Opioid Utilization Research Articles

Evaluating the Effect of COVID-19 on Outpatient Opioid Utilization Among Health First Colorado Members and a National Non-Medicaid Cohort: An Interrupted Time Series Analysis.

COVID-19, coinciding with the opioid epidemic in the United States, has had significant impacts on health-care utilization. While mixed, early analyses signaled a potential resurgence in opioid use following the pandemic. The primary study objective was to assess the association of the COVID-19 pandemic with opioid utilization among Health First Colorado (Colorado's Medicaid Program) members and a non-Medicaid managed care cohort who did not have a diagnosis of cancer or sickle cell disease. Using an interrupted time series and segmented regression analysis, this population-level study assessed the association of the COVID-19 pandemic on prescribed utilization of long- and short-acting opioid analgesics among Health First Colorado members and a random sample of non-Medicaid managed care members. Pharmacy claims data for both cohorts were assessed between October 1, 2018, and September 30, 2021, with April 2020 identified as the interruption of interest. We evaluated the following monthly opioid use measures separately for short-acting and long-acting opioids: number of members filling an opioid, total fills, and total days supplied. Short- and long-acting opioid utilization was significantly decreasing among Health First Colorado members in the 18 months prior to the start of COVID-19. After the onset of the pandemic, utilization stabilized and slopes were not significantly different from zero. Among the non-Medicaid managed care cohort, short- and long-acting opioid utilization significantly decreased in the 18 months leading up to the onset of the pandemic. After the onset of the pandemic, utilization of long-acting opioids stabilized, while utilization of short-acting opioids significantly increased. While we observed an increase in opioid utilization measures post-pandemic in the non-Medicaid managed care cohort, a similar increase was not observed in Health First Colorado members suggesting that thoughtful opioid policies put in place pre-pandemic may have been effective at controlling potential inappropriate opioid utilization.

Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials.

The effectiveness and safety of intraosseous basivertebral nerve ablation (BVNA) for treating vertebrogenic pain is established, but low back pain-related healthcare utilization (LBPr-HU) following BVNA continues to be defined. LBPr-HU data were pooled from 3 prospective studies. LBPr-HU categories of interest included non-invasive conservative care, opioid utilization, lumbosacral spinal injection (LSI), lumbosacral radiofrequency ablation (LRFA), and lumbosacral spinal surgery. Pre- and post-BVNA LBPr-HU were compared at both 1- and 5-years using McNemar's test for proportions and paired t-tests for means. Two hundred forty-seven patients received BVNA and had 1-year follow-up; 205 had long-term follow-up (mean of 5.3 ± 1.33 years). Twenty-seven percent fewer participants initiated conservative care in the year post-BVNA compared to the year preceding BVNA (P < .001; 95% CI 19.8-34.5). Of 77/247 participants taking opioids at baseline, 40.3% and 61.7% fewer were taking them at one-year and 5.3 ± 1.33 years post-BVNA, respectively (P < .001). Of participants receiving LSIs in the year preceding BVNA, 81.2% fewer received LSI(s) in the year post-BVNA (P < .001; 95% CI 70.7-90.7); a 76.4% reduction in LSIs was maintained through a mean of 5.3 ± 1.33 years post-BVNA. LRFA rates were 1.6% at 1-year post-BVNA and 8.3% at 5.3 ± 1.33 years post-BVNA. Lumbar fusion surgery was 0.8% at 1-year post-BVNA and 6.5% at 5.3 ± 1.33 years post-BVNA. In this aggregate analysis of patients with vertebrogenic pain, utilization of conservative care, opioids, LSIs, and LRFA were substantially reduced through 5 years post-BVNA compared to baseline. Lumbar fusion rates were less than half the published value at 5 years in similar populations.

Impact of Opioids on Cellular Metabolism: Implications for Metabolic Pathways Involved in Cancer.

Opioid utilization for pain management is prevalent among cancer patients. There is significant evidence describing the many effects of opioids on cancer development. Despite the pivotal role of metabolic reprogramming in facilitating cancer growth and metastasis, the specific impact of opioids on crucial oncogenic metabolic pathways remains inadequately investigated. This review provides an understanding of the current research on opioid-mediated changes to cellular metabolic pathways crucial for oncogenesis, including glycolysis, the tricarboxylic acid cycle, glutaminolysis, and oxidative phosphorylation (OXPHOS). The existing literature suggests that opioids affect energy production pathways via increasing intracellular glucose levels, increasing the production of lactic acid, and reducing ATP levels through impediment of OXPHOS. Opioids modulate pathways involved in redox balance which may allow cancer cells to overcome ROS-mediated apoptotic signaling. The majority of studies have been conducted in healthy tissue with a predominant focus on neuronal cells. To comprehensively understand the impact of opioids on metabolic pathways critical to cancer progression, research must extend beyond healthy tissue and encompass patient-derived cancer tissue, allowing for a better understanding in the context of the metabolic reprogramming already undergone by cancer cells. The current literature is limited by a lack of direct experimentation exploring opioid-induced changes to cancer metabolism as they relate to tumor growth and patient outcome.

The temporal effects of variable tourniquet use on pain after total knee arthroplasty

BackgroundTourniquet use in total knee arthroplasty (TKA) remains controversial. While widely studied, any temporal effects on pain and opioid utilization have not been investigated. We hypothesized that postoperative opioid utilization increases with increasing tourniquet times in TKA. MethodsWe retrospectively reviewed 1110 TKAs by three arthroplasty surgeons from October 2016 through September 2019. Exclusion criteria included ambulatory surgery, undocumented tourniquet times, simultaneous bilateral TKA, and diagnoses other than osteoarthritis, inflammatory arthritis, or osteonecrosis. Postoperative opioid medications were converted to daily morphine milligram equivalents (MME/day). Secondary outcomes included range of motion (ROM) at 1-month, 3-month, and 1-year visits as well as patient reported outcomes measures (PROMs) at 3 and 12 months. ResultsNine-hundred and eleven patients were included and stratified based on tourniquet use. Three-hundred and four patients were assigned to a “No Use” group (≤10’); 138 patients to “Low Use” (11–60’); 177 patients to “Medium Use” (61–90’); and 292 patients to “Prolonged Use” (91–120). Compared to No Use, MME/day was significantly increased with Medium Use (+7.676 MME/day, p = 0.001) and Prolonged Use (+12.44 MME/day, p =< 0.001). No significant differences were found between No Use and Low Use groups. Estimated blood loss (EBL) in Low Use and No Use groups was significantly increased compared to other groups (+120 mL, p < 0.001, +109 mL, p < 0.001 respectively). Post-operative ROM and complication rates were similar between groups at 1 year post-TKA. ConclusionsA threshold of 60 min of tourniquet time is associated with increased MME/day postoperatively compared to No Tourniquet. Functional and patient-reported outcomes are comparable between groups at 1 year follow-up.

Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients

IntroductionPectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions. MethodsWe reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications. ResultsTwenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006). ConclusionsINC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.

Prescription opioid utilization patterns, and associated outcomes, among privately insured patients prescribed opioids to manage pain associated with osteoarthritis

Objective To describe utilization patterns, negative clinical outcomes and economic burden of patients diagnosed with osteoarthritis (OA) of the hip and/or knee who received a prescription for tramadol or non-tramadol opioids vs. non-opioid drugs. Methods Optum Healthcare Solutions, Inc. commercial claims data were used (1/2012--3/2017). Adults with ≥2 diagnoses of OA of the hip and/or knee, and ≥30 days supply of pain medications were identified during the three-year period from the date of first prescription (index date) after the first OA diagnosis. Drug utilization statistics in the follow-up period were summarized by initial treatment (i.e. tramadol, non-tramadol opioids, non-opioid drugs). Opioid initiators were matched to those initiated on non-opioid treatments using a propensity score model accounting for baseline characteristics. Matched pairs analysis compared outcomes for these cohorts. Results Of 62,715 total patients, 15,270 (24.3%) initiated treatment with opioids, including 3,513 (5.6%) on tramadol and 11,757 (18.7%) on non-tramadol opioids. Opioid initiators had more comorbidities, higher baseline healthcare costs, and were more likely to have OA of the hip. Among non-opioid initiators, 27.5% switched to tramadol and 63% switched to non-tramadol opioids. Among tramadol initiators, 71% switched to non-tramadol opioids. Patients initiated on opioids had 20.4% (p < .01) higher all-cause healthcare costs and higher percentages experiencing multiple negative clinical outcomes (all p < .01) compared to matched controls. Conclusions Most patients with OA of the hip and/or knee either initiate on or switch to opioids for long-term management of OA-related pain despite known risks. This highlights the need for new treatments that delay or prevent use of opioids.

Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques.

Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction

To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR). Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users. Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively. This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use. Level III, retrospective cohort study.

Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project

BackgroundOpioid stewardship protocols reduce opioid overprescription, but many require corrective action within 1 year. Because there are limited data on the sustainability of opioid reduction protocols, we sought to evaluate prescribing trends beyond 1 year. MethodsWe reviewed prescribing data from a tertiary care center to establish a consensus discharge opioid-prescribing guideline. Subsequently, we performed a prospective quality-improvement study for patients on an enhanced recovery protocol undergoing elective colectomies, proctectomies, and stoma-related procedures. We gathered process (protocol compliance), balance (rates of patient-controlled analgesia and nerve blocks, inpatient opioid utilization, pain scores within 48 hours of discharge), and clinical measures (median discharge opioid pills, postdischarge day 7 satisfaction). ResultsIn total, 1,049 patients with similar ages, operative indications, and rates of substance use pre- and postintervention were included. Over 2 years, compliance was 88.6%, and there was a 43.6% reduction in the total discharge number of opioid pills. Phone calls for opioid refills were stable (10.2% pre- vs 7.8% postintervention, P = .16), and the following all decreased significantly: intraoperative nerve blocks, patient-controlled analgesia use, and final 48-hour and total median inpatient opioid use. There was a clinically negligible, statistically significant reduction in pain scores within 48 hours of discharge. Fifty patients provided satisfaction data, and 92% were satisfied or somewhat satisfied with their analgesia. ConclusionOver 2 years, reduced opioid prescribing was maintained without escalating resources. Sustainability suggests that after successfully implementing an opioid reduction protocol, institutions may safely redeploy quality improvement resources elsewhere.

Evaluating the Safety and Efficacy of Naloxegol in Critically Ill Opioid-Induced Constipation Patients.

Background Opioid-induced constipation (OIC) has become more common in the intensive care unit (ICU) due to increased opioid utilization. Traditional laxatives often prove ineffective against OIC, leading to the increased utilization of naloxegol. However, further research is needed to confirm naloxegol's effectiveness and safety in critical care. This study aimed to explore the safety and efficacy of this intervention in critically ill OIC patients. Methods A single-center retrospective study was conducted on 353 patients who received one or more doses of naloxegol from January 1, 2019, to June 30, 2020, for OIC at a tertiary care center. The primary endpoint of this study was to evaluate serious adverse events such as reduced analgesic effect, gastrointestinal perforation, seizure, acute myocardial infarction (AMI), or ventricular arrhythmias using Naranjo Scale in critically ill patients. The secondary goal was to assess the efficacy of naloxegol, measured by the time of the first bowel movement. Results The average duration of naloxegol use was three days, with the first bowel movement occurring at an average of 11.3 hours. Furthermore, 59.8% of individuals had their first bowel movement within 20 hours of receiving naloxegol. There was a low level of causality between naloxegol use and adverse events such as gastrointestinal perforation, seizures, AMI, cardiovascular mortality, stroke, and ventricular arrhythmia. Additionally, reduction in analgesia showed no strong relationship with naloxegol use indicated by the Naranjo Scale assessment. Conclusion Naloxegol showed promising safety and efficacy profiles in treating OIC amongst critically ill patients, though our findings require further validation through prospective studies. This research paves the way for further investigation into naloxegol's role in OIC management, emphasizing the necessity of personalized treatment strategies in critical care settings.

Assessing the Effectiveness of a Consultant Pharmacist-Led Opioid Stewardship Protocol in Skilled Nursing Facilities.

Background More than 1.4 million adults in the United States live in skilled nursing facilities (SNFs). Opioids are prescribed to approximately 60% of skilled nursing residents, a primarily older patient population. Current opioid prescribing guidelines may be difficult to extrapolate to this population because of pain burden and extensive analgesic use. Furthermore, in the older population, opioids are associated with greater frequency of adverse events with potential for hospitalization and increased all-cause mortality. Objective Evaluate the impact of a consultant pharmacist-led opioid stewardship protocol on patient pain-related outcomes in SNFs. Methods An opioid medication management protocol was implemented by consultant pharmacists at participating SNFs. Consultant pharmacists assessed facility residents for active opioid orders and systematically evaluated use and appropriateness of therapy. Facility data pre- and post-implementation of the protocol was compared to determine effectiveness. The primary outcomes included rate of recommendation acceptance, rate of as-needed (PRN) opioid utilization, and number of residents who experienced a fall. Results A total of 114 patients were included in the study. The percentage of patients utilizing opioid therapy pre-intervention was 78.1% and 74.6% post-intervention (P = 0.29; 95% CI 0.033-1.864). Patient pain scores decreased from an average of 3.7 to 3.2 (P < 0.01). Use of PRN opioid orders transitioned from 84.2% to 71.9% (P = < 0.01; 95% CI 0.055-0.675). Conclusion This study revealed significant reductions in average patient pain scores and reduction in PRN opioid medication utilization, overall emphasizing the positive impact of consultant pharmacist involvement in opioid stewardship within the skilled nursing setting.

Geriatric Pain Protocol: Impact of Multimodal Pain Care for Elderly Orthopaedic Trauma Patients.

Hip fractures are costly, and associated complications are the leading cause of injury-related deaths in persons 65 years or older. Pain medications in this population can be more potent, have a longer duration of action, and have serious side effects (Chau et al., 2008). Hip fractures are projected to reach 6.26 million worldwide by 2050 (Gullberg et al., 1997; Kannus et al., 1996). Morrison et al. (2003) report that uncontrolled pain leads to increased hospital length of stay (LOS), delayed physical therapy, and long-term functional impairment. The Geriatric Pain Protocol (GPP) is Cedars-Sinai's multimodal pain management solution, addressing the needs of older adult inpatients who have suffered fractures. Can the implementation of GPP reduce the morphine milligram equivalents (MMEs) used, LOS, and postoperative outcomes compared with non-GPP patients? Study participants included hip fracture patients admitted between February 1, 2019, and March 5, 2021; data were collected prospectively from electronic medical records. Inclusion criteria were patients 65 years or older with a hip fracture sustained from a ground-level fall and surgical candidate. Participants were divided into two categories: Geriatric Fracture Program (GFP) and non-GFP, with physician participation in the GFP being the differentiating factor. End points included postoperative pain, postoperative opioid utilization, LOS, complications, and 30-day readmission rates. The Mann-Whitney U test and Fisher's exact test were used for data analysis. Spearman's rank-based correlation coefficient was used to assess associations. The GPP decreased MME daily totals on Days 1 and 2 and improved pain management compared with non-GPP patients. The MMEs were lower in the GPP group than in the non-GPP group for both Postoperative Day 1 (POD1) (p = .007) and POD2 (p = .043); Numerical Rating Scale (NRS) Pain on POD1 was lower in the GPP group (vs. non-GPP, p = .013). There were no group differences in NRS POD2 Pain or complications (all ps > .1). The study sample (N = 453) had no significant difference between sex and LOS (all ps > .3). Although not statistically significant, the 30-day readmission rate trended lower in patients treated in accordance with the GPP. Use of the multimodal GPP reduced pain levels and MME totals for older adult hip fracture inpatients. More data are needed to evaluate the efficiency of the proposed protocol. Future studies should explore the possibilities of using the GPP across the geriatric orthopaedic patient care continuum.

Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials.

We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.

Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement

IntroductionThe opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. MethodsOne hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. ResultsPatient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. ConclusionsWe created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.

A Randomized Controlled Trial to Assess the Impact of Enhanced Recovery After Surgery on Patients Undergoing Elective Spine Surgery.

To conduct a prospective, randomized controlled trial (RCT) of an enhanced recovery after surgery (ERAS) protocol in an elective spine surgery population. Surgical outcomes such as length of stay (LOS), discharge disposition, and opioid utilization greatly contribute to patient satisfaction and societal healthcare costs. ERAS protocols are multimodal, patient-centered care pathways shown to reduce postoperative opioid use, reduced LOS, and improved ambulation; however, prospective ERAS data is limited in spine surgery. This single-center, IRB-approved, prospective RCT enrolled adult patients undergoing elective spine surgery between March 2019 and October 2020. Primary outcomes were peri-operative and 1-month postoperative opioid use. Patients were randomized to ERAS (n=142) or standard of care (SOC; n=142) based on power analyses to detect a difference in postoperative opioid use. Opioid use during hospitalization and the first postoperative month was not significantly different between groups (ERAS 112.2 vs. SOC 117.6 MME, P=0.76; ERAS 38.7% vs. SOC 39.4%, P=1.00 respectively). However, patients randomized to ERAS were less likely to use opioids at 6 months postoperatively (ERAS 11.4% vs. SOC 20.6%, P=0.046) and more likely to be discharged to home after surgery (ERAS 91.5% vs. SOC 81.0%, P=0.015). Here, we present a novel ERAS prospective RCT in the elective spine surgery population. While we do not detect a difference in the primary outcome of short-term opioid use, we observe significantly reduced opioid use at 6-month follow-up as well as an increased likelihood of home disposition after surgery in the ERAS group.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Retrospective cohort study. This project aims to evaluate the relationship between increased use of intraoperative nonopioid analgesics, muscle relaxers, and anesthetics and postoperative outcomes, including opioid utilization, time until ambulation, and hospital length of stay. Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine that occurs in otherwise healthy adolescents, occurring with a frequency of 1% to 3%. Up to 60% of patients receiving spinal surgeries, particularly posterior spinal fusion (PSF), experience at least 1 day of moderate-to-severe pain after surgery. This is a retrospective chart review of pediatric patients aged 10 to 17 having received PSF with >5 levels fused for AIS at a dedicated children's hospital and a regional tertiary referral center with a dedicated pediatric spine program between January 2018 and September 2022. A linear regression model was used to evaluate the influence of baseline characteristics and intraoperative medications on the total amount of postoperative morphine milligram equivalents received. There were no significant differences in the background characteristics of the two patient populations. Patients receiving PSF at the tertiary referral center received equivalent or greater amounts of all nonopioid pain medications and demonstrated decreased time until ambulation (19.3 vs . 22.3 h), postoperative opioid use (56.1 vs . 70.1 MME), and postoperative hospital length of stay (35.9 vs . 58.3 h). Hospital location was not individually associated with a difference in postoperative opioid use. There was not a significant difference in postoperative pain ratings. When accounting for all other variables, liposomal bupivacaine had the greatest contribution to the decrease in postoperative opioid use. Patients receiving greater amounts of nonopioid intraoperative medications utilized 20% fewer postoperative morphine milligram equivalents, were discharged 22.3 hours earlier and had earlier recorded evidence of mobility. Postoperatively, nonopioid analgesics were as effective as opioids in the reduction of subjective pain ratings. This study further demonstrates the efficacy of multimodal pain management regimens in pediatric patients receiving PSF for AIS.

Opioid Utilization After Scoliosis Surgery is Greater in Marfan Syndrome Than Adolescent Idiopathic Scoliosis.

Retrospective matched case cohort. Compare postoperative opioid utilization and prescribing behaviors between patients with Marfan syndrome (MFS) and adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF). Opioids are an essential component of pain management after PSF. However, due to the potential for opioid use disorder and dependence, current analgesic strategies aim to minimize their use, especially in younger patients. Limited information exists on opioid utilization after PSF for syndromic scoliosis. Twenty adolescents undergoing PSF with MFS were matched with patients with AIS (ratio, 1:2) by age, sex, degree of spinal deformity, and the number of vertebral levels fused. Inpatient and outpatient pharmaceutical data were reviewed for the quantity and duration of opioid and adjunct medications. Prescriptions were converted to morphine milligram equivalents (MMEs) using CDC's standard conversion factor. Compared with patients with AIS, patients with MFS had significantly greater total inpatient MME use (4.9 vs . 2.1 mg/kg, P ≤ 0.001) and longer duration of intravenous patient-controlled anesthesia (3.4 vs . 2.5 d, P = 0.001). Within the first 2 postop days, MFS patients had more patient-controlled anesthesia boluses (91 vs . 52 boluses, P = 0.01) despite similar pain scores and greater use of adjunct medications. After accounting for prior opioid use, MFS was the only significant predictor of requesting an opioid prescription after discharge (odds ratio: 4.1, 95% CI: 1.1-14.9, P = 0.03). Patients with MFS were also more likely to be discharged with a more potent prescription (1.0 vs . 0.72 MME per day/kg, P ≤ 0.001) and to receive a longer-duration prescription (13 vs . 8 d, P = 0.005) with a greater MME/kg (11.6 vs . 5.6 mg/kg, P ≤ 0.001) as outpatients. Despite a similar intervention, patients with MFS and AIS seem to differ in their postoperative opioid usage after PSF, presenting an opportunity for further research to assist clinicians in better anticipating the analgesic needs of individual patients, particularly in light of the ongoing opioid epidemic.

Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability

Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability

Experiences with pain management for survivors of complex cancers: Focus on opioids and cannabis.

12118 Background: Survivors of complex cancers often experience pain. Clinical practice guidelines for pain management in cancer survivors cautiously recommend opioids and cannabis for subgroups with certain pain phenotypes, despite limited evidence regarding benefits and harms in survivor populations. We aimed to better understand pain management for these survivors, focusing on attitudes toward, and experiences with, opioids and cannabis. Methods: We conducted 7 90-minute focus groups with 26 disease-free survivors of head and neck and lung cancer who still experience cancer-related pain. Multiple coders conducted thematic analyses to identify themes regarding 1) experiences with post-treatment pain and pain management and 2) utilization, benefits, and harms of post-treatment cannabis and opioids. Results: Survivors (7-35 months from treatment completion) experienced post-treatment physical and psychological pain that affected multiple aspects of their daily life. Since treatment completion, 69% used opioids previously and 8% currently using. Fifty-four percent had used any cannabis product since treatment completion, and 35% currently use cannabis. While some survivors experienced no pain management challenges, others enumerated various difficulties, including fears of addiction to opioids or cannabis, perceived stigma around both products, and access challenges around provider attitudes, cost and insurance coverage, and legality. Survivors reported that providers did not know how to advise about cannabis; for example: “When I talked [to providers] about marijuana they didn’t want to talk about it. They couldn’t recommend it because there’s no clinical data.” Opioids were often perceived as critical to pain management but came with unpleasant side effects. Cannabis was effective at reducing both pain and anxiety for many, but not all, survivors. For some, cannabis reduced anxiety, which in turn reduced pain: “It just keeps my mind occupied enough where I’m not thinking of pain.” Reducing anxiety also helped some survivors eat: “I have a lot of anxiety around eating because I have a fear of choking, so sometimes it helps that.” Survivors described a balance of benefits and harms of opioids and cannabis; for example: “Where [the doctor has] me now...if I go down any lower, it's not going to work. If I go up any higher, I'm going to be not able to function.” Conclusions: Post-treatment survivors of complex cancers continue to experience cancer-related pain, both psychological and physical, for which both opioids and cannabis present a complex set of harms and benefits that vary across survivors. Providers who care for cancer survivors should be aware of the interplay between psychological and physical pain, patient concerns and stigma around opioids and cannabis, and nuances of the harms, benefits, and access issues regarding these treatments.