Opioid Prescribing Patterns Research Articles

Postoperative opioid protocol: A 5-year resident-led effort to standardize prescribing patterns

ObjectivesThe combined impact of variable surgeon prescribing preferences and low resident prescribing comfort level can lead to significant disparity in opioid prescribing patterns. We report an update on the expanded scope of this now 5-year, resident led initiative to standardize postoperative prescription practices within the Department of Otolaryngology. MethodsWith Institutional Review Board approval, performed a retrospective review of 12 months before (July 2016 – June 2017) and 48 months after (July 2019–June 2021) implementation of the Expanded Postoperative Analgesia Protocol. The Pre-Protocol and Expanded Protocol cohorts were compared using ANOVA, chi-squared and Fisher Exact tests, with ANCOVA and binary logistic regression for covariate analysis. Cost impact was calculated using average medication spending data for 2018–2019. Results470 patients were included in the Pre-Protocol cohort (54 % male, mean age 35 years) and 679 in the Expanded Protocol cohort (63 % male, mean age 36 years). The protocol was effectively implemented as reflected in the reduction of combination opioid medications from 429 (91.3 %) to 26 (3.8 %) (87 % reduction, 95 % CI 86 % to 89 %, p < .001). The protocol resulted in a 66 % reduction in average morphine milligram equivalents per patient (333 mg to 114 mg, mean reduction 219 mg, 95 % CI 206 mg to 232 mg, p < .001), a 68 % reduction in medication refills (refill rate 20 % to 6 %; 14 % reduction, 95 % CI 12 % to 16 %, p < .001) and a 74 % reduction in cost of postoperative medications ($93.82 to $24.64 per patient). ConclusionThrough purposeful standardization, this 5-year resident led effort resulted in sustained changes to departmental wide prescribing practices yielding reduced variability, reduced cost, improved opioid management and superior pain control for postoperative patients.

985: EVALUATION OF DISCHARGE OPIOID PRESCRIBING IN MECHANICALLY VENTILATED ICU PATIENTS

Introduction: Opioids are a core component in the multimodal approach to patient analgesia during invasive mechanical ventilation (IMV). However, the implications of opioid use during IMV on prescribing opioids on hospital discharge is unknown. Methods: We conducted a retrospective cohort study of patients requiring IMV within a tertiary academic medical intensive care unit (MICU) to characterize hospital discharge opioid prescribing patterns between opioid-naive and opioid-users. We included patients that received at least 1 dose of opioid within the first 12-hours of IMV and required IMV for at least 24 hours. Patients were characterized as opioid-naïve or opioid-users based upon opioids prescribed prior to MICU admission. The primary outcome was the percentage of patients prescribed opioids at hospital discharge. Secondary outcomes included the morphine milligram equivalents (MME) per day during IMV, delirium-free days, correlation of pain (critical care pain observation tool (CPOT)) scores and MME during IMV, duration of IMV, and length of hospital stay (LOS). Results: One hundred sixty-seven consecutive patients presenting to the MICU were included. Of these, 128 (76.6%) were opioid-naïve and 39 (23.4%) were opioid-users. Median age was 59 years and 61.7% were Caucasian. More opioid-users had cancer compared to opioid-naïve (35.9% vs 14.8%, p< 0.001). Thirty-two (25%) opioid-naïve and 27 (69.2%) opioid-users were prescribed opioids on discharge. The mean MME prescribed at discharge was higher in opioid-users, compared to opioid-naive (77.2 vs 16.4, p< 0.001). The median quantity of opioids prescribed during IMV did not differ between groups (465 MME in opioid-naïve vs. 467 MME in opioid-user, p=0.49). Median daily CPOT scores did not correlate with MME or dose titrations. There was no difference in duration of IMV or LOS between groups. Opioid-naïve patients had less delirium-free days, compared to opioid-users (0.68 vs. 1.13, p=0.003). Conclusions: Our study found 25% of opioid-naïve patients undergoing IMV were discharged from the hospital on opioids and the daily CPOT score did not correlate with MME and dose titration. It is unclear why 25% of opioid-naïve patients who underwent IMV in a MICU required opioids at hospital discharge and is an area that warrants further investigation.

Changes in postoperative opioid prescribing across three diverse healthcare systems, 2010-2020.

The opioid crisis brought scrutiny to opioid prescribing. Understanding how opioid prescribing patterns and corresponding patient outcomes changed during the epidemic is essential for future targeted policies. Many studies attempt to model trends in opioid prescriptions therefore understanding the temporal shift in opioid prescribing patterns across populations is necessary. This study characterized postoperative opioid prescribing patterns across different populations, 2010-2020. Administrative data from Veteran Health Administration (VHA), six Medicaid state programs and an Academic Medical Center (AMC). Surgeries were identified using the Clinical Classifications Software. Trends in average daily discharge Morphine Milligram Equivalent (MME), postoperative pain and subsequent opioid prescription were compared using regression and likelihood ratio test statistics. The cohorts included 595,106 patients, with populations that varied considerably in demographics. Over the study period, MME decreased significantly at VHA (37.5-30.1; p = 0.002) and Medicaid (41.6-31.3; p = 0.019), and increased at AMC (36.9-41.7; p < 0.001). Persistent opioid users decreased after 2015 in VHA (p < 0.001) and Medicaid (p = 0.002) and increase at the AMC (p = 0.003), although a low rate was maintained. Average postoperative pain scores remained constant over the study period. VHA and Medicaid programs decreased opioid prescribing over the past decade, with differing response times and rates. In 2020, these systems achieved comparable opioid prescribing patterns and outcomes despite having very different populations. Acknowledging and incorporating these temporal distribution shifts into data learning models is essential for robust and generalizable models.

The characteristics of opioid use in patients with proximal humerus fractures.

Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures. A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017. There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01). With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.

Analysis of ophthalmology subspecialty opioid prescribing patterns during the opioid public health crisis

ObjectifCerner les habitudes de prescription d'opioïdes au sein des différentes sous-spécialités d'ophtalmologie et vérifier si la prescription d'opioïdes a diminué pendant la crise de santé publique. NatureÉtude de cohorte rétrospective. ParticipantsOphtalmologistes qui prescrivent au moins 11 médicaments de la section D du programme de remboursement des médicaments délivrés sur ordonnance du régime d'assurance-maladie américain (Medicare). MéthodesOn a utilisé les données publiques de Medicare compilées d'après les réclamations pour 2016, 2017 et 2018. Le statut d'associé (fellowship) a été déduit en fonction de l'appartenance à une association de sous-spécialité ou d'après les codes de diagnostic et d'intervention en vigueur (Current Procedural Terminology). Le principal paramètre mesuré était le pourcentage de médecins de chaque sous-spécialité qui prescrivait des opioïdes. RésultatsLa base de données recensait 19 762, 19 790 et 19 840 ophtalmologistes en 2016, en 2017 et en 2018, respectivement. On a noté une baisse faible, mais significative de la proportion de médecins prescrivant des opioïdes au chapitre des soins ophtalmologiques dans leur ensemble (43,5 % vs 39,6 % vs 35,7 %; p < 0,001; φc = 0,066) et dans les sous-spécialités suivantes : rétinologie (66,5 % vs 60,7 % vs 54,5 %; p < 0,001; φc = 0,101), troubles de la cornée (82,8 % vs 83,9 % vs 77,2 %; p = 0,03; φc = 0,076) et glaucome (53,4 % vs 46,4 % vs 42,0 %; p < 0,001; φc = 0,094). Les taux de prescription d'opioïdes étaient les plus élevés dans les sous-spécialités de l'oculoplastie (86 %–88,8 %), des troubles de la cornée (77,2 %–82,8 %), de la rétinologie (54,5 %–66,5 %) et de l'ophtalmologie pédiatrique (51,5 %–57,9 %). Les taux les plus faibles ont été relevés pour l'ophtalmologie dans son ensemble, le glaucome et l'uvéite. Le nombre médian de réclamations pour la prescription d'opioïdes n'a pas varié de façon notable parmi les médecins qui ont soumis plus de 10 de ces réclamations. Dans l'ensemble des sous-spécialités, les opioïdes ne représentaient qu'une faible proportion des médicaments ayant fait l'objet de réclamations. ConclusionOn n'a enregistré qu'une diminution faible, ou encore aucune variation significative, du pourcentage de médecins prescrivant des opioïdes au sein de l'ensemble des sous-spécialités pendant la période à l’étude. Nous souhaitons encourager la collaboration entre les membres des différentes sous-spécialités d'ophtalmologie afin de mettre tout en œuvre pour réduire la prescription d'opioïdes. Des études supplémentaires sont nécessaires afin de mieux cerner les habitudes de prescription d'opioïdes.

Evaluation of concurrent benzodiazepine and opioid prescribing patterns with a focus on acute muscle spasms indication at hospital discharge

• Concurrent opioids and benzodiazepines increase risk of respiratory depression • Tools to promote risk mitigation with concurrent prescribing • Naloxone recommendations In 2016, the CDC Guidelines for Prescribing Opioids in Chronic Pain recommended avoiding the co-prescribing of opioids and benzodiazepines when possible. This evaluation provides one institution's approach to improve safety for new, acute concurrent opioid and benzodiazepine prescribing. Patients prescribed new, concurrent opioids and benzodiazepines upon discharge within one organization were identified. A chart review for the highest prescribing specialties was completed for a random sample of 100 patients to determine indications for prescribing, safety measures, and post discharge healthcare utilization. Orthopedic surgery, the hospitalist service, neurosurgery, and general surgery had the highest concurrent prescribing rates. The most common indication for benzodiazepine prescribing was muscle spasms, but quantity variability existed across and within all four specialties. Of the subset of patients reviewed, patients were consistently not prescribed naloxone. A prescribing guideline was implemented to provide educational tools, standardized benzodiazepine quantities, and naloxone co-prescribing recommendations for the indication of muscle spasms.

Opioid Prescription Patterns and Disparities During Ambulatory Encounters in Patients With Cirrhosis

The opioid epidemic causes significant morbidity and mortality in the United States,1 and individuals with chronic liver disease receive a high burden of opioid prescriptions,2 despite elevated risk of harm with use in cirrhosis. Characteristics associated with opioid prescriptions in the US cirrhosis population are unknown. Our study sought to describe patient and provider-related characteristics of national ambulatory visits involving cirrhosis and opioid prescriptions, and to identify predictors of and reasons for prescriptions.

Opioid-Prescribing Patterns in Connecticut and New Jersey Following Third Molar Extractions.

In recent years, opioid misuse has resulted in much scrutiny on providers' prescribing habits. The purpose of this study was to analyze prescribing habits in the context of third molar extractions as a model for promoting better postsurgical pain management. This was a cross-sectional survey of oral maxillofacial surgeons in Connecticut and New Jersey. A total of 291 practitioners were contacted to complete an online survey using Qualtrics Research Services to determine prescribing habits following third molar extractions. The most common approach for postoperative analgesia was nonsteroidal anti-inflammatory drugs (NSAIDs) and an opioid/acetaminophen (APAP) combination as 2 separate prescriptions, reported by 36% of participants. The combination of hydrocodone/APAP was the most common opioid formulation, and an average of 10.93 ± 4.51 opioid pills were prescribed with a maximum of 20 pills reported. Most providers (79%) consistently provided patients with opioid information. Only 22% reported always checking opioid-monitoring programs; however, providers were more likely to check if prescribing more than ∼11 opioid pills (P = .0228). Most reported using dexamethasone (82%) and bupivacaine (56%) intraoperatively, while ketorolac was less common (15%). No association was found between the quantity of opioids prescribed and the use of intraoperative ketorolac, steroids, or bupivacaine (P > .05). There remains to be a universal standard for using opioids for postoperative pain management in dentistry. Providers should be mindful when prescribing opioids and consider using NSAIDs and APAP for baseline pain plus a separate opioid prescription for breakthrough pain. Additional focus on minimizing the quantity of opioids prescribed and self-reflecting on prescribing and practice habits to further reduce opioid-related complications is warranted.

Modifying Post-operative Opioid Stewardship Through a System of Educational Feedback.

Background: The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns.Methods: An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered.Results: A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase.Discussion: An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED.

Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study

BackgroundPatients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. MethodsThis quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. ResultsWe identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups’ Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. ConclusionA departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.

Open Versus Endoscopic Carpal Tunnel Release: A Comparison of Opioid Prescription Patterns and Occupational Therapy Referrals.

Endoscopic and open carpal tunnel releases (ECTR and OCTR) are safe and effective operations. We compared the approaches in terms of postoperative opioid refills and occupational therapy (OT) referrals. We conducted a retrospective study of patients with carpal tunnel syndrome (CTS) treated with ECTR or OCTR. Patients with isolated idiopathic CTS were included; patients undergoing simultaneous bilateral carpal tunnel release (CTR), revision CTR, and additional procedures at time of CTR were excluded. Outcomes included number of patients requiring an opioid refill and/or an OT referral within 6 months of surgery. A total of 1125 patients met inclusion criteria. Endoscopic release was performed in 634 (56%) cases and open release in 491 (44%). Unadjusted analysis revealed no difference in number of patients requiring refills (6.0% vs 7.1%, P = .44), mean number of refills among those requiring one (1.29 vs 1.23, P = .69), total oral morphine equivalents (45.1 vs 44.7, P = .84), number of patients calling regarding pain (12.8% vs 14.7%, P = .36), OT referrals (12.1% vs 11.4%, P = .71), or average number of OT visits (4.5 vs 4.2, P = .74) for endoscopic and open techniques, respectively. Adjusted analysis revealed lower age, lower body mass index, and history of muscle relaxant as predictors of opioid refills, and in contrast to the unadjusted analysis, operating surgeon and surgical technique were predictors of referral to OT. Endoscopic CTR and OCTR did not differ in terms of unadjusted postoperative patient calls for pain, number of opioid refills, or OT referrals. After correcting for individual surgeon practice, endoscopic was associated with decreased odds of requiring postoperative OT.

Opioid Legislation in Patients With Inflammatory Bowel Disease: A State-wide Retrospective Cohort Study.

Indiana State opioid prescription legislation has been shown to decrease overall opioid prescriptions. However, this effect has not been studied in specific diseases associated with chronic pain such as inflammatory bowel disease (IBD). We aimed to determine the effect of state opioid prescription legislation on opioid prescribing patterns in IBD. A retrospective cohort analysis using an interrupted time-series from December 15, 2010 to July 1, 2018, with 2 time periods separated by Title 844 of the Indiana Administrative Code, in a statewide health care system capturing the majority of the state's population including all adult patients with IBD. The primary outcome was opioid prescription rate per person-year. In total, 9436 patients met inclusion criteria. After legislation, the total number of opioid orders per patient-year continued to increase (0.543, 95% CI, 0.528-0.558, to 0.663, 95% CI, 0.654-0.672), with fewer scripts from the emergency department (0.113, 95% CI, 0.106-0.120, to 0.092, 95% CI, 0.088-0.095) and more from outpatient providers (0.303, 95% CI, 0.292-0.314 to 0.432, 95% CI, 0.424-0.439). There were increases in biologic (0.206, 95% CI, 0.197-0.215 to 0.517, 95% CI, 0.509-0.525) and steroid (0.182, 95% CI, 0.173-0.190 to 0.237, 95% CI, 0.232-0.243) prescriptions per person-year following legislation. Factors associated with heavy opioid use included chronic steroids (odds ratio, 5.030; 95% CI, 4.176-6.054), history of IBD-related surgery (odds ratio, 2.807; 95% CI, 2.367-3.323) and current smoking (odds ratio, 2.650; 95% CI, 2.223-3.158). Despite legislation and the increased use of disease-modifying drugs, statewide opioid prescriptions continued to increase. The increase in opiate use, high steroid use, and significant health care utilization suggests poor underlying disease control.

Opioid prescribing practices in trauma patients at discharge: An exploratory retrospective chart analysis.

This study examined the opioid prescribing patterns at discharge in the trauma center of a major Canadian hospital and compared them to the guidelines provided by the Illinois surgical quality improvement collaborative (ISQIC), a framework that has been recognized as being associated with reduced risk.This was a retrospective chart review of patient data from the trauma registry between January 1, 2018, and October 31, 2019. A total of 268 discharge charts of naïve opioid patients were included in the analysis. A Morphine Milligram Equivalents per day (MME/day) was computed for each patient who was prescribed opioids and compared with standard practice guidelines.About 75% of patients were prescribed opioids. More males (75%) than females (25%) were prescribed opioids to patients below 65 years old (91%). Best practice guidelines were followed in most cases. Only 16.6% of patients were prescribed over 50 mg MME/day, the majority (80.9%) were prescribed opioids for =<3 days and only 1% for >7 days. Only 7.5% were prescribed extended-release opioids and none were strong like fentanyl. Patients received a multimodal approach with alternatives to opioids in 88.9% of cases and 82.9% had a plan for opioid discontinuation. However, only 23.6% received an acute pain service referral.The majority of the prescriptions provided adhered to the best practice guidelines outlined by the ISQIC framework. These results are encouraging with respect to the feasibility of implementing opioid prescription guidelines effectively. However, routine monitoring is necessary to ensure that adherence is maintained.

Why Doesn’t Opioid Prescribing Change? Surveying Surgical Providers Resistant to a Feedback Intervention Bundle

INTRODUCTION: Opioid prescribing patterns, including those after operation, have been implicated as significant contributors to the US opioid crisis. Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate postoperative opioid prescribing. METHODS: We assessed the rationale of providers who did not respond to our interventions. Since 2019, an automated system emails outlier providers whose prescription sizes exceed the 75th percentile of patient opioid consumption for that procedure. Emails include procedure-specific consumption data for patients at our institution and an option to complete a survey on rationale for over-prescribing. RESULTS: During the study period, 10,672 eligible postoperative patients have been discharged from our institution. A total of 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed for 414 (20.6%) outlier prescriptions. Of patients receiving outlier quantities, 35% did not consume any opioids after discharge and an additional 21.5% consumed less than 50% of their prescription. Only 39.9% of patients receiving outlier prescriptions were outlier consumers. The most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%); 68.0% of outlier providers did not follow our institution-specific prescribing dashboard (Table). CONCLUSION: Among providers who remained outliers in prescribing despite feedback, prescriptions did not align with, and often far exceeded, patient’s post-discharge consumption. Providers cite assessment of patient attributes as a main driver of decision-making, but this does not align with patient usage. Table. - Responses for “Other” Were Thematically Classified by Two Authors Determinant of prescribing decision Resident (N = 266) APP (N = 113) Fellow (N = 11) Attending (N = 23) Attending preference 127 (47.7%) 8 (7.1%) 6 (54.6%) 0 (0%) Analysis of patient characteristics 75 (28.2%) 51 (45.1%) 3 (27.3%) 12 (52.0%) Patient preference 13 (4.9%) 1 (0.9%) 0 (0%) 1 (4.0%) “The amount that I have always prescribed” 2 (0.8%) 8 (7.1%) 0 (0%) 0 (0%) Online prescribing dashboard 6 (2.3%) 0 (0%) 0 (0%) 0 (0%) Department or national guidelines 2 (0.8%) 2 (1.8%) 0 (0%) 1 (4.0%) Other (free response) 41 (15.4%) 43 (38.1%) 2 (18.2%) 9 (39.0%) APP, advanced practice provider.

Economic burden of opioid misuse focused on direct medical costs.

Background: Since their development, synthetic opioids have been used to control pain. With increased opioid use, problematic opioid prescription has also increased, resulting in a growing economic burden. However, there is a paucity of research studies on the economic burden of prescription opioid misuse in Asia, especially South Korea. Objectives: To estimate the incremental economic burden of prescription opioid misuse for the South Korean population. Methods: The National Health Insurance Service-National Sample Cohort database, covering 2% of the South Korean population between 2010 and 2015, was analyzed. Outpatients aged 18 or older who took one or more prescription opioids were selected. Based on their opioid prescription patterns, patients were classified into opioid misuse and non-misuse groups. The direct medical costs per person per year (PPPY) and the incremental economic burden of the opioid misuse group were explored using an exponential conditional model with a suitable distribution and log link function. All analyses were performed using SAS® Enterprise Guide version 9.4, and p < 0.05 was considered statistically significant. Results: The number of patients who had ≥1 opioid prescription was 345,020 including 84,648 (24.53%) in the opioid misuse group and 260,372 (75.47%) in the non-misuse group. The adjusted mean direct medical costs PPPY were estimated to be USD 401 for the opioid misuse group, which is 1.49 times significantly higher than that for the non-misuse group (p < 0.0001). The incremental economic burden of the opioid misuse group in the South Korean population was estimated to be approximately USD 0.52 billion for the period 2010-2015. Conclusion: Prescription opioid misuse was significantly associated with the increased economic burden. Along with proper policies for using opioids, it is necessary to monitor opioid prescription patterns to prevent opioid misuse and reduce the related economic burden.

Patterns of prescribing in primary care leading to high-dose opioid regimens: a mixed-method study.

There are concerns about continuing increases in the number of patients prescribed long-term opioids and the prescribing of 'strong' opioids for chronic pain. Little is known about patients who are prescribed these long-term, high-dose drugs. To understand patterns of opioid prescribing that lead to long-term, high-dose use. A mixed-method study of the opioid prescription histories of patients using high doses in a North Wales GP practice. All patients on high-dose opioids during the census week were identified. Summary graphs of the prescription histories were prepared. Qualitative analysis was conducted individually by four researchers. A workshop was held to arrive at a consensus about common features and to inform further quantitative analysis. A quarter of high-dose regimens were initiated outside the practice, either in a different primary care practice or in secondary care. The majority of the remaining patients showed a pattern of dose increases to high levels over a short period (median 3.5 months). None showed a pattern of gradual increases over a longer timescale. Most of the patients remained on high doses continuously once a daily dose of ≥120 mg oral morphine equivalent (OME) was reached. These findings suggest that high-dose opioid regimens develop quickly in response to unknown clinical factors. An expected insidious upward drift in dose was not seen. The findings have implications for the prevention of potentially dangerous long-term, high-dose opioid prescribing. A dose of 60 mg OME or more is suggested as a useful 'red flag'.

Factors Associated With Total Discharge Opioid Prescription Morphine Milligram Equivalent Amounts Following Primary Anterior Cervical Spine Surgery.

Opioid overuse is a substantial cause of morbidity and mortality in the United States, and orthopaedic surgeons are the third highest prescribers of opioids. Postoperative prescribing patterns vary widely, and there is a paucity of data evaluating patient and surgical factors associated with discharge opioid prescribing patterns after elective anterior cervical surgery (ACS). The purpose of this study was to evaluate the volume of postoperative opioids prescribed and factors associated with discharge opioid prescription volumes after elective ACS. We retrospectively identified patients aged 18 years and older who underwent elective primary anterior cervical diskectomy and fusion (ACDF), cervical disk arthroplasty (CDA), or hybrid procedure (ACDF and CDA at separate levels) at a single institution between 2015 and 2021. Demographic, surgical, and opioid prescription data were obtained from patients' electronic medical records. Univariate and multivariate analyses were conducted to assess for independent associations with discharge opioid volumes. A total of 313 patients met inclusion criteria, including 226 (72.2%) ACDF, 69 (22.0%) CDA, and 18 (5.8%) hybrid procedure patients. Indications included radiculopathy in 63.6%, myelopathy in 19.2%, and myeloradiculopathy in 16.3%. The average age was 57.2 years, and 50.2% of patients were male. Of these, 88 (28.1%) underwent one-level, 137 (43.8%) underwent two-level, 83 (26.5%) underwent three-level, and 5 (1.6%) underwent four-level surgery. Younger age (P = 0.010), preoperative radiculopathy (P = 0.029), procedure type (ACDF, P < 0.001), preoperative opioid use (P = 0.012), and discharge prescription written by a midlevel provider (P = 0.010) were independently associated with greater discharge opioid prescription volumes. We identified wide variability in prescription opioid discharge volumes after ACS and patient, procedure, and perioperative factors associated with greater discharge opioid volumes. These factors should be considered when designing protocols and interventions to reduce and optimize postoperative opioid use after ACS.

A regional approach to reduce postoperative opioid prescribing in Ontario, Canada.

Opioid-related morbidity and mortality continue to rise in the province of Ontario. We implemented a provincial campaign to reduce the number of opioid pills prescribed at discharge after surgery in the Ontario Surgical Quality Improvement Network (ON-SQIN). Activities related to the provincial campaign were implemented between April 2019 and March 2020 and between October 2020 and March 2021. Self-reported data from participating hospitals were used to determine changes in postoperative opioid prescribing patterns across participating hospitals. A total of 33 and 26 hospitals participated in the provincial campaign in the first and second year, respectively. During the first year of the campaign, the median morphine equivalent (MEQ) from opioid prescriptions decreased significantly in a number of surgical specialties, including General Surgery (from 105 [75-130] to 75 [55-107], P < 0.001) (median, interquartile range) and Orthopedic Surgery (from 450 [239-600] to 334 [167-435], P < 0.001). The median number of opioid pills prescribed at discharge per surgery also decreased significantly, from 25 (15-53) to 15 (11-38) for 1 mg hydromorphone (P < 0.001) and 25 (20-51) to 20 (15-30) for oxycodone (P < 0.001). The decrease in opioid prescriptions continued in the second year of the campaign. Our approach resulted in a significant reduction in the number of postoperative opioids prescribed across a number of surgical specialties. Our findings indicate that evidence-based strategies derived from a regional collaborative network can be leveraged to promote and sustain quality improvement activities.

Opioid Use for Operative Foot and Ankle Fractures: A Systematic Review

Category: Ankle; Trauma Introduction/Purpose: Patients treated operatively for foot and ankle fractures may be at higher risk of undertreated pain as well as overuse of opioid medications. We sought to synthesize the recent literature investigating use of opioids for analgesia following foot and ankle fracture surgery. To accomplish this, we aimed to determine the patterns of opioid use and prescription (e.g., quantity, duration, incidence of persistent use), risk or protective factors for persistent opioid use, and clinical outcomes (e.g., relief of pain, adverse events) associated with opioid use in this population. Methods: We followed PRISMA guidelines for our review. We systematically searched PubMed, Embase, Scopus, Cochrane, and Web of Science. We included studies published from 2010 to present that assessed patterns of opioid use, risk factors for increased opioid use, and outcomes associated with opioid use following foot/ankle fracture surgery. Two reviewers performed title/abstract screening and full-text review. The quality of included studies was evaluated using MINORS criteria. Results: In our review, 1713 articles were assessed and 18 were included (Figure 1). MINORS scores ranged from 13 to 18, indicating moderate study quality. Overall, there was wide variability in opioid use between and within studies. Rates of postoperative persistent opioid use ranged from 7-39%. Risk factors for increased opioid use included preoperative opioid exposure, mental health disorders, tobacco consumption, and certain injury patterns. Protective factors were spinal anesthesia, peripheral nerve block, and postoperative ketorolac. Opioid use was not associated with decreased pain or improved satisfaction. Opioid use was associated with increased rates of pain-related emergency department visits and readmission. Preoperative opioid use was associated with the greatest odds of increased postoperative use. Conclusion: There is a high incidence of persistent opioid use after foot and ankle fracture surgery. Opioid use was associated with negative health outcomes without decreasing pain levels or increasing patient satisfaction after foot/ankle fracture surgery. The wide variability of reported opioid use emphasizes the need for standardized guidelines for postoperative opioid use in this patient population, and our findings suggest that lower opioid prescription may be advisable.

Actual situation and prescribing patterns of opioids by pain physicians in South Korea.

BackgroundUse of opioids for chronic intractable pain is increasing globally, and their proper use can improve patients’ quality of life. In contrast, opioid use disorders, such as abuse or addiction, caused by prescribing opioids, are a worldwide issue. This study aimed to understand current opioid prescribing patterns and pain physicians’ experiences with opioid use in South Korea.MethodsPain physicians in 42 university hospitals in South Korea were asked to complete anonymous questionnaires regarding opioid prescriptions.ResultsA total of 69 surveys were completed. Most pain physicians started prescribing opioids at a pain score of 7/10 and aimed to reduce pain by 50%. Most physicians (73.1%) actively explained the prescribed medications and possible side effects, and 61.2% of physicians preferred the prescription interval of 4 weeks. Immediate-release opioids were the most popular treatment for breakthrough pain (92.6%). The most common side effect encountered by physicians was constipation (43.3%), followed by nausea/vomiting (34.3%). Of the physicians, 56.5% replied that addiction and misuse prevalences were less than 5%. However, the most concerning side effect was addiction (33.0%).ConclusionsThe survey results showed that the prescribing patterns of pain physicians generally followed Korean guidelines. Physicians were most interested in the safety and effectiveness of opioid prescriptions. They were most concerned about respiratory depression and abuse or addiction. A significant number of physicians agreed that the NHIS regulations needed improvement for patient convenience and safe and effective treatment, though there were pros and cons of the NHIS restrictions on prescription conditions.