Postoperative Opioid Prescribing Patterns Research Articles

Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery.

Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery. A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed. Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions. While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.

Preoperative Antidepressant Prescriptions Are Associated With Increased Opioid Prescriptions and Health Care Use but Similar Rates of Secondary Surgery Following Primary Anterior Cruciate Ligament Reconstruction in a Young Adult Population

The purpose of this study was to compare adverse events, postoperative opioid prescribing patterns, healthcare utilization, and secondary ACLR surgery rates of patients undergoing primary ACLR with a preoperative antidepressant prescription (ADP) against a propensity matched group with no preoperative antidepressant prescription (NADP) using TriNetX Diamond Network. Patients undergoing primary ACLR between ages 18 and 35 were queried from the database using ICD-10/CPT codes. ADP patients were propensity matched in a 1:1 ratio to NADP patients based on 11 patient characteristics. Post-operative rates of adverse events, emergency department (ED) visits, in-patient hospitalizations, out-patient services, physical therapy evaluations, postoperative opioid prescriptions, and secondary ACLR were compared at various time points. 3736 ADP patients with an average age of 21.4 +/- 4.5 years undergoing primary ACLR were propensity matched to NADP patients. A significantly greater percentage of ADP patients received opioid prescriptions at 2 weeks (ADP: 21%, NADP 11.3%, OR: 2.08), 6 weeks (ADP: 25.5%, NADP 13.9%, OR: 2.13), 3 months (ADP: 27.6%, NADP: 15.6%, OR: 2.07), 6 months (ADP: 30.5%, NADP 17.2%, OR: 2.1), and 1 year (ADP: 35.3%, NADP: 20.2%, OR: 2.16) postoperatively (P < 0.0001 for each time point). ADP patients had higher rates of ED visits (ADP: 9.7%, NADP: 7.1%, P<.0001, OR: 1.39) and outpatient appointments (ADP: 28.3%, NADP: 21.8%) P<.0001, OR: 1.42) at 3 months postoperatively. Secondary surgery rates at 1 and 2 years were non-significant (P = 0.381 and P = 0.062, respectively). Following ACLR, ADP patients had a significant increase in post-operative opioid prescriptions at all time points, and utilized more ED resources and outpatient services compared with NADP patients at 3 months post-operatively. 30-day post-operative adverse events and both 1- and 2-year secondary ACL surgery rates demonstrated no significant differences between the groups. Level III, cohort study.

Post-operative Opioid Reduction Protocol Reduces Racial Disparity in Clinical Outcomes in Children

IntroductionRacial disparities in health outcomes continue to exist for children requiring surgery. Previous investigations suggest that clinical protocols may reduce racial disparities. A post-operative opioid reduction protocol was implemented in children undergoing abdominal surgery who were less than 1 years old at a tertiary level hospital. The purpose of this investigation was to determine if the clinical protocol was associated with a reduction in racial disparity in post-operative opioid prescribing patterns and associated clinical outcomes. MethodsA post-operative opioid reduction protocol based on standing intravenous acetaminophen, educational sessions with nursing staff, and standardized post-operative sign-out between the surgical and NICU teams was implemented in children under 1 year old in 2016. A time series and before and after analysis was conducted using a historical pre-intervention cohort (Jan 2011–Dec 2015) and prospectively collected post-intervention cohort (Jan 2016–Jan 2021). Primary outcomes included post-operative opioid use and post-operative pain scores stratified by race. Secondary outcomes included associated clinical outcomes also stratified by race. ResultsA total of 249 children were included in the investigation, 117 in the pre-intervention group and 132 in the post intervention group. The majority of patients in both cohorts were either White or Black. The two cohorts were equally matched in terms of pre-operative clinical variables. In the pre-intervention cohort, the median post-operative morphine equivalents in White children was 2.1 mg/kg (IQR 0.2, 11.1) while in Black children it was 13.1 mg/kg (IQR 2.4, 65.3), p-value = 0.0352. In the post-intervention cohort, the median value for White children and Black children was statistically identical (0.05 mg/kg (IQR 0, 0.5) and 0.0 mg/kg (IQR 0, 0.3), respectively, p-value = 0.237). This pattern was also demonstrated in clinical variables including length of stay, intubation length and total parenteral nutrition use. In the pre-intervention cohort, the total length of stay for white children was 16 days while for black children it was 45 days (p = 0.007). In the postintervention cohort the length of stay for both White and Black children were identical at 8 days (p = 0.748). ConclusionThe use of a clinical opioid reduction protocol implemented at a tertiary medical center was associated with a reduction in racial disparity in opioid prescribing habits in children. Prior to the protocol, there was a racial disparity in clinical variables associated with prolonged opioid use including length of stay, TPN use, and intubation length. The clinical protocol reduced variability in opioid prescribing patterns in all racial groups which was associated with a reduction in variability in associated clinical variables. Level of EvidenceLevel III.

Describing the decision process of post-operative opioid and pain prescribing patterns in orthopedic and general surgeons.

To describe the post-operative opioid prescribing behaviors of orthopedic and general surgeons through the use of the Integrated Behavioral Model (IBM), and subsequently the steps and logic used by providers in determining post-operative pain prescriptions. This study was a prospective, cross-sectional, cohort study utilizing qualitative methods consisting of semistructured interviews. Data were analyzed using thematic analysis to categorize and identify themes to describe prescriber behavior. All participants were from a regional health system in central Appalachia. Mixed population of orthopedic and general surgeons who completed residency training and performed nontraumatic procedures. Categorization and identification of themes within the constructs of the IBM that described surgeon opioid prescribing. Fifteen surgeons participated in this study. Themes were identified within the context of the IBM. Attitudes by surgeons consisted of blame toward the government, a lack of personal screening of patients, and a theme of the abusing population of patients only being a small group. Norms were identified that included prescribing based on a standard prescribing set, realization of patient fear, and the idea of past mentality. Surgeons believed in their ability to prescribe responsibly and conservatively. The prescribing patterns of surgeons and their keenness to assess patients for opioid abuse vary. Most surgeons did not actively participate in screening activities but rely on ancillary staff. Surgeons utilize federal and state laws to back prescribing patterns and thwart patient attempts for additional medications. Prescribers maintain a sense of self-confidence with their own knowledge and ability to taper and keep patients from becoming reliant on opioid prescribing.

Postoperative Pain Following Coblation of Sinonasal Hereditary Hemorrhagic Telangiectasias.

Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease and epistaxis is the most common symptom. This can be treated conservatively but severe cases may require operative interventions. Endoscopic endonasal coblation of HHT lesions has been used successfully but postoperative pain management has not been well described. This study aimed to assess levels of postoperative pain and opioid use among patients with HHT who underwent coblation of sinonasal lesions. This is a longitudinal, prospective cohort study of adult patients undergoing endoscopic endonasal coblation for treatment of HHT lesions with or without bevacizumab injection between November 2019 and March 2020 at a single academic university hospital. Patients were given preoperative questionnaires and contacted via telephone 48 hours after surgery. If they reported using opioids for pain control, they were called every 2 days until they no longer used these medications. Fourteen cases, including 13 unique patients, were included in this study. Opioids were ordered on discharge in 4 cases and the average morphine milligram equivalent prescribed on discharge was 41. The median pain score on postoperative day (POD) 2 was 4 of 10. Twelve patients reported using acetaminophen and 4 were using opioid pain medications. Of those using opioid pain medications, only 1 patient was using opioid pain medication by POD 4 and denied any use after POD 10. This study is the first to analyze postoperative pain management and opioid prescribing patterns in HHT patients undergoing endonasal coblation of telangiectasias. Postoperative pain was mild to moderate and most patients stopped using opioid medications by POD 4, although the majority of patients solely used acetaminophen. Future studies with increased sample size will be useful to further identify predictors of need for analgesics postoperatively and other non-opioid adjuncts for pain control.

MP54-15 ASSOCIATION BETWEEN PRE-OPERATIVE OPIOID EXPOSURE AND POST-OPERATIVE OPIOID PRESCRIBING PATTERNS FOLLOWING MAJOR CANCER SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP54-15 ASSOCIATION BETWEEN PRE-OPERATIVE OPIOID EXPOSURE AND POST-OPERATIVE OPIOID PRESCRIBING PATTERNS FOLLOWING MAJOR CANCER SURGERY Emily Serrell, Jessica Schumacher, Manasa Venkatesh, Randi Cartmill, Robert Tyllo, Daniel Shapiro, Kyle Richards, E. Jason Abel, David Jarrard, and Tudor Borza Emily SerrellEmily Serrell More articles by this author , Jessica SchumacherJessica Schumacher More articles by this author , Manasa VenkateshManasa Venkatesh More articles by this author , Randi CartmillRandi Cartmill More articles by this author , Robert TylloRobert Tyllo More articles by this author , Daniel ShapiroDaniel Shapiro More articles by this author , Kyle RichardsKyle Richards More articles by this author , E. Jason AbelE. Jason Abel More articles by this author , David JarrardDavid Jarrard More articles by this author , and Tudor BorzaTudor Borza More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most post-operative opioid prescribing guidelines are restricted to opioid naïve populations due to a dearth of data regarding pre-operative opioid use. We aim to quantify pre- and post-operative opioid prescribing patterns among patients undergoing a major cancer surgery and measure the association between pre-operative opioid exposure and post-operative prescribing. METHODS: We used the Wisconsin Health Information Organization database, which includes commercial-payer, Medicare Advantage and Medicaid claims and captures over 75% of Wisconsin’s population. We collected demographic data on adult patients undergoing radical prostatectomy and partial or radical nephrectomy between 1/1/2017 and 12/31/2021. We evaluated pre- and post-operative opioid prescriptions, quantified opioid exposure in morphine milligram equivalents (MME), and compared prescribing characteristics between opioid naïve and opioid exposed patients (defined as those with a filled prescription in 6 months before surgery). RESULTS: We identified 3,693 patients (2,306 prostatectomy; 1,387 partial or radical nephrectomy). 23% of patients were exposed to opioids prior to surgery (18% prostatectomy, 30% nephrectomy). The median pre-operative dose was 202 MME (IQR 100-600), and fills occurred at a median time of 42 days (IQR 18-91), with increasing frequency in the weeks prior to surgery (Figure 1). After surgery, 55% of patients filled an initial opioid prescription, with a median first dose of 171 MME (IQR 100-334), equivalent to 23 oxycodone 5mg tablets. Opioid exposed patients had a significantly higher two-week post-operative dose (238 vs 142 MME, p<0.001) and number of prescriptions filled (1.46 vs 1.23, p<0.001). CONCLUSIONS: Nearly one quarter of prostatectomy and partial or radical nephrectomy patients are exposed to opioids prior to surgery. Post-operative prescribing remains at levels twice the guideline recommendations for all patients, even higher in patients with prior exposure. Understanding the implications of prior opioid exposure on the management of postoperative pain and opioid use is imperative to inform real-world care and guideline recommendations. Source of Funding: AHRQ K08HS028474 award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e759 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily Serrell More articles by this author Jessica Schumacher More articles by this author Manasa Venkatesh More articles by this author Randi Cartmill More articles by this author Robert Tyllo More articles by this author Daniel Shapiro More articles by this author Kyle Richards More articles by this author E. Jason Abel More articles by this author David Jarrard More articles by this author Tudor Borza More articles by this author Expand All Advertisement PDF downloadLoading ...

Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis.

Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA. Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared. The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272). Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients. Level III retrospective cohort.

Changes in postoperative opioid prescribing across three diverse healthcare systems, 2010-2020.

The opioid crisis brought scrutiny to opioid prescribing. Understanding how opioid prescribing patterns and corresponding patient outcomes changed during the epidemic is essential for future targeted policies. Many studies attempt to model trends in opioid prescriptions therefore understanding the temporal shift in opioid prescribing patterns across populations is necessary. This study characterized postoperative opioid prescribing patterns across different populations, 2010-2020. Administrative data from Veteran Health Administration (VHA), six Medicaid state programs and an Academic Medical Center (AMC). Surgeries were identified using the Clinical Classifications Software. Trends in average daily discharge Morphine Milligram Equivalent (MME), postoperative pain and subsequent opioid prescription were compared using regression and likelihood ratio test statistics. The cohorts included 595,106 patients, with populations that varied considerably in demographics. Over the study period, MME decreased significantly at VHA (37.5-30.1; p = 0.002) and Medicaid (41.6-31.3; p = 0.019), and increased at AMC (36.9-41.7; p < 0.001). Persistent opioid users decreased after 2015 in VHA (p < 0.001) and Medicaid (p = 0.002) and increase at the AMC (p = 0.003), although a low rate was maintained. Average postoperative pain scores remained constant over the study period. VHA and Medicaid programs decreased opioid prescribing over the past decade, with differing response times and rates. In 2020, these systems achieved comparable opioid prescribing patterns and outcomes despite having very different populations. Acknowledging and incorporating these temporal distribution shifts into data learning models is essential for robust and generalizable models.

A regional approach to reduce postoperative opioid prescribing in Ontario, Canada.

Opioid-related morbidity and mortality continue to rise in the province of Ontario. We implemented a provincial campaign to reduce the number of opioid pills prescribed at discharge after surgery in the Ontario Surgical Quality Improvement Network (ON-SQIN). Activities related to the provincial campaign were implemented between April 2019 and March 2020 and between October 2020 and March 2021. Self-reported data from participating hospitals were used to determine changes in postoperative opioid prescribing patterns across participating hospitals. A total of 33 and 26 hospitals participated in the provincial campaign in the first and second year, respectively. During the first year of the campaign, the median morphine equivalent (MEQ) from opioid prescriptions decreased significantly in a number of surgical specialties, including General Surgery (from 105 [75-130] to 75 [55-107], P < 0.001) (median, interquartile range) and Orthopedic Surgery (from 450 [239-600] to 334 [167-435], P < 0.001). The median number of opioid pills prescribed at discharge per surgery also decreased significantly, from 25 (15-53) to 15 (11-38) for 1 mg hydromorphone (P < 0.001) and 25 (20-51) to 20 (15-30) for oxycodone (P < 0.001). The decrease in opioid prescriptions continued in the second year of the campaign. Our approach resulted in a significant reduction in the number of postoperative opioids prescribed across a number of surgical specialties. Our findings indicate that evidence-based strategies derived from a regional collaborative network can be leveraged to promote and sustain quality improvement activities.

Post-operative opioid analgesic prescribing patterns in gynecologic oncology patients following the implementation of a statewide -prescription monitoring and reporting system.

To analyze the effect of the Connecticut Prescription Monitoring and Reporting System (CPMRS) on the number of opioid tablets prescribed to gynecologic oncology patients post-operatively. This was a retrospective chart review of patients who received surgery for suspicious masses, premalignant, or malignant conditions of uterus, tubes, ovaries, or cervix. Charts were divided into two groups before and after the implementation of an updated prescription monitoring system in July 2016. Quantitative data were collected on the number of opioids prescribed from hospital discharge summaries. Qualitative data included prescription and/or -recommendation of nonopioid analgesics and type of procedure (open versus minimally invasive). Demographic information included age, ethnicity, and insurance coverage. We identified a statistically significant, 50 percent decrease in opioid tablets in the After July 2016 group (n = 226) compared with the Before July 2016 group (n = 136) (p < 0.001). As anticipated, fewer opioid tablets were prescribed following minimally invasive procedures compared to open cases (p = 0.007). On examining nonopioid analgesic data, we found more patients received a prescription for nonopioid analgesics in the After July 2016 group compared with the Before July 2016 group (p < 0.001). This study confirms a decrease in opioid tablets prescribed to post-operative gynecologic oncology patients since July 2016. This difference cannot be attributed to the implementation of the CPMRS alone, but chronologically relates to updated requirements. Additionally, our results re-emphasize that minimally invasive surgery has a reduced number of prescribed opioids. A multi-institutional study is required with more patients to detail the factors involved in further decreasing opioid prescribing.

Evaluation of Prescribing Patterns Following Surgical Procedures in Opioid Naïve Patients at a Veterans Affairs Teaching Hospital.

To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates. This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations. Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation. Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.

Efficacy and Durability of Opioid Restrictive State Legislation Two Years After Implementation for Total Knee Arthroplasty

BackgroundTo curtail the U.S. opioid crisis, many states have instituted regulations that mandate time and/or dosage limits for opioid prescriptions. This study evaluates the impact of one such law, Florida House Bill 21, on postoperative opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA) and the durability of the law’s impact over time. MethodsAll patients who underwent TKA at a single institution during the same three-month period in 2017 (pre-law), 2018 (post-law), and 2020 (2 years post-law) were identified. Outcomes and measures included: prescribed morphine milligram equivalents (MME) at discharge and for the 90-day surgical episode, refill quantity with associated MME, and quantity of opioid prescribers. Patients with established chronic pain or those who underwent contralateral TKA during the 90-day window were excluded. Data was compared using a one-way analysis of variance. Significance was set at alpha <0.05. ResultsThe average MME of filled opioid prescriptions per patient during the 90-day post-surgical episode decreased from 1310 MME in 2017 to 891 MME in 2018 (P < .001). The average MME in 2020 was 814 MME, which was significantly lower than the average in 2017 (P < .001), and statistically stable compared to the average in 2018 (P = .215). ConclusionRestrictive opioid state policy implementation was associated with reduced overall MME prescription to patients undergoing TKA at discharge and for the 90-day surgical episode. There was no increase in the number of opioid refills or opioid prescribers. Durable change and continued improvement were observed 2 years after implementation of law.

Surgeon Bias in Postoperative Opioid Prescribing

The misuse of opioids is a serious national crisis that is fueled by prescriptions medications. Opioid prescribing habits are known to be highly varied amongst providers. The purpose of this study is to identify patient and surgeon characteristics that predict postoperative opioid prescribing patterns. This is a serial cross-sectional analysis of 20,497 patients who underwent general surgical procedures at a large academic center. Our primary outcome was the total amount of opioids prescribed within 30days of the surgery. Univariate and multivariate linear regression models were used to identify patient and provider characteristics that were associated with increased opioids prescribed. Among patient characteristics studied, patient age, sex, ethnicity, and insurance status were found to have a significant association with the amount of opioids prescribed. Younger patients and male patients received higher morphine milligram equivalents (MMEs) on discharge (p < 0.05). Patients of Hispanic background were prescribed significantly lower opioids compared to Non-Hispanic patients (p < 0.0001). Among the provider characteristics studied, surgeon sex and years in practice were significantly predictive of the amount of opioids prescribed, with surgeons in practice for <15years prescribing the highest MMEs (p < 0.0001). While opioid prescribing habits after surgery seem highly varied and arbitrary, we have identified key predictors that highlight biases in surgeon opioid prescribing patterns. Surgeons tend to prescribe significantly larger amounts of opioids to younger, male patients and those of certain ethnic backgrounds, and surgeons with fewer years in practice are more likely to prescribe more opioids.

Georgia Quality Improvement Programs Multi-Institutional Collection of Postoperative Opioid Data Using ACS-NSQIP Abstraction

Excessive postoperative opioid prescribing contributes to opioid misuse throughout the US. The Georgia Quality Improvement Program (GQIP) is a collaboration of ACS-NSQIP participating hospitals. GQIP aimed to develop a multi-institutional opioid data collection platform as well as understand our current opioid-sparing strategy (OSS) usage and postoperative opioid prescribing patterns. This study was initiated 7/2019, when 4 custom NSQIP variables were developed to capture OSS usage and postoperative opioid oral morphine equivalents (OMEs). After pilot collection, our discharge opioid variable required optimization for adequate data capture and was expanded from a free text option to 4 drop-down selection variables. Data collection then continued from 2/2020-5/2021. Logistic regression was used to determine associations with OSS usage. Average OMEs were calculated for common general surgery procedures and compared to national guidelines. After variable optimization, the percentage where a total discharge prescription OME could be calculated increased from 26% to 70% (P < .001). The study included 820 patients over 10 operations. There was a significant variation in OSS usage between GQIP centers. Laparoscopic cases had higher odds of OSS use (1.92 (1.38-2.66)) while OSS use had lower odds in black patients on univariate analysis (.69 (.51-.94)). On average 7 out of the 10 cases had higher OMEs prescribed compared to national guidelines recommendations. Developing a multi-institutional opioid data collection platform through ACS-NSQIP is feasible. Preselected drop-down boxes outperform free text variables. GQIP future quality improvement targets include variation in OSS use and opioid overprescribing.

Postoperative opioid prescribing patterns in the geriatric patient population

BackgroundOpioid prescription patterns in elderly patients undergoing general surgery are not well characterized. The purpose of this study was to identify trends in postoperative opioid prescriptions in geriatric patients undergoing general surgery procedures and determine prescribing differences between the geriatric and non-geriatric patient population. MethodsWe retrospectively evaluated geriatric and non-geriatric patients undergoing the most frequently performed open and laparoscopic general surgery procedures at our institution from 2014 to 2019. Differences in opioid prescriptions between the groups were analyzed. ResultsWe identified 5874 non-geriatric and 3306 geriatrics patients who underwent the included procedures at our institution. 5169 (88.0%) of non-geriatric patients and 2692 (81.4%) of geriatric patients received a perioperative opioid prescription. While the vast majority of both groups were prescribed opioids, geriatric patients were less likely to receive an opioid prescription (p < 0.0001). Between 2016 and 2019, the amount of opioid prescribed in the geriatric population decreased each year (p < 0.0001). Prescription amounts were significantly higher in geriatric patients aged 65–74 compared to patients 85 or older (p < 0.0001). ConclusionsIndividuals older than 65 years of age represent a growing percent of the population and there is a need to better understand opioid prescribing practices in this complex patient group. Postoperative opioid prescribing patterns differ significantly between the geriatric and non-geriatric patient population and warrant further investigation.

Evaluation of Postoperative Pain Management Using an Opioid-Sparing Protocol in Pediatric Surgical Patients.

Since the 1990s, the U.S. has faced increasing rates of opioid overuse, misuse, and overdose deaths. To combat the opioid epidemic, there have been national initiatives to limit prescribing of opioids. At our institution, we implemented an opioid-sparing protocol in pediatric surgical patients and sought to evaluate its impact on postoperative opioid prescribing patterns. A retrospective chart review of the electronic medical record was performed for 9- to 18-year-old patients who underwent a laparoscopic appendectomy or cholecystectomy before and after the implementation of an opioid-sparing protocol. Data on postoperative opioids administered during the hospitalization and prescribed at discharge, postoperative pain control, use of non-opioid analgesics, and safety were collected. A total of 81 patient charts were analyzed. The median amount of opioids administered during hospitalization was 8 MMEs and 15 MMEs in the pre-implementation and post-implementation, respectively (P = 0.310). The median amount of opioids prescribed at discharge was 150 MMEs and 60 MMEs in the pre-implementation and post-implementation, respectively (P = 0.006). Patients reported mild pain scores throughout the hospitalization in both groups. Among young patients who underwent laparoscopic appendectomy or cholecystectomy, the administration of opioids during hospitalization for postoperative pain was minimal. The opioid sparing protocol did not reduce the amount of inpatient postoperative opioids administered but found a decrease in the amount of opioids prescribed at discharge. The study findings identified further areas of intervention and education to optimize postoperative opioid prescribing after these common pediatric surgical procedures.

Opioid Prescriptions Following Otologic Surgery: A Population-Based Study.

To examine postoperative opioid-prescribing patterns following otologic surgery. Retrospective population-based descriptive study. All hospitals in the Canadian province of Ontario. Of all patients with advanced ear surgery between July 1, 2012, and March 31, 2019, 7 cohorts were constructed: tympanoplasty with or without ossiculoplasty (n = 7812), atticotomy/limited mastoidectomy (n = 1371), mastoidectomy (n = 3717), semicircular canal occlusion (SCO; n = 179), stapedectomy (n = 2735), bone-implanted hearing aid insertion (n = 280), and cochlear implant (n = 2169). Prescriptions filled for narcotics postoperatively were calculated per morphine milligram equivalent (MME) opioid dose. Multivariable regression was used to determine predictors of higher opioid doses. The mean ± SD MMEs prescribed were as follows: tympanoplasty with or without ossiculoplasty, 246.77 ± 1380.78; atticotomy/limited mastoidectomy, 283.32 ± 956.10; mastoidectomy, 280.56 ± 1018.50; SCO, 328.61 ± 1090.86; stapedectomy, 164.64 ± 657.18; bone-implanted hearing aid insertion, 326.11 ± 1054.66; and cochlear implant, 200.87 ± 639.93. SCO (odds ratio [OR], 1.69 [95% CI, 1.16-2.48]) and mastoidectomy (OR, 1.50 [95% CI, 1.36-1.66]) were associated with higher opioid doses than tympanoplasty-ossiculoplasty. Asthma (OR, 1.24 [95% CI, 1.12-1.38]), chronic obstructive pulmonary disease (OR, 1.29 [95% CI, 1.12-1.47]), myocardial infarction (OR, 1.33 [95% CI, 1.05-1.68]), diabetes (OR, 1.22 [95% CI, 1.08-1.39]), and substance-related and addictive disorders (OR, 2.59 [95% CI, 1.67-4.00]) were associated with higher opioid doses prescribed. Overall MME prescribed by year demonstrates a sharp drop from 2017-2018 to 2018-2019. This large comprehensive population study provides insight into the prescribing patterns following otologic surgery. The large amounts prescribed and substantial variation require further study to determine barriers that limit good opioid-prescribing stewardship in the postoperative period.

Opioid prescribing practices in academic otolaryngology: A single institutional survey

ObjectivesOpioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing. MethodsThis quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents. ResultsA total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively). ConclusionThere was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education.Level of evidence: 4.

Impact of policy-based and institutional interventions on postoperative opioid prescribing practices

BackgroundWe assessed the impact of policy-based and institutional interventions to limit postoperative opioid prescribing. MethodsRetrospective cohort study of patients who underwent laparoscopic/open appendectomies, laparoscopic/open cholecystectomies, and laparoscopic/open inguinal hernia repair during a 6-month interval in 2018 (control), 2019 (post-policy intervention), and 2020 (post-institutional intervention) to assess changes in postoperative opioid prescribing patterns. A survey was collected for the 2020 cohort. ResultsComparing the 762 patients identified in 2018, 2019, and 2020 cohorts there was a significant decrease in mean opioid tabs prescribed (23.5 ± 8.9 vs. 16.2 ± 7.0 vs. 12.8 ± 4.9, p < 0.01) and mean OME dosage (148.0 ± 68.0 vs. 108.6 ± 51.8 vs. 95.4 ± 38.0, p < 0.01), without a difference in refill requests. Patient survey (response rate 63%) indicated 91.4% of patients reported sufficient pain control. ConclusionFormalized opioid-prescribing guidelines and statewide regulations can significantly decrease postoperative opioid prescribing with good patient satisfaction. Surgeon education may facilitate efforts to minimize narcotic over-prescription without compromising pain management.

Changes in Single-Specialty Postoperative Opioid Prescribing Patterns in Response to Legislation: Single-Institution Analysis Over Time.

To determine changes in the prescriptions of postoperative opioids in response to Florida state legislation restricting the number of days for which these medications could be prescribed to 3 days in most circumstances or 7 days at provider discretion. A retrospective review was performed for all patients undergoing 7 common outpatient otolaryngology surgical procedures. Single-institution academic center in Florida. Query of the state's online prescription drug monitoring program was used to compare prescription habits 3 months before and after the law and then again 1 year later. A total of 561 patients were identified meeting criteria. The number of days that opioids were prescribed decreased significantly, from 6.42 to 4.48 to 3.03 days. There was a significant decrease in the proportion of patients receiving any postoperative opioid prescription, from 0.80 to 0.52 to 0.32. The total morphine milligram equivalents prescribed decreased from 28.4 before the law to 18.4 at 1 year after. Legislative restrictions on the length of opioid prescriptions were associated with significant decreases in the proportion of patients receiving any opioids, the number of days that opioids were prescribed, and the total morphine milligram equivalents 3 months after the law went into effect, with even more dramatic changes at the 1-year time point. We opine that these changes are due to providers learning that many procedures do not require postoperative opioids and therefore increasingly considering and utilizing nonopioid alternatives in this setting.