Opioid Prescribing Research Articles (Page 1)

We aimed to evaluate the impact of an electronic health record (EHR)-based default "nudge" intervention on opioid prescribing after common surgical operations. Given ongoing national challenges in opioid use and opioid-related adverse events, there is a need to optimize opioid prescribing after surgery. Behavioral nudges built into the EHR may be effective and useful, but they have not been widely tested among surgeons. This is a randomized clinical trial at a large academic medical center involving adult surgical patients. System-wide, 118 surgical clinicians were randomized to control or intervention versions of an electronic discharge order set; the intervention arm had suggested pre-populated opioid and adjunct prescriptions. The outcome was morphine milligram equivalents (MME) prescribed at discharge, analyzed at the surgical encounter level. 663 surgical encounters (377 intervention and 286 control) were analyzed. 57% of the patients were female, and the median age was 49 years. The most common operations were laparoscopic cholecystectomy (39%), laparoscopic appendectomy (25%), and laparoscopic/robotic colectomy (12%). The median opioids prescribed at discharge was 75 MME (~ 10 oxycodone-5mg tablets). Overall, in the intention-to-treat analysis, there were similar MME prescribed in the control and intervention groups (adjusted difference: 2.4 MME, 95% CI: -14.7 to 19.4, P=0.79). Only 21% in the intervention group received prescriptions from pre-populated defaults, while 79% received free form prescriptions. In as-treated analysis, the pre-populated prescriptions were substantially smaller than those written free form (adjusted difference: -22.5 MME, 95% CI: -34.7 to -10.2). The offering of pre-populated opioid prescriptions to surgeons did not reduce postoperative opioid prescribing overall. However, the subset of surgeons who accepted the defaults prescribed much less opioids. Default nudge interventions may be useful in optimizing opioid prescribing, but stronger versions of defaults and co-interventions are likely needed.

Opioids are potent analgesics associated with potentially serious adverse effects, including abuse. The use of patient-provider opioid agreements is a regulatory approach in opioid prescription aimed at achieving pain management goals while minimising adverse effects. While national guidelines in Singapore recommend their use, there are limited data regarding the frequency of use and the experiences associated with them. This study aimed to examine clinicians' awareness, perceptions and frequency of use of opioid agreements in Singapore. A multicentre cross-sectional electronic survey was conducted among doctors from various clinical specialties in Singapore. The survey questionnaire, hosted on a Singapore Government-secured website, was emailed as a link to 1051 potential respondents and remained active for 3 months. All responses were received anonymously and securely collated. There were 139 questionnaire responses, among which 129 (92.8%) participants were opioid prescribers. Eighty-six (66.7%) participants were unaware of the existence of opioid agreements. Only 21 (16.3% of total, 48.8% of aware) participants were actual users of opioid agreements; 95.4% of participants who were aware of opioid agreements felt that they were useful. Awareness and use of opioid agreements among clinicians in Singapore are low, varying by pain management experience, prescribing frequency and practice specialty. Clinicians familiar with opioid agreements generally accept their clinical usefulness. Education and research are needed to increase awareness and develop guidelines for standardised administration of opioid agreements.

Opioids are commonly prescribed for infants after congenital heart disease (CHD) surgery, and prolonged exposure can lead to physiologic dependence requiring methadone treatment. The Risk Adjustment for Congenital Heart Surgery-2 (RACHS-2) categorizes operative mortality risk and may also help identify infants at greatest risk for methadone treatment. A retrospective cohort study of infants < 1year undergoing CHD surgery between 2016-2022 at 48 U.S. children's hospitals using the Pediatric Health Information System was performed. Infants were categorized by RACHS-2 score (1 = lowest, 5 = highest risk). Multivariable hierarchical logistic regression evaluated associations between postoperative opioid days and methadone treatment, including an interaction between RACHS-2 and opioid exposure. Secondary analyses compared postoperative length of stay (LOS), ventilator days, and total parenteral nutrition (TPN) days by methadone status. Among 34,127 infants, higher RACHS-2 scores were associated with longer postoperative opioid exposure (p < 0.001). For infants who received < 17days of opioids, increasing RACHS-2 scores predicted greater probability of methadone treatment. After 17days, RACHS-2 score 1 infants had the highest probability of methadone treatment, though they represented a minority. Methadone was independently associated with longer LOS, ventilator days, and TPN days. Higher RACHS-2 scores were associated with increased likelihood of postoperative methadone treatment in the early postoperative period. Methadone treatment was associated with adverse short-term health outcomes. For infants with prolonged opioid exposure, those with lower RACHS-2 scores were more likely receive methadone treatment- highlighting subpopulations that may benefit from targeted opioid stewardship initiatives.

Early in the SARS-Cov-2 pandemic, modified clinical guidance recommended the provision of take-home methadone doses for those previously ineligible to facilitate social distancing. Following this change, studies reported improved treatment retention among patients granted expanded access to take-home doses. However, most patients resumed daily dispensed methadone within six months. Factors associated with the return to daily dispensed methadone remain unknown. Therefore, we conducted a population-based cohort study to identify patient and prescriber-related characteristics associated with return to daily dispensed methadone. Our study included all residents of Ontario, Canada who received daily dispensed methadone on March 21, 2020, and were then provided at least one take-home dose between March 22, 2020, and April 21, 2020. Follow-up time was divided into 14-day discrete time intervals. The primary outcome was return to daily dispensed methadone, defined as the first interval where a take-home dose was not dispensed. A multilevel discrete time survival model with a complementary log-log link function and random intercepts across prescribers to account for patient clustering by prescriber was used to approximate cause-specific hazard ratios. Within 26 weeks, 1,675 (58.5%) individuals were reverted to daily dispensed methadone. Person-level variables significantly associated with our primary outcome included occurrence of an emergency department visit during or before the interval of interest (HR = 1.27; 95% CI = 1.05, 1.55) and missed methadone dose(s) in the interval prior (HR = 1.59; 95% CI = 1.44, 1.76). Lastly, patients prescribed methadone by a high-volume (top 20 th percentile) opioid agonist treatment prescriber had an increased hazard of return to daily dispensed methadone compared to those prescribed methadone by a low-volume (50 th percentile) prescriber (HR = 1.44; 95% CI = 1.14, 1.83). While patient characteristics that may indicate clinical instability, such as recent history of missed methadone dose(s) were associated with return to daily dispensed methadone, prescriber OAT client volume was also be associated this outcome.

Evaluation of the Morphine Milligram Equivalents Opioid Prescribing Trends Based on Pain Scale in Patients Ordered IV Morphine for Severe Pain.

Abstract Introduction The treatment of acute pain is essential to facilitate recovery from surgery or trauma by enabling early mobilisation and avoiding complications, including the bed-bound risks of venous thromboembolism, pulmonary embolus, pressure sores and pneumonia. Severe, untreated acute pain may also predispose to the development of chronic pain [1]. Opioid toxicity whilst in hospital can be fatal and requires strict adherence to good prescribing guidance. Also, opioid-induced constipation is the most common adverse effect associated with prolonged use of opioids [2]. Aim To ascertain compliance with the Trust’s “Adult Opioid Prescribing Guide” [3] in adult patients in the Princess Royal University Hospital (PRUH) surgical wards. Objectives To determine if all patients prescribed opioids had naloxone 100 micrograms PRN (when required) prescribed. To determine if all patients prescribed opioids had at least one laxative prescribed (if not contraindicated). To assess if both naloxone and a laxative were prescribed concurrently with opioids. Methodology Standards Ethics approval was not required. The audit was approved by the KCH Pharmacy Research and Audit Group. On 23rd August 2023, data was collected prospectively from surgical wards S3 and S6 (20 beds each, all occupied) using Electronic Patient Records (EPR). The Raosoft sample size calculator was used [4]. It recommended 37 patients. However, the total number of patients was included. Data was analysed using Microsoft Excel®. Inclusions: all admitted patients on S3 and S6 on the audit date. Exclusions: opioid/laxative use as part of drug history and contraindications (e.g. allergy, bowel perforation). Results Of the 40 patients, 4 were excluded (2 had opioids as regular medication, 2 had contraindicated laxatives), leaving 36 patients. Of these, 22 were prescribed opioids for acute pain. Only 6 (27%) had naloxone prescribed, 10 (45%) had at least one laxative, and 4 (18%) had both prescribed as per the Trust’s Guidelines [3]. Discussion This was the first audit at this Trust, so no previous data was available for comparison. Compliance with guidelines was poor. Contributing factors included staffing shortages, limited audit resources, lack of awareness among new doctors due to reduced induction time, and junior doctors' and consultants' strikes shortly before the audit. Study limitations included small sample size due to resource constraints, inability to automate data collection, recent staff changes and shortages across the hospital, and limited time for pharmacists to support daily prescribing reviews. There is inadequate compliance with the Trust’s opioid prescribing guidelines (1) in surgical wards at PRUH, increasing the risk of opioid toxicity and constipation-related complications [1,2]. Recommendations are to: 1) Include pharmacists in induction sessions for new prescribers to introduce Trust guidelines, 2) Provide refresher training to surgical doctors during monthly audit days, 3) Email consultants audit findings and guideline reminders, 4) Plan a re-audit in three months, 5) Introduce EPR prompts or protocols to co-prescribe naloxone and laxatives with opioids.

In this study, we investigate clinical outcomes of inflammatory bowel disease (IBD) patients prescribed opioids after discharge from the hospital or emergency department (ED). IBD is commonly associated with abdominal pain. Opioids are frequently prescribed to address pain in IBD patients. Importantly, however, there is limited evidence of analgesic benefit. In addition, there are significant safety concerns about opioid use in this setting. This retrospective study utilized Merative MarketScan claims databases to identify IBD patients who had a hospital or ED visit between 2017 and 2021. Two patient groups were formed based on whether they received an opioid prescription within 7 days of discharge or not. Demographics and baseline clinical features were evaluated. Using χ2 tests and logistic regression, clinical outcomes were compared between groups at 3 time points (1, 3, and 6mo) starting 7 days after discharge. Thirty-five thousand eight hundred ninety IBD patients were included in the analysis, with 7892 (22.0%) patients in the opioid prescription group. Using logistic regression analysis, IBD opioid users were found to be significantly more likely to experience repeat ED visits, hospitalizations and opioid prescriptions at multiple time points. IBD opioid users were also more likely to receive corticosteroids and undergo medication escalation during follow-up. Ulcerative colitis opioid users also trended toward being more likely to undergo IBD-associated surgery 6 months after discharge. Patients who are prescribed opioids after acute hospital care are more likely to have poor clinical outcomes. Physicians should avoid prescribing opioids to IBD patients at discharge from the ED or hospital.

Postoperative pain management is a significant challenge in patients undergoing burn excision. Pharmacologic pain management strategies include both opioid and non-opioid medications. Given the national overuse of opioids and the associated negative effects, it is prudent we find ways to manage pain with fewer or no opioids. We hypothesize that intraoperative administration of intravenous methadone reduces total morphine milligram equivalents per weight used in the 36hours following surgery. This is a retrospective, single-center cohort study of adult burn patients who underwent a first excision of full thickness burn between January 2019 and January 2021. One group received intraoperative intravenous methadone while the non-exposure group did not. The primary outcome was total morphine milligram equivalents per weight utilized in the 36hours following surgery. Secondary outcomes included average pain scores in the PACU and for 36hours postoperatively, as well as discharge opioid prescriptions. The methadone group contained 104 subjects, and the non-exposure group contained 119 subjects. Poisson regression, with adjustment for covariates, showed that the methadone group required fewer 36-hour postoperative opioids (IRR = 0.89, p=.447) and were discharged with fewer opioid prescriptions (IRR = 0.86, p=.363) independent of the age and %TBSA differences. PACU pain scores were lower in the methadone group (IRR = 0.91, p=.350), as were 36-hour postoperative pain scores (IRR = 0.92, p=.310). These trends towards improved pain control and reduced opioid requirements in patients receiving intraoperative, intravenous methadone did not reach statistical significance. Prospective, adequately powered randomized studies are needed to advance these findings.

In the age of the opioid epidemic and a widespread desire to reduce opioid prescriptions, both in outpatient practices and hospitals, we have welcomed non-opioid medications as one possible strategy to reduce the reliance on opioids for the treatment of pain. For anesthesiologists, surgeons, and other perioperative physicians, minimizing exposure to opioids in the perioperative period has been a focal point for several decades now and countless protocols have been described, adopted, and studied. Gabapentin and pregabalin, known collectively as gabapentinoids, have been included in many of these protocols and it is not difficult to see why. They have predictable pharmacokinetics, are one of the only medication classes to treat neuropathic pain, and have sizeable literature support for their ability to reduce pain and opioid consumption. Their use for acute perioperative pain remains off-label. As with many drugs, we have learned more over time and now have a fuller picture of the benefits and risks associated with gabapentinoids. In particular, the central nervous system adverse effects, including dizziness and sedation, are now well established and can be especially problematic in the elderly. Synergistic respiratory depression when combined with opioids and even possible cognitive deficits from prolonged use have been described, forcing some perioperative physicians to rethink their inclusion in enhanced recovery and other perioperative protocols. In this pro-con discussion, we debate the merits of perioperative gabapentinoids in 2025, relying on published evidence for our positions, and ultimately call for a nuanced approach that considers the individual patient before us.

Abstract In this paper, we establish a causal connection between two of the most salient social developments in the United States over the past decades: the opioid epidemic and the political realignment between the Republican and Democratic parties. Drawing on unsealed records from litigation against Purdue Pharma, we uncover rich geographic variation in the marketing of prescription opioids that serves as a quasi-exogenous source of exposure to the epidemic. We use this variation to document significant increases in drug-related mortality and greater reliance on public transfer programs. This induced economic hardship led to substantial changes in the political landscape of the communities most affected by the opioid epidemic. We estimate that from the mid-2000s to 2022, exposure to the opioid epidemic continuously increased the Republican vote share in House, presidential, and gubernatorial elections. By the 2022 House elections, a one-standard-deviation increase in our measure of exposure led to a 4.5 percentage point increase in the Republican vote share. From 2012 until 2022, this increase in the House vote share translated into Republicans winning additional seats.

BackgroundLong-term opioid dependence after critical illness is an emerging concern, yet the incidence and predictors of persistent opioid use among intensive care unit (ICU) survivors remain incompletely characterized. We aimed to estimate the six-month incidence of new persistent opioid use in opioid-naïve ICU survivors and to identify associated risk factors.MethodsWe conducted a retrospective, nationwide cohort study using South Korea’s National Health Insurance Service database. Adults admitted to any ICU between January 1, 2020, and December 31, 2022, were included if they survived to hospital discharge and remained alive for at least six months, with no opioid prescription in the 12 months preceding admission. New persistent opioid use was defined as at least one outpatient opioid prescription within 90 days after discharge and at least one additional prescription between 91 and 180 days. We performed multivariable logistic regression to identify independent predictors.ResultsAmong 567,260 opioid-naïve ICU survivors, 23,945 (4.2%) developed new persistent opioid use within six months. Across the cohort, 22,643 (4.0%) received less-potent opioids (tramadol, dihydrocodeine) and 1,643 (0.3%) received potent opioids (morphine, fentanyl, oxycodone, hydromorphone, methadone). Independent predictors included older age (odds ratio [OR] 1.01 per year; 95% confidence interval [CI], 1.01–1.02; P < 0.001), female sex (OR 1.13; 95% CI, 1.09–1.16; P < 0.001), socioeconomic disadvantage (Medical Aid, OR 1.30; 95% CI, 1.23–1.38; P < 0.001), malignancy (OR 1.05; 95% CI, 1.01–1.09; P = 0.017), metastatic tumor (OR 1.24; 95% CI, 1.15–1.35; P < 0.001), extracorporeal membrane oxygenation (OR 1.80; 95% CI, 1.75–1.89; P < 0.001), and continuous renal replacement therapy (OR 1.24; 95% CI, 1.11–1.37; P < 0.001). The strongest predictor was an early opioid prescription within 30 days of discharge (OR 19.7; 95% CI, 19.1–20.3; P < 0.001). Potency-specific analysis showed potent opioid persistence was largely driven by cancer, while less-potent use was shaped more by demographic and socioeconomic factors.ConclusionsApproximately one in 25 ICU survivors developed new persistent opioid use by six months. Early post-discharge opioid prescription was the dominant risk factor. Risk profiles differed by opioid potency, underscoring the need for early tapering strategies, multimodal non-opioid analgesia, and stewardship programs tailored to patient subgroups and opioid type.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13054-025-05716-w.

Retrospective cohort study. To compare rates of healthcare utilization, complications, opioid use, and revision surgery following anterior lumbar interbody fusion (ALIF) in patients with versus without non-tobacco nicotine dependence (NTND). The prevalence of NTND is rising in the United States due to products such as nicotine e-cigarettes, pouches, gums, and lozenges. Studies have shown that tobacco use can contribute to adverse outcomes following spinal fusion surgery, including pseudarthrosis. However, literature focusing specifically on NTND is sparse. The TriNetX database was queried to identify patients over 18-years-old who underwent primary ALIF. Patients were stratified into two cohorts based on their history of NTND. Patients underwent propensity score matching in a 1:1 ratio based on demographics and relevant co-morbidities. Covariate balance was confirmed by standardized mean differences ≤ 0.1. The following outcomes were collected: 1) medical complications and healthcare utilization within 90 days, 2) opioid use within 2 years, and 3) surgical complications and revision surgery within 2 years. Within 90 days, patients with NTND (n=2,296), compared to those without (n=2,296), had higher rates of emergency department visits (P=0.001), outpatient encounters (P=0.001), pneumonia (P=0.007), ventilator support (P=0.019), and sepsis (P=0.015). Patients with NTND received significantly more opioid prescriptions at all time points (all P≤0.001). More patients with NTND were prescribed opioids at all time points (all P≤0.001) except at one week. Lastly, patients with NTND had higher rates of post-laminectomy syndrome (all P<0.001), pseudarthrosis (all P<0.001), and revision surgery (all P<0.05) at all time points within two years. Patients with NTND have higher rates of healthcare utilization, complications, opioid use, and revision surgery following ALIF. Patients should be screened and counseled in a multi-disciplinary fashion to ensure the best possible outcome after surgery. IV.

To investigate why rural general practitioners prescribe opioids for people with chronic non-cancer pain, with the aims of explaining geographic differences in opioid prescribing and improving pain management in rural areas. Qualitative study; interviews with convenience sample of rural general practitioners. Seventeen rural general practitioners who had prescribed opioids for people with chronic non-cancer pain during the preceding twelve months; the interviews were undertaken during 11 September 2023 - 31 May 2024. Contextual and individual factors that influence decision making by rural general practitioners about prescribing opioids for people with chronic non-cancer pain. We found that rural opioid prescribing is influenced more by health care system deficiencies than lack of knowledge among practitioners. Two major themes were identified: systematic constraints (insufficient time for alternative management strategies and the influence of Medicare remuneration); and limited access to multidisciplinary pain management (limited availability of non-pharmaceutical treatments, colleagues for consultation, and referral pathways). Participants described feeling trapped between brief consultations and complex deprescribing requirements; Medicare remuneration schedules encourage shorter appointments (and therefore continuing current management) rather than comprehensive pain management. Implementing evidence-based guidelines was difficult in rural areas with limited resources. The limited availability of allied health services further restricted alternative pain management approaches. Participants reported greater psychological pressure to justify opioid deprescribing than prescribing. Doctors acknowledged that the evidence for the value of opioids for managing chronic pain was limited but felt caught between inadequate system resources and patient demands. We found a marked disparity between evidence-based guidelines for chronic pain management and the reality of rural medical practice. Rural doctors operating in a difficult context resort to prescribing opioids because of systemic inadequacies rather than lack of awareness of their limited value. Chronic pain management in rural areas could be improved by better Medicare support for longer pain management consultations, improved access to allied health, rural area-specific guidelines that take resource constraints into account, and improved support for general practitioners in pain management and deprescribing.

To evaluate the impact of a pharmacist-led primary care review clinic on reducing opioid prescribing. Retrospective analysis of routinely collected opioid prescription data for patients using strong opioids for pain at a practice with high social deprivation and staffed mainly by locum GPs. Forty-seven patients were reviewed. The median opioid dose before review was 80mg oral morphine equivalent. After intervention, the median dose was 30mg. Thirty-seven (78.7%) patients had reduced doses or discontinued opioids. No adverse events were reported. A pharmacist-led clinic aimed at reducing opioid medication appears feasible and effective.

This cross-sectional study assesses receipt of opioids and daily morphine milligram equivalents among nursing home residents from 2011 to 2022.

Evaluating variation in opioid prescribing for emergency general surgery patients.

The prevalence of persistent opioid use following dispensed dental opioid prescriptions in Australia.

Examination of opioid prescribing guidelines on sinus surgery opioid prescription trends.

Is postoperative ketorolac administration associated with nonunion in adults after proximal humerus open reduction and internal fixation? a propensity-matched retrospective cohort study.

We estimated the extent to which the risk of developing opioid use disorder or overdose over 15 months of follow-up would be affected by applying prescription opioid dose and duration reductions to subsets of newly diagnosed musculoskeletal pain patients, defined in terms of the "riskiness" level of their initial opioid prescription. We studied a cohort of nonpregnant Medicaid patients, aged 19-63 years, without cancer nor on palliative care, who were opioid-naive, newly diagnosed with musculoskeletal pain, and were prescribed an opioid within 3 months from the diagnosis date (N = 324,389). We applied a novel statistical approach to estimate the effects of local modified treatment policies (a generalization of the average treatment effect on the treated). Specifically, we estimated the expected difference in risk of developing opioid use disorder or opioid overdose by sequential 3-month follow-ups among patients with different levels of opioid prescribing had those patients had their prescription opioid dose and/or duration decreased by 20% versus no hypothetical intervention, and had they remained uncensored. We estimated clinically modest effects on absolute opioid use disorder risk when universally reducing opioid prescription dose and duration by 20% across the cohort. In contrast, we estimated much larger, clinically relevant reductions in absolute risk of one percentage point or greater when assessing the localized effects of: (1) a 20% reduction in dose among individuals with doses ≥90 morphine milligram (mg) equivalents, (2) a 20% reduction in days supplied among individuals with >30 days supplied, and (3) 20% reductions in both dose and duration among those with ≥50 morphine mg equivalents and >7 days supplied. We estimate that reductions in opioid prescribing may have a limited impact on the risk of opioid use disorder when applied broadly but possibly meaningful reductions in risk when applied to those with riskier prescriptions.