Opioid Prescription Refills Research Articles

Patients undergoing reverse total shoulder arthroplasty have less pain and require fewer opioid pain medications compared to anatomic total shoulder arthroplasty in the early postoperative period: a retrospective review

Recovery after anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) has many similarities; however, recently surgeons have suggested patients undergoing rTSA have a less difficult postoperative course with less pain compared with aTSA patients. Given the heightened awareness to postoperative pain control and opioid consumption, as well as the expanding indications for rTSA, we sought to determine the differences in pain and opioid consumption between aTSA and rTSA patients in a 12-week postoperative period. A retrospective chart review was performed to identify all patients who underwent a primary aTSA or rTSA from January 2013 to April 2018 at a single institution. Patients with recorded visual analog scale (VAS) and American Shoulder and Elbow Surgeons scores were included for analysis. Revision arthroplasties were excluded. VAS scores were recorded preoperatively and at standard 2-week, 6-week, and 12-week postoperative time points. P values < .05 were considered statistically significant, except where Bonferroni corrections were applied. A total of 690 patients underwent TSA (278 aTSA, 412 rTSA). Preoperatively, aTSA and rTSA patient groups had similar VAS scores (6 vs. 6, P=.38). Postoperatively, the aTSA group had a higher VAS at the 6-week visit, compared with rTSA patients (2.8 vs. 2.2, P=.003). aTSA patients remained on opioids at a higher rate at the 2-week (62.4% vs. 45.6%, P ≤ .001) time period. aTSA patients needed more opioid prescription refills before the 2-week (61.7% vs. 45.5%, P ≤ .001) and 6-week (40.4% vs. 30.7%, P=.01) follow-up visits. Despite similar preoperative VAS and rates of preoperative opioid use, aTSA patients required more opioid medication refills and remained on opioids for a longer duration in the early postoperative period to achieve similar postoperative pain control as indicated by similar VAS. This study suggests that the recovery from rTSA is less difficult compared with aTSA as indicated by VAS and opioid consumption.

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice

BackgroundCurrent evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers. ObjectiveTo determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol (BOSS) compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload. Study DesignThe BOSS intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month post-intervention (BOSS) cohort to 6- month pre-intervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month wash out period was observed after BOSS initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents (OME) prescribed. Pain control was measured by pain scores, post-discharge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and post-discharge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the BOSS protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables. Results416 patients were included in the primary analysis (207 BOSS, 209 Usual Care). Baseline demographics were similar between groups, except a lower proportion of IBS (13% vs 23%; p<0.01) and pelvic pain (15% vs 24.9%; p=0.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; p=0.02) in the BOSS cohort. The BOSS cohort was more likely to be discharged without opioids (68.1% vs 10.0%; p<.01). In those prescribed opioids, total OME on discharge was significantly lower in the BOSS cohort (48.1 vs 81.8; p<.01). The BOSS cohort had a 20.6 greater odds (CI 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to NSAIDs. The BOSS cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; p=0.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; p=0.77), emergency room visits for pain (3.4% vs 2.9%; p=0.76), postoperative pain scores (mean 4.7 vs 4.0; p=0.07), or patient satisfaction with pain control (81.5% vs 85.6%; p=0.21). After BOSS implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; p=0.02). Similar results were identified when non-adherent prescribing was included in the analysis. ConclusionsA bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

Deep learning predicts postoperative opioids refills in a multi-institutional cohort of surgical patients

BackgroundTo combat the opioid epidemic, several strategies were implemented to limit the unnecessary prescription of opioids in the postoperative period. However, this leaves a subset of patients who genuinely require additional opioids with inadequate pain control. Deep learning models are powerful tools with great potential of optimizing health care delivery through a patient-centered focus. We sought to investigate whether deep learning models can be used to predict patients who would require additional opioid prescription refills in the postoperative period after elective surgery. MethodsThis is a retrospective study of patients who received elective surgical intervention at the Mayo Clinic. Adult English-speaking patients ≥18 years old, who underwent an elective surgical procedure between 2013 and 2019, were eligible for inclusion. Machine learning models, including deep learning, random forest, and eXtreme Gradient Boosting, were designed to predict patients who require opioid refills after discharge from hospital. ResultsA total of 9,731 patients with mean age of 62.1 years (51.4% female) were included in the study. Deep learning and random forest models predicted patients who required opioid refills with high accuracy, 0.79 ± 0.07 and 0.78 ± 0.08, respectively. Procedure performed, highest pain score recorded during hospitalization, and total oral morphine milligram equivalents prescribed at discharge were the top 3 predictors for requiring opioid refills after discharge. ConclusionDeep learning models can be used to predict patients who require postoperative opioid prescription refills with high accuracy. Other machine learning models, such as random forest, can perform equal to deep learning, increasing the applicability of machine learning for combating the opioid epidemic.

Clinical and surgical factors associated with opioid refill rates following septorhinoplasty

BackgroundSeptorhinoplasty is one the most common class of procedures performed worldwide, and opioids are frequently prescribed for post-operative pain [1]. ObjectiveThe objective of this study was to examine the rate of post-operative opioid prescription refills following septorhinoplasty. MethodsThis study was a case-control study of patients who underwent septoplasty and other secondary concomitant procedures. ResultsOf the 249 patients included in this study, the majority of patients (94.8%) were prescribed 12 tablets of hydrocodone-acetaminophen 5 mg – 325 mg and only 31 patients (13.3%) received refills. The presence of osteotomies and history of prior opioid use were associated with refills. Nasal valve repair type, open versus closed approach, and presence of autologous auricular cartilage graft harvest were not. DiscussionOur study highlights factors that surgeons should consider when prescribing opioids after septorhinoplasty. Twelve tablets of an opioid are likely sufficient for the majority of patients, but if osteotomies are performed or the patient has a history of prior opioid use, more may be indicated to avoid the need for refills. Additional narcotics are not necessary for an open approach or for patients in which auricular cartilage is needed.

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

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

Liposomal Bupivacaine Suspension Can Reduce the Length of Stay of Patients Undergoing Open Reduction and Internal Fixation of Mandibular Fracture

Poorly controlled postoperative pain results in prolonged length of stay (LOS). The use of liposome bupivacaine injectable suspension (LB) for postoperative pain control is a relatively recent practice. The purpose of this study was to investigate the following. In patients undergoing open reduction and internal fixation of mandibular fracture(s), does the use of LB reduce LOS compared with regular bupivacaine? We implemented a retrospective cohort study of consecutive patients with mandibular fracture(s) presented to Grady Memorial Hospital in Atlanta, GA, from January 2021 to January 2022. Adult patients diagnosed with 1 or more isolated mandibular fracture(s) and treated by open reduction and internal fixation were included. We excluded patients with non-isolated mandibular fracture(s), isolated condyle, infected, previously treated fractures, and documented allergy to amide local anesthetics and/or its preservatives. Primary predictor variable was the use of local anesthetic. Primary outcome variable was LOS, defined as the number of days from surgical procedure until discharge. Secondary outcome variables were number of opioid prescription refill(s) and postoperative pain at discharge, determined with visual analogue score. Demographics, American Society of Anesthesiologists classification, smoking, alcohol exposure, illicit drug use, etiology, location, laterality, number of fracture(s), surgical approach, and method of maxillomandibular fixation. Univariate and bivariate analyses were calculated. Statistical significance was P<.05. Sixty-two subjects met the inclusion criteria (31 subjects in each group). The mean ages in LB/regular bupivacaine and regular bupivacaine alone groups were 33.3 (±12) and 35.1 (±15.6), respectively (P=.94), the mean LOS in days was 0.23 (±0.44) in LB/regular bupivacaine and 1.48 (±1.77) in regular bupivacaine alone (P=<.001), and the mean VAS pain scores for LB/regular bupivacaine and regular bupivacaine alone groups were 0.53 (±1.07) and 1.87 (±2.66), respectively (P=.02). Mean number of opioid prescription refill(s) was 0 in LB/regular bupivacaine and 1 in regular bupivacaine alone group, respectively (P=.01). The study findings suggest that the use of LB/regular bupivacaine for mandibular fracture(s) results in decrease in LOS and number of opioid refills compared to regular bupivacaine alone.

Appendectomy Pain Medication Prescribing Variation inthe U.S. Military Health System.

Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System. This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED). Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only. Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.

Cannabis Use Is Associated With Fewer Filled Opioid Prescriptions After Treatment of Proximal Humerus Fractures.

The purpose of this study was to use a large claims database to determine if there is a difference in opioid use after operative intervention for proximal humerus fractures in patients with known cannabis use compared with those who do not report cannabis use. The PearlDiver database was queried to find all patients who underwent proximal humerus open reduction and internal fixation. A group of patients with reported cannabis use or dependence was matched to a cohort without known cannabis use. Between the two groups, differences in the number of opioid prescriptions filled in the postoperative period (within 3 days), the morphine milligram equivalents (MMEs) prescribed in total and per day, and the number of opioid prescription refills were explored. There were 66,445 potential control patients compared with 1260 potential study patients. After conducting the propensity score match, a total of 1245 patients were included in each group. The patients in the cannabis group filled fewer opioid prescriptions (P=.045) and were prescribed fewer total MMEs (P=.044) in the first 3 days postoperatively. Results of this study indicate that patients who use cannabis products may use fewer opioids after proximal humerus open reduction and internal fixation. [Orthopedics. 2024;47(3):147-151.].

Restrictive opioid prescribing after surgery for prolapse and incontinence: a randomized, noninferiority trial

Opioids are routinely prescribed for postoperative pain control after gynecologic surgery with growing evidence showing that most prescribed opioids go unused. Restrictive opioid prescribing has been implemented in other surgical specialties to combat the risk for opioid misuse and diversion. The impact of this practice in the urogynecologic patient population is unknown. This study aimed to determine if a restrictive opioid prescription protocol is noninferior to routine opioid prescribing in terms of patient satisfaction with pain control after minor and major surgeries for prolapse and incontinence. This was a single-center, randomized, noninferiority trial of opioid-naïve patients who underwent minor (eg, colporrhaphy or mid-urethral sling) or major (eg, vaginal or minimally invasive abdominal prolapse repair) urogynecologic surgery. Patients were excluded if they had contraindications to all multimodal analgesia and if they scored ≥30 on the Pain Catastrophizing Scale. Subjects were randomized on the day of surgery to the standard opioid prescription protocol (wherein patients routinely received an opioid prescription upon discharge [ie, 3-10 tablets of 5 mg oxycodone]) or to the restrictive protocol (no opioid prescription unless the patient requested one). All patients received multimodal pain medications. Participants and caregivers were not blinded. Subjects were asked to record their pain medication use and pain levels for 7 days. The primary outcome was satisfaction with pain control reported at the 6-week postoperative visit. We hypothesized that patient satisfaction with the restrictive protocol would be noninferior to those randomized to the standard protocol. The noninferiority margin was 15 percentage points. Pain level scores, opioid usage, opioid prescription refills, and healthcare use were secondary outcomes assessed for superiority. A total of 133 patients were randomized, and 127 (64 in the standard arm and 63 in the restrictive arm) completed the primary outcome evaluation and were included in the analysis. There were no statistically significant differences between the study groups, and this remained after adjusting for the surgery type. Major urogynecologic surgery was performed in 73.6% of the study population, and minor surgery was performed in 26.4% of the population. Same-day discharge occurred for 87.6% of all subjects. Patient satisfaction was 92.2% in the standard protocol arm and 92.1% in the restrictive protocol arm (difference,-0.1%; P=.004), which met the criterion for noninferiority. No opioid usage in the first 7 days after hospital discharge was reported by 48.4% of the patients in the standard protocol arm and by 70.8% in the restrictive protocol arm (P=.009). Opioid prescription refills occurred in 8.5% of patients with no difference between the study groups (9.4% in the standard arm vs 6.7% in the restrictive arm; P=.661). No difference was seen in the rate of telephone calls and urgent visits for pain control between the study arms. Among women who underwent minor and major surgery for prolapse and incontinence, patient satisfaction rates were noninferior after restrictive opioid prescribing when compared with routine opioid prescribing.

Opioid Prescribing Variation After Laparoscopic Cholecystectomy in the US Military Health System

IntroductionAfter laparoscopic cholecystectomy (LC), there is a wide variation in opioid prescription miligram morphine equivalent dose (MED) and refills across US medical institutions. Given wide variation and opioid prescription guidelines, it is essential to conduct thorough health services research across medical, surgical, and patient-level factors that can be implemented to improve system-wide prescribing practices. Therefore, this study describes discharge MED variation and opioid refill probability after emergent and nonemergent LC. Materials and methodsThis retrospective cohort study included medical record data of adult patients (N = 20,025) undergoing LC from January 2016 to June 2021 in the US Military Health System. Data visualizations and bivariate analyses examined prescription patterns across hospitals and evaluated the relationship between patient-level, care-level, and system-level factors and each outcome: discharge MED and opioid refill probability. Two generalized additive mixed models evaluated the relationship between predictors and each outcome. ResultsThere was a significant variation in opioid and nonopioid pain medication prescribing practices across hospitals. While several factors were associated with discharge MED and opioid refill probability, the strongest effects were related to time period (before versus after a June 2018 Defense Health Agency policy release) and receipt of an opioid/nonopioid combination medication. Despite decreases in MED, the MED remained almost twice the recommended dose per prior research. ConclusionsVariation by hospital suggests the need for system-level changes that target genuine practice change and opioid stewardship. Inclusion of patient-reported outcomes, electronic health record decision support tools, and academic detailing programs may support system-level improvements.

Optimizing opioid prescribing practices after minimally invasive lung resection through a quality-improvement intervention.

In their 2019 guideline on the prescribing and management of opioids after elective ambulatory thoracic surgery, the Canadian Association of Thoracic Surgeons (CATS) recommended 120 morphine milligram equivalents (MME) after minimally invasive (video-assisted thoracoscopic surgery [VATS]) lung resection. We conducted a quality-improvement project to optimize opioid prescribing after VATS lung resection. We assessed baseline prescribing practices for opioid-naive patients. Using a mixed-methods approach, we selected 2 quality-improvement interventions: formal incorporation of the CATS guideline into our postoperative care pathway, and development of a patient information handout regarding opioids. The intervention was initiated on Oct. 1, 2020, and was formally implemented on Dec. 1, 2020. The outcome measure was average MME of discharge opioid prescriptions, the process measure was proportion of discharge prescriptions exceeding the recommended dosage, and the balancing measure was opioid prescription refills. We analyzed the data using control charts, and compared all measures between the pre-intervention (12 mo before) and postintervention (12 mo after) groups. A total of 348 patients who underwent VATS lung resection were identified, 173 before the intervention and 175 after the intervention. Significantly less MME was prescribed after the intervention (100 v. 158, p < 0.001), and a lower proportion of prescriptions were nonadherent to the guideline (18.9% v. 50.9%, p < 0.001). Control charts showed special cause variation corresponding with the intervention, and system stability existed after the intervention. There was no statistically significant difference in the proportion or dosage of opioid prescription refills after the intervention. After implementation of the CATS opioid guideline, there was a significant reduction in opioids prescribed at discharge and no increase in opioid prescription refills. Control charts are a valuable resource for monitoring outcomes on an ongoing basis and for assessing the effects of an intervention.

Patterns of Opioid Demand after Operative Treatment of Distal Radius Fractures.

The PearlDiver database was queried for all patients who underwent open reduction and internal fixation of distal radius fractures between 2010 and 2020. Patients were categorized into two groups: (1) those with an active diagnosis of cannabis use (case) and (2) those without (control). The primary outcome measure was morphine milligram equivalents per prescription filled within 30 days after surgery. A logistic regression was used to determine potential risk factors associated with increased opioid filling patterns. The rates of prescription refills before and after surgery were congruent in both the case and control populations and did not show significant differences (P > 0.05). The average morphine milligram equivalents of patients' first opioid prescription was significantly reduced in the case population compared with the control (352.26 versus 480.61 morphine milligram equivalents/prescription, P = 0.005). A history of chronic opioid use was the strongest predictor of prolonged opioid prescription refills after surgery. This study found a significant reduction in opioid volume in patients with a diagnosis of cannabis use who filled an opioid prescription after open reduction and internal fixation of distal radius fractures. Mental health diagnoses, specifically depression, showed an increased risk of multiple opioid prescription refills in patients without a diagnosis of cannabis use.

Grit Score is Predictive of Increased Risk for Opioid Prescription Refill Following Primary Arthroscopic Rotator Cuff Repair

Grit Score is Predictive of Increased Risk for Opioid Prescription Refill Following Primary Arthroscopic Rotator Cuff Repair

Evaluation of Policies Limiting Opioid Exposure on Opioid Prescribing and Patient Pain in Opioid-Naive Patients Undergoing Elective Surgery in a Large American Health System.

Overprescribing to opioid-naive surgical patients substantially contributes to opioid use disorders, which have become increasingly prevalent. Opioid stewardship programs (OSPs) within healthcare settings provide an avenue for introducing interventions to regulate prescribing. This study examined the association of OSP policies limiting exposure on changes in surgery-related opioid prescriptions and patient pain. We evaluated policies implemented by an OSP in a large American healthcare system between 2016 and 2018: nonopioid medication during surgery, decrease of available opioid dosage vials in operating rooms, standardization of opioid in-patient practices through electronic health record alerts, and limit to postsurgery opioid supply. Generalized linear mixed effects models examined the association of interventions with outcome changes in 9262 opioid-naive patients undergoing elective surgery. Outcomes were discharge pain, morphine milligram equivalent in the first prescription postsurgery, and opioid prescription refills. Decreases in all prescription outcomes and discharge pain were observed following onset of OSP interventions ( P 's < 0.001). Among individual policies, standardization of in-patient prescribing practices was associated with the strongest decrease in prescribed morphine milligram equivalent. Importantly, there was no evidence of an increase in discharge pain related to any intervention. This study promotes the potential of OSP formation and policies to reduce opioid prescribing without compromising patient pain. The most effective policy, standardization of in-patient prescribing practices through alerts, suggests that reminding prescribers to re-evaluate the patient's need is effective in changing behavior. The findings offer considerations for OSP formation and policy implementation across health systems to improve quality and safety in opioid prescribing.

Language barriers and postoperative opioid prescription use after total knee arthroplasty

BackgroundPatients with limited English proficiency (LEP) face difficulties in access to postoperative follow-up care, including post-discharge medication refills. However, prior studies have not examined how utilization of prescription pain medications after discharge from joint replacement surgeries differs between English proficient (EP) and LEP patients. ObjectiveThis study explored the relationship between English language proficiency and opioid prescription refill requests after hospital discharge for total knee arthroplasty (TKA). MethodsThis was an observational cohort study of patients ≥18 years of age who underwent TKA between January 2015 and December 2019 at a single academic center. LEP status was defined as not having English as the primary language and requesting an interpreter. Primary outcome variables included opioid pain medication refill requests between 0 and 90 days from discharge. Multivariable logistic regression modeling calculated the odds ratios of requesting an opioid refill. ResultsA total of 2148 patients underwent TKA, and 9.8% had LEP. Postoperative pain levels and rates of prior opioid use did not differ between LEP and EP patients. LEP patients were less likely to request an opioid prescription refill within 30 days (35.3% vs 52.4%, p < 0.001), 60 days (48.7% vs 61.0%, p = 0.004), and 90 days (54.0% vs 62.9%, p = 0.041) after discharge. In multivariable analysis, LEP patients had an odds ratio of 0.61 of requesting an opioid refill (95% CI, 0.41–0.92, p = 0.019) within 30 days of discharge. Having Medicare insurance and longer lengths of hospitalization were correlated with lower odds of 0–30 days opioid refills, while prior opioid use and being discharged home were associated with higher odds of opioid refill requests 0–30 days after discharge for TKA. ConclusionsLanguage barriers may contribute to poorer access to postoperative care, including prescription medication refills. Barriers to postoperative care may exist at multiple levels for LEP patients undergoing surgical procedures.

Association of Postsurgical Opioid Refills for Patients With Risk of Opioid Misuse and Chronic Opioid Use Among Family Members

The US health care system is experiencing a sharp increase in opioid-related adverse events and spending, and opioid overprescription may be a key factor in this crisis. Ambient opioid exposure within households is one of the known major dangers of overprescription. To quantify the association between the postsurgical initiation of prescription opioid use in opioid-naive patients and the subsequent prescription opioid misuse and chronic opioid use among opioid-naive family members. This cohort study was conducted using administrative data from the database of a US commercial insurance provider with more than 35 million covered individuals. Participants included pairs of patients who underwent surgery from January 1, 2008, to December 31, 2016, and their family members within the same household. Data were analyzed from January 1 to November 30, 2018. Duration of opioid exposure and refills of opioid prescriptions received by patients after surgery. Risk of opioid misuse and chronic opioid use in family members were calculated using inverse probability weighted Cox proportional hazards regression models. The final cohort included 843 531 pairs of patients and family members. Most pairs included female patients (445 456 [52.8%]) and male family members (442 992 [52.5%]), and a plurality of pairs included patients in the 45 to 54 years age group (249 369 [29.6%]) and family members in the 15 to 24 years age group (313 707 [37.2%]). A total of 3894 opioid misuse events (0.5%) and 7485 chronic opioid use events (0.9%) occurred in family members. In adjusted models, each additional opioid prescription refill for the patient was associated with a 19.2% (95% CI, 14.5%-24.0%) increase in hazard of opioid misuse in family members. The risk of opioid misuse appeared to increase only in households in which the patient obtained refills. Family members in households with any refill had a 32.9% (95% CI, 22.7%-43.8%) increased adjusted hazard of opioid misuse. When patients became chronic opioid users, the hazard ratio for opioid misuse among family members was 2.52 (95% CI, 1.68-3.80), and similar patterns were found for chronic opioid use. This cohort study found that opioid exposure was a household risk. Family members of a patient who received opioid prescription refills after surgery had an increased risk of opioid misuse and chronic opioid use.

Variation by default: cesarean section discharge opioid prescription patterns and outcomes in Military Health System hospitals: a retrospective longitudinal cohort study

BackgroundTo examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid naïve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30 days) across a large healthcare system.MethodsThe Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was “female,” age was 18 years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home < 4 days after the Cesarean section.ResultsAcross 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225 mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts.ConclusionSignificant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation.

Opioid Discharge Prescriptions After Inpatient Surgery: Risks of Rebound Refills by Length of Stay

IntroductionAs inpatient stays become shorter, one concern with standardizing discharge opioid prescriptions is the potential risk of “rebound refills.” We sought to compare opioid prescription refill rates and volumes for surgical patients discharged on postoperative day (POD) 2-3, 4-7, and 8+. MethodsIn a prospective quality improvement protocol, faculty volunteered to use either a 5x-multiplier (5x) or usual care (UC) for discharge prescriptions after inpatient (≥48 h stay) surgery from Sep-Dec 2019. The 5x-multiplier is 5-times the patient's last 24-h opioid use (by oral morphine equivalents, OME). Cohorts were compared by POD of discharge: POD 2-3 (“SHORT”), POD 4-7 (“INTERMEDIATE”), and POD 8+ (“LONG”). The primary endpoint was 30-d refill rates. Secondary endpoints included 30-d refill OME and inpatient opioid weaning/discharge metrics. ResultsFrom 22 faculty, 409 patients were included. When stratified by POD, 154 (37.7%) were discharged SHORT, 176 (43.0%) INTERMEDIATE, and 79 (19.3%) LONG. SHORT stay patients had a median last 24-h OME of 10 mg (versus 5 mg INTERMEDIATE, 5 mg LONG; P = 0.268), and a median discharge OME of 55 mg (versus 75 mg INTERMEDIATE, 100 mg LONG; P = 0.221). Patients with SHORT stays did not have higher refill rates (11.7% versus 18.2% INTERMEDIATE, 19.0% LONG; P = 0.193) or higher median refill OME (150 mg versus 300 mg INTERMEDAITE, 339 mg LONG; P = 0.154). ConclusionsDespite concerns of increased refills, patients discharged by POD 2-3 were not associated with “rebound refills.” A patient-centered 5x-multiplier standardization of discharge opioid prescriptions is feasible in all inpatient surgery patients, even those discharged following a short inpatient stay.

Feasibility of an Opioid Sparing Discharge Protocol Following Laparoscopic Bariatric Surgery.

Opioids are commonly prescribed after laparoscopic bariatric surgery but have untoward effects including dependence and diversion. Prior investigation revealed that over three-fourths of discharge opioids prescribed to our patients went unused. To determine the feasibility of an opioid sparing discharge protocol following laparoscopic bariatric surgery. A total of 212 opioid-naïve patients undergoing laparoscopic bariatric surgery were examined and divided into two groups; 106 prior to (Cohort A) and 106 after implementation of an opioid sparing discharge protocol (Cohort B). Opioids were converted to morphine milligram equivalents (MME) and post-operative consumption was examined. Data was described as mean ± standard deviation. No patients in Cohort B and 54.7% (58) in Cohort A received an opioid discharge prescription (37.5 MME). Of the 154 patients that remained, only 1.3% (2) received one after discharge. Cohort A took greater amounts of opioids than Cohort B after discharge (4.74 ± 11 vs. 0.21 ± 2 MME; p < 0.001). During hospitalization, Cohort A took greater amounts of opioids (6.92 ± 11 vs. 2.74 ± 5 MME; p < 0.001) but lower amounts of methocarbamol (759 ± 590 vs. 966 ± 585 mg; p = 0.011). No patient requested an opioid prescription refill or presented to the emergency room secondary to pain. Following laparoscopic bariatric surgery, an opioid sparing discharge protocol is feasible with < 2% of patients receiving opioids after discharge and no increase in emergency room visits. Education regarding these protocols may impact the amount of opioids taken during hospitalization.

Liposomal compared to 0.25% bupivacaine in patients undergoing hemorrhoidectomy: A pre- and post-implementation quality improvement evaluation

Study objectiveThe efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures. DesignA pre- and post-implementation quality improvement evaluation. SettingOperating room and post-anesthesia care unit. PatientsNinety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020. InterventionsA preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration. MeasurementsThe primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery. Main resultsPACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0–6] vs. 0 [IQR 0–4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10–23] vs. 15 [IQR 15–25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07). ConclusionsLiposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups.