Opioid Prescribing Research Articles

Opioid prescribing in the Netherlands during the COVID-19 pandemic: a national register-based study

ObjectivesThe COVID-19 pandemic and related lockdown measures disrupted global healthcare provision, including opioid prescribing. In North America, opioid sales declined while opioid-related deaths increased. In Europe, the effect of the...

Opioid prescription following radical orchiectomy associated with new persistent opioid use

IntroductionOpioid dependence represents a public health crisis and can be observed after outpatient urologic procedures. The purpose of this study was to evaluate the risk of persistent opioid usage after radical orchiectomy for testicular cancer. Materials and methodsThe TriNetX Research network database was queried for men between 15 and 45 years undergoing radical orchiectomy for a diagnosis of testicular cancer. All patients with N+ or M+ disease, prior opioid use, and patients who underwent chemotherapy, radiotherapy, or retroperitoneal lymph node dissection were excluded. Patients were stratified whether they were prescribed opioids or not at time of orchiectomy. The incidence of new, persistent opioid use, defined as a prescription for opioids between 3 and 15 months after orchiectomy, was evaluated. ResultsA total of 2,911 men underwent radical orchiectomy for testicular cancer, of which 89.8% were prescribed opioids at time of orchiectomy. After propensity score matching for age, race, and history of psychiatric diagnosis, 592 patients were included (296 received opioids, 296 did not). Overall, 0% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 10.5% of patients who received postoperative opioids developed new persistent opioid use. Patients prescribed postoperative opioids for orchiectomy had statistically higher risk difference of developing new persistent opioid use (Risk Difference: 10.5%; 95% CI: 7.0-14.0; Z: 5.7; P < 0.01). ConclusionsPostoperative opioid prescription following radical orchiectomy is significantly associated with developing new persistent opioid use, with 1 in 10 young men who received postoperative opioids obtaining a new prescription for opioids well beyond the postoperative period. Future efforts should emphasize nonopioid pathways for pain control following this generally minor procedure.

Estimating price elasticities of demand for pain relief drugs: evidence from Medicare Part D.

Overdose deaths from prescription opioids remain elevated, and policymakers seek solutions to curb opioid misuse. Recent proposals call for price-based solutions, such as opioid taxes and removal of opioids from insurance formularies. However, there is limited evidence on how opioid consumption responds to price stimuli. This study addresses that gap by estimating the effects of prices on the utilization of opioids, as well as other prescription painkillers. I use nationally representative individual-level data on prescription drug purchases and exploit the introduction of Medicare Part D in 2006 as an exogenous change in out-of-pocket drug prices. I find that new users have a relatively high price elasticity of demand for prescription opioids, and that consumers treat over-the-counter painkillers as substitutes for prescription painkillers. My results suggest that increasing out-of-pocket prices of opioids, through formulary design or taxes, may be effective in reducing new opioid use.

Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial.

High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors. Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions. Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA. Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls. EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management. Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation. Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants. Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain. ClinicalTrials.gov ID NCT03889418.

Opioid-Induced Constipation and Associated Symptoms After Orthopedic Trauma

PurposeOpioid-induced constipation is an adverse effect often experienced among patients taking prescription opioid medication. Despite frequent opioid prescribing after orthopedic injury, there is a dearth of research examining opioid-induced constipation presentations in this population. This analysis examines the frequency of opioid-induced constipation manifestations and association with patient-reported outcomes among participants prescribed opioid medication following orthopedic injury. DesignSecondary analysis of 86 clinical trial participants following orthopedic trauma. MethodsParticipants were assessed 2-weeks postoperatively with the following measures: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference, PROMIS Physical Function, past 24-hour average pain intensity captured on the numeric pain rating scale, and the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire. Linear regressions examined the association between PAC-SYM scores and both pain intensity and PROMIS T-scores while accounting for injury severity and opioid medication dosage. ResultsMost participants (69%) reported experiencing opioid-induced constipation symptoms and 7% reported moderate to severe symptoms. Compared to those without symptoms, participants reporting opioid-induced constipation symptoms were found to have a 3-point increase in PROMIS Pain Interference (95% Confidence Interval [CI]: 0.28-5.90; p = .032), a 3-point decline in PROMIS Physical Function (95% CI: -6.57 to -0.02; p = .049), and a 1.7-point increase in average pain scores (95% CI: 0.50-3.01; p = .007) at 2-weeks following surgery. ConclusionsOpioid-induced constipation symptoms are common after orthopedic trauma and linked to increased pain interference and pain intensity as well as reduced physical function. Clinical ImplicationsNurse-led assessments of opioid-induced constipation can support the timely delivery of interventions to alleviate symptoms and potentially improve patient-reported outcomes after injury.

Discrepancy in opioid prescription patterns for Black or African American patients following lower extremity bypass surgery for chronic limb-threatening ischemia

BackgroundDisparity in the allocation of medical services and resources based on race is present within the health care industry today, including the prescription of postoperative analgesics. The purpose of this study was to evaluate the presence of race-based disparity in the prescription of postdischarge opioids after lower extremity bypass (LEB) surgery for chronic limb-threatening ischemia (CLTI). MethodsRetrospective analysis was conducted on adult CLTI patients who underwent LEB from 2000 to 2023 in the TrinetX database. Patients were stratified into two groups based on race: White (group I) and black or African American (AA) (group II). Primary outcomes were defined as oral opioid prescriptions at 7 days and 30 days after discharge, and mortality at 1 year postoperatively. Secondary outcomes included length of stay and 30-day postoperative outcomes, including myocardial infarction, pulmonary embolism, cerebral vascular accident, deep vein thrombosis, acute kidney injury, major amputation, minor amputation, major adverse cardiac events, and major adverse limb events. Stratified analysis was conducted based on disease stage (rest pain vs lower extremity ulcer vs gangrene). Univariate analysis was performed via two-sample t test and χ2 test. Logistic regression was performed to estimate the association of Black or AA (vs White) race while controlling for pertinent preoperative potential confounders. ResultsThere were 3345 patients who met the inclusion criteria. Group I included 2661 White patients and group II included 684 Black or AA patients. Group II patients were more likely to be younger, female, present with gangrene, and have a history of hypertension, diabetes, chronic kidney disease, or diabetic neuropathy. At both 7 and 30 days after discharge, the Black or AA cohort had significantly lower rates of opioid prescriptions (33.2% vs 42.5% and 35.8% vs 47.2%, respectively) (all P < .05). Stratification by indication showed that opioid prescription disparity persisted despite black or AA patients presenting at worse stages of disease both at 7 and 30 days after discharge (7 days: rest pain 43.4% vs 33.7% [P = .013], ulcer 41.4% vs 31.7% [P = .027], gangrene, 42.7% vs 33.6% [P = .006] and 30 days: rest pain 47.8% vs 37.1% [P = .007], ulcer 45.4% vs 33.5% [P = .007], gangrene, 48.2% vs 36.1% [P < .001]). Adjusted analysis confirmed that Black or AA race was associated with lower rates of 7- (adjusted odds ratio, 0.607; P = .001) and 30-day (adjusted odds ratio, 0.56; P = .001) postdischarge opioid prescriptions. ConclusionsBlack or AA patients were less likely to receive postdischarge opioid prescriptions compared with their White counterparts at 7 and 30 days after LEB for CLTI.

Overcoming challenges of prescribing long-term opioid therapy in residency clinics.

To describe the impact of a standardized opioid prescribing intervention when implemented in three family medicine (FM) residency training - clinics-environments that face operational challenges including regular resident turnover. We performed a retrospective cohort study to compare patterns of long-term opioid prescribing between residency and nonresidency clinics. This study took place within a large, academic, health system. Three FM residency clinics were compared with three nonresidency FM clinics. A standardized opioid prescribing process was developed and implemented within the FM residency clinics. Nonresidency clinics used an independent process and were not exposed to the intervention. Descriptive comparisons were performed for treatment and control clinics' opioid prescribing from 2015 to 2018. The primary outcome was a patient's annual opioid exposure supplied from these select clinics. We also examine coprescribing with high-risk medications that potentiate the overdose risk of opioid prescriptions. Difference-in-difference modeling was used to control for clinic-level variation in practice. Statistically significant decreases were observed in both residency and nonresidency clinics for the mean number of opioid prescriptions and the mean daily morphine milligram equivalent. These decreases were comparable between the residency and nonresidency clinics. Residency clinics face unique challenges and require innovative solutions to keep up with best practices in opioid prescribing. Our residency clinics' implementation of a standardized intervention, including electronic health record integration, standardized processes, and metric management, suggests steps that may be valuable in achieving outcomes comparable to nonresidency clinics in large health systems.

Trends in Opioid Prescribing and New Persistent Opioid Use After Surgery in the United States.

To define recent trends in opioid prescribing after surgery and new persistent opioid use in the United States. New persistent opioid use after surgery among opioid-naïve individuals has emerged as an important postoperative complication. In response, initiatives to promote more appropriate post-operative opioid prescribing have been adopted in recent years. However, current estimates of opioid prescribing and new persistent opioid use following surgery remain unknown. A retrospective cohort study of opioid-naïve privately insured adult patients undergoing 17 common surgical procedures between 2013 and 2021 was conducted utilizing multi-payer claims data from the Health Care Cost Institute (HCCI). Initial opioid prescription size in oral morphine equivalents and new persistent opioid use were the outcomes of interest. Trends in opioid prescribing and rates of new persistent opioid use were evaluated across the study period. Mixed effects logistic regression was performed to evaluate independent predictors of new persistent opioid use while adjusting for patient-level factors and year. Among 989,354 opioid-naïve individuals, the adjusted initial opioid prescription size decreased from 282 mg OME to 164mg OME, a reduction of 118mg OME (95% CI: 116-120). The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%-2.8%) to 1.1% in 2021 (95% CI: 1.0%-1.2%). For every 30 OME increase in initial opioid prescription size, new persistent opioid use increased by 3.1%. Other predictors of new persistent opioid use included preoperative non-opioid controlled substances fills (31-365 days: aOR=1.78, 95% CI: 1.70-1.86; 0-30 days: aOR=2.71, 95% CI: 2.59-2.84) and undergoing orthopedic procedures (total knee arthroplasty (aOR=3.43, 95% CI: 3.15-3.72); shoulder arthroscopy (aOR=2.39, 95% CI: 2.24-2.56)). Both opioid prescription size after surgery and new persistent opioid use decreased over the last decade, suggesting that opioid stewardship practices had favorable effects on the risk of long-term opioid use.

Differences in Health Care and Palliative Care Use at the End of Life: A Comparison Study Among Lung Cancer, COPD, and Idiopathic Pulmonary Fibrosis

Patients with lung cancer, idiopathic pulmonary fibrosis (IPF), and chronic obstructive pulmonary disease (COPD) have high symptom burden, poor quality of life, and high healthcare utilization at the end of life. While proactive integration of palliative care in lung cancer can improve outcomes, it is unclear whether similar practices have been adopted in COPD and IPF care. Do patients with COPD and IPF have different patterns of healthcare and palliative care use at the end of life compared to lung cancer? We retrospectively identified deceased patients with lung cancer, COPD, or IPF with ≥1 outpatient visit at [removed] in the last six months of life. We compared outpatient palliative care and opioid prescriptions, inpatient palliative care, hospitalizations, intensive care use, and in-hospital death in the last 6 months of life between each group. We used multivariable logistic regression to calculate adjusted odds ratios of each outcome, with lung cancer as the reference group. Among 1,819 patients, patients with COPD and IPF were more likely to be male and older at the time of death, compared to patients with lung cancer. Compared to lung cancer, patients with COPD and IPF had a lower adjusted odds (p<0.001) of receiving outpatient palliative care (aOR COPD: 0.26, 95% CI: 0.19-0.36; aOR IPF: 0.48, 95% CI: 0.32-0.70), outpatient opioids (aOR COPD: 0.50, 95% CI: 0.40-0.63; aOR IPF: 0.40, 95% CI: 0.29-0.54), and a higher odds of end-of-life ICU use (COPD aOR: 2.88, 95% CI: 2.11-3.93; IPF aOR: 4.15, 95% CI: 2.66-6.49). Patients with IPF had higher odds of receiving inpatient palliative care (aOR: 2.02, 95% CI: 1.30-3.13, p=0.002). Patients with COPD and IPF are less likely to receive outpatient palliative care and opioid prescriptions and more likely to use end-of-life intensive care than patients with lung cancer. Further research should explore health system barriers contributing to differences in care patterns to optimize quality of life and align with patient goals of care.

Assessing Decision Fatigue in General Practitioners' Prescribing Decisions Using the Australian BEACH Data Set.

General practitioners (GPs) make numerous care decisions throughout their workdays. Extended periods of decision making can result in decision fatigue, a gradual shift toward decisions that are less cognitively effortful. This study examines whether observed patterns in GPs' prescribing decisions are consistent with the decision fatigue phenomenon. We hypothesized that the likelihood of prescribing frequently overprescribed medications (antibiotics, benzodiazepines, opioids; less effortful to prescribe) will increase and the likelihood of prescribing frequently underprescribed medications (statins, osteoporosis medications; more effortful to prescribe) will decrease over the workday. This study used nationally representative primary care data on GP-patient encounters from the Bettering the Evaluation and Care of Health program from Australia. The association between prescribing decisions and order of patient encounters over a GP's workday was assessed with generalized linear mixed models accounting for clustering and adjusting for patient, provider, and encounter characteristics. Among 262,456 encounters recorded by 2,909 GPs, the odds of prescribing antibiotics significantly increased by 8.7% with 15 additional patient encounters (odds ratio [OR] = 1.087; confidence interval [CI] = 1.059-1.116). The odds of prescribing decreased significantly with 15 additional patient encounters by 6.3% for benzodiazepines (OR = 0.937; CI = 0.893-0.983), 21.9% for statins (OR = 0.791; CI = 0.753-0.831), and 25.0% for osteoporosis medications (OR = 0.750; CI = 0.690-0.814). No significant effects were observed for opioids. All findings were replicated in confirmatory analyses except the effect of benzodiazepines. GPs were increasingly likely to prescribe antibiotics and were less likely to prescribe statins and osteoporosis medications as the workday wore on, which was consistent with decision fatigue. There was no convincing evidence of decision fatigue effects in the prescribing of opioids or benzodiazepines. These findings establish decision fatigue as a promising target for optimizing prescribing behavior. We found that as general practitioners progress through their workday, they become more likely to prescribe antibiotics that are reportedly overprescribed and less likely to prescribe statins and osteoporosis medications that are reportedly underprescribed.This change in decision making over time is consistent with the decision fatigue phenomenon. Decision fatigue occurs when we make many decisions without taking a rest break. As we make those decisions, we become gradually more likely to make decisions that are less difficult.The findings of this study show that decision fatigue is a possible target for improving guideline-compliant prescribing of pharmacologic medications.

Limited health literacy does not adversely affect compliance with postoperative restrictions, 90-day emergency department return, or opioid use following shoulder arthroscopy

BackgroundLimited health literacy can negatively impact how patients process medical information, make medical decisions, and navigate the healthcare system. The literature with regards to health literacy and its impact on both postoperative compliance and healthcare utilization remains scant. MethodsWe retrospectively analyzed the records for patients who underwent elective shoulder arthroscopy with a minimum 90-day follow-up at a single academic institution. Demographic data including age, gender, prior ipsilateral shoulder arthroscopy, body mass index (BMI) and age-adjusted Charlson Comorbidity Index (ACCI) were collected. A validated 9-item Literacy in Musculoskeletal Problems (LiMP) questionnaire to assess musculoskeletal health literacy (MHL) was administered preoperatively. Postoperative compliance with therapy and surgeon-directed immobilization restrictions, 90-day return to ED, and the number of opioid prescriptions filled within 3 months postoperatively was recorded. ResultsThere were 252 cases included in this study. Seventy-seven (31%) patients demonstrated adequate MHL (AMHL). On multivariable analysis, limited MHL (LMHL) was not significantly associated with 90-day postoperative ED return, compliance with postoperative surgeon instructions regarding shoulder motion or therapy restrictions, or obtaining ≥ 2 postoperative opioid prescriptions. ConclusionsLMHL is highly prevalent amongst patients undergoing elective shoulder arthroscopy. The lack of association between LMHL and postoperative compliance, 90-day ED return, or filling ≥ 2 postoperative opioid prescriptions suggests that further research is needed to identify more relevant modifiable risk factors that could reduce these negative clinical outcomes and healthcare utilization patterns.

Intraoperative pectoral nerve blocks during cardiac implantable electronic device procedures

BackgroundCardiac implantable electronic device (CIED) procedures can cause significant postoperative pain. Opioid use for postoperative pain is associated with risk of persistent use. The benefits of pectoral nerve (PECs) blocks have been established for other chest wall surgeries, but adoption in electrophysiology has been limited. ObjectivesThe purpose of this study was to evaluate the efficacy of intraoperative ultrasound-guided PECs blocks performed at the time of CIED procedures by the implanting physician from within the device pocket. MethodsPatients undergoing a pectoral CIED procedure at 7 centers from 2022–2023 were included. Patients underwent intraoperative PECs blocks and subcutaneous local anesthetic vs subcutaneous local anesthetic only at the discretion of the operator. Patients were prospectively evaluated for postoperative pain. ResultsSix hundred ten patients (age 67 ± 15 years old; 63% male) were enrolled. and half (n = 305) underwent PECs block. Patients who underwent PECs block were more likely to have a history of chronic pain (32% vs 11%, P <.001). PECs block was associated with lower pain scores in the 4 hours after the procedure (1.5 ± 2.1 vs 4.5 ± 2.5, P <.001). Pain scores were not different after 24 hours (2.8 ± 1.7 vs 3.1 ± 2.2) and 2 weeks (0.9 ± 1.4 vs 0.9 ± 1.2). PECs block patients were less likely to receive inpatient opioids (10% vs 48%, P <.001) and to be discharged with an opioid prescription (15% vs 59%, P <.001). In multivariable linear regression, PECs block (P <.001), age (P = .002), and absence of chronic pain (P = .009) were associated with lower acute postoperative pain. ConclusionIntraoperative PECs block can reduce postoperative pain and opioid use. This procedure can be readily performed by the implanting physician from within the device pocket.

Comparing withdrawal- and anxiety-like behaviors following oral and subcutaneous oxycodone administration in C57BL/6 mice.

Excessive prescribing and misuse of prescription opioids, such as oxycodone, significantly contributed to the current opioid crisis. Although oxycodone is typically consumed orally by humans, parenteral routes of administration have primarily been used in preclinical models of oxycodone dependence. To address this issue, more recent studies have used oral self-administration procedures to study oxycodone seeking and withdrawal in rodents. Behavioral differences, however, following oral oxycodone intake versus parenteral oxycodone administration remain unclear. Thus, the goal of the current studies was to compare anxiety- and withdrawal-like behaviors using established opioid dependence models of either home cage oral intake of oxycodone (0.5 mg/ml) or repeated subcutaneous (s.c.) injections of oxycodone (10 mg/kg) in male and female mice. Here, mice received 10 days of oral or s.c. oxycodone administration, and following 72 h of forced abstinence, anxiety- and withdrawal-like behaviors were measured using elevated zero maze, open field, and naloxone-induced precipitated withdrawal procedures. Global withdrawal scores were increased to a similar degree following oral and s.c. oxycodone use, while both routes of oxycodone administration had minimal effects on anxiety-like behaviors. When examining individual withdrawal-like behaviors, mice receiving s.c. oxycodone exhibited more paw tremors and jumps during naloxone-induced precipitated withdrawal compared with oral oxycodone mice. These results indicate that both models of oxycodone administration are sufficient to elevate global withdrawal scores, but, when compared with oral consumption, s.c. oxycodone injections yielded more pronounced effects on some withdrawal-like behaviors.

Neuropathic pain has sex-specific effects on oxycodone-seeking and non-drug-seeking ensemble neurons in the dorsomedial prefrontal cortex of mice.

Approximately 50 million Americans suffer from chronic pain, and nearly a quarter of chronic pain patients have reported misusing opioid prescriptions. Repeated drug seeking is associated with reactivation of an ensemble of neurons sparsely scattered throughout the dorsomedial prefrontal cortex (dmPFC). Prior research has demonstrated that chronic pain increases intrinsic excitability of dmPFC neurons, which may increase the likelihood of reactivation during drug seeking. We tested the hypothesis that chronic pain would increase oxycodone-seeking behaviour and that the pain state would differentially increase intrinsic excitability in dmPFC drug-seeking ensemble neurons. TetTag mice self-administered intravenous oxycodone. After 7days of forced abstinence, a drug-seeking session was performed, and the ensemble was tagged. Mice received spared nerve injury (SNI) to induce chronic pain during the period between the first and second seeking session. Following the second seeking session, we performed electrophysiology on individual neurons within the dmPFC to assess intrinsic excitability of the drug-seeking ensemble and non-ensemble neurons. SNI had no impact on sucrose seeking or intrinsic excitability of dmPFC neurons from these mice. In females, SNI increased oxycodone seeking and intrinsic excitability of non-ensemble neurons. In males, SNI had no impact on oxycodone seeking or neuron excitability. Data from females are consistent with clinical reports that chronic pain can promote drug craving and relapse and support the hypothesis that chronic pain itself may lead to neuroadaptations which promote opioid seeking.

The influence of the built environment on drug misuse and abuse

Drug misuse and overdoses (DMO) continue to rise in the United States and around the world. As the COVID-19 pandemic lockdown brought America to a standstill, the drug overdose epidemic took a sharp turn for the worse. Poorly built environments have been said to pose greater risks for substance use. The inequitable race and socioeconomic status distribution of the built environment might be tipping drug overdose and deaths toward minority populations. This review examined the contribution of the built environment to drug misuse and overdose to identify further research and policy needs. Databases like PubMed and Google Scholar were searched for peer-reviewed empirical studies in the English language published from 2010 to March 2021. MeSH search terms were built environment, overdose, drug, and drug overdose. Using the PRISMA flow diagram of article selection, title, and abstract screening plus text narrative synthesis of included articles were done. The built environment features making it more conducive to initiating and maintaining DMO included disinvestment, geographical context (urban versus rural), spatial characteristics of the built environment, easy access to drugs, low access to interventions, and built-environment-associated environmental and social stressors. Built environment features play some roles in drug misuse problems. Policies and programs are needed that place the built environment at the centre of health, drug overdose prevention, and harm reduction, provide increased treatment facilities for addicted persons, ensure stricter opioid prescription measures, and address poverty as well as hopelessness due to disinvestment.

Prediction Model for Outpatient Opioid Use Following the Minimally Invasive Repair of Pectus Excavatum

IntroductionTo minimize unused outpatient opioids while providing adequate pain control, we sought to create a model to predict outpatient opioid use following the minimally invasive repair of pectus excavatum with cryoablation MIRPE-C. MethodsA retrospective review was conducted at a single center from May 2023 to January 2024 among patients <21 years who underwent MIPRE-C. Demographic and clinical data, including inpatient and outpatient opioid use were reviewed. Patients completed opioid use questionnaires at their first postoperative visit. Simple linear regression was employed to create a model for outpatient opioid use. ResultsSixty-eight patients underwent MIRPE-C: 84% were male (mean age of 15.2 ± 1.7 years, and median Haller index 4.2[IQR:3.7–5.7]). Daily mean inpatient opioid requirement and daily opioid doses were 0.3 ± 0.2 OME/day/kg and 2 ± 1.2 opioid doses/day. At the first outpatient follow-up visit, patients reported using a median of five 5-mg oxycodone tablets [IQR:1.6–10] for 5 days [IQR:2–7] with 22% of patients needing an opioid refill. On linear regression, inpatient opioid use had a significant relationship with the number of outpatient doses taken, while patient factors were not associated with outpatient opioid use. A simple equation for predicting opioid need based on best fit (R2 = 0.211) was developed:#OUTPATIENT OPIOID TABLETS = 3 TABLETS + (0.82 x #INPATIENT OPIOID RECIEVED). ConclusionThe proposed outpatient opioid prescription model is simple to calculate and tailors the prescription to individual patient need. This model has the potential to provide effective pain control and avoid prescription refills, while minimizing over-prescription of opioids. Level of EvidenceTreatment study Level III.

A Double-Blinded Randomized Controlled Trial Assessing the Efficacy of Opioid Disposal Instructions with Parental Education on Proper Opioid Disposal Rates Following Ambulatory Pediatric Urologic Surgery

ObjectivesTo determine if the administration of standardized opioid disposal instructions with focused parental education improves proper disposal of leftover opioid medication among families of children undergoing ambulatory urologic surgery compared to routine postoperative instructions. MethodsA prospective, double-blinded, single-center randomized controlled trial was conducted in children 6-18y undergoing ambulatory urology procedures between October 2021-April 2023. Patients were randomized (1:1) to receive either the Food and Drug Administration (FDA) opioid disposal best practices worksheet plus nursing parental education or routine postoperative instructions alone. All patients were prescribed acetaminophen and ibuprofen and a per-protocol rescue opioid prescription. The primary outcome was rate of proper opioid disposal at 10-14d post-procedure. Secondary outcomes included parents postoperative pain measure (PPPM) scores, numerical pain scale (NPS) scores, and weight-based opioid utilization at 48h and 10-14d. ResultsWe randomized 104 participants (53 intervention, 51 control) with 97% (101/104) complete follow-up data at 10-14d. Patient demographics, procedural characteristics, and analgesia use were similar between groups. We observed no significant difference in proper opioid disposal rates between arms (31% intervention vs. 18% control; estimated difference in proportion 13% [95% CI, -4–29%]; p=0.1). There was no increased odds of proper disposal of leftover opioid medication at 10-14d with the intervention compared to the control (OR 2.0 [95% CI 0.8–5.1]; p=0.1). We observed no differences in PPPM scores, NPS scores, or opioid utilization at 48h or 10-14d. ConclusionsProviding formal opioid disposal instructions with parental education did not improve proper disposal of leftover opioid medication nor did it alter post-discharge opioid utilization after pediatric urologic surgery.

Prescription Opioid Exposure During Pregnancy and Risk of Spontaneous Preterm Delivery

(Abstracted from JAMA Network Open 2024;7(2):e2355990 Up to 21% of pregnant people use opioids to treat acute pain at some point in their pregnancies. Several studies have examined the impact of medication-assisted therapy among women with opioid use disorders and their outcomes, including neonatal opioid withdrawal syndrome.

Changes in Primary Care Health Services During the COVID-19 Pandemic: A Longitudinal Analysis of Data From Ontario.

The COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.

Effectiveness of a discharge analgesia guideline on discharge opioid prescribing after a surgical procedure from a tertiary metropolitan hospital.

The primary objective of this study was to evaluate the effectiveness of a discharge analgesia guideline on the number of days' supply of opioid analgesics provided among surgical patients upon hospital discharge. The secondary objective was to analyze the effect of this guideline on the provision of an analgesic discharge plan. A retrospective historical control cohort study. A tertiary metropolitan hospital. A discharge analgesia guideline recommending the supply of opioid analgesics on discharge based on patient use in the 24 hours prior to discharge and the supply of an analgesic discharge plan. The primary outcome measure was the number of days' supply of opioids. The secondary outcome measure was the proportion of patients receiving an analgesic discharge plan. There was no change in the number of days' supply of opioids provided on discharge (median, interquartile range: 5, 3-9.75 vs 6, 4-10; p = 0.107) and in the proportion of patients receiving an analgesic discharge plan (26 percent vs 22.2 percent; p = 0.604). The results of two multivariable regression models showed no change in the number of days' supply of opioids (adjusted incidence rate ratio, 95 percent confidence interval [CI]: 1.1, 0.9-1.2) and the provision of an analgesic discharge plan (adjusted odds ratio, 95 percent CI: 0.6, 0.2-1.4) after adjusting for confounding variables. Overall, our study found no change in the number of days' supply of opioids provided on discharge and the provision of an analgesic discharge plan after implementation of a discharge analgesia guideline, but we also found that prescribing practices already aligned with the guideline before its implementation.