Risk Of Persistent Opioid Use Research Articles

Predictive Models to Assess Risk of Persistent Opioid Use, Opioid Use Disorder, and Overdose.

This systematic review summarizes the development, accuracy, quality, and clinical utility of predictive models to assess the risk of opioid use disorder (OUD), persistent opioid use, and opioid overdose. In accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines, 8 electronic databases were searched for studies on predictive models and OUD, overdose, or persistent use in adults until June 25, 2023. Study selection and data extraction were completed independently by 2 reviewers. Risk of bias of included studies was assessed independently by 2 reviewers using the Prediction model Risk of Bias ASsessment Tool (PROBAST). The literature search yielded 3130 reports; after removing 199 duplicates, excluding 2685 studies after abstract review, and excluding 204 studies after full-text review, the final sample consisted of 41 studies that developed more than 160 predictive models. Primary outcomes included opioid overdose (31.6% of studies), OUD (41.4%), and persistent opioid use (17%). The most common modeling approach was regression modeling, and the most common predictors included age, sex, mental health diagnosis history, and substance use disorder history. Most studies reported model performance via the c statistic, ranging from 0.507 to 0.959; gradient boosting tree models and neural network models performed well in the context of their own study. One study deployed a model in real time. Risk of bias was predominantly high; concerns regarding applicability were predominantly low. Models to predict opioid-related risks are developed using diverse data sources and predictors, with a wide and heterogenous range of accuracy metrics. There is a need for further research to improve their accuracy and implementation.

Abstract 4835: Demographic factors and risk of persistent opioid use in a diverse cohort of breast cancer survivors

Abstract Background: Persistent opioid use (POU), in breast cancer survivors after they have completed active cancer treatment is an emerging area of concern. We examined rates and identified risk with POU in breast cancers survivors in the year after active cancer treatment going forward, and if these risks differed by race/ethnicity. Methods: We assembled a cohort of female breast cancer survivors diagnosed in 2009-2019 treated for early-stage disease (in situ, local, regional), and had at least two opioid prescriptions after one year of survivorship in a large health plan in southern California. Data were captured from the tumor registry, electronic health records, and pharmacy databases. The primary outcome was POU defined as continuously receiving at least 90 days supplied of opioids during follow-up. Patients were followed through the date once they met POU criteria, died, disenrolled from health plan, or reached study’s end (12/31/2021), whichever came first. We calculated rates as the number of patients who experienced POU per 1,000 person-years (PY). We identified the predictors and estimated hazard ratios (HR) associated with POU using multivariable proportional hazard regression and stratified by race/ethnicity. Results: The cohort included 14,347 breast cancer survivors who used opioids followed for a maximum of 12 years (median: 6.6 years). Overall, the cohort was diverse: 9% Asian/Pacific Islander (API); 14% Black; 22% Hispanic; and 54% White women. Out of 14,347 patients who used opioids, 2,285 (16%) patients developed POU. POU rates was the highest in Whites (36.2 per 1,000 PY) compared other race/ethnicity groups including Blacks, Hispanics, APIs (30.7, 17.3, 10.6 per 1,000 PY, respectively). Patients who developed POU had longer annualized median opioid duration, especially in Black patients (175.0 vs. 5.3 days) and were prescribed stronger opioids (median maximum daily morphine milligram equivalent 83.7 vs 50.0), compared to those who did not develop POU. In adjusted analyses of POU risk, Black (HR, 0.81; 95% CI: 0.72-0.92), API (HR, 0.59; 95% CI, 0.52-0.66), and Hispanic women (HR, 0.59; 95% CI, 0.52-0.66) were less likely to develop POU compared to White women. Patients with older age, Elixhauser Comorbidity Index ≥3, smoking, breast cancer stage (regional); type of opioid (Oxycodone); and who used other psychiatric and pain medications had significantly greater POU risk. In stratified analysis, the POU risk was 2.6 times greater (HR, 2.61; 95% CI, 1.32-5.15) in Hispanic patients aged≥65 vs <40 years. The highest HR was in APIs who were current smokers (HR, 4.26; 95% CI, 1.77-10.29) compared with non-smokers. Conclusion: The findings suggest that patients who are older, current smokers, with more comorbidities, and diagnosed with higher cancer stage were most vulnerable to developing POU. Citation Format: Lie Hong Chen, Rulin C. Hechter, Jiaxiao Shi, Zheng Gu, Moira Brady-Rogers, Rowan T. Chlebowski, Reina Haque. Demographic factors and risk of persistent opioid use in a diverse cohort of breast cancer survivors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4835.

New Persistent Opioid Use After Childbirth.

To examine factors associated with new persistent opioid use after childbirth. We conducted a population-based cohort study of individuals who initiated opioid therapy within 7 days of discharge from hospital after delivery between September 1, 2013, and September 30, 2021. The primary outcome was new persistent opioid use , which was defined as one or more prescriptions for an opioid within 90 days of the first postpartum prescription and one or more subsequent opioid prescriptions in the 91-365 days afterward. We used multivariable logistic regression to assess patient-, pregnancy-, and prescription-related factors associated with new persistent opioid use after delivery. We identified 118,694 unique deliveries after which opioids were initiated, including 99,399 cesarean (83.7%) and 19,295 vaginal (16.3%) deliveries. Among mothers who initiated an opioid after delivery, 1,282 (10.8/1,000 deliveries) met our definition of new persistent opioid use in the subsequent year. Rates of new persistent opioid use were appreciably higher after vaginal (16.0/1,000) compared with cesarean (9.8/1,000) deliveries. Each additional 30 morphine milligram equivalents in the initial opioid prescription was associated with an increased risk of new persistent use after cesarean (adjusted odds ratio [aOR] 1.06, 95% CI 1.04-1.08) and vaginal (aOR 1.05, 95% CI 1.02-1.08) delivery. A concomitant benzodiazepine prescription after cesarean delivery was associated with a markedly increased risk of persistent opioid use (aOR 2.69, 95% CI 1.60-4.52). Among people who filled an opioid prescription after delivery, about 1% displayed evidence of persistent opioid use in the subsequent year. Initial prescriptions for large quantities of opioids and a concurrent benzodiazepine prescription may be important modifiable risk factors to prevent new persistent opioid use after delivery.

A Prescribing Guideline Decreases Postoperative Opioid Prescribing in Emergency General Surgery

IntroductionPatients prescribed higher opioid dosages have a higher risk of persistent opioid use, overdose, and death. There is a lack of standardization for opioid prescribing for acute surgical pain in emergency general surgery (EGS) patients. We hypothesized that implementing a guideline to standardize opioid prescribing would be associated with a decrease in prescribing at hospital discharge for EGS patients without increasing additional postdischarge refills. MethodsThis was a quasi-experimental study evaluating opioid prescribing by EGS providers before and after the implementation of a prescribing guideline. Patients were assigned to preguideline and postguideline groups based on admission date surrounding the implementation of the guideline. The primary outcome was the proportion of patients receiving an opioid prescription for ≥50 Morphine Milligram Equivalents (MME) per day on hospital discharge. ResultsThere were 227 patients in the preguideline group and 226 patients in the postguideline group. After guideline implementation, median total MME prescribed decreased from 113 (interquartile range = 75) to 75 (interquartile range = 75, P = 0.03). The proportion of patients receiving a prescription for daily MME ≥50 also decreased from 75% to 25% (P ≤0.01). There were no increases in requested refills (17% versus 16%, P = 0.72) or received refills (14% versus 14%, P = 0.98). Guideline compliance ranged from 75% in ventral hernia repair patients to 94% in laparoscopic cholecystectomy patients. ConclusionsA departmental guideline to standardize postoperative opioid prescriptions was associated with a decrease in the amount of MMEs prescribed to EGS patients without an increase in requested or received refills.

Postoperative Opioid Prescribing in Adolescents and Young Adults After Urologic Procedures Is Associated With New Persistent Opioid Use Disorder: A Large Claims Database Analysis

To assess the risk of persistent opioid use following various urologic procedures in adolescents and young adults. The TriNetX LLC Diamond Network was queried for patients aged 13-21years who underwent pyeloplasty, hypospadias repair, inguinal hernia repair, inguinal orchiopexy, hydrocelectomy, or circumcision. Cohorts of patients prescribed and not prescribed postoperative opioids were created and propensity-matched for age, race/ethnicity, psychiatric diagnoses, and preoperative pain diagnoses. The primary outcome was new persistent opioid use, defined as new opioid use 3-9months after index procedure without another surgery requiring anesthesia during the postoperative timeframe. Of 32,789 patients identified, 66.0% received a postoperative opioid prescription. After propensity score matching for each procedure, 18,416 patients were included: 197 for pyeloplasty, 469 for hypospadias repair, 1818 for inguinal hernia repair, 2664 for inguinal orchiopexy, 534 for hydrocelectomy, and 3526 for circumcision. Overall, 0.41% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 1.69% of patients who received postoperative opioids developed new persistent opioid use (P<.05). Patients prescribed postoperative opioids had statistically higher odds of developing new persistent opioid use for hypospadias repair (RR: 17.0; 95% CI: 2.27-127.2), inguinal orchiopexy (RR: 3.46; 95% CI: 1.87-6.4), inguinal hernia repair (RR: 2.18; 95% CI: 1.07-4.44), and circumcision (RR: 4.83; 95% CI: 2.60-8.98). The use of postoperative opioids after urological procedures in adolescents and young adults is associated with a significant risk of developing new persistent opioid use.

Prescription of oxycodone versus codeine after childbirth and risk of persistent opioid use: a population-based cohort study.

Oxycodone is increasingly prescribed for postpartum analgesia in lieu of codeine owing to concerns regarding the neonatal safety of codeine during lactation. We examined whether initiation of oxycodone after delivery was associated with an increased risk of persistent opioid use relative to initiation of codeine. We conducted a population-based cohort study of people who filled a prescription for either codeine or oxycodone within 7 days of discharge from hospital after delivery between Sept. 1, 2012, and June 30, 2020. The primary outcome was persistent opioid use, defined as 1 or more additional prescriptions for an opioid within 90 days of the first postpartum prescription and 1 or more additional prescriptions in the 91 to 365 days thereafter. We used inverse probability of treatment weighting to assess the risk of persistent postpartum opioid use, comparing people who initiated oxycodone with those who initiated codeine. Over the 8-year study period, we identified 70 607 people who filled an opioid prescription within 7 days of discharge from hospital: 21 308 (30.2%) received codeine and 49 299 (69.8%) oxycodone. Compared with people who filled a prescription for codeine, receipt of oxycodone was not associated with persistent opioid use (relative risk [RR] 1.04, 95% confidence interval [CI] 0.91-1.20). We found an association between a prescription for oxycodone and persistent use after vaginal delivery (RR 1.63, 95% CI 1.31-2.03), but not after cesarean delivery (RR 0.85, 95% CI 0.73-1.00). Initiation of oxycodone (v. codeine) was not associated with an increased risk of persistent opioid use, except after vaginal delivery.

Factors associated with use of opioid rescue medication after surgery

BackgroundOpioid exposure after surgery increases risk of persistent opioid use. Here, we characterize at-home use of opioid rescue medication during 1–2 days after outpatient surgery (N=270) in a postoperative opioid-sparing...

Supply of opioids and information provided to patients after surgery in an Australian hospital: A cross-sectional study.

Opioids are commonly prescribed to manage pain after surgery. However, excessive supply on discharge can increase patients' risk of persistent opioid use and contribute to the reservoir of unused opioids in the community that may be misused. This study aimed to evaluate the use of opioids in Australian surgical patients after discharge and patient satisfaction with the provision of opioid information after discharge. This prospective cohort study was conducted at a tertiary referral and teaching hospital. Surgical patients were called 7-28 days after discharge to identify their opioid use and the information that they received after discharge. In total, 66 patients responded. Most patients underwent orthopaedic surgery (45.5%; 30/66). The median days of opioids supplied on discharge was 5 (IQR 3-5). In total, 40.9% (27/66) of patients had >50% of their opioids remaining. Patients undergoing orthopaedic surgery were less likely to have >50% of their opioids remaining (P = 0.045), whilst patients undergoing urological or renal surgeries were significantly more likely (P = 0.009). Most patients recalled receiving information about their opioids (89.4%; 59/66). However, the majority (51.5%; 34/66) did not recall receiving any information about the signs of opioid toxicity and interactions between opioids and alcohol. In conclusion, around 40% of patients had more than half of their opioid supply remaining after they ceased taking their opioid. Although most patients recalled receiving information about their opioids, more than half did not recall receiving any information about the signs of opioid toxicity or interactions between opioids and alcohol.

Association Between Payer Type and Risk of Persistent Opioid Use After Surgery.

To assess whether the risk of persistent opioid use after surgery varies by payer type. Persistent opioid use is associated with increased health care utilization and risk of opioid use disorder, opioid overdose, and mortality. Most research assessing the risk of persistent opioid use has focused on privately insured patients. Whether this risk varies by payer type is poorly understood. This cross-sectional analysis of the Michigan Surgical Quality Collaborative database examined adults aged 18 to 64 years undergoing surgical procedures across 70 hospitals between January 1, 2017 and October 31, 2019. The primary outcome was persistent opioid use, defined a priori as 1+ opioid prescription fulfillment at (1) an additional opioid prescription fulfillment after an initial postoperative fulfillment in the perioperative period or at least 1 fulfillment in the 4 to 90 days after discharge and (2) at least 1 opioid prescription fulfillment in the 91 to 180 days after discharge. The association between this outcome and payer type was evaluated using logistic regression, adjusting for patient and procedure characteristics. Among 40,071 patients included, the mean age was 45.3 years (SD 12.3), 24,853 (62%) were female, 9430 (23.5%) were Medicaid-insured, 26,760 (66.8%) were privately insured, and 3889 (9.7%) were covered by other payer types. The rate of POU was 11.5% and 5.6% for Medicaid-insured and privately insured patients, respectively (average marginal effect for Medicaid: 2.9% (95% CI 2.3%-3.6%)). Persistent opioid use remains common among individuals undergoing surgery and higher among patients with Medicaid insurance. Strategies to optimize postoperative recovery should focus on adequate pain management for all patients and consider tailored pathways for those at risk.

Prevalence and Persistence of Prescription Opioid Use Following Hospital Discharge After Childbirth: An Australian Population-Based Cohort Study.

Opioid analgesics are used for acute postpartum pain relief but carry risks, including persistent long-term opioid use. Our primary objective was to estimate the prevalence of persistent use following hospital discharge after childbirth. We conducted a population-based cohort study of women discharged from public or private hospitals in New South Wales, Australia, between 2012 and 2018 following vaginal birth (VB) or cesarean delivery (CD). We used linked hospitalization and medicine dispensing data to calculate the prevalence of opioid use within 14 days of hospital discharge for childbirth using an external estimate of the total number of hospital admissions for childbirth per year as the denominator. Among women dispensed an opioid postdischarge, we estimated the prevalence of persistent use defined as ≥3 dispensings between 30- and 365-days postdischarge. To calculate the odds of persistent opioid use, we performed a series of logistic regressions each including a single characteristic of interest. Included characteristics were maternal and birth characteristics, maternal medical conditions, prior use of certain medicines, and the initial opioid dispensed following discharge for childbirth. The final cohort comprised of 38,832 women who were dispensed an opioid in the 14 days following discharge after childbirth. Between 2012 and 2018, the prevalence of opioid use was increased following CD (public hospital 16.6%-21.0%; private hospital 9.8%-19.5%) compared with VB (public hospital 1.5%-1.5%; private hospital 1.2%-1.4%) and was higher following discharge from public hospitals compared with private. The most commonly dispensed opioids following discharge for childbirth were oxycodone (44.8%; 95% confidence interval [CI], 44.3-45.3), codeine (42.1%; 95% CI, 41.6-42.6), and tramadol (12.9%; 95% CI, 12.6-13.2). Among women dispensed an opioid, the prevalence of persistent opioid use was 5.4% (95% CI, 5.1-5.6). This prevalence was 11.4% (95% CI, 10.5-12.3) following a VB as compared with 4.3% (95% CI, 4.1-4.6) among those who underwent a CD ( P < .001). Characteristics associated with persistent opioid use included smoking during pregnancy, age <25 years, living in remote areas, discharged from a public hospital, history of opioid use disorder, other substance use disorder, mental health diagnosis, or prior use of prescription opioids, nonopioid analgesics, or benzodiazepines. The results of this cohort study indicate that Australian women have a higher prevalence of opioid use following CD compared to VB. One in 19 women dispensed an opioid postdischarge used opioids persistently. Careful monitoring of opioid therapy following childbirth is warranted, particularly among women with characteristics we identified as high risk for persistent opioid use.

O087 Predictors of persistent opioid use after discharge following colectomy: a population-based cohort study from England

Abstract Introduction Little is known regarding whether opioid prescriptions following colectomy lead to persistent use. We aimed to determine the prevalence of persistent post-discharge opioid use following colectomy, stratified by preadmission opioid exposure, and identify associated predictors of prolonged use. Methods This cohort study on adults undergoing colectomy between 2010 and 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data. Patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and prior exposed (prescription 6-12 months before admission). Persistent use was defined as needing an opioid prescription within 90 days of hospital discharge, along with another opioid prescription 91 to 180 days after discharge. Multivariable logistic regression analyses were performed to identify predictors of persistent use. Results Of the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 45.0% were opioid-naïve, 49.9% currently exposed, and 5.0% prior exposed. From the whole cohort, 7540 (8.1%) developed persistent opioid use. Patients with preoperative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group and 305 (9.8%) from the prior exposed group, with only 2.5% from the opioid-naïve group. Predictors of persistent use included prior opioid exposure, high deprivation index, multiple comorbidities, White ethnicity, and open surgery. Conclusion After colectomy, more than 1:12 patients continued to receive opioids three months beyond discharge. Minimally invasive surgery was associated with lower risk of persistent opioid use and may represent a modifiable risk factor.

Surgeon Postoperative Opioid Prescribing Intensity and Risk of Persistent Opioid Use Among Opioid-naive Adult Patients: A Population-based Cohort Study.

The aim of this study was to determine the relationship between surgeon opioid prescribing intensity and subsequent persistent opioid use among patients undergoing surgery. The extent to which different postoperative prescribing practices lead to persistent opioid use among surgical patients is poorly understood. Retrospective population-based cohort study assessing opioid-naive adults who underwent 1 of 4 common surgeries. For each surgical procedure, the surgeons' opioid prescribing intensity was categorized into quartiles based on the median daily dose of morphine equivalents of opioids dispensed within 7 days of the surgical visit for all the surgeons' patients. The primary outcome was persistent opioid use in the year after surgery, defined as 180 days or more of opioids supplied within the year after the index date excluding prescriptions filled within 30 days of the index date. Secondary outcomes included a refill for an opioid within 30 days and emergency department visits and hospitalizations within 1 year. Among 112,744 surgical patients, patients with surgeons in the highest intensity quartile (Q4) were more likely to fill an opioid prescription within 7 days after surgery compared with those in the lowest quartile (Q1) (83.3% Q4 vs 65.4% Q1). In the primary analysis, the incidence of persistent opioid use in the year after surgery was rare in both highest and lowest quartiles (0.3% Q4 vs 0.3% Q1), adjusted odds ratio (AOR) of 1.18, 95% CI 0.83-1.66). However, multiple analyses using stricter definitions of persistent use that included the requirement of a prescription filled within 7 days of discharge after surgery showed a significant association with surgeon quartile (up to an AOR 1.36, 95% CI 1.25, 1.47). Patients in Q4 were more likely to refill a prescription within 30 days (4.8% Q4 vs 4.0% Q1, AOR 1.14, 95% CI 1.04-1.24). Surgeons' overall prescribing practices may contribute to persistent opioid use and represent a target for quality improvement. However, the association was highly sensitive to the definition of persistent use used.

A Preliminary Study of Stress, Mental Health, and Pain Related to the COVID-19 Pandemic and Odds of Persistent Prescription Opioid Use.

The COVID-19 pandemic has been associated with increased opioid prescribing. It is not known if perceived COVID-19 related stress is associated with increased odds of long-term opioid use. To determine if greater COVID-19-related stress and worsening pain attributed to the pandemic was associated with LTOT over a 6-month observation period. Longitudinal cohort. Patients (n=477) from two midwestern health care systems, with any acute or chronic non-cancer pain, starting a new period of 30-90-day prescription opioid use, were invited to participate in the Prescription Opioids and Depression Pathways Cohort Study, a longitudinal survey study of pain, opioid use, and mental health outcomes. Baseline and 6-month follow-up assessments were used to measure the association between perceived COVID-19 stressors, the perception that pain was made worse by the pandemic and the odds of persistent opioid use, i.e., remaining a prescription opioid user at 6-month follow-up. Multivariate models controlled for demographics, opioid dose, and change in pain characteristics, mental health measures, and social support. Participants were, on average, 53.9 (±11.4) years of age, 67.1% White race, and 70.9% female. The most frequently endorsed COVID-19 stressor was "worry about health of self/others" (85.7% endorsed) and the least endorsed was "worsened pain due to pandemic" (26.2%). After adjusting for all covariates, "worsened pain due to pandemic" (OR=2.88; 95%CI: 1.33-6.22), change in pain interference (OR=1.20; 95%CI: 1.04-1.38), and change in vital exhaustion (OR=0.90; 95%CI: 0.82-0.99) remained significantly associated with persistent opioid use. Patients who attribute worsening pain to the COVID-19 pandemic are more likely to be persistent opioid users. Further research is warranted to identify mechanisms underlying this association. Clinicians may consider discussing pain in the context of the pandemic to identify patients at high risk for persistent opioid use.

New Opioid Persistence in Veterans Following Major and Minor Surgery.

Opioids are often a mainstay of managing postsurgical pain. Persistent use of opioids for more than 90 days after surgery is problematic, and the incidence of this adverse outcome has been reported in the civilian population ranging from 0.4% to 7%. Veterans compose a special population exposed to trauma and stressful situations and consequently face increased risk for habit-forming behavior and drug overdose. This evaluation determined the prevalence of opioid persistence after surgery and its relationship to patient characteristics in a military veteran population. A retrospective chart review was completed on 1,257 veterans who were opioid naive and had undergone a surgical procedure between January 2017 and May 2018. Patient characteristics, health conditions, and discharge opioid medications were recorded, and the incidence of persistent opioid use beyond 90 days was determined. The incidence of opioid persistence following major (3.3%) and minor (3.4%) procedures was similar. The incidence in patients younger than 45 years (3.3%), between 45 and 64 years (4.3%), and 65 years and older (2.2%) was also determined to be similar. Univariate patient factors associated with an increased risk for persistent opioid use include cancer (odds ratio [OR], 2.13; 95% CI, 1.11-4.09), mental health disorders (OR, 2.32; 95% CI, 1.17-4.60), and substance use disorders (OR, 2.09; 95% CI, 1.09-4.00). Among a cohort of over 1,200 opioid-naïve veterans undergoing surgery at a VA Medical Center, just over 3% went on to develop persistent opioid use beyond 3 months following their procedure. Persistent use was not found to be related to the type of procedure (major or minor) or patient age. Significant patient-level risk factors for opioid persistence were cancer and a history of mental health and substance use disorders.

Shared decision-making for postoperative opioid prescribing and preoperative pain management education decreases excess opioid burden.

Managing postoperative pain requires an individualized approach in order to balance adequate pain control with risk of persistent opioid use and narcotic abuse associated with inappropriately outsized narcotic prescriptions. Shared decision-making has been proposed to address individual pain management needs. We report here the results of a quality improvement initiative instituting prescribing guidelines using shared decision-making and preoperative pain expectation and management education to decrease excess opioid pills after surgery and improve patient satisfaction. Pre-intervention prescribing habits were obtained by retrospective review perioperative pharmacy records for patients undergoing general surgeries in the 24months prior to initiation of intervention. Patients scheduled to undergo General Surgery procedures were given a survey at their preoperative visit. Preoperative education was performed by the surgical team as a part of the Informed Consent process using a standardized handout and patients were asked to choose the number of narcotic pills they wished to obtain within prescribing recommendations. Postoperative surveys were administered during or after their 2-week postoperative visit. 131 patients completed pre-intervention and post-intervention surveys. The average prescription size decreased from 12.29 oxycodone pills per surgery prior to institution of pathway to 6.80 pills per surgery after institution of pathway (p < 0.001). The percentage of unused pills after surgery decreased from an estimated 70.5% pre-intervention to 48.5% (p < 0.001) post-intervention. 61.1% of patients with excess pills returned or planned to return medication to the pharmacy with 16.8% of patients reporting alternative disposal of excess medication. Patient-reported satisfaction was higher with current surgery compared to prior surgeries (p < 0.001). Institution of procedure-specific prescribing recommendations and preoperative pain management education using shared decision-making between patient and provider decreases opioid excess burden, resulting in fewer unused narcotic pills entering the community. Furthermore, allowing patients to participate in decision-making with their provider results in increased patient satisfaction.

Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review.

Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies. In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery? We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures. Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study. Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use. Level III, therapeutic study.

Factors associated with persistent opioid use 6–12 months after primary total knee arthroplasty

Persistent pain following knee arthroplasty occurs in up to 20% of patients and may require ongoing analgesia, including extended opioid administration. A comprehensive secondary analysis was performed from results of a study that considered persistent postoperative pain in 242 patients who underwent unilateral knee arthroplasty using a standardised enhanced recovery programme. Opioid prescribing for 12 months before and 12 months after surgery was evaluated and converted to oral morphine equivalents. Demographic, functional, psychological and pain questionnaires were completed along with quantitative sensory testing and genetic analysis. Forty-nine percent of patients had at least one opioid prescription in the 12 months before surgery. Opioid prescriptions were filled in 93% of patients from discharge to 3 months and in 27% of patients ≥6 months after surgery. Persistent opioid use ≥6 months after surgery was strongly associated with pre-operative opioid use (RR 3.2, p < 0.001 (95%CI 1.9-5.4)). The median (IQR [range]) oral morphine equivalent daily dose was 3.6 (0.9-10.5 [0-100.0]) mg pre-operatively, 35.0 (22.5-52.5 [4.6-180.0]) mg in hospital, 12.8 (5.1-24.8 [0-57.9]) mg from discharge to 3 months and 5.9 (4.5-12.0 [0-44.5]) mg at ≥6 months following surgery. Predictors of increased daily oral morphine equivalent ≥6 months after surgery included increased average daily oral morphine equivalent dose compared with previous values (lag), increased body mass index and three or more comorbid pain sites. Persistent opioid use was not associated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (RR 1.003, p = 0.655, 95%CI 0.65-1.002) or WOMAC function (RR 1.001, p = 0.99, 95%CI 0.99-1.03) outcomes 6 months after surgery. There was no association between persistent opioid use and pre-operative quantitative sensory testing results or psychological distress. Pre-operatively, patients with a higher body mass index, more comorbid pain sites and those who had filled an opioid prescription in the last 12 months, were at increased risk of persistent opioid use and a higher oral morphine equivalent daily dose ≥ 6 months after surgery. Strategies need to be developed to limit dose and duration of persistent opioid use in patients following knee arthroplasty surgery.

New persistent opioid use among adolescents and young adults with sarcoma.

Adolescents and young adults (AYA) with sarcoma experience both acute and chronic pain related to their disease and treatment. Studies in older adults have reported a high risk of persistent opioid use after cancer therapy among previously opioid-naive patients; however, few studies have evaluated posttreatment opioid use among AYAs. This article describes patterns of new persistent opioid use among AYAs in the year after treatment for sarcoma. Opioid-naive patients who were 10 to 26 years old and diagnosed with sarcoma (2008-2016) were identified with the IBM Marketscan Database. Included subjects had an International Classification of Diseases code for sarcoma (ninth or tenth revision), received anticancer therapy (chemotherapy, surgery, and/or radiation) within 30 days of the first diagnosis code, and had continuous insurance coverage (commercial or Medicaid) for more than 12 months both before the diagnosis and after the last therapy. The primary outcome was new persistent opioid use, which was defined as at least 2 opioid prescriptions in the 12 months following treatment completion. Covariates included age, sex, insurance, tumor type, surgical procedure, mental health (MH) or substance use diagnoses before or during therapy, and concomitant lorazepam use. In total, 938 patients met the inclusion criteria; 521 (56%) were male, and 578 (62%) were younger than 18 years. In total, 727 (78%) had commercial insurance, and 273 (29%) had an MH diagnosis either before or during the treatment period. Of the total group, 464 (49%) used opioids during treatment only. Of those who used opioids during treatment, 135 (23%) received at least 2 prescriptions in the year after therapy. In a multivariable analysis, Medicaid versus commercial insurance (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.15-2.64) and non-soft tissue sarcoma (OR for Ewing sarcoma, 3.23; 95% CI, 1.81-5.78; OR for osteosarcoma, 2.05; 95% CI, 1.36-3.09) conferred a higher likelihood of new persistent use. In this cohort of AYAs treated for sarcoma, 64% of the patients received opioid prescriptions during treatment, and 23% of these patients became new persistent users. Because of the risks associated with persistent opioid use, studies of novel pain management strategies along with age-appropriate education and anticipatory guidance are urgently needed. Using an insurance claims database, we conducted a study to determine the rate of new persistent opioid use among adolescents and young adults treated for sarcoma. We found that 64% of adolescents and young adults treated for sarcoma received opioid prescriptions during treatment, and 23% of these patients met the criteria for new persistent opioid use. These findings support the need for age-appropriate education and novel pain management strategies in this vulnerable population.

Incidence and patterns of persistent opioid use in children following appendectomy

BackgroundThe past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. Study designA retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. Results1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions.Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). ConclusionOpioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. Level of evidenceIII.

Postdischarge opioid use and persistent use after general surgery: A retrospective study

BackgroundOpioid overprescribing after surgery is a significant public health issue in most developed countries, including New Zealand. However, there is a lack of literature on the patterns and risk factors for postoperative opioid use among general surgical patients in New Zealand. This study aimed to examine opioid use in patients undergoing general surgery at Auckland District Health Board between January and December 2019 and to identify factors associated with opioid use after surgery and persistent opioid use (defined as having filled ≥1 opioid prescription in the 91 to 180 days after surgery). Methods and MaterialsThis is a retrospective cohort study. Data from patients’ electronic clinical records and community pharmacy dispensing records were extracted to obtain data on sociodemographics, surgical characteristics, comorbidities, co-prescribed medications, and opioid use. ResultsA total of 1,110 patients were included in the study, with 42.4% dispensed an opioid following discharge after surgery. Of opioid-naïve patients who filled opioids after surgery (n = 401), 9.5% became persistent opioid users. Preoperative use of nonopioid analgesics, longer hospital stays, higher operation severity, procedure type, and higher pain scores were positively associated with opioid use, whereas older age was a negative predictor. Longer hospital stays, an initial discharge prescription with high opioid load, and female sex increased the risk of persistent opioid use. Conversely, a higher severity of surgery was associated with lower risk of persistent opioid use. ConclusionThe findings suggest that a considerable proportion of patients become persistent opioid users after surgery. The risk factors identified can guide clinicians to prescribe in a manner that reduces opioid-related adverse outcomes and help guide future interventions.