Predictors Of Postoperative Opioid Use Research Articles

Rate and predictors of postoperative opioid use and high opioid exposure after surgery in New Zealand: a retrospective study.

Although excessive opioid use is a significant global health issue, there is a lack of literature on the prescribing patterns for postoperative opioid use and exposure after discharge among surgical patients. This study aimed to examine the rate and predictors of opioid dispensing and high opioid exposure after hospital discharge from surgery in New Zealand (NZ) between January 2007 to December 2019. This is a retrospective population-based cohort study inclusive of all ages and surgical specialties. Data were obtained from the NZ Ministry of Health's national health databases. 1 781 059 patients were included in the study and 20.9% (n = 371 882) of surgical patients received opioids within 7 days after hospital discharge. From those who were dispensed with opioids after hospital discharge, 36.6% (n = 134 646) had high opioid exposure. Orthopaedic surgery (AOR 6.97; 95% CI 6.82-7.13) and history of opioid use (AOR 3.18; 95% CI 2.86-3.53) increased the odds of postoperative opioid dispensing and high opioid exposure respectively. Severe multi-morbidity burden (AOR 0.76; 95% CI 0.73-0.78) and alcohol misuse (AOR 0.84; 95% CI 0.77-0.93) lowered the odds of postoperative opioid dispensing and high opioid exposure respectively. Our findings suggest a concerning rate of high opioid exposure among surgical patients after discharge. The predictors for postoperative opioid dispensing and high opioid exposure identified in our study provide insight into opioid prescribing patterns in NZ and inform future postoperative pain management.

Predictors of postoperative opioid use in ventral and incisional hernia repair.

One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription. VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison. 205 patients were included in the study (average age 53.5years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001). Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.

Grit and postoperative opioid use after total joint arthroplasty.

Perioperative multimodal protocols following total joint replacements have significantly decreased the amount of perioperative and postoperative opioids. Further identification of those requiring more or less opioids through individualisation, may further aid in reducing the amount prescribed. Therefore, the purpose of the study was to evaluate whether a patient's grit, the measurable psychological strength of character to persevere during hardship, measured by postoperative opioid consumption. Consecutive patients who had undergone either primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) from February 2019 to August 2020 at our institution logged their opioid use for the first 2 weeks postoperatively, detailing the type, dosage, and number of narcotics they consumed. Those who completed their logs and a grit questionnaire had their average morphine equivalent dose (MED) and grit score calculated. Analysis was then performed to evaluate if any association existed between these 2 variables. There was no correlation between grit score and postoperative opioid consumption in the first 2 weeks following discharge after total joint arthroplasty. A total of 144 patients were eligible to participate and a total of 86 patients met inclusion criteria, 48 patients in the TKA group and 38 in the THA group. Of all patients, 63% were male. The average MED was 95.5 for THAs and 192 for TKAs. The average grit score was 4.23 for THAs and 4.19 for TKAs. There is not an apparent association between grit score and postoperative opioid consumption in the first 2 weeks after total joint arthroplasty. General psychological resiliency may not be an important predictor of postoperative opioid use with modern postoperative protocols.

Application of risk assessment tools to predict opioid usage after shoulder surgery.

BackgroundCurrently 128 people die daily from opioid-related overdoses in the United States. This burden has instigated a search for viable means to guide postoperative prescription decision-making. The Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patient with Pain (SOAPP) are validated risk assessment tools to predict opioid usage in high-risk populations. The purpose of this study was to evaluate the accuracy of these opioid risk assessments and pain intensity scores, including the Patient-Reported Outcomes Measurement Information System (PROMIS), to predict postoperative opioid use and dependence in shoulder surgery.MethodsA retrospective review of 81 patients who underwent shoulder surgery and completed 3 preoperative risk and pain assessments within a single hospital system from 2018 to 2020 was performed. Demographic variables and ORT-O, SOAPP-R (the revised version of the SOAPP assessment), and PROMIS 3a scores were recorded from preoperative assessments. Opioid prescriptions were recorded from Electronic-Florida Online Reporting of Controlled Substances Evaluation. Dependence was defined as opioid prescriptions at or greater than 3 months after surgery. Risk assessment scores were compared and tested against postoperative opioid prescriptions using statistical analyses and logistic regression modeling.ResultsIn the cohort, there were 36 female and 45 male patients with an average age of 64.5 years and body mass index of 28.0. Preoperatively, the average pain score was 6.2, and 7.8% of patients reported prolonged preoperative narcotics use. The average ORT-O score was 3.0, with 35.8% of patients defined as either medium or high risk, and the average PROMIS pain intensity preoperatively was 10.8. Neither the ORT-O nor the PROMIS pain score were good predictors of postoperative opioid dependence (area under curve = 0.39 and 0.43, respectively). The SOAPP-R performed slightly better (area under curve = 0.70) and was the only assessment with significantly different mean scores between patients with postoperative opioid dependence and those without (33.4 and 24.5, respectively, P = .049) and a moderate correlation to postoperative total morphine equivalents (R = 0.46, P = .007).ConclusionWith recent focus on preoperative risk assessments to predict postoperative opioid use and dependence, it is important to understand how well these tools work when applied to orthopedic patients. While the ORT may be helpful in other fields, it does not seem to be a strong predictor of postoperative opioid use or dependence in patients undergoing various types of shoulder surgery. Future studies are needed to explore the utility of the SOAPP-R in a larger sample and identify tools applicable to the orthopedic population to assist surgeons in screening at-risk patients.

Predictive Factors for Postoperative Opioid Use in Elective Skull Base Craniotomies.

Objective In 2017, the United States officially declared opioid overuse a public health emergency. Due to a paucity of published benchmark data in skull base neurosurgery, we quantified postoperative opioid use in patients undergoing skull base craniotomies and identified factors that influence postoperative opioid use. Setting Tertiary academic medical center. Participants Patients who underwent elective craniotomies by two skull base neurosurgeons between January 2015 and May 2020. Main Outcome Measures Demographic and perioperative data were retrospectively extracted from the electronic medical record. Surgical approaches were categorized as having either "significant" or "minimal" muscle dissection. Univariate and multivariate linear regression analyses were performed to identify predictors of postoperative opioid use at 24, 48, and 72 hours. Results We included 300 craniotomies, 206 were supratentorial and 94 were infratentorial. This included 195 women and 105 men, with a mean age of 54.9 years. In multivariable analysis, a history of anxiety or depression, preoperative opioid use, and a history of migraines independently predicted a significantly greater opioid use at 24, 48, and 72 hours. Increased age and minimal muscle dissection independently predicted lower opioid consumption. Sex, infratentorial versus supratentorial approach, length of surgery, and postoperative steroid use did not impact total opioid use. Conclusion Younger age, history of anxiety or depression, preoperative opioid consumption, preexisting history of migraines, and significant intraoperative muscle dissection were associated with higher postoperative opioid consumption. These risk factors provide insight on potential targets for minimizing postoperative opioids in craniotomies.

Evaluating Age as a Predictor of Postoperative Opioid Use and Prescribing Habits in Older Adults With Cancer

To assess the narcotic use of older patients after oncologic resection. Retrospective review. Adults with neoplasms undergoing resection at a tertiary academic medical center. Open and minimally invasive resections of the pancreas, bowel, rectum, lung, breast, and skin were included. Emergent procedures, chronic opioid users, and benign pathology were excluded. Narcotic use was measured using morphine equivalents (MEQs, milligrams of morphine) at multiple time points and compared between younger and older (aged ≥65years) patients. Refill requests were within 30days of index procedure. A total of 445 patients were eligible, and 245 were ≥65years old. Despite longer length of stay (3 vs 2days, P= .01), older patients used less narcotic medication [39.8 (150) mg vs 84 (229) mg, P= .004], and reported lower pain scores [1.3 (3.3) vs 2.8 (4.5), P= .0001] over the course of their hospitalization. Additionally, older patients had lower normalized narcotic use [15.3 (150) mg vs 77.4 (240) mg, P=.0001] in the last 48hours of their admission. Following discharge, older patients had a lower median discharge MEQ (DC MEQ) compared with younger patients, 75 (150) mg vs 112.5 (102.5) mg, P= .002. Further stratifying older patients into age cohorts (65-74years, 75-84years, ≥85years) revealed progressively less narcotic use as measured by total inpatient MEQ and final 48hours. Additionally, progressively older patients were discharged with progressively lower DC MEQ compared with younger patients, 90 (112.5) mg, 50 (131.3) mg, and 0 (60) mg vs 112.5 (102.5) mg, P < .0001, respectively. Finally, older patients requested refills less often than younger counterparts, 6.5% vs 14.5%, P= .006. Older patients with cancer reported lower pain scores, consumed less narcotics, were discharged with significantly less narcotics, and called for refills less often compared with younger patients after surgery. These data suggest this population may require less opioids for satisfactory pain control, and development of a guideline targeting postoperative multimodal analgesia in older adults is warranted.

Risks of Preoperative Opioid Therapy on Ankle Surgery Success

Category:Ankle; HindfootIntroduction/Purpose:Past studies have found that preoperative chronic opioid therapy correlates with increased opioid use post-operatively as well as potentially worse surgical outcomes; however, these trends have not been extensively studied in cases of hindfoot fusions or ankle replacement (TAA). Therefore, we aimed to fill this gap in the research and understand the relationship between preoperative opioid use and postoperative success in order to improve patient outcomes. We hypothesized that patients with chronic opioid use prior to surgery would have increased likelihood of postoperative opioid use, complications, and re-operation.Methods:A retrospective review was conducted of ankle (AA), talo-navicular (TN), and tibio-talo-calcaneal (TTC) fusions, as well as TAAs from December 2014-August 2020 by a single fellowship trained foot and ankle surgeon. Pre- and postoperative opioid and other analgesic use, medical history, demographics, and surgical outcomes were reviewed. Statistical analysis was preformed using correlation, linear multivariate regression, independent-samples t-test, and one-way ANOVA. One-hundred and fifty-two patients (female=66, male=86) with mean BMI of 31.7 and mean follow-up of 1.35 years were included. Thirty-nine underwent isolated AA, 28 TTC, 85 TAA, 9 TAA + other hindfoot fusions, 1 pan-talar fusion, and 1 TN + ankle fusion. Seventeen had a history of substance abuse (i.e., EtOH, opioids, benzodiazepines, other substances). Records of preoperative opioid use were limited to 93 patients, 90-day postoperative opioid use to 81 patients, and 120-day postoperative opioid use to 73 patients.Results:Preoperative opioid use was significantly associated with reoperation rate (P=.027) and continued postoperative opioid use at 90 (P<.001) and 120 days (P<.001). Preoperative benzodiazepine use was significantly associated with continued postoperative benzodiazepine use at 90 (P<.001) and 120 days (P<.001). There was no significant difference in postoperative opioid use, complications, or reoperation rate between substance abusers and other patients. Female sex (P=.029) and BMI (P=.013) were significant predictors of postoperative opioid use. Of comorbidities, mental illness was a significant predictor of postoperative opioid use (P=.022); substance abuse history (P=.006) and mental illness (P=.001) were significant predictors of postoperative benzodiazepine use. In addition, postoperative opioid use significantly differed by surgery type (fusion=64.5 MME, TAA=28.0 MME, TAA + fusion=859.6 MME; P<.001), but postoperative benzodiazepine use did not.Conclusion:We found that patients with pre-operative opioid use have statically significantly higher rates of re-operation and continued post-operative opioid use. We also found that on average, patients undergoing hindfoot fusion require statically significantly more narcotics than those undergoing total ankle arthroplasty. Patients and surgeons should be aware of this data to help appropriately council patients on post-operative expectations.

Risks of Preoperative Opioid Therapy on Forefoot and Hindfoot Surgery Success

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Past studies in total joint arthroplasty and orthopaedic trauma have found that preoperative opioid therapy correlates with increased postoperative opioid use and lesser surgical outcomes. To date, these trends have not been studied in cases of forefoot or hindfoot foot and ankle surgery. We hypothesized that patients with preoperative chronic opioid use would have increased likelihood of postoperative opioid use, complications, and re-operation.Methods:A retrospective review was conducted of forefoot, midfoot and hindfoot surgeries performed from January 2015- September 2020 by a fellowship trained foot and ankle surgeon at an academic medical center. Pre- and postoperative opioid and other analgesic use, medical history, demographic data, operative treatment, and surgical outcomes were reviewed. Records of preoperative opioid use were limited to 50 patients, 90-day postoperative opioid use to 60 patients, and 180-day postoperative opioid use to 69 patients. A total of 149 patients (female=102, male=47) with a mean BMI of 30.87 and mean follow-up up of 1.2 years were included. Of the patients undergoing hindfoot, midfoot, or forefoot arthrodesis, 71/79 joints went on to union, while there were 8 non-unions (3 sub-talar, 2 metatarsophalangeal, 1 tibiotalar, 1 talo-navicular, and 1 calcaneocuboid). The most common procedures were hammertoe correction and Achilles tendon repair. Statistical analysis was performed using correlation, linear multivariate regression, and one-way ANOVA.Results:Preoperative opioid use was statistically significantly associated with loss to follow-up (users=10.0%, non-users=0.0%; p=.044) and continued postoperative opioid use at 90 (92%; p<.001) and 180 days (94%; p<.001). Preoperative benzodiazepine use was significantly associated with continued postoperative benzodiazepine use at 90 (20%; p<.001) and 180 days (26%; p<.001). Of comorbidities, diabetes (p=.007) and psychiatric disease (p=.025) were significant predictors of postoperative opioid use.Psychiatric disease was also a significant predictor of postoperative benzodiazepine use (p=.026). Postoperative opioid use significantly differed by surgical indication (post-traumatic=20.52 MME, prior procedure(s)=232.51 MME, instability=7.64 MME, osteomyelitis=4.67 MME; p<.001), but postoperative benzodiazepine use did not. Additionally, follow-up duration significantly differed by operated area (hindfoot=1.48 years, forefoot=0.92 years, both=3.02 years; p<.001).Conclusion:We found that patients with preoperative opioid use have statistically significantly higher rates of loss to follow-up and continued postoperative opioid use. We also found that on average, patients with a history of prior procedures on the forefoot and/or hindfoot require statistically significantly more narcotics than those with a history of post-traumatic injuries, instability, or osteomyelitis. Patients and surgeons should be aware of this data to help appropriately council patients on post- operative expectations.

Preoperative Opioid Use Predicts Postoperative Opioid Use and Inferior Clinically Notable Outcomes After Total Shoulder Arthroplasty.

Preoperative opioid use (OU) may negatively affect outcomes after total shoulder arthroplasty (TSA). This study aims to evaluate the influence of preoperative OU on achievement of midterm clinically notable outcomes (CSOs) after TSA and identify factors associated with prolonged postoperative OU and persistent pain after TSA. Using a single-institution, prospectively collected TSA registry, we retrospectively identified patients who underwent surgery between 2014 and 2019. Subjects were stratified into two cohorts: preoperative OU within 12 months of surgery and opioid naive (N-OU) patients. Minimum 1-year postoperative scores and achievement of CSOs patient-reported outcome measures (PROMs), as well as predictors of postoperative OU and persistent pain, were analyzed. A total of 817 patients were included with 706 patients in the N-OU cohort and 111 patients in the OU cohort. Although both patients in the N-OU and OU cohorts showed statistically significant improvements at the 1-year follow-up, absolute PROM scores were less favorable in the OU cohort (all P < 0.05). Preoperative opioid users were significantly less likely to achieve minimal clinically important difference (odds ratios [ORs]: 0.47 to 2.4, all P < 0.05) and patient acceptable symptomatic state (ORs: 0.41 to 2.12, all P < 0.05) on the American Shoulder and Elbow Surgeon, Single Assessment Numeric Evaluation, Constant-Murley Shoulder Score, Visual Analogue Scale (VAS) pain, Veterans Rand 12-Item Health Survey, Short-Form 12-Item Health Survey, and Veterans Rand 6D and substantial clinical benefit (OR: 0.50 to 0.56, P < 0.05) on the American Shoulder and Elbow Surgeon and Single Assessment Numeric Evaluation. Preoperative OU significantly predicted increased OU at 6 months (OR: 7.11, P = 0.009) and 1-year follow-up (OR: 40.23, P < 0.001) and persistent pain at 1 year (OR: 2.37, P = 0.001). Preoperative OU markedly correlated with worse PROMs at 1 year postoperatively. Although preoperative opioid users demonstrate improvement in functional-related and health-related quality-of-life PROMs after TSA, they are markedly less likely to achieve CSOs and were more likely to report persistent pain and continued OU at 6-month and 1-year follow-ups. Opioid users undergoing TSA should be counseled regarding their expected outcomes, and preventive measures should aim to limit prolonged OU/abuse after surgery. Level III, retrospective cohort study.

Development and validation of the Gynecologic Oncology Predictor Of Postoperative opioid use (GO-POP) model

<h3>Objectives:</h3> With increasing use of minimally invasive surgical techniques and same-day discharges, the need to predict pain medication use on the day of surgery is critical to post-operative pain control, patient satisfaction and public health concerns. Our goal was to develop and externally validate a statistical model for predicting postoperative opioid use following gynecologic surgery in an increasingly minimally invasive surgical population, incorporating patient-reported surgical concerns. <h3>Methods:</h3> We prospectively enrolled 382 women scheduled for abdominal surgeries (including laparotomies and minimally invasive approaches [MIS]) in an academic gynecologic-oncology practice to a study to develop and validate a predictor of outpatient opioid pill use. Negative binomial, zero-inflated negative binomial, and ordinal regression models were developed using an initial cohort of 216 women enrolled from February 2018-March 2019 and followed for 6 weeks postoperatively. A total of 39 candidate predictors were considered, including preoperative assessments of anxiety and anticipated pain as well as intra-operative factors. The primary model outcome was the number of opioid pills used postoperatively. After fitting models using best predictors, all models were internally validated with 1000 bootstrap samples to obtain bias-corrected accuracy using ordinal concordance index and calibration curves. All models' predictions were then externally validated using a second cohort (n=166) enrolled from May 2019-February 2020. The best model (GO-POP) was updated by combining cohorts and an online calculator and nomogram were created. GO-POP included 7 predictors: age, total operating time, patient's self-reported pre-operative anticipated need for pain medication, whether pregabalin was administered preoperatively, patient educational attainment, smoking history and patients' self-reported preoperative anxiety. <h3>Results:</h3> Most surgeries were performed using MIS approaches (276; 72.3%) while 52 (13.6%) patients underwent planned laparotomies and 14.1% had planned MIS approaches converted to laparotomies. Median total number of opioid pills was 7 in the combined cohort. Nearly 40% of subjects used 0 pills after hospital discharge. After external validation, an updated combined model had the best fit, with ordinal concordance of 0.646 (95% CI:0.615, 0.679). Over 1/3rd of patients were either not planning to dispose of unused opioids or had not yet decided how to handle unused pills. A nomogram was created to facilitate clinical use of the model. <h3>Conclusions:</h3> A prospectively constructed and validated model accurately estimates the number of opioid pills used by women after gynecologic surgery. Use of the GO-POP nomogram enables providers to tailor prescriptions using information available immediately following surgery. More work is needing to educate patients on the importance of disposal of unused opioids post-operatively to protect our communities.

Predictors of postoperative opioid use in NCAA Division 1 collegiate athletes

BackgroundWith the growing severity of the opioid epidemic in the United States, it is increasingly important for surgeons to understand the opioid requirements of their patients, especially in the population of collegiate athletes. The purpose of this study is to determine variables influencing the quantity of total morphine milligram equivalents (TMEs) and percent of prescribed TMEs used following surgery in Division 1 collegiate athletes. MethodsA consecutive cohort of 25 Division 1 collegiate athletes from one institution undergoing knee or shoulder surgery at a single hospital for sport-related injuries between December 2016 and December 2018 were retrospectively identified. A regional prescription drug monitoring program was used to verify discharge medications. Patients were instructed to bring their unused pills to a follow-up visit 2–4 days after surgery. The amount of opioids prescribed and used was standardized using morphine conversion factors to determine milligram morphine equivalents. TMEs Used was determined by summing the amount of morphine equivalents the patients used of their discharge opioids. The Percent of TMEs Used was determined by dividing the amount of TMEs used by the amount of TMEs prescribed at discharge. Demographic variables and other regulated prescriptions were also recorded. Bivariate and multivariate analyses were used to determine variables that influence and/or predict the amount of TMEs Used and Percent of TMEs Used. ResultsMultivariable regression found that a history of non-analgesic controlled substance use (p = 0.027) and the amount of TMEs prescribed at discharge (p < 0.001) were both independent predictors of the amount of TMEs Used. Operative site (p = 0.047) and number of prior orthopaedic surgeries (p = 0.016) were independent predictors of the Percent of TMEs Used. ConclusionsProviders for Division I collegiate athletes should carefully consider a patient’s nonanalgesic controlled substance history, comorbidities, and prescribed opioid burden when planning a postoperative pain management course.

Perioperative Serum 25-Hydroxyvitamin D Levels as a Predictor of Postoperative Opioid Use and Opioid Use Disorder: a Cohort Study.

Vitamin D deficiency is associated with chronic pain syndromes and higher opioid use among cancer patients, but its association with opioid use among opioid-naïve subjects following a major surgical procedure with acute pain has not been explored. To determine the association between serum 25-hydroxyvitamin D (25(OH)D) levels, opioid use, and opioid use disorder. We identified commercially insured subjects aged 18-64years with available perioperative serum 25-hydroxyvitamin D (25D) levels who underwent one of nine major surgical procedures in 2000-2014. Primary outcomes were dose and duration of opioid use measured using pharmacy claims. Secondary outcome was opioid use disorder captured using diagnosis codes. Multivariable negative binomial models with generalized estimating equations were performed examining the association between 25D levels and postoperative opioid use measures, adjusting for age, sex, race/ethnicity, Charlson score, education, income, latitude, and season of blood draw. Adjusted Cox regression was used to examine the association with opioid use disorder. Among 5446 subjects, serum 25(OH)D was sufficient (≥ 20ng/mL) among 4349 (79.9%) subjects, whereas 837 (15.4%) had insufficient (12 to < 20ng/mL) and 260 (4.8%) had deficient (< 12ng/mL) levels. On multivariable analysis, as compared with subjects with sufficient 25(OH)D levels, subjects with deficient 25(OH)D levels had 1.7 more days (95% CI 0.76, 2.58) of opioid use per year and had 98.7 higher morphine milligram equivalent dose (95% CI 55.7, 141.8) per year. Among 11,713 study cohort, subjects with deficient 25(OH)D levels were more likely to be diagnosed with opioid use disorders (HR 2.41; 95% CI 1.05, 5.52). Patients undergoing common surgical procedures with deficient 25D levels are more likely to have higher opioid use and an increased risk of opioid use disorder compared to those with sufficient levels. Serum 25D levels may serve as a biomarker to identify subjects at increased risk of opioid misuse.

Preoperative Opioids Associated With Increased Postoperative Opioid Use in Pediatric Appendicitis

BackgroundIn light of current opioid-minimization efforts, we aimed to identify factors that predict postoperative opioid requirement in pediatric appendicitis patients. MethodsA single-center retrospective cohort study was conducted of children (<18 y) who underwent laparoscopic appendectomy for acute appendicitis between January 1, 2018 and April 30, 2019. Patients who underwent open or interval appendectomies were excluded. The primary outcome was morphine milliequivalents (MMEs) per kilogram administered between 2 and 24 h after surgery. Multivariable analyses were performed to evaluate predictors of postoperative opioid use. Clinically sound covariates were chosen a priori: age, weight, simple versus complicated appendicitis, preoperative opioid administration, and receipt of regional or local anesthesia. ResultsOf 546 patients, 153 (28%) received postoperative opioids. Patients who received postoperative opioids had a longer median preadmission symptom duration (48 versus 24 h, P < 0.001) and were more likely to have complicated appendicitis (55% versus 21%, P < 0.001). Patients who received postoperative opioids were more likely to have received preoperative opioids (54% versus 31%, P < 0.001). Regional and local anesthesia use was similar between groups. Nearly all patients (99%) received intraoperative opioids. Each preoperative MME per kilogram that a patient received was associated with receipt of 0.29 additional MMEs per kilogram postoperatively (95% confidence interval, 0.19-0.40). ConclusionsPreoperative opioid administration was independently associated with increased postoperative opioid use in pediatric appendicitis. These findings suggest that preoperative opioids may potentiate increased postoperative pain. Limiting preoperative opioid exposure, through strategies such as multimodal analgesia, may be an important facet of efforts to reduce postoperative opioid use.

Resolution of Pain and Predictors of Postoperative Opioid use after Bridge-Enhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction

PurposeTo compare postoperative pain scores and opioid use between patients undergoing a standard arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring autograft with those undergoing a suture repair augmented with an extracellular matrix scaffold (bridge-enhanced ACL repair) performed through an arthrotomy and to determine factors predictive of postoperative opioid use and levels of overprescription.MethodsA nonrandomized controlled trial was conducted with 20 patients (10 ACLR, 10 bridge-enhanced ACL repair), aged 18 to 35 years. All surgeries were performed by a single surgeon. A pain medication log was provided to patients on discharge. No regional anesthesia was performed. Pain scores via a visual analog pain scale were recorded at each visit. Correlations between preoperative and intraoperative characteristics and postoperative opioid use were determined.ResultsThe total morphine-equivalent dose ranged from 30 to 309 mg (4-42 pills oxycodone) for the ACLR group and 75 to 254 mg (10-34 pills oxycodone) for the bridge-enhanced ACL repair group. The average opioid use per day was 35.8 mg for the patients undergoing bridge-enhanced ACL repair and 44.2 mg for patients undergoing ACLR (P = .29). Pain scores at time points up to 2 years postoperatively were not significantly different between the 2 groups. Across both groups, the average oversupply of oxycodone was 46 pills per patient, a greater than 70% unused opiate rate. Preoperative body mass index and preoperative Knee Injury and Osteoarthritis Outcome Scores pain score were predictive of greater postoperative opioid use per day, whereas age, concurrent meniscal repair, and operative time were not.ConclusionsTotal overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. Both groups had similar pain scores from 2 weeks to 2 years postoperatively. Greater body mass index and greater preoperative pain (lower Knee Injury and Osteoarthritis Outcome Scores pain score) correlated with greater postoperative opioid use per day. There was an overprescription of opioids across all patients.Level of EvidenceLevel III, case control study (therapeutic).

Implementation of Opioid-Free Thyroid and Parathyroid Procedures: A Single Center Experience

BackgroundInitial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations. Materials and methodsThis is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription. ResultsA total of 515 patients were enrolled in the study: 240 in the control or “pre-intervention” cohort (May through October 2017) and 275 in the intervention or “post” cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001). ConclusionsOpioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia.

Pain Related Psychological Factors Influence Postoperative Opioid Use After Ambulatory Hand Surgery

Grant support received from: 2016 AFSH Residents and Fellows Fast Track Grant Consulting Fee: Medartis (Fufa) Contracted Research: Medatis (Fufa) Pain related psychological factors, including pain catastrophization and dispositional mindfulness, have been shown to influence patient pain levels and outcomes after orthopedic surgery. Less is known about the relationship between these factors and postoperative opioid use after hand surgery. The purpose of this study is to examine the association between preoperative pain catastrophization and mindfulness and postoperative opioid use in patients undergoing ambulatory hand surgery. Patients undergoing ambulatory hand surgery at our institution between May 2017 and January 2018 were prospectively enrolled in an ongoing clinical trial. Procedures (Figure 4-1) were separated into 2 tiers based on anticipated postoperative pain. Patients completed the Pain Catastrophizing Scale (PCS) and Mindfulness Attention Awareness Scale (MAAS) preoperatively (Figure 4-2A). Patients completed a pain medication diary for 2 weeks postoperatively and were contacted on postoperative days 3, 8, and 15 to review their medication usage and pain levels. Spearman’s correlations and Mann Whitney U tests were performed to evaluate the association between PCS/MAAS scores and postoperative opioid use, average patient-reported pain levels, and refill rates (Figure 2B). A total of 71 patients (57% male), mean age 60.2, were included in the analysis (46.4% tier 1 procedures, 53.5% tier 2 procedures). The average total number of opioids used at 2 weeks postoperatively across all procedures was 6.78 pills (range 0-49). Age and sex were not associated with postoperative opioid use. Tier 2 procedures were associated with increased postoperative opioid use, higher average postoperative week 1 pain, and higher refill rates (P = .05) (Figure 4-2B). •Patients demonstrating higher pain catastrophizing scores preoperatively used more opioids postoperatively after a range of ambulatory hand surgeries.•In the setting of the opioid epidemic, hand surgeons should be aware of pain-related psychological factors that can influence postoperative opioid use.•Further studies evaluating predictors of postoperative opioid use may help identify patients for preoperative pain education and pain coping/reduction techniques.Figure 4-2APain Catastrophizing and Mindfulness Attention Awareness Scale Scores (†: PCS= Pain Catastrophizing Scale. Range of scale is 0-52; MAAS= Mindfulness Attention Awareness Scale. Range of scale is 1-6.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4-2BAssociation between PCS/MAAS Score and Postoperative Pain and Opioid use (€= Median [range] for continuous variables, Number of patients [% of cohort] for categorical variables, ρ= Spearman’s correlation coefficient; *= significant P values are defined as <.05Show full caption; ♮= Median [Range])View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) ; ♮= Median [Range]) This research was supported by a Residents & Fellows Fast Track Grant from the American Foundation for Surgery of the Hand.

Does liposomal bupivacaine use intraoperatively decrease postoperative narcotic use in radical cystectomy patients?

311 Background: Bupivacaine liposome injectable suspension (LB) can be used to help control postoperative pain. It slowly releases bupivacaine for up to 96 hours after injection. This study sought to determine if the use of LB intraoperatively for radical cystectomy (RC) patients decreases postoperative narcotic use. Methods: A retrospective cohort study was performed. 281 patients underwent RC between November 2013 and May 2016, 203 received LB. LB was administered after fascial closure but before skin closure by performing suprafascial and subfascial injection with 20ml of LB. Patient demographics, BMI, renal function, operative characteristics, and the total postoperative intravenous morphine equivalents were reviewed. Where appropriate chi-squared, Mann-Whitney and t-tests were used for statical analysis. Multivariable analysis and linear regression models were performed. Because enhanced recovery principles were used simultaneously, enhanced recovery status was also used to adjust for predictors of post-operative opioid use. Results: There was no difference in baseline demographics, BMI, renal function or baseline opioid use between the LB and non-LB group. The operative time was longer in those who had LB administered and there were more open RCs performed in the LB group. Total morphine equivalents averaged to 8.0 mgs for the LB group and 50.7 mgs for the non-LB group, p-value &lt;0.001. More patients had epidurals and IV PCA pumps in the non-LB group, (p=0.001 and &lt;0.001, respectively). There were 42 patients whom did not require any IV morphine equivalents in the LB group compared to only 4 in the non-LB group (p=0.002). After adjusting for modality, and operative time, the linear regression model was predictive of less IV morphine equivalents in those with LB, p=0.044. Conclusions: The addition of LB to enhanced recovery principles increases the number of patients with zero narcotic use postoperatively. Irrespective of open or robotic modality and operative time, LB use decreases opioid use after RC.

The Fibromyalgia Survey Score Correlates With Preoperative Pain Phenotypes But Does Not Predict Pain Outcomes After Shoulder Arthroscopy.

Fibromyalgia (FM) characteristics can be evaluated using a simple, self-reported measure that correlates with postoperative opioid consumption after lower-extremity joint arthroplasty. The purpose of this study was to determine whether preoperative pain history and the FM survey score can predict postoperative outcomes after shoulder arthroscopy, which may cause moderate to severe pain. In this prospective study, 100 shoulder arthroscopy patients completed preoperative validated self-report measures to assess baseline quality of recovery score, physical functioning, depression, anxiety, and neuropathic pain. FM characteristics were evaluated using a validated measure of widespread pain and comorbid symptoms on a 0 to 31 scale. Outcomes were assessed on postoperative day 2 (opioid consumption [primary], pain, physical functioning, quality of recovery score), and day 14 (opioid consumption, pain). FM survey scores ranged from 0 to 13. The cohort was divided into tertiles for univariate analyses. Preoperative depression and anxiety (P<0.001) and neuropathic pain (P=0.008) were higher, and physical functioning was lower (P<0.001), in higher FM survey score groups. The fibromyalgia survey score was not associated with postoperative pain or opioid consumption; however, it was independently associated with poorer quality of recovery scores (P=0.001). The only independent predictor of postoperative opioid use was preoperative opioid use (P=0.038). FM survey scores were lower than those in a previous study of joint arthroplasty. Although they distinguished a negative preoperative pain phenotype, FM scores were not independently associated with postoperative opioid consumption. Further research is needed to elucidate the impact of a FM-like phenotype on postoperative analgesic outcomes.