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The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study.

ABSTRACT: The misuse of opioid analgesics is a major public health concern, and guidelines regarding postoperative opioid use are sparse. The authors examined the use of opioids following outpatient upper extremity procedures to discern the variation by procedure type and patient factors.The authors studied opioid prescriptions among 296,452 adults older than 18 years who underwent carpal tunnel release, trigger finger release, cubital tunnel release, or thumb carpometacarpal arthroplasty from 2009 to 2013 using insurance claims drawn from the Truven Health MarketScan Commercial Claims and Encounters, which encompasses over 100 health plans in the United States. Using multivariable regression, the authors compared the receipt of opioids, number of days supplied, indicators of inappropriate prescriptions, and number of refills by patient factors.In this cohort, 59 percent filled a postoperative prescription for opioid medication, and 8.8 percent of patients had an indicator of inappropriate prescribing. The probability of filling an opioid prescription declined linearly with advancing age. On multivariate analysis, patients who had previously received opioids were more likely to fill a postoperative opioid prescription (66 percent versus 59 percent), receive longer prescriptions (24 versus 5 days), receive refills following surgery (24 percent versus 5 percent), and have at least one indicator of potentially inappropriate prescribing (19 percent versus 6 percent).Current opioid users are more likely to require postoperative opioid analgesics for routine procedures and more likely to receive inappropriate prescriptions. More evidence is needed to identify patients who derive the greatest benefit from opioids to curb opioid prescriptions when alternative analgesics may be equally effective and available.Risk, III.

SUBMITTER: Waljee JF

PROVIDER: S-EPMC5090259 | biostudies-literature | 2016 Feb

REPOSITORIES: biostudies-literature

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The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study.

Waljee Jennifer F JF Zhong Lin L Hou Hechuan H Sears Erika E Brummett Chad C Chung Kevin C KC

Plastic and reconstructive surgery 20160201 2

<h4>Background</h4>The misuse of opioid analgesics is a major public health concern, and guidelines regarding postoperative opioid use are sparse. The authors examined the use of opioids following outpatient upper extremity procedures to discern the variation by procedure type and patient factors.<h4>Methods</h4>The authors studied opioid prescriptions among 296,452 adults older than 18 years who underwent carpal tunnel release, trigger finger release, cubital tunnel release, or thumb carpometac ...[more]

PMID: 26818326

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Project description:ImportanceThe overprescription of pain medications has been implicated as a driver of the burgeoning opioid epidemic; however, few guidelines exist regarding the appropriateness of opioid pain medication prescriptions after surgery.ObjectivesTo describe patterns of opioid pain medication prescriptions after common surgical procedures and determine the appropriateness of the prescription as indicated by the rate of refills.Design, setting, and participantsThe Department of Defense Military Health System Data Repository was used to identify opioid-naive individuals 18 to 64 years of age who had undergone 1 of 8 common surgical procedures between January 1, 2005, and September 30, 2014. The adjusted risk of refilling an opioid prescription based on the number of days of initial prescription was modeled using a generalized additive model with spline smoothing.ExposuresLength of initial prescription for opioid pain medication.Main outcomes and measuresNeed for an additional subsequent prescription for opioid pain medication, or a refill.ResultsOf the 215 140 individuals (107 588 women and 107 552 men; mean [SD] age, 40.1 [12.8] years) who underwent a procedure within the study time frame and received and filled at least 1 prescription for opioid pain medication within 14 days of their index procedure, 41 107 (19.1%) received at least 1 refill prescription. The median prescription lengths were 4 days (interquartile range [IQR], 3-5 days) for appendectomy and cholecystectomy, 5 days (IQR, 3-6 days) for inguinal hernia repair, 4 days (IQR, 3-5 days) for hysterectomy, 5 days (IQR, 3-6 days) for mastectomy, 5 days (IQR, 4-8 days) for anterior cruciate ligament repair and rotator cuff repair, and 7 days (IQR, 5-10 days) for discectomy. The early nadir in the probability of refill was at an initial prescription of 9 days for general surgery procedures (probability of refill, 10.7%), 13 days for women's health procedures (probability of refill, 16.8%), and 15 days for musculoskeletal procedures (probability of refill, 32.5%).Conclusions and relevanceIdeally, opioid prescriptions after surgery should balance adequate pain management against the duration of treatment. In practice, the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir, or 4 to 9 days for general surgery procedures, 4 to 13 days for women's health procedures, and 6 to 15 days for musculoskeletal procedures.

Project description:ContextThe prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America.ObjectiveTo examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures.Data sourcesA systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018.Study selectionTwo investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria.Study designSystematic review.Level of evidenceLevel 4.Data extractionThe quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies.ResultsA total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill.ConclusionOpioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

Project description:Importance:Despite increased focus on reducing opioid prescribing for long-term pain, little is known regarding the incidence and risk factors for persistent opioid use after surgery. Objective:To determine the incidence of new persistent opioid use after minor and major surgical procedures. Design, Setting, and Participants:Using a nationwide insurance claims data set from 2013 to 2014, we identified US adults aged 18 to 64 years without opioid use in the year prior to surgery (ie, no opioid prescription fulfillments from 12 months to 1 month prior to the procedure). For patients filling a perioperative opioid prescription, we calculated the incidence of persistent opioid use for more than 90 days among opioid-naive patients after both minor surgical procedures (ie, varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel) and major surgical procedures (ie, ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy). We then assessed data for patient-level predictors of persistent opioid use. Main Outcomes and Measures:The primary outcome was defined a priori prior to data extraction. The primary outcome was new persistent opioid use, which was defined as an opioid prescription fulfillment between 90 and 180 days after the surgical procedure. Results:A total of 36?177 patients met the inclusion criteria, with 29?068 (80.3%) receiving minor surgical procedures and 7109 (19.7%) receiving major procedures. The cohort had a mean (SD) age of 44.6 (11.9) years and was predominately female (23?913 [66.1%]) and white (26?091 [72.1%]). The rates of new persistent opioid use were similar between the 2 groups, ranging from 5.9% to 6.5%. By comparison, the incidence in the nonoperative control cohort was only 0.4%. Risk factors independently associated with new persistent opioid use included preoperative tobacco use (adjusted odds ratio [aOR], 1.35; 95% CI, 1.21-1.49), alcohol and substance abuse disorders (aOR, 1.34; 95% CI, 1.05-1.72), mood disorders (aOR, 1.15; 95% CI, 1.01-1.30), anxiety (aOR, 1.25; 95% CI, 1.10-1.42), and preoperative pain disorders (back pain: aOR, 1.57; 95% CI, 1.42-1.75; neck pain: aOR, 1.22; 95% CI, 1.07-1.39; arthritis: aOR, 1.56; 95% CI, 1.40-1.73; and centralized pain: aOR, 1.39; 95% CI, 1.26-1.54). Conclusions and Relevance:New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors. New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness.

Project description:ImportanceSurgeons must balance management of acute postoperative pain with opioid stewardship. Patient-centered methods that immediately evaluate pain and opioid consumption can be used to guide prescribing and shared decision-making.ObjectiveTo assess the difference between the number of opioid tablets prescribed and the self-reported number of tablets taken as well as self-reported pain intensity and ability to manage pain after orthopedic and urologic procedures with use of an automated text messaging system.Design, setting, and participantsThis quality improvement study was conducted at a large, urban academic health care system in Pennsylvania. Adult patients (aged ≥18 years) who underwent orthopedic and urologic procedures and received postoperative prescriptions for opioids were included. Data were collected prospectively using automated text messaging until postoperative day 28, from May 1 to December 31, 2019.Main outcomes and measuresThe primary outcome was the difference between the number of opioid tablets prescribed and the patient-reported number of tablets taken (in oxycodone 5-mg tablet equivalents). Secondary outcomes were self-reported pain intensity (on a scale of 0-10, with 10 being the highest level of pain) and ability to manage pain (on a scale of 0-10, with 10 representing very able to control pain) after orthopedic and urologic procedures.ResultsOf the 919 study participants, 742 (80.7%) underwent orthopedic procedures and 177 (19.2%) underwent urologic procedures. Among those who underwent orthopedic procedures, 384 (51.8%) were women, 491 (66.7%) were White, and the median age was 48 years (interquartile range [IQR], 32-61 years); 514 (69.8%) had an outpatient procedure. Among those who underwent urologic procedures, 145 (84.8%) were men, 138 (80.7%) were White, and the median age was 56 years (IQR, 40-67 years); 106 (62%) had an outpatient procedure. The mean (SD) pain score on day 4 after orthopedic procedures was 4.72 (2.54), with a mean (SD) change by day 21 of -0.40 (1.91). The mean (SD) ability to manage pain score on day 4 was 7.32 (2.59), with a mean (SD) change of -0.80 (2.72) by day 21. The mean (SD) pain score on day 4 after urologic procedures was 3.48 (2.43), with a mean (SD) change by day 21 of -1.50 (2.12). The mean (SD) ability to manage pain score on day 4 was 7.34 (2.81), with a mean (SD) change of 0.80 (1.75) by day 14. The median quantity of opioids prescribed for patients who underwent orthopedic procedures was high compared with self-reported consumption (20 tablets [IQR, 15-30 tablets] vs 6 tablets used [IQR, 0-14 tablets]), similar to findings for patients who underwent urologic procedures (7 tablets [IQR, 5-10 tablets] vs 1 tablet used [IQR, 0-4 tablets]). Over the study period, 9452 of 15 581 total tablets prescribed (60.7%) were unused. A total of 589 patients (64.1%) used less than half of the amount prescribed, and 256 patients (27.8%) did not use any opioids (179 [24.1%] who underwent orthopedic procedures and 77 [43.5%] who underwent urologic procedures).Conclusions and relevanceIn this quality improvement study of adult patients reporting use of opioids after common orthopedic and urologic surgical procedures through a text messaging system, the quantities of opioids prescribed and the quantity consumed differed. Patient-reported data collected through text messaging may support clinicians in tailoring prescriptions and guide shared decision-making to limit excess quantities of prescribed opioids.

Project description:BackgroundMisuse 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.Study designElectronic 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.ResultsAmong 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.ConclusionsGiven 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.

Project description:PurposeTo identify targets for corrective interventions and guide improved opioid stewardship, we studied opioid prescribing patterns of attending surgeons compared with surgical trainees for 2 upper-extremity surgeries: open reduction internal fixation (ORIF) of distal radius fractures (DRF), and carpal tunnel release (CTR).MethodsWe retrospectively reviewed records for all patients who underwent CTR or DRF ORIF at 6 hospitals across a large health system from 2016 to 2018. We collected prescriber training level (attending vs trainee), analgesic prescribed, and amount initially prescribed after surgery converted to oral morphine equivalents (OMEs). Regression models evaluated OMEs by prescriber and surgery type. Our final models included an interaction term between prescriber training level and year of surgery to assess group changes over time. No prescription guidelines or formal training was provided during the study period.ResultsWe included 707 CTR and 383 DRF ORIF patients. Opioids prescribed by trainees ranged from 90 to 300 OMEs (median, 180 OMEs). Opioids prescribed by attendings ranged from 100 to 225 OMEs (median, 150 OMEs). Early in the analyses, trainees prescribed significantly more than attendings (320 versus 180). Over time, trainees reduced overprescribing significantly more, by an additional 40 OME/y. By the end of the analysis period, trainees were prescribing less OME than were attendings (112.5 vs 150). Both groups continued to prescribe more than recently suggested amounts for both procedures.ConclusionsOur study found that both attendings and trainees overprescribed opioids after surgery. Trainees prescribed more than attendings over the study period; however, when analyzing for improvement over time and with no formal intervention or training, trainees showed greater improvement, eventually dropping to levels at or below that of attendings. Considering that most change was seen at the trainee level, education for established providers may be an area in which more improvement can be made.Clinical relevanceUnderstanding which providers are more likely to overprescribe opioids can help guide interventions that improve opioid stewardship.

Dataset Information

The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study.

Publications

The Use of Opioid Analgesics following Common Upper Extremity Surgical Procedures: A National, Population-Based Study.

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