Prescriptions For Acute Pain Research Articles

A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing.

To explore the continuum of pain and addiction for patients with chronic pain (CP) who used opioids during a time of restrictive opioid prescribing in West Virginia. This qualitative descriptive study used a content analysis of semistructured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed. West Virginia. Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists. Semistructured interviews. To better understand the impact of restrictive prescribing measures on people who used opioids for CP. Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a "life saver." Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to "get high" but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management. Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence.

Effects of Opioid Prescribing Cap Laws on Opioid and Other Pain Treatments Among Persons with Chronic Pain.

Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments. To evaluate the effects of state opioid prescribing cap laws on opioid and non-opioid treatment among those diagnosed with chronic pain. We used a difference-in-differences approach that accounts for staggered policy adoption. Treated states included 32 states that implemented a prescribing cap law between 2017 and 2019. A total of 480,856 adults in the USA who were continuously enrolled in medical and pharmacy coverage from 2013 to 2019 and diagnosed with a chronic pain condition between 2013 and 2016. Among individuals with chronic pain in each state: proportion with at least one opioid prescription and with prescriptions of a specific duration or dose, average number of opioid prescriptions, average opioid prescription duration and dose, proportion with at least one non-opioid chronic pain prescription, average number of such prescriptions, proportion with at least one chronic pain procedure, and average number of such procedures. State laws limiting opioid prescriptions were not associated with changes in opioid prescribing, non-opioid medication prescribing, or non-opioid chronic pain procedures among patients with chronic pain diagnoses. These findings do not support an association between state opioid prescribing cap laws and changes in the treatment of chronic non-cancer pain.

Collaborative improvement on acute opioid prescribing among diverse health systems.

BackgroundDespite broad awareness of the opioid epidemic and the understanding that patients require much fewer opioids than traditionally prescribed, improvement efforts to decrease prescribing have only produced modest advances in recent years.Methods and findingsBy using a collaborative model for shared expertise and accountability, nine diverse health care systems completed quality improvement projects together over the course of one year to reduce opioid prescriptions for acute pain. The collaborative approach was flexible to each individual system’s goals, and seven of the nine participant institutions definitively achieved their desired results.ConclusionsThis report demonstrates the utility of a collaborative model of improvement to bring about real change in opioid prescribing practices and may inform quality improvement efforts at other institutions.

What lessons from Europe's experience could be applied in the United States in response to the opioid addiction and overdose crisis?

What lessons from Europe's experience could be applied in the United States in response to the opioid addiction and overdose crisis?

PMH27 Impact of State Laws Restricting Opioid Prescriptions forAcute Pain on Opioid-Related Overdose Deaths Assessed Via Interrupted Time Series Analyses

Many states have implemented limitations on opioid prescriptions for patients with acute pain. Few studies have investigated relationships between prescribing restrictions and clinical outcomes. We assessed effects of acute pain prescribing restriction laws on trends in opioid-related overdose deaths among states that implemented these policies.

The opioid epidemic in acute care surgery-Characteristics of overprescribing following laparoscopic cholecystectomy.

Postoperative prescribing following acute care surgery must be optimized to limit excess opioids in circulation as misuse and diversion are frequently preceded by a prescription for acute pain. This study aimed to identify patient characteristics associated with higher opioid prescribing following laparoscopic cholecystectomy (LC). Among patients aged 18 years or older who underwent LC at a single institution in 2014 to 2016, opioids prescribed at discharge were converted to oral morphine equivalents (OME) and compared with developing state guidelines (maximum, 200 OME). Preoperative opioid use was defined as any opioid prescription 1 month to 3 months before LC or a prescription unrelated to gallbladder disease less than 1 month before LC. Univariate and multivariable methods determined characteristics associated with top quartile opioid prescriptions among opioid-naive patients. Of 1,606 LC patients, 34% had emergent procedures, and 14% were preoperative opioid users. Nonemergent LC patients were more likely to use opioids preoperatively (16% vs. 11%, p = 0.006), but median OME did not differ by preoperative opioid use (225 vs. 219, p = 0.40). Among 1,376 opioid-naive patients, 96% received opioids at discharge. Median OME was 225 (interquartile range, 150-300), and 52% were prescribed greater than 200 OME. Top quartile prescriptions (≥300 OME) were associated with gallstone pancreatitis diagnosis, younger age, higher pain scores, and longer length of stay (all p < 0.05). While median OME did not differ by emergent status (median, 225; interquartile range, 150-300 for both, p = 0.15), emergent had more top quartile prescriptions (32% vs. 25%, p = 0.005). After adjusting for diagnosis, age, and sex, emergent status showed evidence of being associated with top quartile prescription (odds ratio, 1.3; 95% confidence interval, 1.0-1.8). Thirty-day refill rate was 5%. Over half of opioid-naive patients undergoing LC were prescribed opioids exceeding draft state guidelines. Variation in prescribing patterns was not fully explained by patient factors. Acute care surgeons have an opportunity to optimize prescribing practices with the ultimate goal of reducing opioid misuse. Therapeutic study, level IV; Epidemiologic study, level III.

Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study.

The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols that promote opioid-free and multimodal analgesia. The objective of this study was to assess the impact of an ERAS intervention for colorectal surgery on discharge opioid prescribing practices. We conducted a historical-prospective quality improvement study of an ERAS protocol implemented for patients undergoing colorectal surgery with a focus on the opioid-free and multimodal analgesia components of the pathway. We compared patients undergoing colorectal surgery 1 year before implementation (June 15, 2015, to June 14, 2016) and 1 year after implementation (June 15, 2016, to June 14, 2017). Before the ERAS intervention, opioids at discharge were not significantly increasing (1% per month; 95% confidence interval [CI], -1% to 3%; P = .199). Immediately after the ERAS intervention, opioid prescriptions were not significantly lower (13%; 95% CI, -30% to 3%; P = .110). After the intervention, the rate of opioid prescriptions at discharge did not decrease significantly 1% (95% CI, -3% to 1%) compared to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%-83%). This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid-free anesthesia and multimodal analgesia, we did not observe an impact on discharge opioid prescribing practices. The majority of patients were discharged with an opioid prescription, including those with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge. This observation in the setting of an ERAS pathway that promotes multimodal analgesia suggests that our findings are very likely to also be observed in non-ERAS settings and offers an opportunity to modify opioid prescribing practices on discharge after surgery. For opioid-free anesthesia and multimodal analgesia to influence the opioid epidemic, the dose and quantity of the opioids prescribed should be modified based on the information gathered by in-hospital pain scores and opioid use as well as pain history before admission.

Utilisation of transdermal fentanyl in Germany from 2004 to 2006

Purpose Oral morphine is the first-choice opioid for moderate to severe cancer pain. Transdermal fentanyl is an alternative in patients with stable requirements of high-potency opioids (HPO) or if drugs cannot be taken orally. Drug regulatory authorities have issued several alerts to use transdermal fentanyl only for chronic pain and in HPO-tolerant patients to minimise the risk of severe opioid side effects. The aim of this study was to characterise utilisation of transdermal fentanyl in Germany. Methods The analysis was based on data from four German statutory health insurances from the years 2004–2006. Descriptive analyses were performed in new users of transdermal fentanyl to assess HPO-naivety, potential difficulties with the oral route in HPO-naive patients and the number of transdermal fentanyl dispensations. The initial dose in new users was assessed in 2005–2006 after marketing of transdermal fentanyl 12.5 µg/hour. Results Of 35 262 patients with new use of transdermal fentanyl, 29 793 (84.5%) were assessed as HPO-naive. Of those, 21 596 (72.5%) did not have diagnoses indicating difficulties with the oral route. For 71.2% of the HPO-naive new users of transdermal fentanyl, the first dose exceeded the recommended dose of 12.5 µg/hour, and 49.3% of them received only one prescription of the drug. Conclusions Transdermal fentanyl was used as a first-choice opioid, which may increase the risk of serious opioid side effects, in a substantial number of HPO-naive patients. Inappropriate prescribing included also high initial doses in HPO-naive patients and possible prescription for acute pain in a considerable proportion of patients. Copyright © 2011 John Wiley & Sons, Ltd.

Utilisation of transdermal fentanyl in Germany from 2004 to 2006

Oral morphine is the first-choice opioid for moderate to severe cancer pain. Transdermal fentanyl is an alternative in patients with stable requirements of high-potency opioids (HPO) or if drugs cannot be taken orally. Drug regulatory authorities have issued several alerts to use transdermal fentanyl only for chronic pain and in HPO-tolerant patients to minimise the risk of severe opioid side effects. The aim of this study was to characterise utilisation of transdermal fentanyl in Germany. The analysis was based on data from four German statutory health insurances from the years 2004-2006. Descriptive analyses were performed in new users of transdermal fentanyl to assess HPO-naïvety, potential difficulties with the oral route in HPO-naïve patients and the number of transdermal fentanyl dispensations. The initial dose in new users was assessed in 2005-2006 after marketing of transdermal fentanyl 12.5 µg/hour. Of 35 262 patients with new use of transdermal fentanyl, 29 793 (84.5%) were assessed as HPO-naïve. Of those, 21 596 (72.5%) did not have diagnoses indicating difficulties with the oral route. For 71.2% of the HPO-naïve new users of transdermal fentanyl, the first dose exceeded the recommended dose of 12.5 µg/hour, and 49.3% of them received only one prescription of the drug. Transdermal fentanyl was used as a first-choice opioid, which may increase the risk of serious opioid side effects, in a substantial number of HPO-naïve patients. Inappropriate prescribing included also high initial doses in HPO-naïve patients and possible prescription for acute pain in a considerable proportion of patients.