Postoperative Opioid Prescribing Research Articles

Association of Race and Ethnicity With Postoperative Gabapentinoid and Opioid Prescribing Trends for Older Adults

BackgroundDisparities in opioid prescribing by race/ethnicity have been described in many healthcare settings, with White patients being more likely to receive an opioid prescription than other races studied. As surgeons increase prescribing of nonopioid medications in response to the opioid epidemic, it is unknown whether postoperative prescribing disparities also exist for these medications, specifically gabapentinoids. MethodsWe conducted a retrospective cohort study using a 20% Medicare sample for 2013–2018. We included patients ≥66 years without prior gabapentinoid use who underwent one of 14 common surgical procedures. The primary outcome was the proportion of patients prescribed gabapentinoids at discharge among racial and ethnic groups. Secondary outcomes were days’ supply of gabapentinoids, opioid prescribing at discharge, and oral morphine equivalent (OME) of opioid prescriptions. Trends over time were constructed by analyzing proportion of postoperative prescribing of gabapentinoids and opioids for each year. For trends by year by racial/ethnic groups, we ran a multivariable logistic regression with an interaction term of procedure year and racial/ethnic group. ResultsOf the 494,922 patients in the cohort (54% female, 86% White, 5% Black, 5% Hispanic, mean age 73.7 years), 3.7% received a new gabapentinoid prescription. Gabapentinoid prescribing increased over time for all groups and did not differ significantly among groups (P = 0.13). Opioid prescribing also increased, with higher proportion of prescribing to White patients than to Black and Hispanic patients in every year except 2014. ConclusionsWe found no significant prescribing variation of gabapentinoids in the postoperative period between racial/ethnic groups. Importantly, we found that despite national attention to disparities in opioid prescribing, variation continues to persist in postoperative opioid prescribing, with a higher proportion of White patients being prescribed opioids, a difference that persisted over time.

Enhanced recovery program in ambulatory pediatric urology: A quality improvement initiative

Enhanced Recovery After Surgery (ERAS) was established in 2001 for adult patients undergoing complex procedures. ERAS in adult ambulatory surgery later followed with similar positive outcomes. For the pediatric population, ERAS implementation has shown promising results in complex surgeries such as bladder reconstruction. Its application in pediatric ambulatory surgery has only recently been reported. We hereby report a Quality Improvement initiative in implementing an Enhanced Recovery Protocol (ERP) for pediatric urology in an ambulatory surgery center. A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used. The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged. This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.

STANDARD OPIATE PRESCRIBING IN PEDIATRIC AND ADOLESCENT GYNECOLOGIC SURGERY TO REDUCE OPIATE USE: BRIEF REPORT

Study objective: The aim of this quality improvement (QI) project was to assess postoperative narcotic use after pediatric gynecologic surgeries and establish standard postoperative opioid dosing. Through standard dosing we hoped to decrease variability in postoperative opioid prescriptions and decrease excess opioid doses in the community. Methods: This QI project was approved by the Children's Minnesota IRB. Counseling on postoperative pain management was provided pre- and post-operatively. At the two-week postoperative visit, patients were asked the number of opioid doses used and pain control satisfaction. Baseline data was collected for 6 months with surgeons prescribing the number of opioid doses based on their personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established, and data collection repeated. Results: Complete data was recorded for 30 cases prior to implementation of standard doses and for 29 cases following implementation. Standardized opioid dosing resulted in 30% decrease in total opioid doses in circulation (252→176 doses; P=0.014) and 15% reduction in excess doses in circulation (162→137 doses). Forty-three percent of patients did not use any opioid doses. There was no significant difference P=0.8818) in patient pain control satisfaction rating. Conclusions: Standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient pain control satisfaction. Opioid dose standardization may decrease opioid circulation within the community. Approximately 2 out of every 5 patients used zero opioid doses which suggests further reduction in the standard dose prescriptions is possible.

Drivers of Variation in Opioid Prescribing after Common Surgical Procedures in a Large Multihospital Healthcare System.

Misuse of prescription opioids is a well-established contributor to the United States opioid epidemic. The primary objective of this study was to identify which level of care delivery (i.e. patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures. Electronic health record (EHR) data from a large multihospital healthcare system was used in conjunction with random-effect models to examine variation in opioid prescribing practices following similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation. Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5mg oxycodone tablets following surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents (MMEs) prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider. Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing.

Deep learning predicts postoperative opioids refills in a multi-institutional cohort of surgical patients

BackgroundTo combat the opioid epidemic, several strategies were implemented to limit the unnecessary prescription of opioids in the postoperative period. However, this leaves a subset of patients who genuinely require additional opioids with inadequate pain control. Deep learning models are powerful tools with great potential of optimizing health care delivery through a patient-centered focus. We sought to investigate whether deep learning models can be used to predict patients who would require additional opioid prescription refills in the postoperative period after elective surgery. MethodsThis is a retrospective study of patients who received elective surgical intervention at the Mayo Clinic. Adult English-speaking patients ≥18 years old, who underwent an elective surgical procedure between 2013 and 2019, were eligible for inclusion. Machine learning models, including deep learning, random forest, and eXtreme Gradient Boosting, were designed to predict patients who require opioid refills after discharge from hospital. ResultsA total of 9,731 patients with mean age of 62.1 years (51.4% female) were included in the study. Deep learning and random forest models predicted patients who required opioid refills with high accuracy, 0.79 ± 0.07 and 0.78 ± 0.08, respectively. Procedure performed, highest pain score recorded during hospitalization, and total oral morphine milligram equivalents prescribed at discharge were the top 3 predictors for requiring opioid refills after discharge. ConclusionDeep learning models can be used to predict patients who require postoperative opioid prescription refills with high accuracy. Other machine learning models, such as random forest, can perform equal to deep learning, increasing the applicability of machine learning for combating the opioid epidemic.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study

BackgroundClinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear.MethodsUsing a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients’ surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool.ResultsOf the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME.ConclusionsPsychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Association Between Opioid-Related Mortality and History of Surgical Procedure: A Population-Based Case-Control Study

Objective: This study examined whether there is an association between opioid-related mortality and surgical procedures. Methods: A case-control study design using deceased controls compared individuals with and without opioid death and their exposure to common surgeries in the preceding 4 years. This population-based study used linked death and hospitalization databases in Canada (excluding Quebec) from January 01, 2008 to December 31, 2017. Cases of opioid death were identified and matched to 5 controls who died of other causes by age (±4 years), sex, province of death, and date of death (±1 year). Patients with HIV infection and alcohol-related deaths were excluded from the control group. Logistic regression was used to determine if there was an association between having surgery and death from an opioid-related cause by estimating the crude and adjusted odds ratios (ORs) with the corresponding 95% confidence interval (CI). Covariates included sociodemographic characteristics, comorbidities, and the number of days of hospitalization in the previous 4 years. Results: We identified 11,865 cases and matched them with 59,345 controls. About 11.2% of cases and 12.5% of controls had surgery in the 4 years before their death, corresponding to a crude OR of 0.89 (95% CI: 0.83–0.94). After adjustment, opioid mortality was associated with surgical procedure with OR of 1.26 (95% CI: 1.17–1.36). Conclusions: After adjusting for comorbidities, patients with opioid mortality were more likely to undergo surgical intervention within 4 years before their death. Clinicians should enhance screening for opioid use and risk factors when considering postoperative opioid prescribing.

Changes in lymph node surgery in breast cancer and preoperative drug prescription analysis for postoperative pain management: A retrospective, cross-sectional study.

This study aimed to investigate the changes in lymph node surgery types and prescription patterns of postoperative medications for pain management in patients with breast cancer using national health insurance claim data from South Korea. The study population comprised patients with at least one record of a principal diagnosis of breast cancer (ICD-10 code: C50) from the national health insurance claim database between 2010 and 2019. Patients who underwent mastectomy or lumpectomy only once were selected for the analysis. Patients who underwent axillary lymph node dissection (ALND) with mastectomy or lumpectomy on the day of surgery were included in the ALND group, whereas those who underwent sentinel lymph node biopsy (SLNB) were included in the SLNB group. Prescription records of opioids before, after and on the date of breast cancer surgery were collected and categorized according to the opioid type. Multivariate logistic regression modeling was used to compare postoperative opioid prescriptions. The proportion of those undergoing ALND among 3,080 patients decreased consistently after 2014, while the proportion undergoing SLNB increased. Although the rate of pain medication prescription on the day of surgery was similar between the two groups, the rate of prescription of postoperative pain medication and anticancer agents was lower in the SLNB group than in the ALND group. Logistic regression modeling showed that the SLNB group had lower odds of receiving opioids than did the ALND group (Odds ratio (OR) = 0.727, Confidence Interval (CI) = 0.546-0.970). A consistent trend was observed when the model was adjusted for neoadjuvant chemotherapy and the use of preoperative pain medications (OR = 0.718, CI = 0.538-0.959). To manage postoperative pain and prevent chronic pain with minimal side effects, sufficient discussion among clinicians, patients, and other healthcare professionals is imperative, along with adequate treatment planning.

Predictors of persistent opioid use in bladder cancer patients undergoing radical cystectomy: A SEER-Medicare analysis

PurposeTo evaluate patient and provider characteristics that predict persistent opioid use following radical cystectomy for bladder cancer including non-opioid naïve patients. MethodsPatients undergoing cystectomy between July 2007 and December 2015 were identified using the SEER-Medicare database. Opioid exposure was identified before and after cystectomy using Medicare Part D data. Multivariable analyses were used to identify predictors of the primary outcomes: persistent opioid use (prescription 3–6 months after surgery) and postoperative opioid prescriptions (within 30 days of surgery). Secondary outcomes included physician prescribing practices and rates of persistent opioid use in their patient cohorts. ResultsA total of 1,774 patients were included; 29% had prior opioid exposure. Compared to opioid-naïve patients, non-opioid naïve patients were more frequently younger, Black, and living in less educated communities. The percentage of persistent postoperative use was 10% overall and 24% in non-opioid naïve patients. Adjusting for patient factors, opioid naïve individuals were less likely to develop persistent use (OR 0.23) while a 50-unit increase in oral morphine equivalent per day prescribed following surgery nearly doubled the likelihood of persistent use (OR 1.98). Practice factors such as hospital size, teaching affiliation, and hospital ownership failed to predict persistent use. 29% of patients filled an opioid prescription postoperatively. Opioid naïve patients (OR 0.13) and those cared for at government hospitals (OR 0.59) were less likely to fill an opioid script along with those residing in the Northeast. Variability between physicians was seen in prescribing practices and rates of persistent use. ConclusionsNon-opioid naïve patients have higher rates of post-operative opioid prescription than opioid-naïve patients. Physician prescribing practices play a role in persistent use, as initial prescription amount predicts persistent use even in non-opioid naïve patients. Significant physician variation in both prescribing practices and rates of persistent use suggest a role for standardizing practices.

Evaluation of an Opioid-free Pathway for Perineal Reconstructive Surgery: A 1-year Pilot Study

ObjectiveTo evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution. MethodsPatients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record in order to assess the efficacy of an opioid-free pathway. Results67 patients met criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription. ConclusionAn opioid-free pathway is appropriate for opioid naïve men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain.

Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital

Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for...

Outpatient Prescription Opioid Use following Discharge after Deep Inferior Epigastric Perforator Breast Reconstruction with and without an Educational Intervention.

There is limited evidence for appropriate postoperative opioid prescribing in autologous breast reconstruction. We sought to describe postoperative outpatient prescription opioid use following discharge after deep inferior epigastric perforator (DIEP) breast reconstruction with and without an educational video. Patients undergoing DIEP reconstruction were given a 28-day postoperative pain and medication logbook from August 2022 to June 2023. Our practice implemented an educational video upon discharge on proper opioid consumption. Descriptive statistics on patient characteristics, intraoperative and postoperative opioid consumption, and outpatient prescription opioid use after discharge were compared between the two cohorts. A total of 53 logbooks were completed with 20 patients in the no video cohort and 33 in the video cohort. On average, the days to cessation of opiates was longer in the no video cohort (8.2 vs. 5.1 days, p = 0.003). The average number of oxycodone 5 mg equivalents consumed following discharge was 13.8 in the no video cohort and 7.8 in the video cohort, which was statistically significant (p = 0.01). Overall, the percentage of opioids prescribed that were consumed in the video cohort was 28.3% versus 67.1% in the no video cohort. For patients discharging home after DIEP reconstruction, we recommend a prescription for 12 oxycodone 5 mg tablets. With the use of an educational video regarding proper opioid consumption, we were able to reduce the total outpatient opioid use to 5 oxycodone 5 mg tablets following hospital discharge.

Current evidence of multimodal anesthesia on postoperative outcomes (ICTRP).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Current evidence of multimodal anesthesia on postoperative outcomes (ClinicalTrials.gov).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Current evidence of multimodal anesthesia on postoperative outcomes (Web of Science).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Current evidence of multimodal anesthesia on postoperative outcomes (Ovid MEDLINE).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Current evidence of multimodal anesthesia on postoperative outcomes (Ovid Embase).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Current evidence of multimodal anesthesia on postoperative outcomes (CINAHL).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Current evidence of multimodal anesthesia on postoperative outcomes (Cochrane Library).

Abstract In times of the opioid crisis in the USA and Europe there is a growing interest in reducing peri- and correlated postoperative opioid consumption and prescription. One approach of dealing with the reduction of opioid application is opioid-free anesthesia (OFA). Despite some uncontestable advantages of OFA, it remains a contentious issue. Multimodal anesthesia (MMA) offers a comprehensive and patient-centered alternative to OFA, and could be considered as a change in paradigm. The goal of MMA is to provide superior perioperative pain management while minimizing the risks and limitations associated with opioids. By improving patient satisfaction, amending pain control, diminishing side effects of opiate utilization, accelerating recovery, alleviation of the opioid crisis and optimization of scarce resources multimodal anesthesia has the potential to transform the field of anesthesiology and perioperative medicine. This systematic review is conducted to examine the current evidence of multimodal anesthesia on postoperative outcomes.

Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use.

Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline. We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed. A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively. Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.