Oral Morphine Milligram Research Articles

Comparison of the Centers for Disease Control (CDC) recommendations and the risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) tool for guiding naloxone coprescribing.

Patients treated with ongoing opioid therapy may be at an increased risk of respiratory depression or death, which may be mitigated through prompt administration of naloxone. The Centers for Disease Control (CDC) guidelines for prescribing opioids in primary care settings recommend patients treated with ongoing opioid analgesic therapy be offered a coprescription of naloxone based on total oral morphine milligram equivalents per day or concurrent benzodiazepine therapy. Opioid overdose risk is dose-dependent, yet other patient-specific factors contribute to this risk. The risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) incorporates additional risk factors to assess the risk of overdose or clinically relevant respiratory depression. This study compared the frequency of meeting CDC, Veterans' Health Administration (VA) RIOSORD, or civilian RIOSORD criteria for naloxone coprescribing. A retrospective chart review of 42 Federally Qualified Health Centers in Illinois was conducted for all CII-CIV opioid analgesic prescriptions. Ongoing opioid therapy was defined as patients who received seven or more CII-CIV opioid analgesic prescriptions during the 1-year study period. Patients aged 18-89, receiving opioids for nonmalignant pain, and meeting the criteria of ongoing opioid therapy were included in the analysis. A total of 41,777 controlled substance analgesic prescriptions were prescribed during the study period. Data from 651 individual patient charts were evaluated. Of those, 606 patients met inclusion criteria. From these data, 57.9 percent of patients (N = 351) met civilian RIOSORD criteria, 36.5 percent (N = 221) met VA RIOSORD criteria, and 22.8 percent (N = 138) met CDC guideline recommendations for naloxone coprescribing. The percentage of patients who met RIOSORD criteria compared to CDC criteria was significantly higher (p < 0.001). Of all patients meeting ongoing opioid therapy criteria, only seven had been coprescribed naloxone. Coprescribing of naloxone is significantly underutilized in patients treated with opioid therapy for nonmalignant chronic pain and should not solely be based on total oral morphine milligram equivalents per day or concurrent benzodiazepine therapy. As risk assessment improves, consideration of other risk-conferring variables, such as gabapentinoids, skeletal muscle relaxants, and sleep hypnotics, should be considered.

Quadratus Lumborum Blockade for Postoperative Analgesia in Infants and Children Following Colorectal Surgery.

Adult studies have indicated that the quadratus lumborum block (QLB) may provide superior analgesia compared to single-shot neuraxial and other truncal peripheral nerve blocks. The technique is being increasingly used for postoperative analgesia in children undergoing lower abdominal surgery. To date, these pediatric reports have been limited by small sample sizes, which may hinder the interpretation of results and assessment of safety. In this study, we retrospectively examined QLBs performed at a large tertiary care hospital for evidence of effectiveness and safety in the pediatric colorectal surgery population. Patients less than 21 years of age who underwent abdominal surgery and received a unilateral or bilateral QLB over a 4-year period were identified in the electronic medical record. Patient demographics, surgery type, and QLB characteristics were retrospectively examined. Pain scores and opioid consumption were tabulated over the first 72-h postoperative period. QLB procedural complications or adverse events attributable to the regional anesthetic were obtained. The study cohort included 204 QLBs in 163 pediatric-aged patients (2 days to 19 years of age, median age of 2.4 years). The most common indication was unilateral blockade for ostomy creation or reversal. The majority of QLBs were performed using ropivacaine 0.2% with a median volume of 0.6 mL/kg. The median opioid requirement in oral morphine milligram equivalents (MMEs) was 0.7, 0.5, and 0.3 MME/kg on the first, second, and third postoperative days, respectively. Median pain scores were less than 2 over each time period. Aside from block failure (incidence 1.2%), there were no complications or postoperative adverse events related to the QLBs. This retrospective review in a large cohort of pediatric patients demonstrates that the QLB can be performed safely and efficiently in children undergoing colorectal surgery. The QLB provides adequate postoperative analgesia, has a high success rate, may limit postoperative opioid consumption, and is associated with a limited adverse effect profile.

Variations in Postpartum Opioid Prescribing Practices among Obstetrician-Gynecologists.

There have been many efforts to combat the United States opioid crisis that has been occurring for the past two decades, specifically with postpartum patients that often were prescribed opioids. Prior studies described how accounting for usage of inpatient opioids on the day prior to discharge had an impact on how much discharge opioids were prescribed on the day of discharge. These studies provided a guideline to use the inpatient opioid amount from the day before discharge to determine discharge opioid quantity and minimize how much was being prescribed. In July 2018, the American College of Obstetrics and Gynecologists (ACOG) published Committee Opinion 742, guidelines for obstetricians-gynecologists about post-partum pain management. Prescription pain medications (including opioids, if necessary) require a shared decision-making approach between the physician and patient to determine the medication type and quantity. This study aimed to determine if there were differences in prescribing practices based on the specific post-operative day that opioid prescriptions were written, and if there were differences in the prescribing practices for cesarean deliveries following the publication of ACOG Committee Opinion 742. This retrospective chart review included patients who had a live cesarean birth at one rural Midwest facility anytime between July 1, 2017 and February 28, 2021. This study excluded those with chorioamnionitis and those discharged after more than four days. Opioid amounts were converted to oral morphine milligram equivalents (MME) for comparison, and total MME was calculated for each prescription. Patients were stratified into two groups based on the day that their discharge opioid medication prescriptions were written (i.e., a day prior to discharge or the day of discharge). Patients were also stratified based on date of delivery, before or after the publication of ACOG Committee Opinion 742. Of 411 cesarean patients, 93.9% (n = 386) had opioids prescribed at discharge, 86% (n = 330) of whom received a prescription written on the day of discharge. There was no difference in the quantity of MMEs, doses per day, or dosage from discharge prescriptions between those written on the day of discharge and those written on a prior day. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 (63.9%, n = 263) received discharge prescriptions with fewer average MMEs (159.53 ± 61.64) than those whose deliveries occurred before the publication (36%, n = 148; 187.35 ± 53.42; χ2 (1, N = 411) = 17.71; p < 0.001), and they were prescribed fewer doses per day. After cesarean sections, the specific post-operative day did not seem to impact the prescribing trends as there were no differences in MMEs, doses per day, or dosage between prescriptions that were written on the day of discharge and before the day of discharge. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 received discharge prescriptions with fewer MMEs, fewer doses per day, and the same dosage than those whose deliveries occurred before the publication, reflecting the overall national trend of decreasing prescription opioids over these years.

Preliminary Experience With Quadratus Lumborum Catheters for Postoperative Pain Management in Pediatric-Aged Patients With Contraindications to Epidural Anesthesia.

Although neuraxial techniques such as caudal and epidural anesthesia were initially the predominant regional anesthetic technique used to provide postoperative analgesia in children, there has been a transition to the use of peripheral nerve blockade such as the quadratus lumborum block (QLB). We present preliminary experience with QL catheters for continuous postoperative analgesia in a cohort of pediatric patients following colorectal surgery. After institutional review board (IRB) approval, we retrospectively reviewed the records of patients who underwent major colorectal surgery and received QL catheters for postoperative analgesia. The postoperative pain control data consisted of QL catheter characteristics, anesthetic agents, adjuncts, pain scores, and opioid consumption during the postoperative period. The study cohort included eight pediatric patients, ranging in age from 1 to 19 years (median age 11.8 years). The QL catheters were placed in the operating room after the induction of anesthesia. Comorbid conditions in the cohort that were contraindications to neuraxial anesthesia included spinal/vertebral malformations, presence of a ventriculoperitoneal (VP) shunt, anal atresia, tracheo-esophageal fistula (VACTERL) association, and coagulation disturbances. All patients underwent complex colorectal or genito-urologic procedures. Bilateral QL catheters were placed in six patients, and unilateral catheters were placed in two patients. Four patients received 0.5% ropivacaine and four patients received 0.2% ropivacaine of an initial bolus. The local anesthetic used for continuous infusion was 0.2% ropivacaine in five patients, 0.1% ropivacaine in two patients, and 1.5% chloroprocaine in one patient, with a median infusion rate of 0.11 mL/kg/h. QL catheter infusions were supplemented with intravenous opioids delivered by patient-controlled or nurse-controlled analgesia. The median opioid requirements in oral morphine milligram equivalents (MME) were 1.2, 1.0, 1.1, 0.5, and 0.6 MME/kg on postoperative days 1 - 5. Daily median pain scores were ≤ 2 during the 5-day postoperative course. All catheters functioned successfully and were in place for a median of 79.3 h. Other than early inadvertent removal of two catheters, no adverse effects were noted. Although our preliminary data suggest the efficacy of QL catheters in providing prolonged postoperative analgesia for up to 3 - 5 days following colorectal procedures, attention needs to be directed at measures to ensure that the catheter is secured to avoid inadvertent removal.

Extubation delays and the associated prostaglandin and opiate dose following coarctation of the aorta repair

BackgroundCoarctation of the aorta (COA) is one of the most common congenital heart lesions. Most patients undergoing repair extubate without complication. A subset of patients are unable to extubate within 24 h postoperatively. ObjectiveWe examined risk factors determined a priori and their association with delays in extubation. MethodsThis is a retrospective single-center study at an academic quaternary children's hospital. All neonates (0–28 days) who underwent isolated coarctation repair via lateral thoracotomy between January 2008 – December 2019 were included. Delay in extubation was defined as duration from cardiac intensive care unit admission to time of extubation >24 h. Risk factors examined were total preoperative prostaglandin dose and total perioperative opiate dose following repair. Logistic regression analyses were performed using appropriate statistics with significance level set at p = 0.05. ResultsThere were 149 patients who met inclusion criteria, 102 (68.5 %) were intubated for >24 h. We found that patients who were smaller (3.2 kg vs. 3.4 kg, p = 0.012) and patients who were in the intensive care unit preoperatively (p = 0.048), were more likely to remain intubated >24 h. There was also a statistically significant difference between those that were extubated before 24 h postoperatively and those that were not with respect to the total amount of oral morphine milligram equivalent received (1.5 mg vs. 2.82 mg, p = 0.005). ConclusionsOf the 149 patients in our study, the majority (102 patients, 68.5 %) were unable to be extubated within 24 h of surgery following coarctation repair via lateral thoracotomy. Risk factors for delayed extubation were smaller neonates and patients who received greater amounts of opiates.

No association of postoperative opioid usage with long-term surgery outcomes in patients with liver cancer: a population-based retrospective cohort study.

Hepatocellular carcinoma (HCC) is a fatal cancer worldwide, and surgical resection remains the standard treatment. Postoperative opioid prescription has been believed to affect cancer recurrence through complex biological pathways. We conducted a retrospective cohort study using the Longitudinal Health Insurance Database of Taiwan to evaluate the relationship between postoperative opioid use and long-term surgical outcomes of patients with HCC. This study had a retrospective cohort design. In total, 812 patients older than 20 years who underwent hepatectomy because of HCC were included. The exposure group comprised patients who used opioids during hospitalization postoperatively. The comparison group included those who never used opioids during hospitalization postoperatively. A Cox proportional hazards model was used to evaluate the overall survival or recurrence-free survival rate between the opioid group and the nonopioid group. A total of 530 patients received opioids postoperatively and 282 patients did not. The hazard ratios of overall survival and recurrence-free survival were 1.10 (95% confidence interval [CI], 0.85-1.41) and 1.15 (95% CI, 0.91-1.46), respectively. Total postoperative opioids were converted into oral morphine milligram equivalents and then divided into 3 equal subgroups: low dose, <40 mg; medium dose, 40 to 144 mg; and high dose, ≥145 mg. The hazard ratios of overall survival were 0.88 (95% CI, 0.63-1.24) for the low-dose group, 1.27 (95% CI, 0.92-1.74) for the medium-dose group, and 1.14 (95% CI, 0.83-1.58) for the high-dose group. Postoperative opioids do not affect overall and recurrence-free survival in patients undergoing hepatectomy or liver transplantation because of HCC. Cancer recurrence should not be a clinical concern regarding postoperative opioid prescription.

Multimodal Analgesia's Impact on Opioid Use and Adverse Drug Effects in a Multihospital Health System.

Purpose:In addition to opioid abuse and dependency, opioid use can lead to opioid related adverse drug events (ORADEs). ORADEs are associated with increased length of stay, cost of care, 30-day readmission rate, and inpatient mortality. The addition of scheduled non-opioid analgesic medications has shown to be effective in reducing opioid utilization in post-surgical and trauma populations, but evidence in entire hospital patient populations is limited. The objective of this study was to determine the effects of a multimodal analgesia order set on opioid utilization and adverse drug events in adult hospitalized patients. Methods: This retrospective pre/post implementation analysis was conducted at 3 community hospitals and a level II trauma center between January 2016 and December 2019. Patients included were 18 years of age or older, admitted for greater than 24 hours, and had at least one opioid ordered during hospital admission. The primary outcome of this analysis was the average oral morphine milligram equivalents (MME) used on days 1 through 5 of hospitalization. Secondary outcomes included the percentage of hospitalized patients with an opioid ordered for analgesia who received a scheduled non-opioid analgesic medication, the average number of ORADEs recorded in nursing assessments on hospitalization days 1 through 5, length of stay, and mortality. Multimodal analgesic medications included acetaminophen, gabapentinoids, non-steroidal anti-inflammatory drugs, muscle relaxants, and transdermal lidocaine. Results: The pre- and post-groups included 86 535 patients and 85 194 patients, respectively. The average oral MMEs used on days 1 through 5 were lower in the post-group (P < .0001). Utilization of multimodal analgesia as measured by the percentage of patients with 1 or more scheduled multimodal analgesia agent ordered increased from 33% to 49% at the end of the analysis. Conclusion: Utilization of a multimodal analgesia order set was associated with a decrease in opioid use and an increase in multimodal analgesia use in an entire hospital adult population.

Optimization of Opioid Discharge Prescriptions Following Thyroid and Parathyroid Surgery.

To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy. This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions. A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%; P < .001; number needed to treat = 3) and an adjusted odds ratio (OR) of 0.08 (95% CI, 0.04-0.19; P < .001). The bundle was associated with reductions in opioid discharge prescriptions that exceeded 112.5 oral morphine milligram equivalents (33% pre- vs 10% postimplementation; adjusted OR, 0.20; P = .001) or 5 days of therapy (17% pre- vs 6% postimplementation; adjusted OR, 0.34; P = .049). Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy. Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community. The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.

Limited cryoablation reduces hospital stay and opioid consumption compared to thoracic epidural analgesia after minimally invasive repair of pectus excavatum.

pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia (cryoablation of the intercostal nerves) during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years (range, 4–33 years). The median postoperative hospital stay was 4 days (range, 2–6 days), with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2; P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.

Enhanced recovery after surgery protocol is associated with a lower postoperative opioid use and a reduced postoperative office burden (470)

<b>Objectives:</b> Patients receiving postoperative opioids have a dosedependent risk of misuse and addiction. While the introduction of the enhanced recovery after surgery (ERAS) protocol has been shown to decrease hospital narcotic use, less attention has been directed towards the impact of ERAS on the clinic burden with respect to postoperative care. The objective of our study was to determine the impact of an ERAS protocol on narcotic prescription patterns after laparoscopic gynecologic surgery measured as the number of prescription pain medication refill requests, clinic phone calls, and unscheduled visits in the 30-day postoperative period. <b>Methods:</b> This retrospective study compared postoperative narcotic prescriptions and clinic burden ten months prior to and ten months following the implementation of a standard ERAS protocol after laparoscopic gynecologic surgery. The study included patients who underwent surgeries between January 2018, and July 2019, with the ERAS implementation in November 2018. The total oral morphine milligram equivalents (MMEs) prescribed postoperatively, and the number of unscheduled clinic visits and phone calls were compared before and after the implementation of the ERAS protocol. Postoperative prescribing practices were not standardized during the study period. <b>Results:</b> A total of 791 patients were identified with clinic follow-up; 445 before and 346 after ERAS implementation. All patients underwent laparoscopic or robotic-assisted surgery alone or in combination with mini-laparotomy. Baseline characteristics, including procedure, diagnosis, smoking, and alcohol use did not differ between groups. Use of ERAS was associated with higher rates of same-day discharge (49% vs 39%, p=0.003) and lower readmission rates (2.0% vs 5.6%, p=0.011). Postoperatively, patients who received the ERAS protocol were prescribed significantly less narcotics (197.8 vs 223.5 MMEs, p=0.0087) even though the postop narcotic doses were not specified. The number of refill requests was lower with ERAS (1.7% vs 3.6%, p=0.11). ERAS was associated with a lower chance of postoperative clinic phone calls (38% vs 46%, p=0.023), including calls for pain (10% vs 16%, p=0.021). There was a decrease in unscheduled visits related to pain (1.5% vs 5.8%, p=0.001), and a trend towards a decrease in the number of overall unscheduled visits (14% vs 18%; p=0.08) after ERAS implementation. <b>Conclusions:</b> Implementation of the ERAS protocol after laparoscopic gynecologic surgery resulted in a decrease in postoperative opioid prescribing and a lower incidence of unplanned interactions with the clinic staff, despite the lower amount of prescribed postoperative narcotics.

Developing a patient-centered opioid prescribing model: A prospective evaluation of opioid prescribing and utilization patterns among gynecologic oncology patients (581)

<b>Objectives:</b> The opioid epidemic is recognized as a public health crisis. Overprescribing opioids for postoperative pain management is commonly reported in surgical specialties, yet prescription guidelines are not well described after gynecologic oncology surgery. We sought to describe opioid prescribing and utilization patterns in gynecologic oncology patients to inform the development of a patient-centered opioid prescribing algorithm. <b>Methods:</b> This prospective cohort study recruited opioid naïve, gynecologic oncology patients undergoing hysterectomy. Demographic data, surgical data, inpatient opioid use, validated PROMIS pain inference questionnaires, and satisfaction surveys were collected. Medication diaries were collected at the 2- and 6-week postoperative visits. Outpatient postoperative opioid use was collected and converted to oral morphine milligram equivalents (MME). A retrospective chart view was completed to abstract details of the operation and the patient's inpatient opioid requirement. Descriptive statistics were used to quantify opioid prescribing and utilization patterns in MME. Wilcoxon rank-sum tests were used to compare opioid requirements by the surgical route. Nonparametric statistical methods were used to identify factors associated with outpatient narcotic use. An algorithm for future opioid prescribing was developed using the 95^th percentile of outpatient opioid use. <b>Results:</b> From January 2021 to July 2021, 65 women were recruited, with 57 completing follow-up data collection. The surgical approach was divided evenly with 49% open and 51% minimally invasive groups (MIS). The amounts of outpatient opioid prescription and use were lower in the MIS group compared to the open surgery group (p 0.011 and p 0.045, respectively). In the MIS group, the median prescribed opioids were 38 MME (IQR: 20-75 MME), equivalent to five pills of 5mg Oxycodone while median usage was 4 MME (IQR: 0-22), equivalent to one pill of 5mg Oxycodone. For the open group, 96 MME was prescribed (IQR: 38-150), equivalent to 20 pills, while usage was 31 MME (IQR: 0-82), equivalent to five pills. Twenty-four patients (42%) did not use any narcotics. Factors that correlated with postoperative opioid use included surgical procedure, estimated blood loss, the amount of narcotic taken during the last 24 hours as an inpatient, tobacco use, and patient's BMI. Patient reported high satisfaction with their preoperative teaching specific to pain control. Finally, 84% of patients had pain ratings on the PROMIS survey within normal limits at 6-week compared to a referent population. <b>Conclusions:</b> In this cohort, opioids were overprescribed for all patients, necessitating the need for more restrictive, personalized prescribing practices. As described in Figure 1, surgical route and last 24 hours inpatient MME can help delineate patient's opioid requirements and aid in the development of patient-centered guidelines for opioid prescribing in the postoperative period. Fig. 1

Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures

There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. The majority of patients were male (68.8%) with a median age of 53y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P<0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P<0.01) were predictive of high MME prescribed on discharge. For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.

Risk factors for opioid toxicity requiring naloxone rescue in adults: a case-control study.

Opioid-induced sedation and respiratory depression (OSRD) is a potentially life-threatening side effect of opioid analgesia. However, little is known about the individual and clinical-related factors associated with OSRD in the New Zealand context. To identify risk factors for OSRD in patients admitted to a large regional health board in New Zealand-Auckland District Health Board (ADHB). A retrospective matched case-control study design was undertaken among adults who were admitted to ADHB and prescribed opioids in hospital between August 2015 and April 2020. Those who were prescribed opioids and received naloxone for OSRD were defined as cases, whereas those who received opioids but did not experience OSRD were identified as controls. Cases and controls were matched on a1:1 basis by age (± 10 years). Data were retrieved from the electronic medical records of ADHB. A conditional logistic regression model was used to identify the risk factors for OSRD. We identified 51 cases, and these were matched with 51 control patients. The odds of experiencing OSRD were four times higher among opioid-naïve patients compared to those exposed to opioids prior to hospital admission (OR 4.113; 95% CI 1.14-14.89). Increased risk of OSRD was also associated with higher serum creatinine level prior to OSRD episode (OR 1.015; 95% CI 1.01-1.03) and a higher oral morphine milligram equivalent (OME) (OR 1.023; 95% CI 1.01-1.04). Increased risk of OSRD was associated with a higher OME, a higher serum creatinine level prior to OSRD episode, and opioid naivety. Our findings can inform policies that aim to prevent serious adverse effects related to opioids.

At-home Topical Sevoflurane Added to the Conventional Analgesic Treatment for Painful leg Ulcers Greatly Improved the Analgesic Effectiveness and Reduced Opioid Consumption in a Single-Center Retrospective Comparative Study with one-Year Follow-up.

The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. This study was aimed to compare the analgesic effectiveness and safety of systemic analgesics alone or plus at-home topical sevoflurane for the management of patients with painful nonrevascularizable leg ulcers who were referred to a Pain Clinic by their attending vascular surgeons. We reviewed charts of patients treated in a single Pain Clinic with analgesic Standard of Care either alone (group SoC) or plus at-home topical sevoflurane (group SoC + Sevo), according to safety criteria. The area under the curve of pain over a year (AUC-Pain) was the primary outcome for analgesic effectiveness. Opioids were converted into Oral Morphine Milligram Equivalents. Groups SoC (n = 26) and SoC + Sevo (n = 38) were similar in baseline characteristics. Compared to SoC, median values [interquartile range] of area under the curve of pain for one-year follow-up were markedly lower for SoC + Sevo (54 [35-65] vs. 15 [11-23]; p < 0.000001, U Mann-Whitney test). Oral Morphine Milligram Equivalents were similar at baseline (SoC: 78.5 [22.5-135] vs. SoC + Sevo: 101.3 [30-160]; p = 0.753), but significantly lower for SoC + Sevo at three (120 [22.5-202.5] vs. 30 [0-80]; p = 0.005), six (120 [11.3-160] vs. 20 [0-67.5]; p = 0.004), nine (114.4 [0-154] vs. 0 [0-37]; p = 0.018), and 12 months (114.4 [0-154] vs. 0 [0-20]; p = 0.001). Multiple linear regression analysis revealed the addition of sevoflurane to be the most likely variable to explain this difference in outcome (ß:-33.408; p < 0.000001). Nine patients (24%) in SoC + Sevo had adverse effects attributed to sevoflurane, but only one patient needed to stop using sevoflurane due severe dermatitis. In conclusion, the addition of topical sevoflurane to the analgesic standard of care in patients with painful nonrevascularizable leg ulcers was a well-tolerated therapy that significantly improved pain control and allowed for a significant reduction in opioid consumption.

Outcomes of Patients Undergoing Total Knee Arthroplasty with Spinal Anesthesia: A Comparison of Mepivacaine versus Bupivacaine

Introduction: Previous literature indicates that mepivacaine used for spinal anesthesia may lead to reduced recovery time and urinary retention compared to bupivacaine in patients undergoing total knee arthroplasty (TKA). We sought to compare outcomes between spinal anesthetics in our high-volume joint institution. Materials and Methods: A retrospective review of 553 unilateral primary TKA patients who received spinal anesthesia was conducted. Patients were divided by their receipt of mepivacaine or bupivacaine. Univariate comparisons before and after propensity score matching were used to compare outcomes for TKA patients receiving mepivacaine with those who did not. Results: Of the 553 patients, 102 received mepivacaine, and 451 received bupivacaine. After propensity score matching, patients who received bupivacaine experienced longer lengths of stay, received more oral morphine milligram equivalents (OMMEs), and were less likely to be discharged home. No differences in rates of nausea, urinary retention, or 30-day readmissions were observed between the groups. Discussion: In patients undergoing TKA with a spinal anesthesia, after adjusting for potentially confounding factors using propensity score matching, the use of mepivacaine was associated with shorter length of stay, less overall OMME requirements, and increased likelihood of home discharge, with no increase in complication rates. Based on these results, mepivacaine appears to be a viable alternative to bupivacaine for use in TKA rapid recovery protocols.

Early Initiation of Sub-Anesthetic Ketamine Infusion in Adults with Vaso-Occlusive Crises Is Associated with Greater Reduction in Sickle Cell Pain Intensity: A Single Center's Experience.

Recurrent, severely painful episodes, known as vaso-occlusive crises (VOCs) are the hallmark of sickle cell disease (SCD) and the primary reason for hospitalization. Opioids have been the gold standard for VOC treatment without significant improvement pain outcomes. To aid analgesia and combat opioid related adverse effects (ORAEs), some SCD clinicians have trialed infusions of sub-anesthetic ketamine along with opioids to treat VOCs. In this retrospective analysis, we compared adult SCD patients who received early vs late adjunctive sub-anesthetic ketamine infusions for VOCs. We identified adult SCD patients (age 18-50 years) who presented to Duke University with a VOC and received sub-anesthetic ketamine infusions from July 2015 to June 2019. We assessed both daily opioid consumption (measured as oral morphine milligram equivalents (MME)) and self-reported 0-10 numeric pain ratings (NPR) at 1, 2, and 3 days after infusion initiation, as well as 1 day after discontinuation. A total of 56 patients were identified with a median age of 30 years. Compared to late administration, early infusion of sub-anesthetic ketamine was associated with a 24.5% (P = .0003) and 25.9% (P = .0006) reduction, respectively, in median NPR at 1 day and 2 days after infusion initiation but did not persist at 3 days following initiation of the infusion. A statistically significant reduction in MME was not observed. In a nonrandomized study of sickle cell patients with VOCs, early sub-anesthetic ketamine infusion led to greater reduction in subjective pain intensity than late initiation of the infusion. Randomized studies should further explore whether early vs late ketamine infusion improves management of acute SCD pain.

Trends of Dispensed Opioids in Catalonia, Spain, 2007-19: A Population-Based Cohort Study of Over 5 Million Individuals.

Objective: To characterize the trend of opioid use (number of users, dispensations and oral morphine milligram equivalents) in Catalonia (Spain). Design, setting, and participants: This population-based cohort study included all individuals aged 18 years or older, registered in the Information System for Research in Primary Care (SIDIAP), which covers >75% of the population in Catalonia, Spain, from 1 January 2007, to 31 December 2019. Main exposure and outcomes: The exposures were all commercialized opioids and their combinations (ATC-codes): codeine, tramadol, oxycodone, tapentadol, fentanyl, morphine, and other opioids (dihydrocodeine, hydromorphone, dextropropoxyphene, buprenorphine, pethidine, pentazocine). The main outcomes were the annual figures per 1,000 individuals of 1) opioid users, 2) dispensations, and 3) oral morphine milligram equivalents (MME). Results were stratified separately by opioid types, age (5-year age groups), sex (male or female), living area (rural or urban), and socioeconomic status (from least, U1, to most deprived, U5). The overall trends were quantified using the percentage change (PC) between 2007 and 2019. Results: Among 4,656,197 and 4,798,114 residents from 2007 to 2019, the number of opioid users, dispensations and morphine milligram equivalents per 1,000 individuals increased 12% (percentage change: 95% confidence interval (CI) 11.9–12.3%), 105% (95% confidence interval 83%–126%) and 339% (95% CI 289%–390%) respectively. Tramadol represented the majority of opioid use in 2019 (61, 59, and 54% of opioid users, dispensations, and total MME, respectively). Individuals aged 80 years or over reported the sharpest increase regarding opioid users (PC: 162%), dispensations (PC: 424%), and MME (PC: 830%). Strong opioids were increasingly prescribed for non-cancer pains over the years. Conclusion: Despite the modest increase of opioid users, opioid dispensations and MME increased substantially, particularly in the older population. In addition, strong opioids were incrementally indicated for non-cancer pains over the years. These findings suggest a transition of opioid prescriptions from intermittent to chronic and weak to strong and call for more rigorous opioid stewardship.

Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty.

Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty. We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block. This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8±36.1 MMEs vs. 60.9±42.1 MMEs, P=.01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6±1.8 vs. 3.3±3.0, P=.06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9±3.1 hours vs. 4.6±2.7 hours, P=.008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3±26.8 vs. 38.5±27.8, P=.01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P=.16) and sleep management (82.1% vs. 76.8%, P=.48). There was no difference in the length of inpatient stay (32.2±14.8 hours vs. 34.1±12.8 hours, P=.44). In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.

Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention’s 2016 opioid prescribing guideline

BackgroundThe Centers for Disease Control and Prevention’s (CDC) March 2016 opioid prescribing guideline did not include prescribing recommendations for surgical pain. Although opioid over-prescription for surgical patients has been well-documented, the potential effects of the CDC guideline on providers’ opioid prescribing practices for surgical patients in the United States remains unclear.MethodsWe conducted an interrupted time series analysis (ITSA) of 37,009 opioid-naïve adult patients undergoing inpatient surgery from 2013–2019 at an academic medical center. We assessed quarterly changes in the discharge opioid prescription days’ supply, daily and total doses in oral morphine milligram equivalents (OME), and the proportion of patients requiring opioid refills within 30 days of discharge.ResultsThe discharge opioid prescription declined by -0.021 (95% CI, -0.045 to 0.003) days per quarter pre-guideline versus -0.201 (95% CI, -0.223 to -0.179) days per quarter post-guideline (p < 0.0001). Likewise, the mean daily and total doses of the discharge opioid prescription declined by -0.387 (95% CI, -0.661 to -0.112) and -7.124 (95% CI, -9.287 to -4.962) OME per quarter pre-guideline versus -2.307 (95% CI, -2.560 to -2.055) and -20.68 (95% CI, -22.66 to -18.69) OME per quarter post-guideline, respectively (p < 0.0001). Opioid refill prescription rates remained unchanged from baseline.ConclusionsThe release of the CDC opioid guideline was associated with a significant reduction in discharge opioid prescriptions without a concomitant increase in the proportion of surgical patients requiring refills within 30 days. The mean prescription for opioid-naïve surgical patients decreased to less than 3 days’ supply and less than 50 OME per day by 2019.

The Declining Use of Opioids at a Level 1 Trauma Center.

The epidemic of opioid-related overdose in the United States prompted a public health response that included implementation of opioid prescribing guidelines and restrictions. Such directives, however, were not applicable to hospitalized trauma patients. We hypothesized that although prescribing mandates did not apply to hospitalized trauma patients, inpatient opioid administration had nonetheless decreased over time. Opioid administrations for each patient admitted to a level I trauma center between January 1, 2016 and July 31, 2020 were converted into oral morphine milligram equivalents (MMEs) and summed at the patient level to obtain a total amount of MME administered for each hospitalization. MME was natural log transformed to achieve a normal distribution. General linear models were then used to determine the average patient MME administered by year. Patients who were pregnant or mechanically ventilated during their hospitalization were excluded. Six thousand five hundred ninety-four patients were included in our analysis, of which 5037 (76.4%) were treated with opioids during their hospitalization (morphine 72.7%, oxycodone 9.6%, tramadol 10.2%, fentanyl 5.5%, and hydromorphone 2.1%). The percentage of patients administered an opioid decreased stepwise from 79.3% in 2016 to 71.4% in 2020 (P < .001). For patients administered opioids, a 28% decrease in average total MME from 2016 to 2020 (P < .001) was observed. When stratified by ISS (<9, 9-15, 16+), average total MME consistently trended downward over time. Our trauma center realized a stepwise reduction in opioid administration in the absence of rules or restrictions surrounding in-hospital opioid prescribing.