BC radiation patients, HNC radiation patients had an odds ratio of 3.34 (95% CI: 1.79-6.80, p = &lt; 0.01) in favor of opioid prescriptions and 8.26 (95% CI: 5.74-12.15, p = &lt; 0.01) for adjunctive medicine prescriptions. There was no significant difference between prescriptions by age, race, ethnicity, or prior smoking history. Males compared to females had a lower odds ratio of 0.37 (p = &lt; 0.01) for opioid prescriptions. Conclusions: HNC radiation patients have high rates of opioid and adjunctive medicine prescriptions at our center. Opioids are most prescribed before and during radiation and decrease by &gt; 80% by 6 months after radiation started. 6% of HNC patients still require opioid prescriptions over 6 months after the start of radiation. HNC radiation patients use opioids and adjunctive medicines much more frequently than BC radiation patients.

How much narcotics are really needed after bariatric surgery: results of a prospective study.

To mitigate the opioid crisis, physicians are reevaluating opioid prescribing patterns. To evaluate outcomes of maximal opioid reduction on top of an existing Enhanced Recovery after Surgery (ERAS) pathway in our The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery program. Academic tertiary care hospital, United States. Patients undergoing primary bariatric operation were studied from July 2017 to April 2019, (standard ERAS cohort), and compared to patients from April 2019 to February 2021 (standard ERAS with Sparing Opioid Use Postoperatively protocol) (SOUP cohort). The primary endpoint was reduction of perioperative opioid use. Of 367 patients, 212 (57.8%) and 155 (42.2%) were in the ERAS and SOUP cohorts, respectively. Roux-en-Y gastric bypass was 48.6% (n = 103) versus 54.2% (n = 84) and sleeve gastrectomy was 51.4% (n = 109) versus 45.8% (n = 71) for ERAS versus SOUP, respectively (P = .29). The SOUP cohort of patients required a low median inpatient morphine equivalent dose of 4 mg [0-6.2]. The ERAS cohort was discharged on a higher morphine equivalent dose than the SOUP cohort at 186.7 mg ± 92.9 versus 37.6 ± 32.3 (P < .05), and median consumption of the standard 5 mg oxycodone tablet was 1.5 tablets [0-4]. The SOUP cohort patients rated their pain satisfaction score on a scale of 1 to 10 at 9.1 points (standard deviation ± 1.8). The SOUP cohort had a shorter length of stay (P < .05), with comparable readmission rates. An opioid-sparing protocol can be implemented after bariatric surgery with high overall satisfaction with pain control.

Excess Opioid Medication and Variation in Prescribing Patterns Following Common Breast Plastic Surgeries.

Purpose: Excess opioid prescribing has societal impacts including addiction, dependence, and misuse. This study aims to investigate prescribing patterns and self-reported patient experiences with opioid use, pain control, and disposal of unused medication following common breast surgeries. Methods: A total of 46 patients undergoing 5 breast procedures were identified during a predefined 14-week period. All procedures were carried out at a single tertiary care hospital by 9 plastic surgeons. Provincial narcotic monitoring program provided linked prescription information for identified patients. All patients were invited to participate in a telephone interview regarding postoperative opioid use. Results: A total of 41.6% of patients received and filled an opioid prescription following a breast procedure. Hydromorphone was the most commonly prescribed narcotic. The average number of opioid tablets dispensed following breast procedures was 31.9. Four percent of breast patients required an opioid refill. A total of 75% of breast patients used at least 1 over-the-counter analgesic, most commonly acetaminophen alone. Average self-reported pain score and total pain period were not significantly different between those using opioids and those not. A total of 6.7% and 23.1% of patients report returning excess narcotics to a pharmacy, while the majority report still having or self-disposing of excess tablets. Conclusions: Opioids are prescribed in excess for the breast procedures we analyzed. The majority of unused opioids were noted to still be at home or disposed of inappropriately. This suggests a role for reviewing opioid-prescribing patterns for common plastic surgery procedures to reduce the burden of the ongoing opioid epidemic.

Impact of state mandates on electronic prescribing of acute opioid prescriptions for the treatment of pain in Kansas and Colorado

BackgroundGovernment and health care entities are seeking solutions to optimize safe opioid prescribing practices. Electronic prescribing of controlled substance (EPCS) state mandates are becoming common, but lack thorough evaluation. ObjectiveThis study aimed to evaluate whether EPCS state mandates affect opioid prescribing patterns for acute pain treatment. MethodsThis retrospective study was designed to assess prescribing patterns via percent change for quantity, day supply, and prevalence of prescribing method utilized for opioid prescriptions 3 months pre- and post-EPCS mandate. Prescription data are extracted from two regional divisions of a large community-based pharmacy chain between April 1, 2021 to October 1, 2021. Relationships of patient geographical locations and prescribing methods were assessed. Likewise, the relationship of opioids prescribed between insurance types were evaluated. Data was evaluated utilizing Chi-Square and Mann-Whitney U tests, with an a-priori alpha of 0.05. ResultsThere was an increase before to after state mandate of quantity and day supply (0.8% and 1.3% [P = 0.02; P < 0.001], respectively). There were significant decreases in total daily dose and daily morphine milligram equivalent (2.0% and 1.9% [P < 001; P = 0.254], respectively). A 16.3% increase was seen in electronic prescribing before to after state mandate for prevalence of electronic prescribing versus other prescribing methods. ConclusionThere is a correlation between EPCS and prescribing patterns for acute pain treatment with opioids. The use of electronic prescribing increased after state mandate. By promoting the use of electronic prescribing, the benefit of awareness and caution of opioid use draws attention to prescribers.

Opioid prescribing patterns among medical practitioners in New South Wales, Australia.

Prescriber behaviour is important for understanding opioid use patterns. We described variations in practitioner-level opioid prescribing in New South Wales, Australia (2013-2018). We quantified opioid prescribing patterns among medical practitioners using population-level dispensing claims data, and used partitioning around medoids to identify clusters of practitioners who prescribe opioids based on prescribing patterns and patient characteristics identified from linked dispensing claims, hospitalisations and mortality data. The number of opioid prescribers ranged from 20,179 in 2013 to 23,408 in 2018. The top 1% of practitioners prescribed 15% of all oral morphine equivalent (OME) milligrams dispensed annually, with a median of 1382 OME grams (interquartile range [IQR], 1234-1654) per practitioner; the bottom 50% prescribed 1% of OMEs dispensed, with a median of 0.9 OME grams (IQR 0.2-2.6). Based on 63.6% of practitioners with ≥10 patients filling opioid prescriptions in 2018, we identified four distinct practitioner clusters. The largest cluster prescribed multiple analgesic medicines for older patients (23.7% of practitioners) accounted for 76.7% of all OMEs dispensed and comprised 93.0% of the top 1% of practitioners by opioid volume dispensed. The cluster prescribing analgesics for younger patients with high rates of surgery (18.7% of practitioners) prescribed only 1.6% of OMEs. The remaining two clusters comprised 21.2% of prescribers and 20.9% of OMEs dispensed. We observed substantial variation in opioid prescribing among practitioners, clustered around four general patterns. We did not assess appropriateness but some prescribing patterns are concerning. Our findings provide insights for targeted interventions to curb potentially harmful practices.

Effects of state opioid prescribing cap laws on providers' opioid prescribing patterns among patients with chronic non-cancer pain

Prior work suggests opioid prescribing cap laws are not associated with changes in opioid prescribing among patients with chronic pain. It is unknown how these effects differ by provider specialty, provider opioid prescribing volume, or patient insurer. This study assessed effects of state opioid prescribing cap laws on opioid prescribing among providers of patients with chronic non-cancer pain, by high volume prescribing, provider specialty, and patient insurer. We identified 224,290 providers of patients with low back pain, fibromyalgia, or headache from the IQVIA administrative database. Using a difference-in-differences approach, we examined impacts of opioid prescribing cap laws implemented between 2016 and 2018 on the annual proportion of a provider's patient panel who received any opioid prescription, as well as on dose and duration of opioid prescriptions. For providers overall, high volume prescribers, all specialties, and patient insurance categories, prescribing cap laws were associated with non-significant changes of <1.0, 1.5, and 3.5 percentage points in the proportion of chronic non-cancer patients receiving any opioid prescription, a prescription with 7 days' supply, or with >50 morphine milligram equivalents (MME)/day, per year, respectively. There were two exceptions with high dose prescribing: prescribing cap laws were associated with a 1.5 percentage point increase in the proportion of high-volume prescribers' patient panel receiving an opioid prescription with ≥50 MME/day, and a 3.0 percentage point decrease in the same measure among surgeons. Among nearly all measured subgroups of providers and patient insurers, opioid prescribing cap laws were not associated with changes in opioid prescribing.

Implementation and Effectiveness of Opioid Prescribing Guidelines After Hiatal Hernia Repair

IntroductionWe defined institutional opioid prescribing patterns, established prescribing guidelines, and evaluated the adherence to and effectiveness of these guidelines in association with opioid prescribing after hiatal hernia repair (HHR). MethodsA retrospective chart review was completed for patients who underwent transthoracic (open) or laparoscopic HHR between January and December 2016. Patient-reported opioid use after surgery was used to establish prescribing recommendations. Guideline efficacy was then evaluated among patients undergoing HHR after implementation (August 2018 to June 2019). Data are reported in oral morphine equivalents (OMEs). ResultsThe initial cohort included n = 87 patients (35 open; 52 laparoscopic) with a 68% survey response rate. For open repair, median prescription size was 338 mg OME (interquartile range [IQR] 250-420) with patient-reported use of 215 mg OME (IQR 78-308) (P = 0.002). Similarly, median prescription size was 270 mg OME (IQR 200-319) with patient-reported use of 100 mg OME (IQR 4-239) (P < 0.001) for laparoscopic repair. Opioid prescribing guidelines were defined as the 66th percentile of patient-reported opioid use. Postguideline implementation cohort included n = 108 patients (36 open; 72 laparoscopic). Median prescription amount decreased by 54% for open and 43% laparoscopic repair, with no detectable change in the overall refill rate after guideline implementation. Patient education, opioid storage, and disposal practices were also characterized. ConclusionsEvidence-based opioid prescribing guidelines can be successfully implemented for open and laparoscopic HHR with a high rate of compliance and without an associated increase in opioid refills.

Chronic overlapping pain conditions and long-term opioid treatment.

One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT). Retrospective cohort study. We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT. Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC. Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients.