Outpatient Opioid Prescriptions Research Articles

Evidence for the Use of Opioid Medication for Pediatric Acute Pain in the Outpatient Setting: Technical Report.

This technical report summarizes the results of a systematic review designed to support the American Academy of Pediatrics' "Clinical Practice Guideline: Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings." PubMed and Excerpta Medica Database were searched from 2010 to 2023 to identify randomized clinical trials and systematic reviews related to outpatient opioid prescribing to children. Overall, 11 randomized controlled trials were included. Although data were limited, no evidence was found that pain control by opioids is superior to nonopioid alternatives. Further, opioids are often associated with adverse events. The review also suggests that family and patient education and providing disposal methods may decrease risks associated with opioid prescription. Future studies can build on this foundation of evidence to support the appropriate use of opioids for acute pain in children treated in the outpatient setting.

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.

Using implementation science to decrease variation and high opioid administration in a surgical ICU.

High doses and prolonged duration of opioids are associated with tolerance, dependence, and increased mortality. Unfortunately, despite recent efforts to curb outpatient opioid prescribing because of the ongoing epidemic, utilization remains high in the intensive care setting, with intubated patients commonly receiving infusions with a potency much higher than doses required to achieve pain control. We attempted to use implementation science techniques to monitor and reduce excessive opioid prescribing in ventilated patients in our Surgical ICU. We conducted a prospective study investigating opioid administration in a closed SICU at an academic medical center over 18 months. Commonly accepted conversions were used to aggregate daily patient opioid use. Patients with a history of chronic opioid use and those being treated with an ICP monitor/drain, neuromuscular blocker, or ECMO were excluded. If the patient spent a portion of a day on a ventilator, that day's total was included in the "vent group." MMEs per patient were collected for each patient and assigned to the on-call intensivist. Intensivists were blinded to the data for the first seven months. They were then provided with academic detailing followed by audit & feedback over the subsequent 11 months, demonstrating how opioid utilization during their time in the SICU compared to the unit average and a blinded list of the other attendings. Student's T-tests were performed to compare opioid utilization before and after initiation of academic detailing and audit & feedback. Opioid utilization in patients on a ventilator decreased by 20.1% during the feedback period, including less variation among all intensivists and a 30.9% reduction by the highest prescribers. Implementation science approaches can effectively reduce variation in opioid prescribing, especially for high outliers in a SICU. These interventions may reduce the risks associated with prolonged use of high-dose opioids. Prospective pre-post-intervention, Level II.

Ambulatory Robotic Colectomy: Factors Affecting and Affected by Postoperative Opioid Use.

The ongoing opioid crisis demands an investigation into the factors driving postoperative opioid use. Ambulatory robotic colectomies are an emerging concept in colorectal surgery, but concerns persist surrounding adequate pain control for these patients who are discharged very early. We sought to identify key factors affecting recovery room opioid use (ROU) and additional outpatient opioid prescriptions (AOP) after ambulatory robotic colectomies. This was a single-institution retrospective review of ambulatory robotic colon resections performed between 2019 and 2022. Patients were included if they discharged on the same day (SDD) or postoperative day 1 (POD1). Outcomes of interest included ROU [measured in parenteral morphine milligram equivalents (MMEs)], AOP (written between PODs 2 to 7), postoperative emergency department presentations, and readmissions. Two hundred nineteen cases were examined, 48 of which underwent SDD. The mean ROU was 29.4 MME, and 8.7% of patients required AOP. Between SDD and POD1 patients, there were no differences in postoperative emergency department presentations, readmissions, recovery opioid use, or additional outpatient opioid scripts. Older age was associated with a lower ROU (-0.54 MME for each additional year). Older age, a higher body mass index, and right-sided colectomies were also more likely to use zero ROU. Readmissions were strongly associated with lower ROU. Among SDD patients, lower ROU was also associated with higher rates of AOP. Ambulatory robotic colectomies and SDD can be performed with low opioid use and readmission rates. Notably, we found an association between low ROU and more readmission, and, in some cases, higher AOP. This suggests that adequate pain control during the postoperative recovery phase is a crucial component of reducing these negative outcomes.

Opioid analgesics prescribing trends 2010-2019 in Slovenia: National database study.

Significant increases in global opioid use have been reported in recent decades. This study analyzed opioid utilization in outpatient care in Slovenia between 2010 and 2019. This retrospective cross-sectional study performed a nationwide database analysis of all outpatient opioid analgesic prescriptions based on Slovenian health insurance claims data. Prevalence was defined as the number of recipients prescribed at least one opioid per 1000 inhabitants. Opioid consumption was presented as the total number of dispensed prescriptions per 1000 inhabitants and dispensed defined daily doses (DDD) per 1000 inhabitants for each year analyzed. The age-standardized prevalence of opioid recipients decreased by 21.5% during the study period. Total opioid consumption decreased both in the number of prescriptions (-9.2%) and DDD (-5.4%). Tramadol consumption decreased in terms of the number of prescriptions (-12.2%) and DDD (-2.7%), whereas prescriptions for strong opioids increased (10.2%) and DDDs decreased (-16.2%). The results suggest less intensive prescribing of strong opioids and more intensive prescribing for tramadol. The most frequently used strong opioids were fentanyl and oxycodone/naloxone. The prevalence of opioid recipients and opioid consumption is decreasing in Slovenia. Further research is needed to understand whether this finding reflects safe use or underuse of these important analgesics.

Opioid prescriptions among the World Trade Center Health Program population

BackgroundThe World Trade Center Health Program (Program) provides limited health care to those directly affected by the 9/11 terrorist attacks. Because of physical/mental trauma arising from the 9/11 attacks, Program members might be at high risk of opioid use. To prevent prescription opioid overuse, in 2018 the Program implemented various measures to improve opioid prescribing and expand access to non-opioid pain management among Program members. However, the characteristics of opioid prescriptions dispensed among this population has never been described.MethodsAdministrative and claims data from 07/01/2011 to 09/30/2022 were used to describe opioid prescriptions dispensed during 2013–2021.ResultsFrom 2013–2021, 108,285 members were Program-enrolled for ≥ 10 months, 4,053 (3.7%) had 22,938 outpatient opioid prescriptions, of which, 62.1% were for cancer-related pain, 11.1% for hospice/end of life care, 4.8% for surgery pain, and 9.8% for acute/chronic pain. Among members with Program-paid diagnostic/treatment claims (n = 70,721), the proportion with opioid prescriptions for cancer/hospice/end of life care increased from 0.5% in 2013 to 1.6% in 2018 (p = 0.010), then decreased to 1.1% in 2021 (p = 0.070), and the proportion for non-cancer surgery/acute/chronic pain decreased from 0.6% in 2013 to 0.23% in 2021 (p = 0.0005). Among members prescribed opioids without cancer/hospice/sickle cell disease, the proportion who started with long-acting opioids or had opioid prescriptions from ≥ 4 prescribers were below 6.5% annually; the proportion receiving a high-dose (≥ 90 morphine milligram equivalents per day [MED]), or with concurrent opioids and benzodiazepines use, or who started opioids with MED ≥ 50 or with long duration (≥ 7 days’ supply) were above 10% annually, but decreased since 2017.ConclusionsPrevalence of outpatient opioid prescriptions paid by the Program was very low and prescriptions were primarily dispensed for cancer/hospice/end of life care. Although Program efforts to improve opioid prescribing coincided with improvements in outcomes, ongoing surveillance is needed.

Knowing the Dose to Control the Dose: Optimizing Patient-Controlled Analgesia in Adults with Sickle Cell Disease (SCD)

Introduction: Acute painful episodes are the most common cause of hospitalization in SCD. Intravenous (IV) opioids are the analgesic of choice to treat pain requiring hospitalization in adults. On-demand IV opioid dosing can be either via a patient-controlled analgesia (PCA) pump or via intermittent nurse bolus. Advantages of PCA include better analgesia accessibility and relative independence from staff. However, significant variability exists in PCA management. A multicenter, randomized-controlled trial of PCA strategies in SCD was terminated early due to slow accrual, stemming from barriers such as suboptimal communication between inpatient teams. Additional limitations with PCA include technological limitations and incomplete charting through a manual process. We initiated a quality improvement project to understand patterns of PCA use in patients hospitalized for SCD pain crises at our institution. Methods: We performed a retrospective manual chart review on all adult patients diagnosed with SCD pain crises admitted to the University of Cincinnati Medical Center (UCMC) from October 1 through December 31, 2022. Inpatient data collected included reason for admission, length of stay, and documentation of inpatient opioid usage in daily clinical notes. Hospitalizations requiring intensive care admission for severe complications were excluded. Outpatient data collected included demographics and outpatient opioid prescriptions via the state prescription drug monitoring database. The study was approved by the UCMC IRB. Results: Fifteen patients were admitted to UCMC a total of 24 times for SCD pain crises during the 3-month period. The patients ranged in age from 21 years to 73 years (median age 33 years, interquartile range (IQR) 19.5 years) and the majority (11/15) were women. Disease-modifying therapies prescribed included hydroxyurea (8/15, 53%), chronic transfusions (2/15, 13%), chronic transfusions plus hydroxyurea (1/15), voxelotor (1/15), no disease-modifying therapy (2/15). Nine patients were prescribed daily outpatient opioids that included an oral long-acting opioid plus an oral short-acting opioid. Out of the 24 hospitalizations, 11 were for an uncomplicated pain crisis, 10 were complicated by mild acute chest syndrome (mild hypoxia and/or abnormal chest imaging), and 3 patients experienced other treatable complications (2 with Staphylococcus epidermidis bacteremia, 1 with deep venous thrombosis). Five patients were admitted two or more times. Two patients, admitted a total of 5 times, were maintained on nurse-administered IV bolus opioids during their admissions, in addition to oral opioids. The remainder of the patients were treated with a hydromorphone PCA pump with on-demand bolus dosing only, in addition to home long-acting oral opioids when applicable. Two patients were ultimately transitioned from PCA onto nurse-administered bolus IV opioids, due to failure to achieve adequate analgesia with PCA. In 9 out of the 19 admissions using a PCA, daily MME or the equivalent was charted in at least one progress note (47%). The median LOS in the subgroup in which PCA use was charted at least once was 7 (IQR 3.5) days. In the 10 admissions on a PCA in which daily MME was never charted (53%), the median LOS was 11 (IQR 6.25) days. Among patients not receiving outpatient opioids, daily MMEs from the PCA in the first few days of hospitalization (when recorded) ranged from 24 to 520 (median 178, IQR 241) MME. In patients who had daily chronic pain on outpatient opioid therapy, daily inpatient MME from PCA ranged from 360 to 1020 (median 545, IQR 418) MME. In patients with multiple admissions during the study period, the recorded daily opioid use was about two times that in the single admission group (median 673, IQR 500 MME in the multiple admissions group; vs median 329, IQR 351 MME in the single admission group). Conclusions: Our data suggest that length of stay is shortened by ~4 days when clinicians quantify daily opioid use for patients on PCA. In addition, patients with frequent admissions tend to have higher inpatient daily opioid use. This hints that readmission may be partly driven by mild withdrawal when on outpatient opioids at lower MME. A major barrier to data collection was inconsistent documentation of daily opioid use. The next step in our quality improvement project is an educational curriculum on inpatient opioid management for residents and hospitalists.

Risk Factors for Thrombosis in Pregnant People with Sickle Cell Disease: A Multinational Study.

Background People with sickle cell disease (SCD) have exceptionally high rates of maternal morbidity, including increased risk for venous thromboembolic events (VTE). Data from the National Inpatient Sample shows that VTE risk in hospitalized Black pregnant people with SCD is 14 times that of unaffected Black and non-Black pregnant people. 1 There is little disease-specific data to inform anticoagulation (AC) use during pregnancy. 2 The purpose of this study is to describe VTE events in a SCD pregnancy cohort and to identify risk factors for VTE during pregnancy and compare maternal-fetal outcomes for subjects with or without VTE in pregnancy. Methods The Mount Sinai Hospital (MSH) Research Ethics Board and The Johns Hopkins Hospital (JHH) Institutional Review Board approved this retrospective study of pregnant people with SCD of ≥ 20 weeks gestation cared for at MSH, Toronto (1990-2017) or JHH (2000-2021). At MSH and JHH, all pregnant people with SCD and VTE history are prescribed antenatal prophylactic LMWH and for 6-weeks postpartum. At MSH, but not JHH, all receive AC prophylaxis for 6-weeks postpartum. At both centers, hospitalized pregnant people receive prophylactic AC. We stratified subjects by VTE occurrence during pregnancy. First, we described the cohort with VTE during pregnancy, including subject characteristics, VTE recurrence and pregnancy outcomes. Second, we compared cases with a first pregnancy with VTE to controls without VTE. We excluded repeat pregnancies in both groups. We compared cases and controls by SCD characteristics, medication use before pregnancy, and pregnancy outcomes. Painful events were defined as pain requiring acute care or hospital admission. Chronic transfusion therapy (CTT) was defined as pregnancies treated with scheduled, prophylactic transfusion; opioid use was defined as receiving an outpatient opioid prescription during pregnancy. We used the Chi-squared test for categorical variables and Wilcoxon signed-rank tests for continuous variables. A p-value of &amp;lt;0.05 was considered significant. Results There were 290 singleton pregnancies in 199 subjects. Half of the pregnancies were first pregnancies (142/290), with fewer second (51/290), third (2/290), fourth (3/290) or fifth (1/290) pregnancies. The cohort comprised of 58% subjects with HbSS/HbSβ 0, while 42% had HbSC/HbSβ+ genotype (Table 1). VTE occurred in 7% of pregnancies (20/290) including deep vein thrombosis (DVT, N=9), pulmonary embolism (PE, N=8), DVT+PE (N=3). Median age was 27 years (IQR 23,30). Before pregnancy, most VTE subjects received hydroxyurea (N=10). During pregnancy, six received CTT. Fourteen subjects had VTE in a single pregnancy; three had VTE recurrence in subsequent pregnancies. All three had HbSS/HbSβ 0. Two subjects had VTE history outside of pregnancy. One had DVT in two consecutive pregnancies and was prescribed AC in both pregnancies due to history of VTE. VTE occurred in first (N=4), second (N=8), third (N=4), fourth (N=1) and fifth (N=4) pregnancies. Most VTE occurred at JHH (11 JHH vs 6 MSH, p=0.008). To investigate SCD-specific risk factors for VTE in pregnancy, we compared characteristics in VTE subjects (N=17) to no-VTE subjects (N=182) by first study pregnancy with an event or first study pregnancy while enrolled in the study. VTE was associated with markers of disease severity including history of VTE before pregnancy (6/17 VTE vs 8/182 no-VTE, p&amp;lt;0.001), ACS during pregnancy (7/17 VTE vs 19/182 no-VTE, p&amp;lt;0.001), painful events requiring acute care during pregnancy (16/17 VTE vs 119/182 no-VTE, p=0.015) and hydroxyurea use before pregnancy (10/17 VTE vs 35/184 no-VTE, p&amp;lt;0.001). There was no difference in age or genotype. VTE was associated with earlier delivery and c-section delivery (Table 1). Conclusion In this study, 7% of cohort pregnancies had VTE. This rate exceeds reports from administrative datasets. 1 This may be due to the acuity of patients cared for at our centers and/or reflect undercounting of VTE in administrative datasets. In pregnant people with SCD, VTE is associated with VTE history, intrapartum painful events and ACS. Interventions to reduce acute events in pregnancy may help reduce VTE risk. While AC can be beneficial in preventing thrombotic events, careful assessment is essential to manage bleeding risks. Prospective data is needed to define the subpopulation of pregnant SCD patients who would benefit from AC prophylaxis antenatally.

Opioid Utilization after Cardiac Surgery in the Pediatric Medicaid-Insured Population

To determine the variation of outpatient opioid prescribing across the US in postoperative pediatric cardiac patients. Retrospective, cross-sectional study using a concatenated database of Medicaid claims between from 2016 through 2018 of children 0-17years, discharged after cardiac surgery and receiving an opioid prescription within 30days. Filled prescriptions were identified and converted to morphine milligram equivalents (MME). Use, duration, and dose were analyzed by sex, race, ethnicity, residence urbanicity, and region. Among 17 186 Medicaid-enrolled children after cardiac surgery, 2129 received opioids within 30days of discharge. Females received lower doses than males (coefficient -0.17, P=.022). Hispanic individuals were less likely to receive opioids (coefficient 0.53, P<.05, 95% CI: 0.38-0.71) and for shorter periods (coefficient 0.83, P<.001). Midwest (MW) (OR 0.61, 95% P-values < 0.05, 95% CI: 0.46-0.80) and Northeast (NE) (OR 0.43, 95% P-values < 0.05, 95% CI: 0.30-0.61) regions were less likely to receive opioids but used higher doses compared with the Southeast (SE) (MW coefficient 0.41, Southwest (SW) coefficient 0.18, NE coefficient 0.32, West (W) coefficient 0.19, P<.05). There were significant variations in opioid prescribing after cardiac surgery by race, ethnicity, sex, and region. National guidelines for outpatient use of opioids in children after cardiac surgery may help limit practice variation and reduce potential harms in outpatient opioid usage.

A personalized protocol for prescribing opioids after cesarean delivery: leveraging the electronic medical record to reduce outpatient opioid prescriptions

Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have mostly focused on the immediate postpartum period when patients are still admitted to the hospital. At discharge, most providers prescribe a fixed number of opioid tablets. Most patients do not use all the opioids that they are prescribed at hospital discharge. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion. This study aimed to determine whether a transition from universal opioid prescribing to a personalized, patient-specific protocol decreases morphine milligram equivalents prescribed at hospital discharge after cesarean delivery while adequately controlling pain. This was a prospective cohort study of patients undergoing cesarean delivery before and after the implementation of a personalized opioid-prescribing practice at the time of hospital discharge. Each patient was prescribed scheduled ibuprofen and acetaminophen, with a prescription for oxycodone tablets equal to 5 times the morphine milligram equivalents used in the 24 hours before discharge, calculated via an electronic order set. The previous traditional cohorts were routinely prescribed 30 tablets of acetaminophen-codeine 300/30 mg. The primary outcome was morphine milligram equivalents prescribed at discharge. A hotline to address pain control issues after discharge was established, and calls, emergency department visits, and readmissions were examined. Statistical analyses was performed using chi-square and Wilcoxon rank-sum test, with a P value of <.05 considered statistically significant. Overall, 412 patients underwent cesarean delivery in the 6 weeks after initiation of the personalized prescribing protocol and were compared with 367 patients before the change. The median morphine milligram equivalents prescribed at discharge was lower with personalized prescribing (37.5 [interquartile range, 0-75] vs 135 [interquartile range, 135-135]; P<.001). Moreover, 176 patients (43%) were not prescribed opioids at discharge, which was a substantial change as all 367 patients in the traditional cohort received opioids at discharge (P<.001). Of note, 9 hotline phone calls were received; none required additional opioids after a 24-hour trial of scheduled ibuprofen, which none had taken before the call. In addition, 11 patients (2.7%) presented to the emergency department for pain evaluation, of which none required readmission or an outpatient prescription of opioids. A personalized protocol for opioid prescriptions after cesarean delivery decreased the total morphine milligram equivalents and the number of opioid tablets at discharge, without hospital readmissions or need for rescue opioid prescriptions after discharge. Opioids released into our community will be reduced by more than 90,000 tablets per year, without demonstrable adverse effect.

Differences in adverse outcomes across race and ethnicity among Veterans with similar predicted risks of an overdose or suicide-related event.

To evaluate the degree to which differences in incidence of mortality and serious adverse events exist across patient race and ethnicity among Veterans Health Administration (VHA) patients receiving outpatient opioid prescriptions and who have similar predicted risks of adverse outcomes. Patients were assigned scores via the VHA Stratification Tool for Opioid Risk Mitigation (STORM), a model used to predict the risk of experiencing overdose- or suicide-related health care events or death. Individuals with the highest STORM risk scores are targeted for case review. Retrospective cohort study of high-risk veterans who received an outpatient prescription opioid between 4/2018-3/2019. All VHA medical centers. In total, 84 473 patients whose estimated risk scores were between 0.0420 and 0.0609, the risk scores associated with the top 5%-10% of risk in the STORM development sample. We examined the expected probability of mortality and serious adverse events (SAEs; overdose or suicide-related events) given a patient's risk score and race. Given a similar risk score, Black patients were less likely than White patients to have a recorded SAE within 6 months of risk score calculation. Black, Hispanic, and Asian patients were less likely than White patients with similar risk scores to die within 6 months of risk score calculation. Some of the mortality differences were driven by age differences in the composition of racial and ethnic groups in our sample. Our results suggest that relying on the STORM model to identify patients who may benefit from an interdisciplinary case review may identify patients with clinically meaningful differences in outcome risk across race and ethnicity.

Outpatient opioid prescribing by Alzheimer’s diagnosis among older adults with pain in United States

ObjectiveTo examine opioid prescribing practices for pain in older adults with and without Alzheimer’s Disease and Related Dementias (ADRD).MethodsThis cross-sectional study used National Ambulatory Medical Care Survey data (2014–2016, and 2018). Adults aged ≥ 50 years with pain were analyzed. Prescribing of opioid and concomitant sedative prescriptions (including benzodiazepines, Z-drugs, and barbiturates) were identified by the Multum lexicon code. Multivariable logistic regression evaluated the risk of opioid prescribing or co-prescribing of opioid and sedative associated with ADRD in older adults with pain.ResultsThere were 13,299 office visits in older adults with pain, representing 451.75 million visits. Opioid prescribing occurred in 27.19%; 30% involved co-prescribing of opioids and sedatives. ADRD was not associated with opioid prescribing or co-prescribing of opioid and sedative therapy.ConclusionsOpioid and sedatives are commonly prescribed in older adults with pain. Longitudinal studies need to understand the etiology and chronicity of opioid use in older patients, specifically with ADRD.

Best Practice Alerts: A Poke in the Eye or an Efficient Method for Safer Prescribing?

Best Practice Alerts: A Poke in the Eye or an Efficient Method for Safer Prescribing?

A Novel Approach to Improving Post-Operative Pain and Minimizing Opioid Consumption After a Hip Arthroscopy.

There have been many different approaches to controlling pain in patients undergoing hip arthroscopy. These include medications, nerve blocks, and intra-articular injections among many others. We introduced a combination of a pre-operative pericapsular nerve group (PENG) block, and intra-operative pericapsular injection of BKK (bupivacaine, ketamine, and ketorolac). Patients undergoing primary hip arthroscopy were identified. There were three patient cohorts based on type of anesthesia: general anesthesia only (GA), general anesthesia and a pericapsular Marcaine injection (GA/Marcaine), or GA with pre-operative PENG block and an intraoperative BKK pericapsular injection (GA+PENG/BKK). Data collected included post-operative pain scores in the PACU (Post-Anesthesia Care Unit), time spent in the PACU, inpatient opioid consumption (both PACU and inpatient), and outpatient opioid prescriptions filled. 20 patients received GA, 11 patients received GA/Marcaine, and 20 patients received GA+PENG/BKK. The GA+PENG/BKK group had average PACU pain score of 3.9 out of 10 compared to 7.7 in the GA group (p<.001) and 6.6 in the GA/Marcaine injection group (p=.048). The GA+PENG/BKK group had shorter mean PACU times than either other group (p<.001). The GA+PENG/BKK also consumed less opioids than the GA or GA/Marcaine groups in the PACU (p<.001), and in the total inpatient stay (p=.002, p=.003), as well as outpatient (p=.019, p=.040). In patients undergoing a hip arthroscopy, performing a pre-operative PENG block and intra-operative BKK pericapsular injection will result in decreased postoperative pain, PACU time, and inpatient and outpatient opioids compared to general anesthesia only and general anesthesia with intracapsular Marcaine.

Outpatient Opioid Dispensing Patterns for SC Medicaid Children 1–36 Months Old

We sought to identify the most common diagnostic categories linked to dispensed opioid prescriptions among children 1-36 months old and changes in patterns over the years 2000 to 2017. This study used South Carolina's Medicaid claims data of pediatric dispensed outpatient opioid prescriptions between 2000 and 2017. The major opioid-related diagnostic category (indication) for each prescription was identified using visit primary diagnoses and the Clinical Classification System (AHRQ-CCS) software. The variables of interest were the rate of opioid prescriptions per 1,000 visits for each diagnostic category and the relative percentage of opioid prescriptions assigned to each category compared to all categories. Six major diagnostic categories were identified; Diseases of the respiratory system (RESP), Congenital anomalies (CONG), Injury (INJURY), Diseases of the nervous system and sense organs (NEURO), Diseases of the digestive system (GI), and Diseases of the genitourinary system (GU). The overall rate of dispensed opioid prescriptions per category declined significantly for four diagnostic categories throughout the study period, RESP by 15.13, INJURY by 8.49, NEURO by 7.33, and GI by 5.93. Two categories increased during the same time, CONG (by 9.47) and GU (by 6.98). RESP was the most prevalent category linked to a dispensed opioid prescription within 2010-2012 (almost 25%) but CONG was the most prevalent by 2014 (17.77%). Among Medicaid children 1-36 months old, annual dispensed opioid prescription rates declined for most major diagnostic categories (RESP, INJURY, NEURO, and GI). Future studies should explore alternatives to current opioid dispensing practices for GU and CONG cases.

Trends in outpatient opioid prescriptions during pregnancy by clinician specialty in utah, 2014-2017

Statewide public health efforts have sought to reduce opioid prescriptions in Utah, which has one of the highest rates of opioid prescribing during pregnancy in the country. The objective of this study was to evaluate trends in outpatient opioid prescriptions during pregnancy in Utah from 2014 to 2017 and to determine prescribing trends by clinician specialty.

Evaluation of the prescription amount of narcotic analgesics based on cancer pain relief management

Abstract Background A basic plan for promoting pain relief management for cancer patients was formulated in Japan, and proper use of narcotic analgesics is being promoted to relieve cancer pain. We aimed to explore the relationship between age and opioid narcotic dose in cancer patients and examine the effects of healthcare systems and social policies to prevent opioid abuse and addiction in a national cohort in Japan. Methods Data were collected from April 2014 to March 2019 from the nationwide health insurance claims open database in Japan. Prescription data were collected for opium alkaloids and synthetic narcotics. A multivariate logistic regression analysis was performed based on the age groups and in- or out-of-hospital prescription quantities (mg), taking into account equivalences in quantities of opioids prescribed yearly on the hypothesized relationships between variables. Results The average annual quantities of opium alkaloid prescribed gradually decreased by 2.8% (mg = 10,249,115) over six years, especially in in-hospital prescriptions. On the other hand, in-hospital annual prescriptions of synthetic narcotics increased by 24.1% (mg = 2,135,568), out-of-hospital opium alkaloid by 1.3% (mg = 37,565,229), and synthetic narcotics by 25.9% (mg = 1,404,641). Among the demographic variables, cancer patients aged 65 years or older were significantly associated with the types of opioid variables (p &amp;lt; .001) and annual reductions in prescribed amounts (p &amp;lt; .001). Conclusions Treatment with opium alkaloids and synthetic narcotics increased among outpatients in the years examined; however, the trend varied across age groups. Our findings suggest that improvements in early detection and treatment have resulted in a rise in the number of cancer patient survivors, thereby leading to an increase in narcotic analgesic dose. The palliative care for cancer patients will contribute as an epidemiological indicator to review the evidence-based health-related impact on public health. Key messages • Treatments other than medical intervention should also be considered, taking into account the increase in the number of outpatient opioid prescription recipients due to increased cancer survival. • Social interventions to prevent opioid abuse during cancer pain relief will contribute to preventing substance abuse by promoting collaboration between clinicians and local communities.

Predictors of High-Dose Initial Opioid Prescriptions in Primary Osteoarthritis: A Single Institution Analysis

Category: Ankle Arthritis; Other Introduction/Purpose: High-dose opioid prescriptions in osteoarthritis (OA) increase the risk of overdose and chronic opioid dependence, which is associated with worse perioperative outcomes in total joint arthroplasty (TJA). The purpose of this study was to determine the (1) incidence and (2) identify independent risk factors for receiving high-dose initial opioid prescriptions in OA patients. Methods: A retrospective chart review was performed to evaluate initial outpatient opioid prescriptions for OA in opioid-naïve adult patients at a single academic institution between 2013 and 2020. Patients with prior surgery or opioid prescriptions were excluded. Patient demographic data, medical comorbidities, Charlson Comorbidity Index (CCI) scores, and prescription metadata were recorded. High-dose prescriptions were defined as daily oral morphine equivalents (OME/d) &gt;=50. Univariate analysis and multivariate logistic regression were used to identify independent predictors for high-risk opioid prescriptions. Results: A total of 1,527 patients were identified with an initial opioid prescription for OA, with 21.5% of patients receiving high- dose prescriptions. The majority of high-dose prescriptions (&gt;=50 OME/d) were given oxycodone (56.1%), while low-dose prescriptions (&lt;50 OME/d) were more commonly prescribed hydrocodone-acetaminophen (34.2%) and tramadol (32.5%). Using multivariate logistic regression, patient factors that are independently associated with high-dose prescriptions include decreased age, decreased BMI, white race, and non-orthopaedic encounters. Comorbid factors that were independently predictive of high- dose prescriptions include hip OA, higher CCI scores, and depression. (Table 1) Conclusion: Independent predictors for high-dose initial opioid prescriptions in OA include younger age, decreased BMI, white race, non-orthopaedic encounters, hip OA, higher CCI scores, and depression.

Provider and patient sex disparities in opioid prescribing and patient outcomes.

To assess sex disparities in opioid prescribing practices and patient outcomes. A retrospective cross-sectional study. Thirty-three primary care clinics in an academic health system. 2,738 adults prescribed 10+ outpatient opioid prescriptions within 12 months. Patient and primary care provider (PCP) sexbased differences in clinical outcomes, opioid prescribing, and rates of adherence to guideline-concordant opioid prescribing practices. Female PCPs were more likely (p < 0.001) to prescribe lower morphineequivalent daily dose (MEDD) of opioids and complete risk assessment for opioid misuse than male PCPs. PCPs did not differ by sex in adherence rates to controlled substance agreements, urine drug, depression screening, or opioid-benzodiazepine coprescribing. Female patients were more likely (all p ≤ 0.01) to be screened for opioid misuse, treated with lower MEDD, receive opioid-benzodiazepine coprescriptions, have higher pain interference, anxiety and depression diagnoses, and have an overdose diagnosis; they were less likely (all p < 0.001) to report alcohol use or have an alcohol use disorder diagnosis and utilized health care at higher rates than male patients. Sex differences were found in clinician opioid-prescribing practices and adherence to opioid prescribing guidelines and patient characteristics associated with long-term opioid therapy. Strategies to identify sex-related disparities and enhance guideline-concordant opioid prescribing and monitoring could contribute to improved patient care, and clinical and safety outcomes.

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