Amount Of Opioids Research Articles

Efficacy and Safety of Pericapsular Nerve Group Block (PENG) in Hip Surgery Under General Anaesthesia: A Systematic Literature Review and Meta-Analysis

Background: The pericapsular nerve group (PENG) block is a novel ultrasound-guided regional technique that may provide analgesia to patients undergoing hip surgery. It has been extensively studied in recent years, but the evidence of superiority over other regional anaesthetic techniques is inconclusive. This review aimed to compare outcomes of the PENG block in patients undergoing hip surgery with standard techniques under general anaesthesia. Methods: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed throughout the preparation of this review. Randomised trials from electronic databases were included. We investigated postoperative pain scores, required analgesia, and adverse events associated with the block. Results: Ten studies satisfied the criteria to be included in the meta-analysis. Data from 646 patients were analysed, in which 321 patients received PENG block and 325 were included in the comparative groups. Pain scores at rest, at 24 h (p = 0.04) and 48 h (p = 0.02) were lower in patients who had received the PENG block. This group also required a smaller amount of opioids at 24 h after the procedure, but this difference was not statistically significant (p = 0.53); while a similar non-significant reduction in opioid consumption was also observed at 48 h. Although PENG seems to delay the time to the first analgesic request, we failed to prove a statistically significant difference (p = 0.83). Patient satisfaction also seems to be better in the PENG group, but not in a statistically significant way. No important side effects related to the block were described. Conclusions: PENG block for major hip surgery offers better postoperative analgesia, with possibly less opioid consumption. It seems to prolong the time to the first analgesic but does not significantly affect common side effects of anaesthesia/analgesia such as PONV or duration of hospital stay.

Lumpectomy Patients are at Highest Risk for Opioid Overprescription: A Comparison Between Practice Patterns and OPEN National Guidelines.

Nearly 25% of opioid-related deaths are from prescribed opioids, and the exacerbation of the opioid epidemic by the coronavirus disease 2019 (COVID-19) pandemic underscores the urgent need to address superfluous prescribing. Therefore, we sought to align local opioid prescribing practices with national guidelines in postoperative non-metastatic breast cancer patients. A single-institution analysis included non-metastatic breast surgery patients treated between April 2020 and July 2021. 'Overprescription' was defined as a discharge prescription quantity of oral morphine equivalents (OMEs) greater than the upper limit of the procedure-specific Michigan Opioid Prescribing Engagement Network (OPEN) recommendations. Univariable and multivariate analyses identified risk factors associated with opioid prescribing. Overall, 464 patients met the inclusion criteria: 280 patients underwent lumpectomy, and 184 patients underwent mastectomy. 52% of patients were overprescribed opioids, including 74% of lumpectomy patients (p<0.001) and 90% of patients undergoing lumpectomy with axillary surgery (p<0.001). Mastectomy patients were overprescribed less frequently (< 25%). The quantity of opioids prescribed at discharge did not correlate to inpatient opioid requirements (r=0.024, p=0.604). Increased age, tobacco use, and long surgery duration were associated with higher quantities of opioids prescribed at discharge. Patients undergoing less aggressive breast surgery are at very high risk of overprescription, and real-life prescribing patterns do not correlate to national guidelines or inpatient need. Future work will optimize adherence to procedure-specific guidelines and implement tailored discharge protocols.

Inpatient Multimodal Pain Regimens Do Not Impact Hospital Length of Stay or Long-term Postoperative Opioid Use Following 1 and 2-Level Lumbar Fusion.

Retrospective cohort study. To determine hospital length of stay (LOS) and long-term opioid consumption among patients who received inpatient multimodal analgesia following lumbar spine surgery, as opposed to those who received opioids alone. Opioids have long been the historical choice for managing postoperative pain. The use of multimodal analgesia has become more commonplace in recent years as it is thought to achieve similar levels of pain control while simultaneously diminishing opioid consumption and decreasing LOS. Patients who underwent 1 or 2-level lumbar fusion from 2018 to 2019 were included. Patients who received opioids on an as-needed basis were propensity-matched to a cohort who received multimodal analgesia based on demographics, surgical approach, and levels fused. LOS was collected for each patient. One year preoperative to 2 postoperative opioid use was obtained from the Pennsylvania Prescription Drug Monitoring Program and included total prescriptions and total morphine milligram equivalents (MMEs). A subanalysis was also performed comparing preoperative, perioperative, and postoperative tramadol consumption during this time frame. A total of 69 patients received an opioid-only pain regimen, while 207 patients received multimodal analgesia. Patients receiving a multimodal pain regimen consumed a higher daily tramadol MME but a comparable total in-hospital MME to patients in the opioid-only cohort. No statistically significant differences existed between cohorts with regards to LOS, preoperative, perioperative, and postoperative opioid consumption, though multimodal patients consumed more tramadol from 0 to 30 days postoperatively. Patients who received a multimodal pain regimen consumed comparable quantities of opioids to those who received opioids alone and did not have a longer LOS following 1 and 2-level lumbar fusion.

Multi-institutional retrospective study on opioid prescribing patterns of oral and maxillofacial surgeons.

The opioid epidemic is a serious crisis in the United States. It has been proposed that opioid prescriptions after dental procedures are a major contributor to opioid use and abuse. The American Dental Association has been working to educate dental care providers about safe opioid prescribing practices. The authors hypothesized that oral and maxillofacial surgeons, following the efforts and publications from the American Dental Association, have been prescribing fewer postoperative opioids. This was a multi-institutional retrospective study with a total of 3,710 patients from Loma Linda University and University of Texas Health Science Center at Houston undergoing ambulatory surgical tooth extraction under general anesthesia or sedation. The total quantity of postoperative opioids (ie, morphine milligram equivalents) was analyzed during the following 2 periods: from 2011 through 2016 and from 2017 through2021. The amount of opioids prescribed decreased significantly over time at both study institutions across all demographic characteristics and cohorts. The mean (SD) morphine milligram equivalents prescribed per patient was significantly reduced from 143.01 (71.08) in the 2011 through 2016 period to 72.09 (55.40) in the 2017 through 2021 period (P < .001). The data suggested that there has been a significant decrease in the amount of opioids prescribed after ambulatory oral surgery procedures during the 10-year study period. This provides evidence that dental care providers have responded to the opioid crisis. By means of identifying opioid prescribing patterns, the authors presented an opportunity to help inform interventions and policies that promote responsible prescribing, enhance patient safety, and support optimal pain management.

Comparison of postoperative and outpatient opioid use in adolescent idiopathic scoliosis patients treated with posterior spinal fusion surgery and vertebral body tethering.

Surgical treatments for adolescent idiopathic scoliosis (AIS) include posterior spinal fusion (PSF) and vertebral body tethering (VBT), but there is limited data that compares pain between these groups. We aimed to compare postoperative pain between these patients through inpatient opioid use and opioid prescriptions post-discharge. A retrospective review of patients diagnosed with AIS whounderwent PSF or VBT surgery was reviewed to determine LOS, inpatient opioid use, and opioids prescribed post-discharge. Only PSF patients who received liposomal bupivacaine and intrathecal (IT) hydromorphone, and VBT patients who received a paravertebral catheter of lidocaine and in addition toIT hydromorphone were included. Opioid amounts were reported as oral morphine equivalents (OMEs). Of 198 AIS patients that met inclusion, there were 89 PSF and 109 VBT patients. PSF patients had an increased LOS by 0.6 days compared to VBT patients (p < 0.001). Patients in the PSF group were administered a mean of 30.0 OMEs/day compared with the VBT group who received 12.5 OMEs/day (p < 0.001). At discharge, PSF patients were initially prescribed a mean of 227.7 OMEs while VBT patients' mean prescription was 139.7 (p < 0.001). PSF patients received more refills (Χ2 (1, n = 198) = 26.8, p < .001) and had a higher mean total of outpatient OMEs prescribed when compared to VBT patients (359.4 vs 185.8, p < 0.001). In AIS patients undergoing surgical correction, those who underwent PSF had longer LOS, received more inpatient OMEs, and were prescribed more OMEs both at initial discharge and total as an outpatient, when compared to VBT patients. Level III: (retrospective cohort study).

Developing and Implementing a Patient-Centered Opioid Prescribing Algorithm among Gynecological Oncology Patients.

Background: The opioid epidemic is a public health crisis. However, opioid prescription recommendations have not been established in gynecological oncology, and guidelines that incorporate patient-reported pain are lacking. Objectives: The article aims to evaluate prescribing patterns, utilization, and patient-reported pain control in gynecological oncology patients at a large tertiary academic center. Methods: This was a two-phase, prospective cohort study. For Phase 1, patients undergoing hysterectomy through the gynecological oncology division at the University of New Mexico were enrolled. Postoperative opioid use was collected and standardized to oral morphine milligram equivalents (MMEs). The factors associated with outpatient opioid use were used to develop an opioid prescription algorithm. In Phase 2, we evaluated the implementation of the prescription algorithm. For both phases, patients completed a demographic survey, satisfaction survey, and validated pain questionnaires. Results: In Phase 1, the amount of opioids used was significantly lower than the amount of opioids prescribed. Factors that correlated with postoperative opioid use included surgical procedures and last 24-hour inpatient MME use. A standardized opioid prescription algorithm was developed by incorporating these factors. In Phase 2, the opioid prescribing algorithm there was no significant difference in pain scores between the two phases. Conclusions: Opioids were substantially overprescribed in gynecological oncology patients undergoing hysterectomy. Our study found that the surgical route and last 24-hour MME inpatient usage were reliable predictors of outpatient opioid use. We developed and implemented a standardized opioid prescription algorithm that was validated by comparing the pain control measures in the two phases.

Implementation of a Patient-Specific Opioid Taper Calculator for Total Hip and Knee Arthroplasty: A Pre-Post Study

BackgroundGiven the association between high opioid use and postoperative complications after total joint arthroplasty, it is important to prescribe opioids responsibly in the postoperative period. While many pain regimen protocols exist to try and limit opioid use, an optimal approach to narcotic prescription for arthroplasty patients is yet to be established. This study evaluated the effects of using an individualized opioid taper calculator for patients undergoing elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that using the calculator would lead to a decrease in the amount and variability of opioids prescribed postoperatively. MethodsAll primary THAs (117 pre- and 105 post-calculator) and TKAs (172 pre- and 139 post-calculator) meeting study inclusion and exclusion criteria were reviewed at a single academic hospital from January 2016 to December 2018 (pre-calculator) and January 2020 to December 2022 (post-calculator). The primary outcome measure was the quantity of opioids prescribed at discharge in morphine milligram equivalents (MME) between the two groups. Secondary measures included opioid refills, visual analog scale (VAS) pain scores, and emergency department (ED) presentations or clinic calls due to pain. Statistical significance was defined as P < 0.05. ResultsImplementation of the opioid taper calculator resulted in a 40% decrease in the median MME prescribed at discharge for both THA (450 versus 270; P < 0.0001) and TKA (450 versus 270; P < 0.0001) patients, respectively. There was no significant difference within the THA or TKA cohorts when comparing VAS pain scores (THA, three versus four; P = 0.47; TKA; five versus six, P = 0.26), and no increase in percentage of patients who had ED visits (THA, 5.98 versus 0.95%; P = 0.069; TKA, 6.40 versus 11.5%; P = 0.155) or calls to the clinic for pain (THA, 17.1 versus 24.8%; P = 0.186; TKA, 36.6 versus 37.4%; P = 0.906) between the pre-calculator and post-calculator groups. ConclusionsOur findings support the use of a patient-specific opioid taper calculator to decrease the volume and variability of narcotics prescribed postoperatively for THA and TKA pain management. Our findings confirmed the general applicability and effectiveness of the opioid taper calculator outside of its institution of origin.

Anesthetic Approach in Anti-N-methyl-D-aspartate Receptor Encephalitis Associated with Ovarian Teratoma: A Case Report

Autoimmune encephalitis associated with ovarian teratoma has recently been related to the development of antibodies to specific heteromers of the N-methyl-d-aspartate receptor. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune condition that is brought on by the production of anti-NMDAR antibodies. It frequently presents on young females and manifests in different ways, including psychiatric symptoms, seizures, hypoventilation, and instability of the autonomic nervous system. Patients who have early surgical tumor excision in addition to immunotherapy had better outcomes than the other patients with this condition. Because the NMDAR is one of the main sites of action for frequently used anesthetic drugs, it is crucial to comprehend the pharmacological interaction between the anesthetic agents and the impaired NMDAR in order to build an anesthetic plan. This study describes a young female patient with autoimmune encephalitis who needed to have an ovarian teratoma surgically removed. Surgery was done under general anesthesia and peripheral nerve block (PNB). Sevoflurane and propofol did not appear to alter psychoneuronal function or cause autonomic instability despite their indirect effects on anti-NMDAR. A quadratus lumborum block was performed to reduce the amount of opioids required for anesthesia.

Safety and Efficacy of Opioid-sparing Anesthesia Compared With Traditional Opioid Anesthesia: A Scoping Review.

The rationale of adoption opioid-sparing anesthesia (OSA) is to achieve perioperative analgesia with a minimal amount of opioids combined with nonopioid adjuvants during and after surgery, namely multimodal anesthesia. The OSA approach was originally developed to overcome the known complications of opioid-based anesthesia (OA), and the present scoping review (ScR) aims at providing clinical evidence of the safety and efficacy of OSA with respect to OA. This ScR is mainly focused on studies presenting evidence on the safety and efficacy of OSA versus OA. PubMed and EMBASE databases were utilized to find relevant studies. The search strategy included the following keywords: "opioid sparing anesthesia complications, opioid sparing anesthesia efficacy, opioid sparing anesthesia safety." The findings from the 25 included studies were categorized into the following subsections: article characteristics, goals of the studies, OSA protocols, and surgical settings analyzed. In the 25 reviewed studies, evidence related to the impact of OSA versus OA was considered. Intraoperative safety and efficacy end points include hemodynamic stability and anesthetic/analgesic requirements. Postoperative end points include early cognitive dysfunction, opioid-induced bowel disorder, the physical status of mothers and newborns after labor and emergency cesarean, systemic immune and inflammation modifications, postoperative recovery, in-hospital and long-term opioid requirement, early postoperative pain, and chronic postsurgical pain. The studies reported lower intraoperative mean arterial pressure and heart rate fluctuations when α 2 agonists were adopted, while no differences were recorded for other complication rates. Analysis of OSA approaches for the postoperative conditions includes α 2 agonists, NMDA receptor blocking agents, gabapentinoids, nefopam hydrochloride, and locoregional anesthesia techniques with a positive impact on most of the end points considered. The clinical implementation of OSA encompasses the perioperative use of nonopioid drugs and locoregional anesthesia techniques. The reviewed studies reported OSA as a feasible approach to reduce opioid-related complications with no impact on patient safety.

Opioid use patterns following discharge from elective colorectal surgery: a prospective cohort study.

Opioid overprescription after colorectal surgery can lead to adverse events, persistent opioid use, and diversion of unused pills. This study aims to assess the extent to which opioids prescribed at discharge after elective colorectal surgery are consumed by patients. This prospective cohort study included adult patients (≥ 18yo) undergoing elective colorectal surgery at two academic hospitals in Montreal, Canada. Patients completed preoperative questionnaires and data concerning demographics, surgical details, and perioperative care characteristics (including discharge prescriptions) were extracted from electronic medical records. Self-reported opioid consumption was assessed weekly up to 1-month post-discharge. The total number of opioid pills prescribed and consumed after discharge were compared using the Wilcoxon signed-rank test. Negative binomial regression was used to identify predictors of opioid consumption. We analyzed 344 patients (58 ± 15years, 47% female, 65% laparoscopic, 31% rectal resection, median hospital stay 3days [IQR 1-5], 18% same-day discharge). Most patients received a TAP block (67%). Analgesia prescription at discharge included acetaminophen (92%), NSAIDs (38%), and opioids (92%). The quantity of opioids prescribed at discharge (median 13 pills [IQR 7-20]) was significantly higher than patient-reported consumption at one month (median 0 pills [IQR 0-7]) (p < 0.001). Overall, 51% of patients did not consume any opioids post-discharge, and 63% of the prescribed pills were not used. Increased opioid consumption was associated with younger age (IRR 0.99 [95%CI 0.98-0.99]), higher preoperative anxiety (1.02 [95%CI 1.00-1.04]), rectal resections (IRR 1.45 [95%CI 1.09-1.94]), and number of pills prescribed (1.02 [95%CI 1.01-1.03]). A considerable number of opioid pills prescribed at discharge after elective colorectal surgery are left unused by patients. Certain patient and care characteristics were associated with increased opioid consumption. Our findings indicate that post-discharge analgesia with minimal or no opioids may be feasible and warrants further investigation.

Opioid Prescribing Trends Among Workers' Compensation Patients Undergoing Foot and Ankle Surgery.

The purpose of this study was to evaluate opioid usage and prescribing trends among workers' compensation (WC) patients who underwent foot or ankle operative procedures compared with a control group. A retrospective review was conducted for WC and non-WC patients who underwent foot or ankle procedures in a single academic orthopaedic surgery practice. Outcome measures were total morphine milligram equivalents (MME) and number of opioid prescriptions. A total of 118 patients were identified, including 51 patients in the WC group and 67 in the non-WC group. After index surgery, 67% (34 of 51) of WC patients had 2 or more additional opioid prescriptions compared to 39% (26 of 67) of non-WC patients (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.4-6.7; P = .003). Collectively, there were greater prescriptions of oxycodone MME (P = .002) and hydrocodone MME (P = .07) in the WC cohort. Workers' compensation patients seem to be prescribed and consume opioids at a higher rate postoperatively. It is important for treating physicians to be aware of these trends, and discussions with patients regarding expected opioid use when planning surgical intervention may be beneficial. Physicians may need to set expectations preoperatively and suggest there are limits on the amount of opioids that can safely be prescribed. Level III, Retrospective cohort study, Prognostic.

Liposomal bupivacaine plus intrathecal hydromorphone associated with shortened length of stay and decreased opioid use in pediatric patients following posterior spinal fusion surgery.

We aimed to determine if the use of intrathecal (IT) hydromorphone and/or liposomal bupivacaine (LB) decreased the amount of postoperative and post-discharge opioids for pediatric patients undergoing fusion (PSF) surgery to treat adolescent idiopathic scoliosis (AIS). A retrospective review of AIS patients undergoing PSF surgery was conducted. Hospital LOS, and inpatient and post-discharge opioid use were compared. Opioid use was reported as oral morphine equivalents (OMEs). Three groups were formed from 186 patients: the control (CG) (n = 39), the IT hydromorphone only (IT) (n = 58), and the liposomal bupivacaine with intrathecal hydromorphone (LB + IT) group (n = 89). The mean LOS were 4.8, 4.2, and 3.5 days for the CG, IT, and LB + IT groups, respectively, with the LB + IT group being shorter than both the CG (p < 0.001) and IT groups (p < 0.001). The mean inpatient OMEs were 106.3/day, 69.2/day, and 30.0/day for the CG, IT, and LB + IT groups, respectively, with each group being significantly different than each other (all pairwise comparisons, p < 0.001). The mean total OMEs that patients were prescribed post-discharge were 693.6 in the CG, 581.1 in the IT, and 359.4 in the LB + IT group (F(2,183) = 14.5, p < 0.001), with the LB + IT group being prescribed significantly less than both the IT (p = 0.003) and CG groups (p < 0.001). Both the use of IT hydromorphone and LB were associated with shortened LOS and fewer total and per day in-hospital OMEs; however, the group who received both IT and LB (LB + IT) had the greatest decrease in LOS, and both inpatient and post-discharge OME usage. Level III (retrospective comparative study).

Effect of cryoablation in Nuss bar placement on opioid utilization and length of stay.

Our institution recently transitioned from paravertebral nerve blocks (PVBs) to intercostal nerve cryoablation (INC) for pain control following minimally invasive repair of pectus excavatum (MIRPE). This study aimed to determine how INC affected the operative time, length of stay, complication rates, inpatient opioid use, and outpatient prescription of opioids at a single center. A retrospective review was performed at a single pediatric referral center of all patients who underwent MIRPE between 2018 and 2023. Patient demographics, operative details, and perioperative course were collected. The use of INC versus PVB was recorded. Univariate analyses were performed using Wilcoxon rank sum tests for continuous variables and chi-squared tests for categorical variables. 255 patients were included with a median age of 15years, median BMI of 18.50kg/m2, and median Haller index of 4.40. INC was utilized in 41% (105/255), and 59% (150/255) received PVB. The two groups did not differ significantly in BMI, Haller index, or complications, though the INC patients were older by 1year (15.0 vs. 16.0, p = 0.034). INC was associated with an increased operative time (INC: 92min vs. PVB: 67min, p < 0.001), decreased length of stay (3 vs. 4days, p = < 0.001), more than twofold decrease in inpatient opioids per day (INC: 16 MME vs. PVB: 41 MME, p < 0.001), and a fourfold decrease in the amount of opioids prescribed at discharge (INC: 90 MME vs. PVB: 390 MME, p < 0.001). INC after MIRPE significantly decreased both the inpatient opioid utilization and our outpatient prescribing practices while also decreasing our overall length of stay without increasing complications. Level III.

Hip Surgery is Not More Painful Than Spine Surgery in Children With Cerebral Palsy.

Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery. A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications. Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P <0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery ( P <0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 ( P <0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 ( P <0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 ( P =0.041), and lower average pain scores on POD3 ( P =0.043). This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP. Level 3.

Preoperative versus Postoperative Ultrasound-Guided Quadratus Lumborum Block for Postoperative Analgesia Following Radical Nephrectomy, A Comparative Study

Abstract Background The QLB is an effective analgesic technique for various abdominal wall incisions. The QLB covers T7 to L1 dermatomes by the spread of LA drugs either into the paravertebral space or in the thoracolumbar plane, through iliohypogastric and ilioinguinal nerves, A and C fiber nociceptors, mechanoreceptors and high-density network of lumbar sympathetic fibers. Objective To compare the effectiveness of ultrasound-guided preoperative to postoperative QLB on the effectiveness and duration of postoperative analgesia represented as time of first analgesia requested by patients. Patients and Methods After approval of research ethical committee of Ain Shams University Hospitals, this prospective double blinded randomized clinical study was conducted between April 2023 till September 2023, written consent was taken from all participants after explaining the procedure. One hundred and eight patients were included. later on. eight patient were excluded due to bleeding, failed block, duration of surgery more than 180 minutes. Included patients were divided into 2 groups 50 each. Results The current study also calculated and compared the standard deviation for each of the two groups analyzed, as well as the postoperative NRS score, initial time to rescue analgesia, and total amount of opioids (Nalbuphine) administered in the first 24 h. When compared to the postoperative QLB group (Group B), preoperative QLB patients (Group A) showed higher values. Postoperative QLB was found to be more effective than preoperative QLB in this clinical trial. Group B was found to be superior to Group A in terms of analgesia (Nalbuphine), total Nalbuphine consumption, and NRS score. Group A had higher pain ratings and were the first to rescue analgesia. There are no many studies were done comparing preoperative versus postoperative plan block especially with QLB in postoperative pain management and that’s the gab of knowledge in our study. Conclusion Postoperative administration of QLB in nephrectomy provides a prolonged duration of postoperative analgesia, with reduced analgesic requirements, a better quality of analgesia in terms of NRS compared to preoperative administration of QLB.

Distributed Opioids in Morphine Equivalent: A Global Measure of Availability for Palliative Care

ContextEstimates of serious health-related suffering (SHS) demonstrate immense unmet need for palliative care, predominately in low- and middle-income countries (LMICs). Because opioids are essential medicines in palliative care (PC), measuring their availability can be used to evaluate the capacity of health systems to meet need. ObjectivesPresent the methodology for calculating Distributed Opioids in Morphine Equivalents (DOME)— introduced in the Lancet Commission on Global Access to Palliative Care and Pain Relief report - and how it can be used as a simple indicator to quantify unmet pain relief and PC need. MethodsUsing International Narcotics Control Board (INCB) data, DOME applies relative potency estimates to convert the annualized quantities of clinically appropriate opioids procured by a country to oral morphine equivalent milligrams. To quantify unmet need, an expert group proposed health condition-specific estimates for opioid need and used available data on the burden of SHS to posit the annual opioid quantity required by country for symptomatic treatment of pain or breathlessness. Comparing this to DOME generates DOME%SHSNEED, the proportion of opioids needed for palliative care that can be fulfilled by the opioid procured by a country during a year. ResultsDOME and DOME%SHSNEED can be used to measure, over time, the capacity of countries to meet PC need, as a key component of universal health coverage. Identifying access gaps disproportionately impacting LMICs can promote better health system performance and guide countries and institutions in policy making. ConclusionDOME and DOME%SHSNEED can be used to monitor health system progress to redress disparities and promote access to medically indicated opioid therapy in palliative care.

Is Opioid Consumption Impacted by Study Participation? Maintenance of Fewer Opioid Refills With Reduced Prescription Quantity After Posterior Spinal Fusion in Adolescents With Idiopathic Scoliosis.

Opioid overprescribing can lead to nonmedical opioid use. In a previous prospective study (STUDY), we showed that a standardized protocol involving preoperative education and reduced opioid prescription quantity decreased opioid use in idiopathic scoliosis patients following posterior spinal fusion (PSF). A potential limitation was the Hawthorne effect, where participant behavior changes due to observation. At STUDY conclusion, we continued the reduced opioid prescriptions but discontinued the formal preoperative education. This retrospective study (post-STUDY) assessed if opioid refill requests increased outside of a study setting. Post-STUDY included patients aged 10 to 17 years who underwent PSF for idiopathic scoliosis between January 2022 and December 2023 and were discharged with a prescription of ≤30 oxycodone doses. Patients were excluded if they had previous spine surgery or were discharged with an opioid other than oxycodone. Demographics, perioperative variables, and opioid refill requests were compared with the data from STUDY, in which patients were aware their opioid use would be tracked. Patient-reported outcomes were collected via Scoliosis Research Society-22r (SRS-22r) surveys. The post-STUDY cohort included 67 patients (69% female). The average age at the time of PSF was 13.9 years (range, 11 to 17y). The mean number of levels fused was slightly higher (10.9 vs. 10.0, P=0.04), and intraoperative estimated blood loss was lower (211 vs. 303mL, P<0.01) compared with the STUDY cohort. Demographics, preoperative major curve magnitude, surgery duration, and length of hospital stay were similar. The percentage of patients who requested and received opioid refills between the post-STUDY and STUDY cohorts was also similar [6/67 (9%) vs. 3/49 (6%), P=0.30]. SRS-22r showed improvements in self-image, satisfaction, and mean total score from preoperative to postoperative. Reduced opioid prescriptions did not result in increased opioid refill requests in adolescents undergoing PSF for idiopathic scoliosis outside of a study setting. While formal preoperative discussions about postoperative pain control are important, other factors likely influence opioid use. Further research should explore characteristics that predispose patients to require higher amounts of postoperative opioids. Level III-therapeutic.

Reducing Postoperative Opioids in Pediatric Orthopaedics: An Updated Tiered Prescription Guideline with a “Tier 0”

BackgroundThere is growing data on strategies to reduce opioid prescriptions in pediatric orthopaedics. Our institution implemented tiered guidelines for opioid discharge prescriptions in 2018 to standardize prescribing patterns across our entire pediatric orthopaedics practice. In 2022, we updated the tiered system with a goal to further minimize the quantity of opioids prescribed and eliminate opioids altogether for certain procedures. The aim of this project was to evaluate the effects of the updated tiered guidelines for discharge opioid prescribing following common pediatric orthopaedic procedures. MethodsA quality improvement project was conducted at a single academic institution. Guidelines for discharge opioid prescriptions were updated in January 2022 and established 5 tiers of increasing invasiveness for 28 procedures. The updated guidelines included a “Tier 0” which provided no opioids, reorganized surgical tiers based on prior data, and decreased the doses recommended for tiers. Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of updated guideline eras, comparing 2020–2021 and 2022. ResultsOverall, 747 patients (2020–2021, n ​= ​500; 2022, n ​= ​247) were included. The proportion of patients receiving discharge opioid prescriptions decreased from 89.8% to 80.6% (P ​< ​0.05), between 2020 and 2021 and 2022. This resulted in decreased overall OME prescribed (median 75 vs 45, P ​< ​0.05) and OME prescribed in those >10 years (135 vs 113, P ​< ​0.05) while 30-day refill rates (9.4% vs 6.1%), and OME per kilogram in those <11 years of age (median 0.9 vs 0.8) remained unchanged (both P ​> ​0.05). Discharge prescriptions falling within overall guidelines increased after guideline implementation (83.3% vs 85.4%), though this was not statistically significant and guideline adherence was low among Tier 0 ​at 31%. ConclusionsIncluding “Tier 0” of procedures receiving no opioid prescriptions, reorganizing procedures within tiers, and decreasing the recommended doses to an already strict tiered guideline for discharge opioid prescriptions significantly decreased the quantity of opioids prescribed. We noted continued excellent overall adherence and, importantly, no overall increase in refills, with areas for improvement in Tier 0. Quality improvement projects can continue to reduce the amount of opioids prescribed following pediatric orthopaedic procedures. Key Concepts(1)Updated tiered guidelines, including a “Tier 0” for discharge opioid prescriptions following pediatric orthopaedic procedures were effective in reducing the quantity of opioids provided at discharge.(2)A continued high adherence rate was observed with the updated guidelines, though areas for improvement include adherence to no opioids in Tier 0.(3)Refill rates remained similar after implementation of the updated guidelines.(4)The study results suggest opportunities for continued improvement projects to reduce the number of unnecessary opioids prescribed to pediatric orthopaedic patients. Level of EvidenceIII.

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

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

Sex Disparities in Opioid Prescription and Administration on a Hospital Medicine Service

IntroductionDecisions to prescribe opioids to patients depend on many factors, including illness severity, pain assessment, and patient age, race, ethnicity, and gender. Gender and sex disparities have been documented in many healthcare settings, but are understudied in inpatient general medicine hospital settings.ObjectiveWe assessed for differences in opioid administration and prescription patterns by legal sex in adult patient hospitalizations from the general medicine service at a large urban academic center.Designs, Setting, and ParticipantsThis study included all adult patient hospitalizations discharged from the acute care inpatient general medicine services at the University of California, San Francisco (UCSF) Helen Diller Medical Center at Parnassus Heights from 1/1/2013 to 9/30/2021.Main Outcome and MeasuresThe primary outcomes were (1) average daily inpatient opioids received and (2) days of opioids prescribed on discharge. For both outcomes, we first performed logistic regression to assess differences in whether or not any opioids were administered or prescribed. Then, we performed negative binomial regression to assess differences in the amount of opioids given. We also performed all analyses on a subgroup of hospitalizations with pain-related diagnoses.ResultsOur study cohort included 48,745 hospitalizations involving 27,777 patients. Of these, 24,398 (50.1%) hospitalizations were female patients and 24,347 (49.9%) were male. Controlling for demographic, clinical, and hospitalization-level variables, female patients were less likely to receive inpatient opioids compared to male patents (adjusted OR 0.87; 95% CI 0.82, 0.92) and received 27.5 fewer morphine milligram equivalents per day on average (95% CI - 39.0, - 16.0). When considering discharge opioids, no significant differences were found between sexes. In the subgroup analysis of pain-related diagnoses, female patients received fewer inpatient opioids.ConclusionsFemale patients were less likely to receive inpatient opioids and received fewer opioids when prescribed. Future work to promote equity should identify strategies to ensure all patients receive adequate pain management.