Postoperative Opioid Prescribing Research Articles

A randomized trial of standard vs restricted opioid prescribing following midurethral sling

Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens. Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points. Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval,-∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P<.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P<.001). Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.

Postoperative opioid prescribing, use and pain trends following general surgery procedures: a retrospective cohort study among veterans comparing non-opioid versus chronic opioid users

IntroductionUnderstanding postoperative opioid use patterns among different populations is key to developing opioid stewardship programs.MethodsWe performed a retrospective cohort study on opioid prescribing, use, and pain after general surgery procedures...

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.

Does In-Hospital Opioid Use Affect Opioid Consumption After Total Joint Arthroplasty?

Preoperative opioid use strongly correlates with greater postoperative opioid use and complications following total joint arthroplasty (TJA). However, there is a lack of information regarding the effect of opioid consumption during the hospital stay and within the operating room on postoperative opioid use. We retrospectively reviewed 369 consecutive patients undergoing primary TJA at an academic center over a 9-month period. Ninety-day preoperative and postoperative opioid prescriptions were obtained from the state's drug monitoring database. In-hospital opioid consumption data was obtained from the preoperative unit, operating room, postanesthesia care unit (PACU), and hospital floor. Multivariate analysis was utilized to compare patients' total in-hospital opioid consumption with their preoperative and postoperative use, along with opioid use throughout the hospitalization. Total in-hospital opioid consumption was independently associated with postoperative opioid use (rs= 0.17, P= .0010). Opioids consumed on the hospital floor correlated with opioid use in the preoperative unit (rs= 0.11, P= .0338) and PACU (rs= 0.15, P= .0032). Increased preoperative opioid consumption was the greatest risk factor for excessive postoperative use (rs= 0.44, P < .0001). A greater proportion of patients <65 years of age were high posthospital opioid consumers (P= .0146) and significantly more TKA patients were in the higher use groups (P= .0006). In-hospital opioid use is independently associated with preoperative and postoperative consumption. Preoperative opioid use remains the greatest risk factor for increased opioid consumption after TJA. Multimodal approaches to decrease reliance on opioids for pain control during hospitalization may offer hope to further decrease postoperative usage. III.

MP16-01 EFFECT OF SURGERY-SPECIFIC FINANCIAL INCENTIVE ON OPIOID PRESCRIBING PRACTICES: OUTCOMES OF A STATEWIDE SURGICAL COLLABORATIVE

You have accessJournal of UrologyCME1 May 2022MP16-01 EFFECT OF SURGERY-SPECIFIC FINANCIAL INCENTIVE ON OPIOID PRESCRIBING PRACTICES: OUTCOMES OF A STATEWIDE SURGICAL COLLABORATIVE John Michael DiBianco, Stephanie Daignault-Newton, Bronson Conrado, David Wenzler, Hector Pimentel, S. Mohammad Jafri, Rebn Frontera, Jessica Phelps, John Hollingsworth, Khurshid R. Ghani, Casey A. Dauw, and for the Michigan Urological Surgery Improvement Collaborative John Michael DiBiancoJohn Michael DiBianco More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Bronson ConradoBronson Conrado More articles by this author , David WenzlerDavid Wenzler More articles by this author , Hector PimentelHector Pimentel More articles by this author , S. Mohammad JafriS. Mohammad Jafri More articles by this author , Rebn FronteraRebn Frontera More articles by this author , Jessica PhelpsJessica Phelps More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reducing unnecessary opioid prescriptions after ureteroscopy (URS) has been advocated. The Michigan Pain Optimization Pathway (MPOP) was a payor initiative begun in 7/2019 funded by Blue Cross Blue Shield of Michigan that provided a 35% increased reimbursement to urologists if no opioids were prescribed after URS. It is unknown how financial incentives effect opioid prescribing practices after ambulatory URS. We therefore aimed to understand the effect of this statewide financial incentive on opioid prescribing after URS as compared to shockwave lithotripsy (SWL) where no such incentive was in place. METHODS: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry we identified all SWL and URS cases from 2018-2020. We separated cases by date with January 2018 - June 2019 as pre-MPOP and July 2019 - December 2020 as post-MPOP. We assessed surgeon rates of postoperative opioid prescription by treatment modality. Urologists (N=80) who had performed at least 5 SWL and URS during the study period were included. We compared opioid prescription rates pre- and post-MPOP by modality. Changes were classified as increase, small decrease and large decrease, defined as any rate increase, ≤20% and >20%, respectively. Change in pre- and post-MPOP opioid rates between SWL and URS paired by surgeon were compared using the signed rank test. RESULTS: A total of 17,355 cases (5,027 SWL and 12,328 URS) were performed. Rates of opioid prescriptions pre- and post-MPOP after SWL were 64.2% and 45.6% (p<0.001) and URS were 54.4% and 24.4% (p<0.001). For SWL, 31% of urologists demonstrated an increase, 39% demonstrated a small decrease, and 30% demonstrated a large decrease. For URS, 16% of urologists demonstrated an increase, 35% demonstrated a small decrease, and 49% demonstrated a large decrease (Figure). Both SWL and URS had a reduction in opioid prescriptions, with urologists reducing their prescribing more for URS than for SWL (p=0.001). CONCLUSIONS: Opioid prescriptions after ambulatory stone surgery decreased over the last 3 years in the state of Michigan. Urologists reduced opioid prescriptions significantly more for URS than SWL, suggesting the benefit of payor incentives to change practice to align with quality improvement. Source of Funding: Blue Cross Blue Shield of Michigan © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e274 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Michael DiBianco More articles by this author Stephanie Daignault-Newton More articles by this author Bronson Conrado More articles by this author David Wenzler More articles by this author Hector Pimentel More articles by this author S. Mohammad Jafri More articles by this author Rebn Frontera More articles by this author Jessica Phelps More articles by this author John Hollingsworth More articles by this author Khurshid R. Ghani More articles by this author Casey A. Dauw More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF DownloadLoading ...

Outcomes of Opioid-Free Pathways Post-Ureteroscopy: Joint Analysis From Two Academic Centers

ObjectiveTo combat alarming postoperative opioid prescribing in the United States (U.S.), many surgical specialties implement pathways to limit routine use of opioids with the goal of zero opioid prescribing. We sought to examine outcomes after implementing non-opioid post ureteroscopy (URS) pathways at two academic centers in the U.S.Materials and MethodsWe examined patients who underwent URS utilizing a non-opioid postoperative pathway from November 1, 2016 – March 31, 2020. Primary outcomes included adverse events (Emergency Department (ED) presentation, and office phone calls for postoperative genitourinary symptoms).ResultsIn total, 699 patients underwent URS with stent placement. Of these, 652 (89.4%) were discharged without opioids and 74 (10.6%) received opioids. Of those discharged without opioids, 484 (77.4%) received non-steroidal anti-inflammatory medications. Compared to patients discharged without opioids, patients prescribed opioids were more likely to present to the ED (67 (10.7%) vs 14 (19.9%), p=0.037) and call the clinic (102 (16.3%) vs 22 (29.7%), p=0.004). In a multivariate analysis, patients prescribed opioids post URS (OR 1.9, 95% CI 1.1 – 3.5, p=0.024) and patients who had an opioid prescription preop (OR 2.2, 95% CI 1.1 – 4.5, p=0.032) were associated with higher odds of calling the clinic. Older patients (OR 0.98, 95% CI 0.97 – 0.99, p=0.006) were less likely to call.ConclusionsThe study highlights almost 90% of patients can be discharged safely without opioids following URS. In our cohort, patients prescribed opioids experienced higher postoperative healthcare interactions. We hope our results encourage consideration of non-opioid pathways.

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.

Tailored order set in the electronic health record decreases postoperative opioid prescriptions

BackgroundAdherence to opioid prescribing protocols after operations remains challenging despite published guidelines. Integration of these guidelines with the electronic health record could potentially improve their adoption. We hypothesize that implementing an electronic health record order set containing prepopulated tablet quantities tailored to surgical procedures based on published guidelines will decrease postoperative opioid prescription. MethodsWe conducted a 12-month prepost intervention study on adult patients who underwent appendectomy, cholecystectomy, inguinal or umbilical hernia repair, thyroidectomy, or parathyroidectomy at a single institution. An electronic health record order set was developed with prepopulated opioid tablet quantities reflecting the upper limit of published recommendations. The primary endpoint was change in morphine milligram equivalent prescribed postintervention and was analyzed using linear regression adjusting for age, race, procedure, and prescriber training level. Secondary endpoints were emergency department visits for pain-related issues and opioid refill rates. ResultsWe identified 524 patients (mean age = 53, 51% male) in our baseline cohort and 433 patients (mean age = 52, 58% male) in our postintervention group. The mean morphine milligram equivalent prescribed was 62.6 and 50.4 for the preintervention and postintervention cohorts, respectively (P = .049). Thyroidectomies and parathyroidectomies achieved the largest decrease after intervention, which decreased to 42.6 morphine milligram equivalent from 79.7 morphine milligram equivalent preintervention (P < .001). Refill rate was 1.6% postintervention compared to 3.1% preintervention (P = .20), and emergency department visit for pain control rate was 0.2% post intervention and 2.5% preintervention (P = .005). ConclusionAn electronic health record tailored order set based on prescription guidelines is a safe, effective, and scalable intervention for decreasing opioid prescriptions after operations.

Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers.

Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

Perioperative Medicine: Managing for Outcome, 2nd Edition

Perioperative Medicine: Managing for Outcome, 2nd Edition

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.

Ibuprofen prescription following adult tonsillectomy reduces postoperative opioid use

BackgroundBased on a 2018 American Academy of Otolaryngology - Head and Neck Surgery survey, an average of 37 tablets of opioid medication, or about a week's worth of medication, were prescribed after adult tonsillectomy. Nearly 15% of patients will still be taking opioids one year after an initial weeklong prescription, according to data from the Centers for Disease Control and Prevention. Non-steroidal anti-inflammatory medications have traditionally been avoided in adult tonsillectomy patients due to concern for increased bleeding risk from platelet dysfunction, despite little evidence supporting this claim. This study sought to demonstrate that ibuprofen prescriptions after tonsillectomy could be a safe and effective way to reduce postoperative opioid use. MethodsThis study was a retrospective chart review of patients undergoing tonsillectomy with one surgeon over three years. Half of the patients received a prescription for postoperative opioid medications and were counseled against taking ibuprofen. The other half of patients were prescribed ibuprofen following surgery and only provided with opioid analgesia as a rescue medication. The New Mexico Prescription Monitoring System was used to verify opioid prescriptions. Descriptive statistics and logistic regression were used to analyze the data. ResultsNinety-nine patients were included in analysis, with 53 in the first group that did not receive ibuprofen and 46 in the second group that did receive ibuprofen. There was no difference in the bleeding rate between the two groups. Significantly fewer patients in the ibuprofen group filled postoperative opioid prescriptions when compared to the group that did not receive ibuprofen (40% vs. 96.2%, p < 0.0001, OR = 0.02). ConclusionIbuprofen is a safe and effective analgesic following adult tonsillectomy and significantly reduces the proportion of patients who must fill a postoperative opioid prescription.

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.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome

BackgroundWe sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy. Methods104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length. ResultsThe average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed. ConclusionPatient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system. Level of evidenceIII, retrospective cohort study.

Chronic opioid use after joint replacement surgery in seniors is associated with increased healthcare utilization and costs: a historical cohort study.

Postoperative opioid use may be associated with increased healthcare utilization and costs. We sought to examine the relationship between duration of postoperative opioid prescriptions and healthcare costs and resource utilization in senior patients following hip and knee replacement. We conducted a historical cohort study evaluating postoperative opioid use and healthcare costs in patients over the age of 65 yr undergoing primary total hip or knee arthroplasty over a ten-year period from 1 April 2006 to 31 March 2016. The last follow-up date was 31 March 2017. We identified preoperative and postoperative opioid prescriptions, patient characteristics, and healthcare costs using deidentified Ontario administrative databases (Institute of Clinical Evaluative Sciences). Duration of postoperative opioid use was divided into four categories: short-term (1-90 days), prolonged (91-180 days), chronic (181-365 days), and undocumented. The study included 49,638 hip and 85,558 knee replacement patients. Although the initial hospitalization accounted for the greatest cost in all patients, over the following year patients in the short-term opioid use group incurred the lowest average costs, and those in the chronic group incurred the highest (hip, CAD 17,528 vs CAD 26,736; knee, CAD 16,043 vs CAD 23,007), driven by increased healthcare resource utilization. Chronic opioid use after arthroplasty was associated with higher resource utilization and healthcare costs during the year following surgery. These results can be used to develop predictors of longer opioid use and higher costs. Further research is planned to determine whether recently implemented opioid reduction strategies can reduce healthcare resource utilization.

Hip Fracture Surgery: Regional Anesthesia and Opioid Demand.

Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery. This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables. After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand. RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery. Level III, retrospective, therapeutic cohort study.

Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice

BackgroundOpioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia. Material/methodA systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0–18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records. ResultsFifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33–100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male – 113, median age – 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04–0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14–0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge. ConclusionThere is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.

Association of opioid exposure before surgery with opioid consumption after surgery

ObjectiveTo determine the effect of prescription opioid use in the year before surgery on opioid consumption after surgery.BackgroundRecently developed postoperative opioid prescribing guidelines rely on data from opioid-naïve patients. However,...

A machine learning algorithm for predicting prolonged postoperative opioid prescription after lumbar disc herniation surgery. An external validation study using 1,316 patients from a Taiwanese cohort

Preoperative prediction of prolonged postoperative opioid prescription helps identify patients for increased surveillance after surgery. The SORG machine learning model has been developed and successfully tested using 5,413 patients from the United States (US) to predict the risk of prolonged opioid prescription after surgery for lumbar disc herniation. However, external validation is an often-overlooked element in the process of incorporating prediction models in current clinical practice. This cannot be stressed enough in prediction models where medicolegal and cultural differences may play a major role. The authors aimed to investigate the generalizability of the US citizens prediction model SORG to a Taiwanese patient cohort. Retrospective study at a large academic medical center in Taiwan. Of 1,316 patients who were 20 years or older undergoing initial operative management for lumbar disc herniation between 2010 and 2018. The primary outcome of interest was prolonged opioid prescription defined as continuing opioid prescription to at least 90 to 180 days after the first surgery for lumbar disc herniation at our institution. Baseline characteristics were compared between the external validation cohort and the original developmental cohorts. Discrimination (area under the receiver operating characteristic curve and the area under the precision-recall curve), calibration, overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithm in the validation cohort. This study had no funding source or conflict of interests. Overall, 1,316 patients were identified with sustained postoperative opioid prescription in 41 (3.1%) patients. The validation cohort differed from the development cohort on several variables including 93% of Taiwanese patients receiving NSAIDS preoperatively compared with 22% of US citizens patients, while 30% of Taiwanese patients received opioids versus 25% in the US. Despite these differences, the SORG prediction model retained good discrimination (area under the receiver operating characteristic curve of 0.76 and the area under the precision-recall curve of 0.33) and good overall performance (Brier score of 0.028 compared with null model Brier score of 0.030) while somewhat overestimating the chance of prolonged opioid use (calibration slope of 1.07 and calibration intercept of -0.87). Decision-curve analysis showed the SORG model was suitable for clinical use. Despite differences at baseline and a very strict opioid policy, the SORG algorithm for prolonged opioid use after surgery for lumbar disc herniation has good discriminative abilities and good overall performance in a Han Chinese patient group in Taiwan. This freely available digital application can be used to identify high-risk patients and tailor prevention policies for these patients that may mitigate the long-term adverse consequence of opioid dependence: https://sorg-apps.shinyapps.io/lumbardiscopioid/.