Opioid Use In Patients Research Articles

Association Between Early Surgery and Postoperative Opioid Use in Patients With Lumbar Disc Herniation: A Propensity Score-Matching Analysis Using an Administrative Claims Database in Japan.

Retrospective cohort study. This study aimed to investigate whether early surgery shortens the duration of opioid use in patients who underwent surgery with lumbar disc herniation. We extracted patients who underwent surgery at least 2weeks after they were diagnosed with lumbar disc herniation between April 2014 and May 2021. Opioid use after surgery was compared between patients who underwent surgery within 90days (early surgery group) and 90 days or later (late surgery group). Propensity-score-matching analysis and multivariable Cox hazard regression analysis with a restricted cubic spline model were conducted to evaluate the association between the timing of surgery and termination of opioid use after surgery. A total of 1597 eligible patients were identified, with 807 (51%) in the early surgery group. In the propensity-score-matched cohort, the early surgery group had a significantly lower proportion of opioid use than the control group (28% vs 48%, percent difference -20%, P < .001). Multivariable Cox hazard regression analysis showed that early surgery was significantly associated with the earlier termination of opioid use (HR, 3.13; 95% CI, 1.97-4.97; P < .001). Restricted cubic spline model showed a monotonically decreased hazard ratio and decreased hazard ratio of .50 in patients who underwent surgery 111days or later after the diagnosis. Early surgery, especially within 90days, was associated with earlier opioid use termination after surgery. Regarding the duration of opioid use following surgery, surgical treatment may be preferable to perform within around 4months after the diagnosis.

Addition of Pericapsular Nerve Group and Transversus Abdominis Plane Blocks Significantly Reduces Opioid Use in Patients Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy.

Previous studies have evaluated the effect of the pericapsular nerve group block for hip arthroscopy and the transverse abdominis plane block for periacetabular osteotomy and have shown decreased narcotic consumption in both groups. No published study has evaluated the effectiveness of combining the blocks when performing hip arthroscopy and periacetabular osteotomy under the same general anesthesia. It was hypothesized that patients treated for hip dysplasia with hip arthroscopy and concomitant periacetabular osteotomy using a pericapsular nerve group block, transverse abdominis plane block, and general anesthesia would have decreased postoperative pain and require less narcotic consumption than those undergoing the procedure with general anesthetic alone. Methods:A single surgeon performed a retrospective analysis of consecutive patients undergoing concomitant hip arthroscopy and periacetabular osteotomy between 11/2020 and 6/2021. Fifteen consecutive patients undergoing the procedure with a general anesthetic alone (no-block group) were compared to 15 patients undergoing the same procedure with a combined pericapsular nerve group block, transverse abdominis plane block, and general anesthetic (block group).Hip arthroscopy was performed utilizing a post-free technique, and a rectus sparing approach was used for the periacetabular osteotomy. The nerve blocks were performed by multiple anesthesiologists using previously published methods. Operating room time, length of stay, visual analog scale pain scores, and total narcotic consumption in morphine milliequivalents were analyzed. Groups were compared using the chi-squared test for non-continuous demographic variables and a two-tailed t-test for continuous variables utilizing Microsoft Excel (Microsoft, Redmond, WA, USA), p-value set at 0.05 for significance. Results:The no-block group consisted of 14 females and one male, while the block group was all females. No significant differences were observed between age, sex, BMI, surgery time, length of stay, or procedures performed, p>0.05. The maximal visual analog scale score in the post-anesthesia care unit was 8 ± 1.3 vs. 7 ± 1.9 in the no-block vs. block groups, respectively, p=0.15. The average hospital floor visual analog scale score was 5.7 ± 1.3 vs. 4.8 ± 1.3 in the no-block vs. block groups, respectively, p=0.07. Total pain medications required were 217.6 ± 54.6 vs. 154 ± 41.9 morphine milliequivalents in the no-block vs. block groups, respectively, p=0.001. No complications were reported in either group, and no patient in the block group demonstrated motor nerve palsy or postoperative fall. This study demonstrated that patients undergoing combined hip arthroscopy and periacetabular osteotomy for symptomatic acetabular dysplasia who had pericapsular nerve group, transverse abdominal plane block, and general anesthesia required fewer narcotics in the first 24 hours after surgery compared to those who had general anesthesia alone.

Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy

Chronic narcotic use may cause opioid-induced esophageal dysfunction and associated type III achalasia, hypercontractile esophagus (HE), diffuse esophageal spasm (DES), and esophagogastric junction outflow obstruction (EGJOO). The frequency of opioid use and its impact on peroral endoscopic myotomy (POEM) in these patients is unknown. Consecutive patients between April 2017 and September 2021 who underwent POEM for type III achalasia, EGJOO, DES, or HE with≥6 months follow-up were identified. Baseline evaluation was done with EGD, esophageal high-resolution manometry (HRM), and functional lumen impedance planimetry (FLIP) of the esophagogastric junction (EGJ). Eckardt scores (ESs) were calculated at baseline and follow-up at 6 to 12 months after POEM for opioid users and nonusers. Clinical response was defined as ES≤3, EGJ distensibility index >2.8mm2/mm Hg, maximum EGJ diameter >14mm, and integrated relaxation pressure (IRP)<15mm Hg. Opioid use before baseline HRM was assessed. One hundred twenty-six patients underwent POEM, and 89 had≥6 months of follow-up. Daily opioid use was present in 18 of 89 patients (20%). Baseline demographics, FLIP metrics, IRP, distribution of motility disorders, and POEM characteristics were similar between both groups. At 6 to 12 months after POEM, clinical response and frequency of GERD, esophagitis, and proton pump inhibitor use were similar between opioid users and nonusers. Heartburn was more frequent in the opioid group (82.4% vs 38.6%, P= .002). In this single-center study of 89 patients with type III achalasia, EGJOO, DES, or HE treated with POEM, daily opioid use was present in 20%. Response to POEM and post-POEM GERD were similar between opioid users and nonusers. (Clinical trial registration number: NCT02770859.).

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.

Cryoablation in lung transplantation: Its impact on pain, opioid use, and outcomes

ObjectiveTo assess the effect of intraoperative cryoablation on postoperative patient-reported pain, opioid use, and clinical outcomes in lung transplantation. MethodsWe performed a single-center retrospective cohort study of adult lung transplant recipients from August 2017 to September 2018. We compared outcomes of patients who received intraoperative cryoablation of the intercostal nerves with those who did not. Primary outcomes were postoperative patient-reported pain scores and opioid use. Secondary outcomes included postoperative sedation and agitation levels and perioperative outcomes. Data were abstracted from patients' electronic health records. ResultsOf the 102 patients transplanted, 45 received intraoperative cryoablation (intervention group) and 57 received the standard of care, which did not include intercostal or serratus blocks or immediate postoperative epidural placement (control group). The intervention group had significantly lower median and maximum postoperative pain scores at days 3 and 7 and significantly lower oral opioid use at days 3, 7, and 14 compared with the control group. Chronic opioid use at 3 and 6 months' posttransplant was lower in the intervention group. Differences in perioperative outcomes, including length of mechanical ventilation, sedation and agitation levels, and hospital stay, were not clinically meaningful. Survival at 30 days and 1 year was superior in the intervention compared with the control group. ConclusionsFindings suggest that use of intraoperative cryoablation is an effective approach for treating pain and reducing opioid use in patients who undergo lung transplant, but a randomized study across multiple institutions is needed to confirm these findings.

Opioid prescription trends after ambulatory anterior cervical discectomy and fusion

BACKGROUND CONTEXTOpioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown. PURPOSETo characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures. STUDY DESIGN/SETTINGRetrospective cohort study. PATIENT SAMPLEOpioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. OUTCOME MEASURESRate, amount, and type of perioperative opioid prescription. METHODSOpioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively). RESULTSA total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066). CONCLUSIONSAmbulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.

Naloxone Training: An Opportunity for Oncology Nurses to Save Lives.

Opioids are commonly prescribed for pain management in oncology; however, there is a growing concern for nonmedical opioid use in patients with cancer. The oncology practice can implement harm-reducing strategies such as prov.

Cannabis use and opioid relapse: An exploratory survival analysis of prospectively collected data.

It is known that only minority of patients with opioid use disorder (OUD) receive treatment, of which only a fraction successfully complete treatment as intended. Factors associated with poor treatment outcomes remain unclear, and there is emerging but conflicting evidence that cannabis use may mitigate opioid use. To analyze predictors of relapse amongst patients receiving buprenorphine-naloxone for OUD and identify the association between cannabis use and time to relapse. Data were prospectively collected between May 2018 and October 2020, and patients were followed for 12 months. Thirty-one outpatient opioid agonist treatment clinics across Ontario, Canada. All patients 16 years of age or older receiving buprenorphine-naloxone for OUD who had a urine toxicology screen negative for opioids at baseline were eligible for inclusion. Of the 488 patients consecutively sampled, 466 were included. Cannabis use. Relapse to opioid use assessed using urine toxicology screens. We employed a multivariable Cox-proportional hazard model for our analyses. We found that cannabis use was not protective against relapse [hazard ratio (HR) = 1.03, 95% confidence interval (CI): 0.78, 1.36, p = 0.84]. We found that participants who have been in treatment for at least two years had a 44% decrease in the hazard of relapse compared to those in treatment for less than a year (HR = 0.56, 95% CI: 0.34, 0.92, p = 0.021). We also found that the hazard of relapse was 2.6 times higher for participants who were intravenous drug users (HR = 2.61, 95% CI: 1.74, 3.91, p < 0.001), and that for every 1mg increase in the participants' buprenorphine-naloxone dose, the hazard of relapse is 2% greater (HR = 1.02, 95% CI: 1.01, 1.03, p < 0.001). Our analysis failed to show cannabis to be protective against relapse to opioid use in patients receiving buprenorphine-naloxone for OUD. We identified that individuals who inject drugs, are on higher doses of buprenorphine-naloxone, or have been in treatment for less than two years have a higher hazard for relapse. The presence of such factors may thus warrant closer patient follow-up and more stringent treatment protocols to mitigate risk of relapse and potential overdose.

Associations between postpartum pain type, pain intensity and opioid use in patients with and without opioid use disorder: a cross-sectional study

BackgroundPain is a multidimensional construct. The purpose of this cross-sectional, single-centre study was to evaluate the relationship between postpartum pain type with pain intensity and opioid use in people with and without opioid use disorder (OUD). MethodsPostpartum pain type was coded from McGill Pain Questionnaire and Patient-Reported Outcome Measurement Information System (PROMIS) inventories in people with or without OUD after childbirth in a 4-month period. The co-primary outcomes were pain intensity (0–10 scale) and total inpatient oxycodone (mg). Multivariable linear mixed-effects models assessed between- and within-person relationships for pain type (primary predictor) and outcomes. ResultsThere were 44 522 unique pain scores and types from 2610 people. Pain types were associated with pain intensity (P<0.001). Between-person comparisons showed affective pain was associated with a small but higher total oxycodone dose (difference 1.04 mg compared with no affective pain, P<0.001). Among people with OUD, within-person comparisons showed that the presence of affective pain resulted in pain scores 1 point higher than when affective pain was not present (P=0.002); between-person comparisons showed that people with affective pain had pain scores 6 points higher (P=0.048). Within-person and between-person comparisons among OUD showed that nociceptive/neuropathic pain was associated with a higher total oxycodone dose (1.6 and 11.4 mg, respectively). ConclusionsPostpartum pain type was associated with pain intensity and opioid use. Further research is required to address the multiple dimensions of postpartum pain in people with and without OUD to improve treatment of postpartum pain.

Incidence of persistent postoperative opioid use in patients undergoing ambulatory surgery: a retrospective cohort study.

The opioid crisis remains a major public health concern. In ambulatory surgery, persistent postoperative opioid use is poorly described and temporal trends are unknown. A population-based retrospective cohort study was undertaken in Ontario, Canada using routinely collected administrative data for adults undergoing ambulatory surgery between 1 January 2013 and 31 December 2017. The primary outcome was persistent postoperative opioid use, defined using best-practice methods. Multivariable generalised linear models were used to estimate the association of persistent postoperative opioid use with prognostic factors. Temporal trends in opioid use were examined using monthly time series, adjusting for patient-, surgical- and hospital-level variables. Of 340,013 patients, 44,224 (13.0%, 95%CI 12.9-13.1%) developed persistent postoperative opioid use after surgery. Following multivariable adjustment, the strongest predictors of persistent postoperative opioid use were pre-operative: utilisation of opioids (OR 9.51, 95%CI 8.69-10.39); opioid tolerance (OR 88.22, 95%CI 77.21-100.79); and utilisation of benzodiazepines (OR 13.75, 95%CI 12.89-14.86). The time series model demonstrated a small but significant trend towards decreasing persistent postoperative opioid use over time (adjusted percentage change per year -0.51%, 95%CI -0.83 to -0.19%, p=0.003). More than 10% of patients who underwent ambulatory surgery experienced persistent postoperative opioid use; however, there was a temporal trend towards a reduction in persistent opioid use after surgery. Future studies are needed that focus on interventions which reduce persistent postoperative opioid use.

Opioid Use Patterns in a Statewide Adult Medicaid Population Undergoing Elective Lumbar Spine Surgery.

Retrospective administrative database review. Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population. Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients. Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU). A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001). Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

Continuous local anesthetic wound infusion: Impact on pain score and opioid use in patients undergoing elective mastectomy.

Opioids are commonly used to control acute postoperative pain but their usage is associated with significant complications and the potential of addiction. This study was designed to assess the effect of a Continuous Local Anesthetic Wound Infusion Catheter (CLAWIC) on pain score and as an opioid-sparing agent in patients undergoing elective mastectomy. The search was done using all patients' record from February 2013 to February 2018. The data were collected through the acute pain service database, operation room lists, surgical site infection database, acute pain service sheet, and anesthesia sheet. The patients inclusion criteria were adults who underwent elective mastectomy surgery at King Fahad Specialist Hospital. Patient age, sex, weight, and height were also recorded. The opioid use intraoperatively and postoperatively was significantly lower in the CLAWIC than in the control group. Also, accumulative opioid use was significantly lower in the CLAWIC group. From transfer to the PACU until 48 hours postoperatively, the percentage of patients requiring opioids was significantly lower in the CLAWIC group. After 48 hours, there was no difference in opioid use between the two groups. Visual Analog Scale (VAS) pain scores were significantly lower in the CLAWIC than in the control group. CLWIC showed opioid-sparing effects following mastectomy, as shown by a significantly lower mean opioid dose and a lower percentage of subjects needing opioid analgesia. The procedure is easy to perform and relatively safe. CLWIC could reduce opioid consumption while maintaining good postoperative pain control.

Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain

The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements. Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control. Tertiary care, academic center. A total of 100 women with endometriosis or pelvic pain. Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists. A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n=1) and maximum of 20 (n=3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p=.044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p=.013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p=.051; 7.7 vs 5.2, p=.155; 8.1 vs 5.6, p=.118). Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.

Preoperative Patient-Reported Data Indicate the Risk of Prolonged Opioid Use After Hand and Upper Extremity Surgeries

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery. We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve. We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n= 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit. We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management. Prognostic II.

155. What are the risk factors for continued opioid use in patients following spine surgery?

BACKGROUND CONTEXT Although studies have explored acute opioid use within 30 days after surgery and chronic opioid use longer than 90 days after surgery, the impact of opioid use within the subacute phase of 31-90 days after surgery has not been studied. However, this subacute postoperative period has been identified as a potential predictor of chronic opioid use. PURPOSE This study aims to identify factors common in opioid-naïve patients who are at a high risk of opioid use during the subacute phase of 31-90 days after discharge. STUDY DESIGN/SETTING Retrospective analysis. PATIENT SAMPLE Adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019. OUTCOME MEASURES Opioid refills in the subacute postoperative period of 31-90 days following discharge. METHODS In this retrospective cohort study, the electronic medical record of adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019 were analyzed. Opioid refills in the subacute postoperative period of 31-90 days following discharge were the primary study outcome. RESULTS Of the study cohort consisting of 3,024 patients, 2,685 (89%) required inpatient opioids in the last 24 hours before discharge, 733 (26%) required an opioid refill 1-30 days after discharge, and 579 (19%) required opioid refill 31-90 days after discharge. Moreover, a postoperative opioid refill 1-30 days after discharge conferred the strongest risk of an opioid refill 31-90 days after discharge (OR 4.66, 95% CI 3.84-5.64). Other factors associated with the increased risk of an opioid refill 31-90 days after discharge were gabapentinoid use, discharge disposition to facilities other than home or self-care, reoperation, and female gender. Meanwhile, Asian American race was associated with the reduced risk. Those requiring opioid refills were noted to be younger, underwent longer surgeries, had extended inpatient hospital stays, required higher doses of inpatient opioids, and required higher doses of discharge opioid prescriptions for longer durations. CONCLUSIONS In opioid-naïve postoperative spine patients, opioid refills 1-30 days after discharge were strongly associated with an increased risk of opioid refills 31-90 days after discharge. Factors associated with opioid refill requirements also included longer surgeries and inpatient hospital stays as well as higher doses of inpatient opioids. Overall, this study enables physicians to identify patients at a higher risk of opioid use and to intervene early during the postoperative course. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Although studies have explored acute opioid use within 30 days after surgery and chronic opioid use longer than 90 days after surgery, the impact of opioid use within the subacute phase of 31-90 days after surgery has not been studied. However, this subacute postoperative period has been identified as a potential predictor of chronic opioid use. This study aims to identify factors common in opioid-naïve patients who are at a high risk of opioid use during the subacute phase of 31-90 days after discharge. Retrospective analysis. Adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019. Opioid refills in the subacute postoperative period of 31-90 days following discharge. In this retrospective cohort study, the electronic medical record of adult opioid-naïve patients who underwent spine surgeries at a quaternary medical care center from June 2012 to December 2019 were analyzed. Opioid refills in the subacute postoperative period of 31-90 days following discharge were the primary study outcome. Of the study cohort consisting of 3,024 patients, 2,685 (89%) required inpatient opioids in the last 24 hours before discharge, 733 (26%) required an opioid refill 1-30 days after discharge, and 579 (19%) required opioid refill 31-90 days after discharge. Moreover, a postoperative opioid refill 1-30 days after discharge conferred the strongest risk of an opioid refill 31-90 days after discharge (OR 4.66, 95% CI 3.84-5.64). Other factors associated with the increased risk of an opioid refill 31-90 days after discharge were gabapentinoid use, discharge disposition to facilities other than home or self-care, reoperation, and female gender. Meanwhile, Asian American race was associated with the reduced risk. Those requiring opioid refills were noted to be younger, underwent longer surgeries, had extended inpatient hospital stays, required higher doses of inpatient opioids, and required higher doses of discharge opioid prescriptions for longer durations. In opioid-naïve postoperative spine patients, opioid refills 1-30 days after discharge were strongly associated with an increased risk of opioid refills 31-90 days after discharge. Factors associated with opioid refill requirements also included longer surgeries and inpatient hospital stays as well as higher doses of inpatient opioids. Overall, this study enables physicians to identify patients at a higher risk of opioid use and to intervene early during the postoperative course.

Impact of an Enhanced Recovery after Surgery Protocol on Postoperative Outcomes in Cardiac Surgery

Background: Enhanced recovery after surgery (ERAS) protocols are perioperative care pathways designed to achieve early recovery after procedures. ERAS protocols have shown shortened recovery time, and lower opioid utilization and postoperative complication rates. Evidence to support the use of ERAS protocols is robust, however, minimal data exists in cardiac surgery patients. Methods: This observational cohort compared adults receiving post-operative care after coronary artery bypass or valve procedures who received an ERAS protocol containing acetaminophen, gabapentin, and methocarbamol to historical controls. The primary outcome of this study was postoperative opioid use during the first 72-hours following cardiac surgery. Secondary outcomes included length of stay, average pain scores 72-hours postoperatively, and incidence of opioid-related complications. Results: Total cumulative 72-hour post-operative opioid consumption showed a trend toward reduction in opioid use in patients who received the ERAS protocol vs the historic control group [75.8 mg vs 105.4 mg oral morphine equivalents (P = .09)]. Median postoperative lengths of stay and pain scores were similar between groups. Opioid related complications including constipation and respiratory depression occurred more frequently in the control group compared to the ERAS group [47.7% vs 60.5% (P < .05) and 57.1% vs 62.7% (P < .05) respectively]. Conclusions: Use of an ERAS protocol shows a promising trend toward less postoperative opioid use in cardiac surgery patients. Lower rates of opioid-related adverse events, including constipation and respiratory depression, were observed in the ERAS protocol group. This study indicates that ERAS protocols have a potential role for cardiac surgery patients postoperatively.

Total Knee Arthroplasty After Genicular Nerve Radiofrequency Ablation: Reduction in Prolonged Opioid Use Without Increased Postsurgical Complications.

Introduction:Genicular nerve radiofrequency ablation (GNRFA) is an increasingly used nonsurgical treatment modality for patients with advanced knee osteoarthritis. Previous studies have demonstrated this to be an effective and safe method to decrease pain and increase functionality in this patient population. The purpose of this study was to compare 2-year postoperative complication rates and rates of prolonged postoperative opioid usage between patients undergoing total knee arthroplasty (TKA) after previous GNRFA and those undergoing TKA alone.Methods:Patients who underwent primary TKA after prior GNRFA (GNRFA-TKA) of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2019. Univariate and multivariable analyses were conducted comparing those with prior GNRFA and those without. Outcomes of interest included prolonged postoperative opioid usage, 2-year revision rates, and 90-day medical complications. Statistical analysis was conducted using R software provided by the PearlDiver Database.Results:In total, 675 patients in the GNRFA-TKA cohort were compared with a control cohort of 255,351 patients. Genicular nerve radiofrequency ablation-total knee arthroplasty patientshad lower odds of prolonged opioid use postoperatively (OR: 0.478; 95%: 0.409 to 0.559; P < 0.001). No notable difference was observed in the 2-year surgical outcomes between cohorts. Patients in the GNRFA-TKA cohort had lower odds of requiring a blood transfusion and having postoperative anemia, all arrhythmias, and urinary infections compared with primary TKA control patients.Conclusion:Preoperative GNRFA leads to a lower rate of prolonged postoperative opioid use in patients undergoing TKA, without an increased risk of complications. Future prospective studies are needed to validate the findings of this database study.

Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review.

Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies. In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery? We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures. Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study. Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use. Level III, therapeutic study.

A qualitative assessment of perceptions and attitudes toward postoperative pain and opioid use in patients undergoing elective knee arthroscopy.

Background:Orthopedic surgeons routinely prescribe opioids to manage post-operative pain. In the face of an opioid epidemic, a one-size-fits-all approach to pain management is no longer appropriate. Patient-centred prescribing practices should be used by surgeons; however, little is known about what influences patient attitudes toward postoperative pain and its management to inform such practices. We sought to explore patient attitudes toward postsurgical pain management, including opioids.Methods:We conducted qualitative, semistructured interviews of 11 opioid-naive patients (age 16–46 yr) who were scheduled to undergo arthroscopic knee surgery. Transcripts were analyzed thematically using a framework analysis that involved familiarization, developing a thematic framework, indexing, charting and mapping, and interpretation.Results:Participant attitudes toward postoperative pain and opioids were influenced by perceived tolerance to pain based on personal experience, perceived predisposition to addiction based on personal assumptions regarding addictive personality traits and risk factors, and perceptions of opioid use shaped by external influences, including family, friends and the media’s depiction of the opioid epidemic. Every patient expressed that preoperative counselling and education regarding postoperative pain management would be beneficial in improving their knowledge base, easing anxieties and clarifying misunderstandings.Conclusion:Surgeons can address the patient-reported factors identified in this study to help optimize a patient’s perioperative experience without relying solely on prescribed analgesia. By improving accessibility to education and promoting safe, patient-centred prescribing practices, we may reduce reliance on opioids in orthopedic surgery.

Factors associated with persistent opioid use 6–12 months after primary total knee arthroplasty

Persistent pain following knee arthroplasty occurs in up to 20% of patients and may require ongoing analgesia, including extended opioid administration. A comprehensive secondary analysis was performed from results of a study that considered persistent postoperative pain in 242 patients who underwent unilateral knee arthroplasty using a standardised enhanced recovery programme. Opioid prescribing for 12 months before and 12 months after surgery was evaluated and converted to oral morphine equivalents. Demographic, functional, psychological and pain questionnaires were completed along with quantitative sensory testing and genetic analysis. Forty-nine percent of patients had at least one opioid prescription in the 12 months before surgery. Opioid prescriptions were filled in 93% of patients from discharge to 3 months and in 27% of patients ≥6 months after surgery. Persistent opioid use ≥6 months after surgery was strongly associated with pre-operative opioid use (RR 3.2, p < 0.001 (95%CI 1.9-5.4)). The median (IQR [range]) oral morphine equivalent daily dose was 3.6 (0.9-10.5 [0-100.0]) mg pre-operatively, 35.0 (22.5-52.5 [4.6-180.0]) mg in hospital, 12.8 (5.1-24.8 [0-57.9]) mg from discharge to 3 months and 5.9 (4.5-12.0 [0-44.5]) mg at ≥6 months following surgery. Predictors of increased daily oral morphine equivalent ≥6 months after surgery included increased average daily oral morphine equivalent dose compared with previous values (lag), increased body mass index and three or more comorbid pain sites. Persistent opioid use was not associated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (RR 1.003, p = 0.655, 95%CI 0.65-1.002) or WOMAC function (RR 1.001, p = 0.99, 95%CI 0.99-1.03) outcomes 6 months after surgery. There was no association between persistent opioid use and pre-operative quantitative sensory testing results or psychological distress. Pre-operatively, patients with a higher body mass index, more comorbid pain sites and those who had filled an opioid prescription in the last 12 months, were at increased risk of persistent opioid use and a higher oral morphine equivalent daily dose ≥ 6 months after surgery. Strategies need to be developed to limit dose and duration of persistent opioid use in patients following knee arthroplasty surgery.