Opioid Utilization Research Articles

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction

To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR). Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users. Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively. This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use. Level III, retrospective cohort study.

Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project

BackgroundOpioid stewardship protocols reduce opioid overprescription, but many require corrective action within 1 year. Because there are limited data on the sustainability of opioid reduction protocols, we sought to evaluate prescribing trends beyond 1 year. MethodsWe reviewed prescribing data from a tertiary care center to establish a consensus discharge opioid-prescribing guideline. Subsequently, we performed a prospective quality-improvement study for patients on an enhanced recovery protocol undergoing elective colectomies, proctectomies, and stoma-related procedures. We gathered process (protocol compliance), balance (rates of patient-controlled analgesia and nerve blocks, inpatient opioid utilization, pain scores within 48 hours of discharge), and clinical measures (median discharge opioid pills, postdischarge day 7 satisfaction). ResultsIn total, 1,049 patients with similar ages, operative indications, and rates of substance use pre- and postintervention were included. Over 2 years, compliance was 88.6%, and there was a 43.6% reduction in the total discharge number of opioid pills. Phone calls for opioid refills were stable (10.2% pre- vs 7.8% postintervention, P = .16), and the following all decreased significantly: intraoperative nerve blocks, patient-controlled analgesia use, and final 48-hour and total median inpatient opioid use. There was a clinically negligible, statistically significant reduction in pain scores within 48 hours of discharge. Fifty patients provided satisfaction data, and 92% were satisfied or somewhat satisfied with their analgesia. ConclusionOver 2 years, reduced opioid prescribing was maintained without escalating resources. Sustainability suggests that after successfully implementing an opioid reduction protocol, institutions may safely redeploy quality improvement resources elsewhere.

Evaluating the Safety and Efficacy of Naloxegol in Critically Ill Opioid-Induced Constipation Patients.

Background Opioid-induced constipation (OIC) has become more common in the intensive care unit (ICU) due to increased opioid utilization. Traditional laxatives often prove ineffective against OIC, leading to the increased utilization of naloxegol. However, further research is needed to confirm naloxegol's effectiveness and safety in critical care. This study aimed to explore the safety and efficacy of this intervention in critically ill OIC patients. Methods A single-center retrospective study was conducted on 353 patients who received one or more doses of naloxegol from January 1, 2019, to June 30, 2020, for OIC at a tertiary care center. The primary endpoint of this study was to evaluate serious adverse events such as reduced analgesic effect, gastrointestinal perforation, seizure, acute myocardial infarction (AMI), or ventricular arrhythmias using Naranjo Scale in critically ill patients. The secondary goal was to assess the efficacy of naloxegol, measured by the time of the first bowel movement. Results The average duration of naloxegol use was three days, with the first bowel movement occurring at an average of 11.3 hours. Furthermore, 59.8% of individuals had their first bowel movement within 20 hours of receiving naloxegol. There was a low level of causality between naloxegol use and adverse events such as gastrointestinal perforation, seizures, AMI, cardiovascular mortality, stroke, and ventricular arrhythmia. Additionally, reduction in analgesia showed no strong relationship with naloxegol use indicated by the Naranjo Scale assessment. Conclusion Naloxegol showed promising safety and efficacy profiles in treating OIC amongst critically ill patients, though our findings require further validation through prospective studies. This research paves the way for further investigation into naloxegol's role in OIC management, emphasizing the necessity of personalized treatment strategies in critical care settings.

Assessing the Effectiveness of a Consultant Pharmacist-Led Opioid Stewardship Protocol in Skilled Nursing Facilities.

Background More than 1.4 million adults in the United States live in skilled nursing facilities (SNFs). Opioids are prescribed to approximately 60% of skilled nursing residents, a primarily older patient population. Current opioid prescribing guidelines may be difficult to extrapolate to this population because of pain burden and extensive analgesic use. Furthermore, in the older population, opioids are associated with greater frequency of adverse events with potential for hospitalization and increased all-cause mortality. Objective Evaluate the impact of a consultant pharmacist-led opioid stewardship protocol on patient pain-related outcomes in SNFs. Methods An opioid medication management protocol was implemented by consultant pharmacists at participating SNFs. Consultant pharmacists assessed facility residents for active opioid orders and systematically evaluated use and appropriateness of therapy. Facility data pre- and post-implementation of the protocol was compared to determine effectiveness. The primary outcomes included rate of recommendation acceptance, rate of as-needed (PRN) opioid utilization, and number of residents who experienced a fall. Results A total of 114 patients were included in the study. The percentage of patients utilizing opioid therapy pre-intervention was 78.1% and 74.6% post-intervention (P = 0.29; 95% CI 0.033-1.864). Patient pain scores decreased from an average of 3.7 to 3.2 (P < 0.01). Use of PRN opioid orders transitioned from 84.2% to 71.9% (P = < 0.01; 95% CI 0.055-0.675). Conclusion This study revealed significant reductions in average patient pain scores and reduction in PRN opioid medication utilization, overall emphasizing the positive impact of consultant pharmacist involvement in opioid stewardship within the skilled nursing setting.

Geriatric Pain Protocol: Impact of Multimodal Pain Care for Elderly Orthopaedic Trauma Patients.

Hip fractures are costly, and associated complications are the leading cause of injury-related deaths in persons 65 years or older. Pain medications in this population can be more potent, have a longer duration of action, and have serious side effects (Chau et al., 2008). Hip fractures are projected to reach 6.26 million worldwide by 2050 (Gullberg et al., 1997; Kannus et al., 1996). Morrison et al. (2003) report that uncontrolled pain leads to increased hospital length of stay (LOS), delayed physical therapy, and long-term functional impairment. The Geriatric Pain Protocol (GPP) is Cedars-Sinai's multimodal pain management solution, addressing the needs of older adult inpatients who have suffered fractures. Can the implementation of GPP reduce the morphine milligram equivalents (MMEs) used, LOS, and postoperative outcomes compared with non-GPP patients? Study participants included hip fracture patients admitted between February 1, 2019, and March 5, 2021; data were collected prospectively from electronic medical records. Inclusion criteria were patients 65 years or older with a hip fracture sustained from a ground-level fall and surgical candidate. Participants were divided into two categories: Geriatric Fracture Program (GFP) and non-GFP, with physician participation in the GFP being the differentiating factor. End points included postoperative pain, postoperative opioid utilization, LOS, complications, and 30-day readmission rates. The Mann-Whitney U test and Fisher's exact test were used for data analysis. Spearman's rank-based correlation coefficient was used to assess associations. The GPP decreased MME daily totals on Days 1 and 2 and improved pain management compared with non-GPP patients. The MMEs were lower in the GPP group than in the non-GPP group for both Postoperative Day 1 (POD1) (p = .007) and POD2 (p = .043); Numerical Rating Scale (NRS) Pain on POD1 was lower in the GPP group (vs. non-GPP, p = .013). There were no group differences in NRS POD2 Pain or complications (all ps > .1). The study sample (N = 453) had no significant difference between sex and LOS (all ps > .3). Although not statistically significant, the 30-day readmission rate trended lower in patients treated in accordance with the GPP. Use of the multimodal GPP reduced pain levels and MME totals for older adult hip fracture inpatients. More data are needed to evaluate the efficiency of the proposed protocol. Future studies should explore the possibilities of using the GPP across the geriatric orthopaedic patient care continuum.

Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials.

We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.

Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement

IntroductionThe opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. MethodsOne hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. ResultsPatient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. ConclusionsWe created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

A Randomized Controlled Trial to Assess the Impact of Enhanced Recovery After Surgery on Patients Undergoing Elective Spine Surgery.

To conduct a prospective, randomized controlled trial (RCT) of an enhanced recovery after surgery (ERAS) protocol in an elective spine surgery population. Surgical outcomes such as length of stay (LOS), discharge disposition, and opioid utilization greatly contribute to patient satisfaction and societal healthcare costs. ERAS protocols are multimodal, patient-centered care pathways shown to reduce postoperative opioid use, reduced LOS, and improved ambulation; however, prospective ERAS data is limited in spine surgery. This single-center, IRB-approved, prospective RCT enrolled adult patients undergoing elective spine surgery between March 2019 and October 2020. Primary outcomes were peri-operative and 1-month postoperative opioid use. Patients were randomized to ERAS (n=142) or standard of care (SOC; n=142) based on power analyses to detect a difference in postoperative opioid use. Opioid use during hospitalization and the first postoperative month was not significantly different between groups (ERAS 112.2 vs. SOC 117.6 MME, P=0.76; ERAS 38.7% vs. SOC 39.4%, P=1.00 respectively). However, patients randomized to ERAS were less likely to use opioids at 6 months postoperatively (ERAS 11.4% vs. SOC 20.6%, P=0.046) and more likely to be discharged to home after surgery (ERAS 91.5% vs. SOC 81.0%, P=0.015). Here, we present a novel ERAS prospective RCT in the elective spine surgery population. While we do not detect a difference in the primary outcome of short-term opioid use, we observe significantly reduced opioid use at 6-month follow-up as well as an increased likelihood of home disposition after surgery in the ERAS group.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Retrospective cohort study. This project aims to evaluate the relationship between increased use of intraoperative nonopioid analgesics, muscle relaxers, and anesthetics and postoperative outcomes, including opioid utilization, time until ambulation, and hospital length of stay. Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine that occurs in otherwise healthy adolescents, occurring with a frequency of 1% to 3%. Up to 60% of patients receiving spinal surgeries, particularly posterior spinal fusion (PSF), experience at least 1 day of moderate-to-severe pain after surgery. This is a retrospective chart review of pediatric patients aged 10 to 17 having received PSF with >5 levels fused for AIS at a dedicated children's hospital and a regional tertiary referral center with a dedicated pediatric spine program between January 2018 and September 2022. A linear regression model was used to evaluate the influence of baseline characteristics and intraoperative medications on the total amount of postoperative morphine milligram equivalents received. There were no significant differences in the background characteristics of the two patient populations. Patients receiving PSF at the tertiary referral center received equivalent or greater amounts of all nonopioid pain medications and demonstrated decreased time until ambulation (19.3 vs . 22.3 h), postoperative opioid use (56.1 vs . 70.1 MME), and postoperative hospital length of stay (35.9 vs . 58.3 h). Hospital location was not individually associated with a difference in postoperative opioid use. There was not a significant difference in postoperative pain ratings. When accounting for all other variables, liposomal bupivacaine had the greatest contribution to the decrease in postoperative opioid use. Patients receiving greater amounts of nonopioid intraoperative medications utilized 20% fewer postoperative morphine milligram equivalents, were discharged 22.3 hours earlier and had earlier recorded evidence of mobility. Postoperatively, nonopioid analgesics were as effective as opioids in the reduction of subjective pain ratings. This study further demonstrates the efficacy of multimodal pain management regimens in pediatric patients receiving PSF for AIS.

Opioid Utilization After Scoliosis Surgery is Greater in Marfan Syndrome Than Adolescent Idiopathic Scoliosis.

Retrospective matched case cohort. Compare postoperative opioid utilization and prescribing behaviors between patients with Marfan syndrome (MFS) and adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF). Opioids are an essential component of pain management after PSF. However, due to the potential for opioid use disorder and dependence, current analgesic strategies aim to minimize their use, especially in younger patients. Limited information exists on opioid utilization after PSF for syndromic scoliosis. Twenty adolescents undergoing PSF with MFS were matched with patients with AIS (ratio, 1:2) by age, sex, degree of spinal deformity, and the number of vertebral levels fused. Inpatient and outpatient pharmaceutical data were reviewed for the quantity and duration of opioid and adjunct medications. Prescriptions were converted to morphine milligram equivalents (MMEs) using CDC's standard conversion factor. Compared with patients with AIS, patients with MFS had significantly greater total inpatient MME use (4.9 vs . 2.1 mg/kg, P ≤ 0.001) and longer duration of intravenous patient-controlled anesthesia (3.4 vs . 2.5 d, P = 0.001). Within the first 2 postop days, MFS patients had more patient-controlled anesthesia boluses (91 vs . 52 boluses, P = 0.01) despite similar pain scores and greater use of adjunct medications. After accounting for prior opioid use, MFS was the only significant predictor of requesting an opioid prescription after discharge (odds ratio: 4.1, 95% CI: 1.1-14.9, P = 0.03). Patients with MFS were also more likely to be discharged with a more potent prescription (1.0 vs . 0.72 MME per day/kg, P ≤ 0.001) and to receive a longer-duration prescription (13 vs . 8 d, P = 0.005) with a greater MME/kg (11.6 vs . 5.6 mg/kg, P ≤ 0.001) as outpatients. Despite a similar intervention, patients with MFS and AIS seem to differ in their postoperative opioid usage after PSF, presenting an opportunity for further research to assist clinicians in better anticipating the analgesic needs of individual patients, particularly in light of the ongoing opioid epidemic.

Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability

Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability

Experiences with pain management for survivors of complex cancers: Focus on opioids and cannabis.

12118 Background: Survivors of complex cancers often experience pain. Clinical practice guidelines for pain management in cancer survivors cautiously recommend opioids and cannabis for subgroups with certain pain phenotypes, despite limited evidence regarding benefits and harms in survivor populations. We aimed to better understand pain management for these survivors, focusing on attitudes toward, and experiences with, opioids and cannabis. Methods: We conducted 7 90-minute focus groups with 26 disease-free survivors of head and neck and lung cancer who still experience cancer-related pain. Multiple coders conducted thematic analyses to identify themes regarding 1) experiences with post-treatment pain and pain management and 2) utilization, benefits, and harms of post-treatment cannabis and opioids. Results: Survivors (7-35 months from treatment completion) experienced post-treatment physical and psychological pain that affected multiple aspects of their daily life. Since treatment completion, 69% used opioids previously and 8% currently using. Fifty-four percent had used any cannabis product since treatment completion, and 35% currently use cannabis. While some survivors experienced no pain management challenges, others enumerated various difficulties, including fears of addiction to opioids or cannabis, perceived stigma around both products, and access challenges around provider attitudes, cost and insurance coverage, and legality. Survivors reported that providers did not know how to advise about cannabis; for example: “When I talked [to providers] about marijuana they didn’t want to talk about it. They couldn’t recommend it because there’s no clinical data.” Opioids were often perceived as critical to pain management but came with unpleasant side effects. Cannabis was effective at reducing both pain and anxiety for many, but not all, survivors. For some, cannabis reduced anxiety, which in turn reduced pain: “It just keeps my mind occupied enough where I’m not thinking of pain.” Reducing anxiety also helped some survivors eat: “I have a lot of anxiety around eating because I have a fear of choking, so sometimes it helps that.” Survivors described a balance of benefits and harms of opioids and cannabis; for example: “Where [the doctor has] me now...if I go down any lower, it's not going to work. If I go up any higher, I'm going to be not able to function.” Conclusions: Post-treatment survivors of complex cancers continue to experience cancer-related pain, both psychological and physical, for which both opioids and cannabis present a complex set of harms and benefits that vary across survivors. Providers who care for cancer survivors should be aware of the interplay between psychological and physical pain, patient concerns and stigma around opioids and cannabis, and nuances of the harms, benefits, and access issues regarding these treatments.

The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients.

To compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients. A retrospective cohort study based on the Resident Assessment Instrument-Home Care (RAI-HC) assessments and electronic medical records. The study sample included all regular home care clients aged ≥65years (n= 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants). Health care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use. Compared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08-1.48), home visits (1.23; 1.01-1.49), phone contacts (1.38; 1.13-1.68), and consultations without a patient attending a practice (1.22; 1.04-1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses' median work hours per week were 4.3 (Q1-Q3 1.5-7.7) among opioid users and 2.8 (1.0-6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use. Long-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients' needs. The exact reasons for opioid users' greater health care utilization should be examined in future.

HSD4 Opioid Use Among Migraine Patients Treated with Acute and Preventive Treatment

Opioids are not part of guideline-recommended treatment regimen for migraine; however, migraine patients are still prescribed opioids in clinical practice. The study assesses the real-world opioid utilization among migraine patients initiating on newer acute (ubrogepant, rimegepant, lasmiditan) and preventive (galcanezumab, erenumab, fremanezumab) migraine therapies and on standard of care (triptans).

EPH198 The Sustained Impact of COVID-19 on Opioid Dispensing in California

Opioid overprescribing played a major role in the onset of the American opioid epidemic. During the COVID-19 pandemic, healthcare access had dramatic changes that potentially impacted high-risk opioid prescribing among healthcare providers and high-risk opioid seeking behaviors among opioid recipients. The study aims to assess the impact of the COVID-19 pandemic on trends in opioid dispensing during the 14 months before COVID-19 and 21 months after in California. Analyzing dispensing data from California’s Controlled Substance Utilization Review and Evaluation System (CURES)-Prescription Drug Monitoring Programs (PDMPs), the study harnessed a segmented regression model to measure changes in temporal trends in high-risk opioid dispensing associated with the onset of the COVID-19 pandemic. Four measures of high-risk opioid utilization were analyzed: (1) multiple provider episodes, (2) overlapping opioid prescription for seven or more days, (3) overlapping opioid and benzodiazepine for seven or more days, and (4) high standardized dosage of opioid prescriptions per month. The study assessed dispensing records from 1,737,984 recipients before the pandemic period from January 18, 2019, to December 17, 2021, and 1,873,962 recipients during the pandemic period from January 18, 2019, to December 17, 2021. The segmented regression analysis showed that the onset of the pandemic significantly changed the decreasing trend on high-risk measurements of (1) multiple provider episodes (P-value=0.0125) and (4) high standardized dosage of opioid prescriptions (P-value=0.0312). Although all four indices presented a decreasing trend from the study initiating time, the model findings show that COVID-19 significantly resisted such long-term declining trends. We observed a gradual decrease in opioid dispensing in recent years. The COVID-19 pandemic had a sustained effect on high-risk opioid dispensing behavior, decelerating the declining trend of high-risk behavior occurrences.

Opioid prescriptions and patients' health services utilization and cost before and during the COVID-19 pandemic: an exploratory population-based administrative data analysis.

The objective was to explore percentages of the population treated with prescribed opioids and costs of opioid-related hospitalizations and emergency department (ED) visits among individuals treated with prescription opioids and costs of all opioid-related hospitalizations and ED visits in the province (i.e., provincial costs) before and during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada. In administrative data, we identified individuals treated with prescription opioids and opioid-related hospitalizations and ED visits among those individuals and among all individuals in the province between 2015/16 and 2021/22 fiscal years. Services used were counted on an item-by-item basis and costed using case-mix approaches. Annually, from 9.98% (2020/21-2021/22) to 14.52% (2017/18) of the provincial population was treated with prescription opioids. Between 2015/16 and 2021/22, annual costs of opioid-related hospitalizations and ED visits among individuals treated with prescription opioids were ∼$5 and ∼$2 million, respectively. In 2020/21-2021/22, the provincial costs of opioid-related hospitalizations (∼$14 million) and ED visits (∼$7.0 million) were almost twice the costs observed in 2015/16 and immediately before the pandemic (2019/20). Our findings suggest that increases in the opioid-related utilization of inpatient and ED services between 2015/16 and 2021/22, including the drastic increases observed during the COVID-19 pandemic, were likely driven by unregulated substances.

Outcomes of medicaid patients undergoing TJA with previous positive urine toxicology screens.

Previous studies have demonstrated that patients with positive preoperative urine toxicology (utox) screens prior to total joint arthroplasty (TJA) have higher readmission rates, greater complication rates, and longer hospital stays compared to patients with negative screens. The aim of this study was to investigate the effect of postponing surgery for patients with positive preoperative utox in the Medicaid population. This retrospective, observational study reviewed the Medicaid ambulatory database at a large, academic orthopedic specialty hospital for patients with a utox screen prior to TJA from 2012 to 2020. Patients were categorized into three groups: (1) controls with negative preoperative utox or a utox consistent with prescription medications (Utox-) with TJA completed as scheduled; (2) positive preoperative utox with TJA rescheduled and surgery completed on a later date (R-utox+); (3) positive preoperative utox inconsistent with prescription medications with TJA completed as scheduled (S-utox+). Primary outcomes included mortality, 90-day readmission rate, complication rate, and length of stay. Of the 300 records reviewed, 185 did not meet inclusion criteria. The remaining 115 patients included 80 (69.6%) Utox-, 5 (6.3%) R-utox+, and 30 (37.5%) S-utox+. Mean follow-up time was 49.6months. Hospital stays trended longer in the Utox- group (3.7 ± 2.0days vs. 3.1 ± 1.6 S-utox+ vs.2.5 ± 0.4 R-utox+, p = 0.20). Compared to the R-utox+group, the S-utox+ group trended toward lower home discharge rates (p = 0.20), higher in-hospital complication rates (p = 0.85), and more all-cause 90-day emergency department visits (p = 0.57). There were no differences in postoperative opioid utilization between groups (p = 0.319). Duration of postoperative narcotic use trended toward being longer in the Utox- patients (820.7 ± 1073.8days vs. 684.6 ± 1491.8 S-utox+ vs. 585.1 ± 948.3 R-utox+, p = 0.585). Surgical time (p = 0.045) and revision rates (p = 0.72) trended toward being higher in the S-utox+ group. Medicaid patients with positive preoperative utox who had surgeries postponed trended towards shorter hospital stays and greater home discharge rates. Larger studies should be conducted to analyze the implications of a positive preoperative utox on risk profiles and outcomes following TJA in the Medicaid population. Study design Retrospective cohort study.

Perioperative Dexamethasone Associated With Decreased Length of Stay After Total Hip and Knee Arthroplasty.

Dexamethasone is increasingly used after total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting (PONV) and pain. The primary aim of this study was to examine the relationship between perioperative intravenous (IV) dexamethasone and length of stay (LOS) in patients undergoing primary, elective TJA. All patients who underwent TJA from 2015 to 2020 and received perioperative IV dexamethasone were queried from the Premier Healthcare Database. The cohort of patients who received dexamethasone was randomly truncated by a power of 10 and matched in a 1:2 ratio based on age and sex to patients who did not receive dexamethasone. Patient characteristics, hospital factors, comorbidities, 90-day postoperative complications, LOS, and postoperative morphine milligram equivalents were recorded for each cohort. Univariate and multivariate analyses were conducted to assess differences. Overall, 190,974 matched patients were included, 63,658 (33.3%) of whom received dexamethasone and 127,316 (66.7%) did not. The dexamethasone cohort was composed of fewer patients with uncomplicated diabetes (11.6% vs. 17.5%, P < 0.001). Patients who received dexamethasone had significantly decreased mean LOS compared with patients who did not receive dexamethasone (1.66 vs. 2.03 days, P < 0.001). After controlling for confounding variables, dexamethasone was associated with significantly lower risk of pulmonary embolism (adjusted odds ratio [aOR]: 0.74, 95% CI: 0.61 to 0.90, P = 0.003), deep vein thrombosis (aOR: 0.78, 95% CI: 0.68 to 0.89, P < 0.001), PONV (aOR: 0.75, 95% CI: 0.70 to 0.80, P < 0.001), acute kidney injury (aOR: 0.82, 95% CI: 0.75 to 0.89, P < 0.001), and urinary tract infection (aOR: 0.77, 95% CI: 0.70 to 0.80, P < 0.001). In aggregate, dexamethasone was associated with similar postoperative opioid utilization between cohorts ( P = 0.061). Perioperative dexamethasone was associated with reduced LOS and decreased postoperative complications including PONV, pulmonary embolism, deep vein thrombosis, acute kidney injury, and urinary tract infection after TJA. Although perioperative dexamethasone was not associated with notable reductions in postoperative opioid utilization, this study supports the use of dexamethasone to decrease LOS through multifactorial mechanisms beyond decreased pain.

746 Burn Provider Perceptions Before and After Implementation of a Pain and Sedation Clinical Practice Guideline

Abstract Introduction Pain and sedation management is a crucial yet challenging aspect of burn care. We sought to survey a multidisciplinary group of nurses (RN), physicians (MD), advanced practice providers (APP), and therapists (PT/OT) to determine perceptions of pharmacologic pain and sedation management before and after the implementation of a standardized clinical practice guideline (CPG) at our institution. Methods A 28-question survey assessing knowledge, pain and sedation practices, and therapy participation was distributed to all intensive care unit (ICU) and non-ICU burn care providers at our institution before (n=135, 2019) and after (n=185, 2022) CPG implementation. Comparison of proportions was calculated using Chi-squared test. Results Survey response was 61 (45%) before and 51 (28%) after CPG, with 18 participating in both. Most respondents (63%) had 0-5 years of experience caring for burn patients. Patients were perceived to have significant background pain &amp;gt;50% of the time by 69% of RN before vs 55% after (p=0.26). Intermittent opioid boluses were preferred to continuous infusions in intubated patients before (57%) and after (59%) CPG implementation (p=0.87). Perceived utilization of multimodal pain management was high (82%) amongst all responders, except for ICU RN (53%) (p=0.05). While &amp;lt; 30% of all providers believed analgesics were underutilized for procedural pain, non-ICU RN consistently reported patients were in significant pain 50-75% of the time during procedures (78% before vs 85% after, p=0.61). Perceptions of sedative underutilization were unchanged before and after CPG (ICU RN 58% vs 33%, p=0.15; non-ICU RN 69% vs 71%, p=0.91; MD/APP 69% vs 71%, p=0.95). PT/OT reported pain as the most common reason for nonparticipation in therapy sessions with one-third reporting underutilization of analgesics in both surveys. In the after survey, 50% agree we manage pain effectively. Areas for improvement included open communication between disciplines regarding pain and sedation plan, increased use of intermittent sedatives compared to continuous, and less IV opioid utilization with more focus on nonopioid therapy. Fifty percent of after survey respondents were aware of the CPG. Conclusions Implementation of a CPG did not change perceptions of pain and sedation at our institution. This may be due to limited education surrounding CPG and overall lack of utilization. Future efforts should focus on education and communication between disciplines. Applicability of Research to Practice Variability in provider perceptions of pain and sedation management in patients with burn injury remain despite implementation of a CPG.