Prescription Opiate Research Articles

Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

Background: Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis. Methods: We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007–14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other non-opiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models. Results: Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05–1.10), 1.07 (1.01–1.13), and 1.00 (0.94–1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use). Conclusions: In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.

Opiates prescribed for acute renal colic are associated with prolonged use.

Patients presenting with acute renal colic may be at risk of opiate abuse. We sought to analyze prescribing patterns and identify risk factors associated with prolonged opiate use during episodes of acute renal colic. Retrospective study of patients presenting with both a stone confirmed on imaging and an acute pain episode from 6/2017-2/2020. Opiate prescription data was obtained from a statewide prescribing database. Primary outcome was an opiate refill or new opiate prescription prior to resolution of the stone episode (either passage or surgery). Univariate and multivariate linear regression analysis was performed. A total of 271 patients met inclusion criteria. Mean age was 52years and 48% had a history of nephrolithiasis. 180 (66%) patients filled a new opiate prescription during their acute stone episode. Thirty-eight (14%) patients had an existing opiate prescription within 3months of their stone episode. Seventy-four (27%) patients refilled an opiate prescription prior to stone passage or surgery. Larger stone size, need for surgery, prolonged time to treatment, existing opiate prescription, new opiate prescription at presentation, and greater initial number of pills prescribed were associated with increased risk of requiring a refill prior to stone resolution. Patients prescribed new opiates for acute nephrolithiasis and those with an existing opioid prescription are likely to require refills before resolution of the stone episode. Larger stones that require surgery (not spontaneous passage) also increase the risk. Timely treatment of these patients and initial treatment with non-narcotics may reduce the risk of prolonged opiate use.

Risk Factors for Prolonged Opioid Use after Orthopedic Trauma: Inner-City Hospital versus Community Hospital

Abstract Introduction Prescription opiate use has exponentially increased. The aim of this study was to identify risk factors associated with prolonged opioid use (> 12 weeks) after isolated orthopedic trauma requiring surgery, and compare two different hospital settings: a large community based hospital vs. inner-city hospital. Methods A retrospective review was performed of adult trauma patients requiring operative fixation of their isolated long bone fractures at two Level I trauma centers between 2011-2016. Patients were identified using CPT codes for fracture fixation. Demographics, fracture type, mechanism of injury (MOI), index procedure, medical/psychiatric history, employment status at time of injury, drug screen, blood alcohol and smoking status at presentation, insurance type/status, preinjury opioid use, and duration of opioid use postoperatively was collected. The primary outcome was the duration of opioid use postoperatively, stratified < 6 weeks, 6-12 weeks, or > 12 weeks. Categorical variables analyzed using chi-square and t-test used for continuous variables. Results 196 patients were included (115 inner-city and 81 community hospital). The mean age was 38.4 ± 15 years, 68% were male, the mean ISS 7 ± 3. With results stratified by opioid duration: MOI (P = 0.023), smoking (P = 0.001), drug use (P = < 0.001), and insurance type (P = 0.005) were significantly different between those who stop using opioids by six weeks vs. those who didn’t. Employment status (P=0.046), smoking (P = 0.001), drug use (P<0.001), insurance type (P = 0.025), and preinjury opioid use (P = 0.024) were significantly different between those who stop using opioids by 12 weeks vs. those with continued using opioids. In both hospital settings, positive drug screen and current smokers were associated with increased risk of prolonged opioid use (P ≤ 0.001). Conclusion Risk factors for prolonged opioid use were insurance type, employment status, and preinjury opioid use. In addition, patients with positive drug screen or current smokers were at an increased risk regardless of hospital setting. These findings can help identify patients who would benefit from a different treatment approach, but further studies are needed to determine the best intervention for these high risk patients.

4169 The influence of serious mental illness on medical care of patients with lower back pain in the emergency department

OBJECTIVES/GOALS: To determine whether length of stay (LOS) and opioid prescribing differ among patients who present to the emergency department (ED) with low back pain (LBP) and serious mental illness (SMI+) compared to patients without SMI (SMI−). METHODS/STUDY POPULATION: Eligible patients that visited the ED within the Mount Sinai Health Care System from 2016-2019 were identified from the Mount Sinai Data Warehouse. Data on patient demographics, number of medications prescribed, and length of stay (LOS) were compared between the groups. Patients were excluded if English was not their primary language and if the LOS exceeded 24 hours. The final dataset consisted of 940 patients (SMI+: n = 181; SMI−: n = 759). RESULTS/ANTICIPATED RESULTS: SMI+ cases included patients with a diagnosis of depression (n = 152), anxiety (n = 134), schizophrenia (n = 9), bipolar (n = 1), and/or post-traumatic stress disorder (n = 33); 26% of cases had a single diagnosis, 66% with two, and the remaining 8% had three diagnoses. There was no significant difference in pain scores between the two groups (SMI-: 7.0 ± 0.1; SMI+: 6.8 ± 0.3; p = 0.6). We found no significant differences in LOS between the groups (SMI-: 3.9 ± 0.1 hours; SMI+: 3.8 ± 0.2 hours; p = 0.8), nor was there a significant difference in number of medications prescribed (SMI-: 1.7 ± 0.9; SMI+: 1.7 ± 0.6; p = 0.4). Further analysis revealed that the odds of receiving an opiate prescription in the SMI- group was 0.92 (95% CI: 0.54,1.55). DISCUSSION/SIGNIFICANCE OF IMPACT: Comparable opioid prescribing and LOS exist in patients with and without serious mental illness who are seeking treatment for low back pain in the ED. Despite similarities in approaches to care, more information is needed to determine if other social determinants influence these practices.

Prescription Patterns and Risk Factors for Prolonged Opioid Dependence in Elective Anterior Cruciate Ligament Reconstruction in a Military Population.

Background:Limited data are available regarding excessive opioid prescribing in the perioperative period after routine orthopaedic procedures in US military personnel.Purpose:To examine the demographic profile of the patients receiving these medications and to identify potential risk factors for prolonged opioid use after anterior cruciate ligament reconstruction (ACLR) in the active duty military population.Study Design:Case-control study; Level of evidence, 3.Methods:The Military Analysis and Reporting Tool (M2) was used to search the Military Health System Data Repository (MDR) for patients undergoing ACLR from 2012 through 2015 and specifically for active duty personnel with an arthroscopically assisted ACLR (Current Procedural Terminology [CPT] code 29888). Complete opioid prescription filling history was also obtained. This study had 2 primary outcomes: (1) use of opiate analgesics more than 90 days after surgery, representing prolonged opiate prescriptions, and (2) high levels of postoperative opiate use, defined as having filled prescriptions accounting for greater than the 95th percentile of morphine equivalents for patients in the study cohort. Data were analyzed via multivariate regression analysis to identify potential associations with the primary outcomes.Results:A total of 9474 patients met the inclusion criteria. Median patient age was 27 years, and the sample included 1316 (14%) female and 8158 (86%) male patients. A total of 66 (0.7%) patients had a preoperative diagnosis for substance abuse; 2656 (28%) patients continued to receive opioid prescriptions more than 90 days after surgery, and 502 (5%) patients were in the top 95th percentile of all opioid users within the study cohort. Total preoperative morphine equivalents per day and total perioperative morphine equivalents per day were highly important risk factors for both outcomes, although other demographic factors such as race, sex, and age may play minor roles.Conclusion:We identified total preoperative morphine equivalents, total perioperative morphine equivalents, sex, and race as potential predictors of prolonged opioid use after ACLR. This information may prove useful in developing a predictive model to identify at-risk patients before surgery. This could help mitigate future misuse or abuse and improve preoperative patient counseling regarding pain management expectations.

Association of Default Electronic Medical Record Settings with Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study

Given that opioid addiction for many people starts with prescription medications, it is important that physicians use caution when prescribing opioids. The number of opiate prescriptions by emergency physicians has reportedly decreased over the past several years; however the opioid crisis is still a public health problem. Despite the education of providers and the presence of published guidelines, there are still an excessive number of opioids being prescribed from the emergency department (ED).

Impact of inpatient hospitalization on opiate usage for minimally invasive hysterectomy amongst gynecologic oncology patients.

e18109 Background: The overdose death rate related to opiates has quadrupled in the last two decades. Up to 27% of chronic opiate users report initiation in the post-op period. Among cancer patients, 10% of opioid-naive patients continue chronic use one year after surgery. Restrictive opiate prescribing has demonstrated promise in other studies. However, lacking from current literature is an analysis of the effect that same day discharge (SDD) has on post-op opiate usage at home. The objective of this study is to evaluate the impact of SDD versus physician-elected observation for 1 to 2 days on acute post-op opiate usage and safety following minimally-invasive hysterectomy (MIH). Methods: This is a prospective observational study of women undergoing MIH. Sixty patients were assigned to either the SDD or hospitalization group at provider discretion based on practice pattern, distance from hospital, or comorbidities. One patient was lost to follow up. Patients were followed through 30 days after surgery. Total opiate usage included the inpatient usage (if hospitalized) and home usage assessed at the post-op visit. Anonymous surveys were used to collect home opiate usage practices, satisfaction, and self-reported risk factors for continued use. Continuous variables were analyzed by independent Student’s t-test and the Mann-Whitney U test. Categorical variables were analyzed using Chi-square test and Fisher's Exact test. Results: 29 SDD and 30 hospitalized patients were available for review. Demographics including age, BMI, tobacco use, and procedure indication were well matched. SDD patients used a median 5.0 (1.5-13.5) versus 8.5 (2.25-14.25) 5mg oxycodone tabs (p 0.33). SDD patients used opiates less for non-pain indications including to sleep (4 vs 9, p 0.24) or relax (3 vs 5, p 0.71). One SDD patient had a complication of a cuff hematoma, which spontaneously drained. There were no readmissions. Only one SDD patient felt she would have benefited from longer stay due to nausea. All hospitalized patients took their own opiates at home while 7 SDD had a family member dispense. Psychiatric disorders were the highest comorbidities in both groups (depression n = 12 and 10, anxiety n = 10 and 12). Conclusions: SDD demonstrated a trend towards less opiate usage, although not statistically significant. Patients did not feel that they needed to stay longer in the hospital. The safety of SDD is supported by lack of readmissions and one minor post-op complication. The high rates of psychiatric disease are a concerning risk factor for chronic use.

Post-discharge opioid prescribing after laparoscopic appendicectomy and cholecystectomy.

Opioid over-prescription following surgery is a significant public health issue in most developed countries. Multiple studies have been conducted in the USA demonstrating and investigating the issue; however, there is a lack of literature addressing this topic in the Australian setting. The aim of this study is to review prescribing practices at an Australian tertiary referral hospital on discharge in patients having undergone laparoscopic cholecystectomy (LC) or laparoscopic appendicetomy (LA). Additionally, to identify potential factors which influence medical officer prescribing practices. A retrospective observational study on opioid prescribing practice on all patients who underwent LC or LA over a 12-month period at an Australian tertiary referral hospital. A total of 435 patients (223 LC, 214 LA) were prescribed a mean opioid dose on discharge of 25 oral morphine milli-equivalents (range 0-180 morphine milli-equivalents). Less opioids were prescribed following elective procedures (42% versus 10%, P < 0.001). There is a downward trend of opioid prescribing on discharge as the Junior Medical Officer clinical year progresses (P < 0.001). This study demonstrates a lower rate of opiate prescription on discharge for LC and LA in an Australian setting when compared to the US data. There is a wide diversity of prescribing demonstrated. This indicates the need for better training of opioid prescribers to reduce over-prescribing.

Outpatient healthcare utilization and prescribing patterns for herpes zoster in United States adults.

Little is known about health resource utilization and treatment patterns for herpes zoster (HZV) after the introduction of HZV virus vaccination. The objective of this study is to characterize trends in HZV utilization, racial disparities, and treatment patterns in the United States. Data from the 1993-2015 National Ambulatory Medical Care Survey were analyzed, including 15,400,000 weighted primary acute HZV visits in adults. Overall, the weighted frequency (95% confidence interval) of HZV visits increased from 1993-1998 to 2007-2015 (1,269,815 [565,455-1,974,175]-8,017,911 [6,424,491-9,611,331], P = 0.0001). HZV visits were associated with African-American (38.8% [35.8-41.7%] vs. 8.2% [7.4-9.0%]) and Hispanic race/ethnicity (12.6% [6.6-18.5%] vs. 8.0% [7.3-8.5%]), public insurance (42.7% [36.6-49.2%] vs. 33.7% [32.2-35.2%]) in comparison with all other visits. Oral antiviral agents were prescribed in 64.3% (58.1-70.1%) of HZV visits. HZV visits were associated with higher rates of opioid prescriptions compared to all other visits (18.4% [14.0-23.9%] vs. 6.1% [5.6-6.6%], P < 0.0001). The limitation is no data on HZV severity. HZV visits increased over time, even after introduction of HZV vaccines. There were significant racial/ethnic and healthcare disparities of, and high rates of opiate and corticosteroid prescriptions at HZV visits. Future efforts are needed to address these practice gaps, and encourage vaccination and evidence-based prescribing in HZV.

Transparency as Justice: The Ethics of Public Attorneys and Judicial Seals

In 2004, the State of West Virginia settled a lawsuit against Purdue Pharma LP accusing the company of pushing pills by understating the addictive effects of OxyContin. As a result, the judge in the case sealed his ruling denying Purdue’s motion to dismiss. The seal was not vacated until the United States was enveloped by the opioid crisis twelve years and 245,000 overdose deaths later. The pattern nearly repeated itself in 2019 until the United State Court of Appeals for the Sixth Circuit vacated a judicial seal in In re National Prescription Opiate Litigation, allowing press access to information in discovery and in the pleadings. Such seals in mass products liability cases stretch back decades, but they are getting renewed attention based on the Sixth Circuit’s pattern tightening requirements for such seals in Shane Group, Inc. v. Blue Cross Blue Shield of Michigan. This article addresses the duties of public sector attorneys in situations involving judicial seals of information relevant to the public health and safety. Although the Supreme Court has held that seals may only issue after the trial court balances the public interest in disclosure against the private interest in confidentiality, courts typically grant an uncontested motion to seal without performing it. Because the public interest is in favor of such disclosures — particularly where the government is a party — government attorneys have a duty to ensure the public release of such data. Thus, reform is needed through the imposition of legal or ethical requirements that ensure this result and, by extension, require public servants to protect the public.

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery.

To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS). Case series with planned data collection. Tertiary referral medical center. We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7. A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3. Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.

Eliminating Opiate Prescribing for Children after Non-Perforated Appendectomy

Opiates are the traditional treatment for postoperative pain. Recognition that increased availability of opiates in the community is associated with increased addiction has led to efforts to decrease postoperative opiate distribution. However, there are concerns that without opiates, pain relief might be inadequate. We analyzed opiate prescriptions to children who had undergone appendectomy during 3 time periods: before intervention (July 2012 through February 2013), after opiate prescriptions were standardized and reduced (December 2016 through December 2017), and after opiate prescriptions were eliminated (January 2018 through December 2018). We determined how many opiate prescriptions had been written and how many had been filled in each time period. Patients were contacted by phone to identify their medication use and quality of pain management. Pre-intervention, 75 children underwent appendectomy, and all received opiate prescriptions, with a mean of 15 doses of oxycodone prescribed per patient. After reduction, 208 children underwent appendectomy and 30% received opiate prescriptions, for a mean of 1.5 doses of oxycodone per patient. After elimination, 270 patients underwent appendectomy and 3 patients (1.1%) received opiate prescriptions, for a mean of 0.05 doses of oxycodone per patient. Patients contacted by phone expressed no pain relief issues and no patients needed opiates later. Using a stepwise process, we have eliminated the use of opiates for postdischarge pain in children undergoing laparoscopic appendectomy. This intervention has resulted in the elimination of 4,035 doses of oxycodone from the community during the study period, while ensuring that postoperative pain control has been adequate.

PD05-03 OPIATE OMISSION AFTER URETEROSCOPY DOES NOT LEAD TO INCREASED EMERGENCY DEPARTMENT VISITS: RESULTS FROM A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety I (PD05)1 Apr 2020PD05-03 OPIATE OMISSION AFTER URETEROSCOPY DOES NOT LEAD TO INCREASED EMERGENCY DEPARTMENT VISITS: RESULTS FROM A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE Scott Hawken*, Spencer Hiller, Kavya Swarna, Jill Slayton, Conrad Maitland, David Wenzler, John Hollingsworth, Khurshid Ghani, Casey Dauw, and for the Michigan Urological Surgery Improvement Collaborative Scott Hawken*Scott Hawken* More articles by this author , Spencer HillerSpencer Hiller More articles by this author , Kavya SwarnaKavya Swarna More articles by this author , Jill SlaytonJill Slayton More articles by this author , Conrad MaitlandConrad Maitland More articles by this author , David WenzlerDavid Wenzler More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Casey DauwCasey 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.0000000000000825.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Emergency department (ED) visits after ureteroscopy (URS) are common and are often due to postoperative pain. As a part of a statewide quality initiative to reduce ED visits, we sought to determine if opiate omission following URS is associated with unintended consequences, such as increased ED visits. METHODS: The Michigan Urological Surgery Improvement Collaborative’s Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) initiative was established in 2016. It is comprised of urologists across the state whose goal is to improve the care of patients with stone disease. We identified patients that underwent primary URS and examined quarterly trends in postoperative opiate prescription. Variation in opiate prescribing was assessed at the practice level. Using demographic, clinical, and operative data, we constructed a multivariable model to define risk factors for opiate prescription. After adjusting for patient and practice-level factors, we determined whether opiate omission was associated with postoperative ED visits within 30 days of surgery. RESULTS: We identified 9,268 patients who underwent URS (2016-2019). Post-URS opiate prescriptions have shown an absolute decline of 43.4% since the inception of MUSIC ROCKS (Figure). There was wide variation in practice-level opiate use (8.8% to 98.7%, p<0.01). The odds of receiving an opiate were higher in males (OR 1.32, 95%CI 1.17-1.49, p<0.01), those with a stent (OR 1.72, 95%CI 1.49-1.99, p<0.01), or a diagnosis of chronic pain (OR 1.68, 95%CI 1.01-2.66, p=0.04). Those less likely to receive opioids were older (OR 0.99, 95%CI 0.98-0.99, p<0.01), had greater comorbidity (OR 0.82, 95%CI 0.69-0.98, p=0.03), and were prescribed an NSAID (OR 0.23, 95%CI 0.19-0.28, p<0.01). Omission of opiates following URS was not associated with increased ED visits (OR 0.83, 95%CI 0.67-1.04). CONCLUSIONS: Since establishment of a statewide quality improvement program in Michigan, opiate prescriptions following URS have declined substantially without an increase in ED visits. Patient factors and practice variation contribute to the risk of receiving an opiate underscoring the need for continued efforts in this area. Source of Funding: funding from Blue Cross Blue Shield of Michigan © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e84-e85 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Scott Hawken* More articles by this author Spencer Hiller More articles by this author Kavya Swarna More articles by this author Jill Slayton More articles by this author Conrad Maitland More articles by this author David Wenzler More articles by this author John Hollingsworth More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP69-18 IMPACT OF HEALTH LITERACY ON URETEROSCOPY OUTCOMES AMONG KIDNEY STONE PATIENTS

You have accessJournal of UrologyStone Disease: Surgical Therapy VII (MP69)1 Apr 2020MP69-18 IMPACT OF HEALTH LITERACY ON URETEROSCOPY OUTCOMES AMONG KIDNEY STONE PATIENTS Naren Nimmagadda*, Caroline Kang, Nicole Miller, S Duke Herrell, and Ryan Hsi Naren Nimmagadda*Naren Nimmagadda* More articles by this author , Caroline KangCaroline Kang More articles by this author , Nicole MillerNicole Miller More articles by this author , S Duke HerrellS Duke Herrell More articles by this author , and Ryan HsiRyan Hsi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000949.018AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephrolithiasis is a disease dependent on patients’ self-management; however, little is known on the effect of health literacy on treatment outcomes. We sought to understand the impact of health literacy in this population using the validated Brief Health Literacy Screen (BHLS). METHODS: A retrospective review was conducted of all patients who underwent ureteroscopy for upper tract stones between January and June 2017. Of the 244 patients, BHLS data was available for 105 patients. Demographic, surgical, and postoperative data were collected using the electronic medical record. Opiate usage was obtained from the local controlled substance monitoring database. Univariate and multivariable logistic regression analysis were performed to assess the association of BHLS scores with postoperative complications, stone outcomes, adherence to follow-up and treatment, and opiate use. RESULTS: Mean BHLS score was 13.37 (range 4.09-15.0). 81% of patients attended their initial postoperative visit of which 87.6% maintained subsequent follow-up. On univariate analysis, health literacy did not associate with 30-day complications, ipsilateral stone recurrence or progression, ipsilateral stone events, rates of postoperative follow-up, 24-hour urine collection prescription at initial follow-up, 24-hour urine collection completion by subsequent follow-up, or additional requests for opiates within 30 days. Lower BHLS scores were significantly associated with new chronic opiate usage, defined as obtaining an opiate prescription > 60 days postoperatively without a prior history of chronic usage (OR 0.75, 95% CI 0.59-0.96, p = 0.02). Preoperative opiate prescription patterns were also associated with new chronic opiate usage including increased number of preoperative prescriptions, days supplied, and number of prescribing providers. On multivariable logistic regression, lower health literacy remained a significant predictor of postoperative opiate usage > 60 days (Table 1). CONCLUSIONS: An assessment of health literacy can further screen individuals at risk of postoperative opiate dependence after ureteroscopy. These data identify a need to develop decision-making and counseling tools that account for varying levels of health literacy among kidney stone patients. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1052-e1053 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Naren Nimmagadda* More articles by this author Caroline Kang More articles by this author Nicole Miller More articles by this author S Duke Herrell More articles by this author Ryan Hsi More articles by this author Expand All Advertisement PDF downloadLoading ...

Prescribing heroin: John Marks, the Merseyside clinics, and lessons from history

The prescribing of heroin has a long and contentious history as a method for treating people with heroin problems. This paper revisits a controversial ‘experiment’ with heroin prescribing in Northwest England between 1982 and 1995, led by the psychiatrist Dr. John Marks. Marks’ work has been shrouded in myth and misinformation for many years and the paper presents an evidence-based reconstruction of this episode, drawing on archival sources, published and unpublished documents, and a small number of interviews with key informants. During this 13-year period, Marks worked across clinics in Liverpool and two neighbouring towns, founding his practice on the long-term maintenance prescribing of opiates, including injectable heroin and smokable heroin reefers. The high media profile of the work, in the context of a febrile local politics in Liverpool, a powerful British addiction psychiatry establishment and an always-heated international politics of drug control, brought immense political pressure and led eventually to the closure of the clinics. The Marks ‘experiment’ raises important challenges to the premises, practices and philosophy of heroin maintenance – particularly the questions of thresholds and criteria for access, and the purposes of intervention – as well as to the wider regime of prohibitive drug laws.

The Effect of the Strengthen Opioid Misuse Prevention Act on Opiate Prescription Practices Within the Orthopaedic Surgery Department of an Academic Medical Center.

Introduction:In 2017, the Department of Health and Human Service declared a public health emergency known as the opioid crisis. In North Carolina, the “Strengthen Opioid Misuse Prevention Act of 2017” (STOP Act) went into effect on January 1, 2018, seeking to strengthen oversight over opioid prescriptions. Among other mandates, this legislation limited the duration of the initial prescription to 5 or 7 days. The purpose of this study was to compare narcotic prescription practices within the Department of Orthopaedic Surgery at an academic medical center before and after the enactment of the STOP Act. We hypothesized that there would be a statistically significant decrease in the amount of postoperative opioids prescribed after the STOP Act and that this decrease would be consistent across all types of providers in the Orthopaedic Surgery Department.Methods:Opiate prescriptions data from all orthopaedic surgery providers at our academic institution were collected from January to the end of September in 2017 and from January to the end of September in 2018. After filtering the providers by our study's inclusion and exclusion criteria, we included data from 49 providers in our analysis. We used a paired t-test to compare the prescription data between the two periods.Results:There was a 35% decrease in morphine milligram equivalents prescribed at our institution between 2017 and 2018 (P = 0.0003). This reduction was statistically significant and equaled 27,374 less morphine milligram equivalents prescribed per provider (95% confidence interval 13,226 to 41,523). The average number of opiate prescriptions per provider decreased from 171.5 in 2017 to 161 in 2018 (P = 0.48), although this was not statistically significant.Conclusion:The STOP Act effectively decreased the amount of opiates prescribed within our Orthopaedic Surgery Department. Similar legislation may be effective in other states and at the federal level to decrease narcotic prescriptions and subsequent abuse.

No pain is gain: A prospective evaluation of strict non-opioid pain control after pediatric appendectomy

IntroductionOpiates are often prescribed after pediatric operations despite safety concerns and lack of evidence confirming superiority compared to other pain control modalities. In this study, we use daily parental surveys to prospectively evaluate a strict non-opioid pain control strategy after laparoscopic appendectomy. MethodsAfter IRB approval, children who underwent laparoscopic appendectomy for nonperforated acute appendicitis were recruited to the study. For these patients, our standard practice is to provide instructions to administer alternating acetaminophen and ibuprofen over-the-counter (OTC) postoperatively, and no opiate prescriptions are written. Parents of enrolled children received a daily RedCap survey via text message or e-mail on postoperative days (POD) 1 through 5 to prospectively assess pain control and medication usage. Trends were compared across postoperative days. ResultsOne hundred twenty patients were enrolled in the study, and none received opiate prescriptions. Postoperative pain survey response rates were 54% on POD1, 47% on POD2, 35% on POD3, 34% on POD4, and 29% on POD5. Pain level was 4.7 ± 2.3 (out of 10) on POD1, and down-trended significantly each postoperative day to reach 0.7 ± 1.2 by POD5. On POD1, 85% of parents administered OTC medications, which reduced significantly to 14% by POD5. Parent-reported success rates to manage pain by OTC regimen were 85% on POD1, 94% on POD2, 91% on POD3, and 100% on POD4 and POD5. ConclusionStrict non-opioid pain control after appendectomy exhibits high performance based upon prospective parental surveys. This strategy should be implemented as standard of care and tested for application to other surgical conditions. Level of EvidenceLevel II.

Pain catastrophizing as a predictor of suicidal ideation in chronic pain patients with an opiate prescription

Chronic pain and opioid use are associated with increased risk for suicidal ideation and behaviors (SIB) in cross-sectional studies, particularly among individuals who catastrophize about their pain. This study examined the longitudinal association between two styles of pain coping, catastrophizing and hoping/praying, as predictors of subsequent SIB, as well as possible mediators of this association among patients with chronic pain receiving long-term opioid therapy. Participants (n = 496) were adults with chronic nonmalignant pain on long-term opioid therapy who did not develop an opioid use disorder. Participants were assessed for pain coping, suicidal ideation, depression, social support and pain interference at baseline, and were reassessed for SI, depression, and pain interference at 6- and 12-month follow-ups. Catastrophizing was a significant predictor of increased subsequent SIB, whereas hoping/praying did not protect against future SIB. The relationship between catastrophizing and future SIB was mediated by depression, but not social support or pain interference. In conclusion, catastrophizing was an important predictor of subsequent SIB due to its effect on increasing depression among patients with chronic nonmalignant pain receiving long-term opioid therapy. Future research should explore the extent to which targeting catastrophizing reduces subsequent depression and suicide risk.

Plastic Surgery Patient Expectations for Postoperative Opioid Prescriptions.

The opioid epidemic is a healthcare crisis perpetuated by analgesic overprescribing. Despite public health attention on this issue, expectations for pain management and opioid use by plastic surgery patients are poorly understood. This study aimed to evaluate patient expectations of postoperative pain, concern for opioid dependence, and anticipated analgesic plan after plastic surgery. New patients presenting to an academic plastic surgery clinic were prospectively enrolled from November 2017 to September 2018. These patients completed a preconsultation survey regarding their pain history and anticipated postoperative pain and analgesics regimens. Responses between cohorts expecting and not expecting postoperative opioids were compared using descriptive and univariate analyses. A total of 168 patients (63.9% female, 36.1% male; mean ± SD age 46 ± 17 years) completed the survey before breast (21.9%), cosmetic (5.3%), craniofacial (3.0%), general reconstruction (13.0%), hand (3.0%), and skin and soft tissue (49.1%) surgeries. Twenty-eight percent of patients expected opioid prescriptions. On a standard visual analog scale, patients who expected opioids anticipated greater postoperative pain (6.9 vs 4.6, P < 0.05). They were more concerned about experiencing pain (5.8 vs 4.9, P < 0.05), expected a longer duration of opioid use (63.0% vs 37.0%, P < 0.05), and were less interested in nonnarcotic analgesic alternatives (57.9% vs 19.8%, P < 0.05). Less than one-third of plastic surgery patients in this study expect opioid pain medications after surgery. This supports broader use of nonopioid, multimodal pain regimens. Identification and management of patient pain expectations, especially among those anticipating a need for opioids, provide a critical opportunity for preoperative education on the benefits of nonopioid analgesics, thus minimizing opiate prescribing.

Trajectories of pain and anxiety in a longitudinal cohort of adolescent twins.

Adolescence is critical to intercept chronic/persistent pain and decipher its association with anxiety. We ascertained adolescent pain trajectories, their demographic and clinical correlates, the longitudinal association with opiate prescriptions at age 19, and the etiology of the covariation between adolescent pain problems and anxiety symptoms. Longitudinal assessment of: 6 common pain problems at age 12, 13, 14, 15, and 17 years; 7 common anxiety symptoms at age 12, 13, and 14 years; opiates' prescriptions at age 19, in the Quebec Newborn Twin Study birth cohort of 667 twin pairs born between 1995-1998. Analyses yielded three trajectories of: "none-to-minimal" (34.3%), "sporadic" (56.7%), and "frequent" (9.0%) pain problems between age 12-17. Anxiety (odds ratios [OR] ORage12 : 2.38; confidence interval [CI]: 1.26-4.47; ORage13 : 3.96; CI: 1.73-9.05; ORage14 : 5.45; CI: 2.67-11.11), the female sex (OR: 3.69; CI: 2.20-6.21), and lower socioeconomic status (OR: 0.87; CI: 0.77-0.98) were associated with the "frequent" compared to the "none-to-minimal" pain trajectory. Only the "frequent" pain trajectory predicted opioid prescriptions at age 19 (OR: 4.14; CI: 1.16-14.55). A twin bivariate latent growth curve model and a cross-lagged model showed that genetic factors and non-shared environmental factors common to both phenotypes influence the longitudinal association between anxiety and adolescent pain problems. The relatively common, adolescent "frequent pain" trajectory predicts early opioid prescriptions, and anxiety and adolescent pain share multiple etiological components. These data can inform diagnostic reasoning, clinical practice, and help reducing opioid prescriptions and abuse.