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Jarlbaek, Lene. "Opioid prescribing habits differ between Denmark, Sweden and Norway – and they change over time." Scandinavian Journal of Pain 19, no. 3 (July 26, 2019): 491–99. http://dx.doi.org/10.1515/sjpain-2018-0342.
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Abstract Background and aims The medical use of opioids in different countries is often subject to public concern and debate, frequently based on rough figures from prescription databases made for registration of consumption. However, public access to some of these databases allow for further exploration of the prescription data, which can be processed to increase knowledge and insight into national opioid prescribing-behavior. Denmark, Sweden and Norway are considered closely related with regard to health care and culture. So, this study aims to provide a more detailed picture of opioid prescribing and its changes in the three Scandinavian countries during 2006–2014, using public assessable prescription data. Methods Data on dispensed opioid prescriptions (ATC; N02A, and R05DA04) were downloaded from each country’s prescription-databases. The amounts of dispensed opioids were used as proxy for consumption or use of opioids. Potential differences between dispensed prescriptions and actual use cannot be drawn from these databases. Consumption-data were converted from defined daily doses (DDDs) to mg oral morphine equivalents (omeqs). Changes in the choice of opioid-types, consumption and number of users were presented using descriptive statistics and compared. Results Opioid users: during the whole period, Norway had the highest, and Denmark the lowest, number of opioid users/1,000 inhabitants. From 2006 to 2014 the numbers of users/1,000 inhabitants changed from 98 to 105 in Norway, from 66 to 75 in Denmark, and from 79 to 78 in Sweden. Opioid consumption/1,000 inhabitants: The results depended much on the unit of measurement. The differences between the countries in consumption/1,000 inhabitants were small when DDDs was used as unit, while using mg omeqs significant differences between the countries appeared. Denmark had a much higher consumption of omeqs per 1,000 inhabitants compared to Sweden and Norway. Opioid consumption/user: during the whole period, Norway had the lowest, and Denmark the highest consumption/user. In 2006, the annual average consumption/user was 1979, 3615, 6025 mg omeq/user in Norway, Sweden and Denmark, respectively. In 2014 the corresponding consumption was 2426, 3473, 6361 mg omeq/user. The preferred choices of opioid-types changed during the period in all three countries. The balance between use of weak or strong opioids showed more prominent changes in Norway and Sweden compared to Denmark. Conclusions This study has shown how public assessable opioid prescription data can provide insight in the doctors’ prescribing behavior, and how it might change over time. The amounts of dispensed opioids, opioid prescribing habits and changes were compared between the countries, and significant differences appeared. Within each country, the overall picture of opioid consumption appeared rather stable. Implications Studies like this can contribute to qualify the ongoing debates of use of opioids in different nations and to monitor effects of initiatives taken by health-care authorities and health-care policy-makers.
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Bhashyam, Abhiram R., Cornelia Keyser, Christopher P. Miller, Jennifer Jacobs, Eric Bluman, Jeremy T. Smith, and Christopher Chiodo. "Prospective Evaluation of Opioid Use After Adoption of a Prescribing Guideline for Outpatient Foot and Ankle Surgery." Foot & Ankle International 40, no. 11 (July 18, 2019): 1260–66. http://dx.doi.org/10.1177/1071100719863711.
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Background: In 2016, our provider group adopted an initial prescription opioid maximum guideline to reduce overprescription of opioids. The purpose of this study was to prospectively assess opioid consumption patterns following implementation of this guideline in patients undergoing outpatient foot and ankle surgery. Methods: Over a 1-year period, we prospectively analyzed opioid prescription and use patterns of 303 consecutive patients. Opioid consumption was verified by pill counts completed at the 2- and 6-week postoperative visits. The morphine equivalent dose was calculated for each prescription and converted to the equivalent 5-mg oxycodone “pill.” We used the regression coefficients from a regression model of opioid consumption to create a revised guideline for maximum initial opioid prescriptions based on patient age, bony vs nonbony procedure, and anatomic location (forefoot/midfoot/hindfoot/ankle). Results: On average, 37.4 pills were prescribed and 18.9 pills used (47.6% utilization). Only 17.2% of patients used their full prescription quantity. By 2 weeks, 88% of patients no longer used opioids. Only 1.3% of patients used prescription opioids beyond 6 weeks. Independent risk factors for increased opioid consumption were younger age ( P = .003), male sex ( P = .007), recent preoperative opioid use ( P = .019), bony procedures ( P < .001), and ankle/hindfoot procedures ( P = .016 and P < .001). Conclusion: This study showed the amount of opioid consumption for patients undergoing foot and ankle procedures. We present a modified guideline for the maximum initial prescription of opioids following outpatient foot and ankle procedures that can be used as a benchmark for further study in decreasing overprescribing. Level of Evidence: Level II, prospective observational cohort study.
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Wilson, Sylvia H., Bethany J. Wolf, Stefanie M. Robinson, Cecil Nelson, and Latha Hebbar. "Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial." Pain Medicine 20, no. 8 (December 17, 2018): 1584–91. http://dx.doi.org/10.1093/pm/pny253.
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Abstract Objective Examination of postoperative analgesia with intravenous and oral acetaminophen. Design Prospective, three-arm, nonblinded, randomized clinical trial. Setting A single academic medical center. Subjects Parturients scheduled for elective cesarean delivery. Methods This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects. Results Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group. Conclusions Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.
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Miller, Andrew, Nayoung Kim, and Asif M. Ilyas. "Prospective Evaluation of Opioid Consumption Following Hand Surgery Performed Wide Awake Versus With Sedation." HAND 12, no. 6 (November 28, 2016): 606–9. http://dx.doi.org/10.1177/1558944716677536.
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Background: We prospectively evaluated opioid consumption postoperatively following trigger finger release (TFR) and open carpal tunnel release (CTR), and hypothesized that cases performed wide awake with local anesthesia and no tourniquet (WALANT) would result in increased opioid consumption compared with cases performed under monitored anesthesia care (MAC). Methods: Postoperative opioid consumption following CTR and TFR was prospectively collected over 6 months. The primary end points of the study were: (1) total opioid consumption; and (2) the number of days an opioid was used for both groups. Results: Mean opioid use and number of days the opioid was used for all MAC cases were 3.95 pills and 1.8 days, respectively. The results for WALANT were 3.85 pills and 1.6 days. Conclusions: These results suggest that effective pain control postoperatively may be independent of anesthesia type for soft tissue procedures of the hand. Specifically, average opioid consumption and days of utilization were similar in both the MAC and WALANT groups. Average postoperative opioid consumption was approximately only 4 opioid pills. Consideration should be given to prescribing fewer opioids for surgeries such as CTR and TFR.
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Kvarda, Peter, Noortje Catharina Hagemeijer, Gregory Waryasz, Daniel Guss, Christopher W. DiGiovanni, and Anne H. Johnson. "Opioid Consumption Rate Following Foot and Ankle Surgery." Foot & Ankle International 40, no. 8 (May 21, 2019): 905–13. http://dx.doi.org/10.1177/1071100719848354.
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Background: The rapid increase in the consumption of prescription opioids has become one of the leading medical, economic, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among all operative specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures and identify risk factors associated with higher use. Methods: A total of 535 patients who underwent foot and/or ankle surgery between August 2016 and March 2018 were included in the study. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the 2-week postoperative visit, the patients self-reported the amount of consumed opioids. Prescription details, number of opioid pills consumed, refill requests, pain-issue-related telephone calls, and additional physician/emergency department visits were documented. Patient demographics, comorbidities, use of regional anesthesia, hospitalization, surgery type/severity, and preoperative opioid use were collected. A total of 244 patients had a sufficiently complete data set for inclusion in the final cohort. Subjects had a mean age of 50 years (±16.3) and a body mass index (BMI) of 29 (±6.1). Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure. Results: On average, patients consumed 46.6% of the prescribed pills following a bony procedure and 42.4% after a soft tissue procedure, which resulted in a total of 4496 leftover pills. BMI, procedure type (bony vs soft tissue)/severity, and number of opioids prescribed were positively correlated with elevated consumption rates ( P = .008, P < .001, P < .001, P < .001, respectively). Conclusion: BMI, procedure type, and higher initial pill dispensation correlated with a larger number of consumed pills during the postoperative period. On average, patients took 42.4% of the prescribed opioid after soft tissue procedures and 46.6% after bony procedures, resulting in a significant number of unused pills. Future guidelines are necessary to improve postoperative pain management to prevent narcotic overprescription and minimize the downstream potential for unprescribed community opioid access. Level of Evidence: Level III, retrospective case series, analytic.
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Merrill, Haley M., Daniel M. Dean, Jay L. Mottla, Steven K. Neufeld, Daniel J. Cuttica, and Matthew M. Buchanan. "Opioid Consumption Following Foot and Ankle Surgery." Foot & Ankle International 39, no. 6 (March 5, 2018): 649–56. http://dx.doi.org/10.1177/1071100718757527.
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Background Orthopedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, leftover) are unknown. Methods: Patients undergoing foot/ankle surgery during a 3-month period who met inclusion criteria were surveyed at their first postoperative visit. Information collected included gender, number of prescribed pills remaining, satisfaction with pain control, and willingness to surrender leftover opioids to a Drug Enforcement Administration (DEA) disposal center. Additional data, including utilization of a perioperative nerve block and type (bony versus nonbony) and anatomic region of procedure, were collected through review of the medical record. All data were analyzed in a retrospective fashion. A total of 171 patients with a mean age of 53.1 ± 15.5 years (range, 18-81 years) were included in the study. Results: The mean number of opioids taken was 27.2 ± 17.5 pills (range, 0-70). The mean number of short-acting opioids and long-acting opioids taken was 21.4 ± 14.8 and 9.2 ± 5.0 pills, respectively. Most (73.5%) patients were satisfied with their pain control. Patients who underwent ankle/hindfoot surgery took more long-acting opioids on average than others ( P = .047). There was not a significant difference in opioid usage between bony and nonbony procedures. Of those with leftover opioids, 63% were willing to surrender them to a DEA disposal center. Patients willing to surrender leftover medications had both more short-acting ( P < .001) and long-acting ( P = .015) opioids leftover than those not willing to surrender them. Conclusion: Most patients undergoing foot/ankle surgery had opioids leftover at the first postoperative visit, and most were willing to surrender them. We can adequately treat patients’ pain and decrease the number of opioid pills available in the community by decreasing the number of pills prescribed and encouraging disposal of leftovers. Level of Evidence: Level IV, retrospective case series.
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Chapman, Talia, Nayoung Kim, Mitchell Maltenfort, and Asif M. Ilyas. "Prospective Evaluation of Opioid Consumption Following Carpal Tunnel Release Surgery." HAND 12, no. 1 (July 7, 2016): 39–42. http://dx.doi.org/10.1177/1558944716646765.
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Background: Postoperative pain management and opioid consumption following carpal tunnel release (CTR) surgery may be influenced by many variables. To understand factors affecting opioid consumption, a prospective study was undertaken with the hypothesis that CTR performed under local anesthesia (wide awake local anesthesia with no tourniquet [WALANT]) would result in increased opioid consumption postoperatively compared with cases performed under sedation. Methods: All patients undergoing open CTR surgery were consecutively enrolled over a 6-month period. Information collected included patient demographics, surgical technique, amount and type of narcotic prescribed, number of pills taken, and type of anesthesia. Results: 277 patients were enrolled (56% women, 44% men). On average, 21 pills were prescribed, and 4.3 pills (median = 2) were consumed. There was no difference in consumption between patients who received WALANT (78 cases) versus (198 cases) sedation (4.9 vs 3.9 pills, respectively) ( P = .22). There was no difference in opioid consumption based on insurance type ( P = .47) or type of narcotic ( P = .85). However, more men consumed no opioids (47%) compared with women (36%) ( P < .05) and older patients consumed less than younger patients ( P < .05). Conclusions: Opioid consumption following CTR is more influenced by age and gender, and less influenced by anesthesia type, insurance type, or the type of opioid prescribed. Many more opioids were prescribed than needed, on an average of 5:1. Many patients, particularly older patients, do not require any opioid analgesia after CTR.
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CLAUSEN, T. G. "International opioid consumption." Acta Anaesthesiologica Scandinavica 41, no. 1 (January 1997): 162–65. http://dx.doi.org/10.1111/j.1399-6576.1997.tb04632.x.
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McKissack, Haley, Jun Kit He, Robert D. Stibolt, Aaradhana J. Jha, Perry Washburn, Sameer M. Naranje, Gerald McGwin, and Michael D. Johnson. "Effect of Postoperative Gabapentin Administration on Opioid Consumption." Foot & Ankle Orthopaedics 4, no. 4 (October 1, 2019): 2473011419S0030. http://dx.doi.org/10.1177/2473011419s00301.
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Category: Foot & Ankle Surgery Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. This study aims to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. Those prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients prescribed gabapentin plus opioids, total opioids prescribed (in morphine equivalents, OME) was 68.33, 221.25, 87.50, and 400.83 at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. Although not statistically significantly different, patients prescribed only opioids had greater average amounts of opioids prescribed at all time intervals, equaling 98.34 OME, 553.52 OME, 540.53 OME, and 766.25 OME at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. When excluding patients taking opioids preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed gabapentin (196.94 OME) in comparison to those prescribed only opioids (457.41 OME) (p=0.0255). Conclusion: The findings of this study suggest that gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Gabapentin may be particularly beneficial within the three to six week postoperative period. Prospective clinical trials are warranted to further validate these results.
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Balsamo, Duilio, Paolo Bajardi, Alberto Salomone, and Rossano Schifanella. "Patterns of Routes of Administration and Drug Tampering for Nonmedical Opioid Consumption: Data Mining and Content Analysis of Reddit Discussions." Journal of Medical Internet Research 23, no. 1 (January 4, 2021): e21212. http://dx.doi.org/10.2196/21212.
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Background The complex unfolding of the US opioid epidemic in the last 20 years has been the subject of a large body of medical and pharmacological research, and it has sparked a multidisciplinary discussion on how to implement interventions and policies to effectively control its impact on public health. Objective This study leverages Reddit, a social media platform, as the primary data source to investigate the opioid crisis. We aimed to find a large cohort of Reddit users interested in discussing the use of opioids, trace the temporal evolution of their interest, and extensively characterize patterns of the nonmedical consumption of opioids, with a focus on routes of administration and drug tampering. Methods We used a semiautomatic information retrieval algorithm to identify subreddits discussing nonmedical opioid consumption and developed a methodology based on word embedding to find alternative colloquial and nonmedical terms referring to opioid substances, routes of administration, and drug-tampering methods. We modeled the preferences of adoption of substances and routes of administration, estimating their prevalence and temporal unfolding. Ultimately, through the evaluation of odds ratios based on co-mentions, we measured the strength of association between opioid substances, routes of administration, and drug tampering. Results We identified 32 subreddits discussing nonmedical opioid usage from 2014 to 2018 and observed the evolution of interest among over 86,000 Reddit users potentially involved in firsthand opioid usage. We learned the language model of opioid consumption and provided alternative vocabularies for opioid substances, routes of administration, and drug tampering. A data-driven taxonomy of nonmedical routes of administration was proposed. We modeled the temporal evolution of interest in opioid consumption by ranking the popularity of the adoption of opioid substances and routes of administration, observing relevant trends, such as the surge in synthetic opioids like fentanyl and an increasing interest in rectal administration. In addition, we measured the strength of association between drug tampering, routes of administration, and substance consumption, finding evidence of understudied abusive behaviors, like chewing fentanyl patches and dissolving buprenorphine sublingually. Conclusions This work investigated some important consumption-related aspects of the opioid epidemic using Reddit data. We believe that our approach may provide a novel perspective for a more comprehensive understanding of nonmedical abuse of opioids substances and inform the prevention, treatment, and control of the public health effects.
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Lovecchio, Francis, Ajay Premkumar, Tyler Uppstrom, Jeffrey Stepan, Brittany Ammerman, Moira McCarthy, Beth Shubin Stein, et al. "Opioid Consumption After Arthroscopic Meniscal Procedures and Anterior Cruciate Ligament Reconstruction." Orthopaedic Journal of Sports Medicine 8, no. 4 (April 1, 2020): 232596712091354. http://dx.doi.org/10.1177/2325967120913549.
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Background: Procedure-specific opioid-prescribing guidelines have the potential to decrease the number of unused pills in the home without compromising patient satisfaction. However, there is a paucity of data on the minimum necessary quantity to prescribe for outpatient orthopaedic surgeries. Purpose: To prospectively record daily opioid use and pain levels after arthroscopic meniscal procedures and anterior cruciate ligament reconstruction (ACLR) at a single institution. Study Design: Case series; Level of evidence, 4. Methods: A total of 95 adult patients who underwent primary arthroscopic knee surgery (meniscectomy, repair, or ACLR) were enrolled. Patients with a history of opioid dependence were ineligible. Daily opioid consumption and Numeric Rating Scale pain scores were collected through an automated text-messaging platform starting on postoperative day 1 (POD1). At 6 weeks or at patient-reported cessation of opioid use, final survey questions were asked. Patients who failed to complete data collection were excluded. Opioid use was converted into “pills” (oxycodone 5-mg equivalents) to facilitate comparisons and clinical applications. Factors associated with high and low opioid use were compared. Results: Of the 95 patients enrolled, 71 (74.7%) were included in the final analysis. Of these, 40 (56.3%) underwent meniscal surgery and 31 (43.7%) underwent ACLR. After outpatient arthroscopic meniscectomy or repair, the total median postdischarge opioid use was 0.3 pills (oxycodone 5-mg equivalents), with 75% of patients consuming 3.3 or fewer pills (range, 0-19 pills). For ACLR, the median postdischarge consumption was 7 pills (75th percentile, 23.3 pills; range, 0-41 pills). Almost one-third of patients (32.3%) took no opioids after surgery (3 ACLR, 20 meniscus). All meniscus patients and 71% of ACLR patients ceased opioid consumption by postoperative day 7. Conclusion: Opioids may not be necessary in all patients, particularly after meniscal surgery and in comparison with ACLR. For patients requesting opioids for pain relief, reasonable prescription quantities are 5 oxycodone 5-mg pills after arthroscopic meniscal procedures and 20 5-mg pills after ACLR. Slowing the current opioid epidemic and preventing future crises is dependent on refining prescribing habits. Clinicians should strongly consider patient education regarding expected pain as well as pain management strategies.
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Kvarda, Peter, Noortje Hagemeijer, Gregory R. Waryasz, Daniel Guss, Christopher W. DiGiovanni, and A. Holly Johnson. "Opioid Consumption Rate After Foot and Ankle Surgery." Foot & Ankle Orthopaedics 4, no. 2 (April 1, 2019): 2473011419S0000. http://dx.doi.org/10.1177/2473011419s00004.
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Category: Opioid consumption rate and risk factors investigation after foot and ankle surgery Introduction/Purpose: The rapid increase in the consumption of prescription opioids has become one of the leading medical, economical, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among surgical specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopaedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures, and to identify patient risk factors associated with higher use. Methods: A total of 535 patients who underwent a F&A surgery performed by one orthopedic surgeon from August 2016 to March 2018 were investigated. The study was approved by our IRB. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the two-week postoperative visit, the patient-reported amount of consumed opioids was recorded. Prescription details, the amount of opioids taken, refill requests, pain-issue related telephone calls, and additional MD/ED visits were also documented. Patient demographics and co-morbidities, use of regional anesthesia, postoperative inpatient hospitalization, surgery type and severity, and pre-operative opioid use were collected retrospectively. Total amounts of morphine equivalents were calculated and converted into oxycodone 5 mg pills for standardization. P-values of <0.05 were considered significant. Results: Two hundred forty-four patients with a mean age of 50 years (±16.3) and a BMI of 29 (±6.1) were included. Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure. 225 (92.2%) patients received regional block. Patients reported that they consumed only 51.2% of prescribed pills after a bony procedure and 42.4% after a soft tissue procedure, respectively, which resulted in a total of 4,496.2 left over pills that derived from this study amongst only 244 patients enrolled. There were 11 refill requests (4.5%), two (0.8%) additional MD/ED visits, and 19 (7.8%) telephone calls related to pain. BMI, procedure type, and number of opioids prescribed were positively correlated with the consumption rate (P =.002, P<.001, P<0.001, respectively). Conclusion: BMI, surgery type (bony vs. soft tissue), and a higher number of pills dispensed were correlated with higher use in the postoperative period. After an educative discussion on postoperative pain, patients took 42.4% of the prescribed opioid after soft tissue procedures and 51.2% after bony procedures, resulting in a significant number of unused pills now available to the community. Future guidelines are necessary to improve our postoperative pain management, but this study suggests that current amounts of dispensed pills after orthopaedic F&A procedures are approximately twice as high as necessary.
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Ramaswamy, Karunakaran. "Opioid Free Cardiac Anesthesia." Journal of Cardiac Critical Care TSS 05, no. 01 (January 2021): 043–44. http://dx.doi.org/10.1055/s-0041-1723931.
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AbstractOpioids are one of the effective forms of analgesia for acute pain in the perioperative period but, with overprescription, have become detrimental to public health. There has been a steady increase in opioid consumption and the number of opioid-related deaths, and the U.S. government has declared the opioid epidemic as a public health emergency. Anesthesiologists have a responsibility as the first exposure to opioids was during the perioperative period in the majority of cases. Acute tolerance and hyperalgesia are well known after opioid use in the postoperative opioid further increasing opioid consumption. More importantly, anesthesiologists have no control after the postoperative period, where the prescriptions continue to be repeated from general practice physicians. We have a moral responsibility to reduce opioid use to avoid it if feasible.
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Richards, Georgia C., Jeffrey K. Aronson, Carl Heneghan, Kamal R. Mahtani, Constantinos Koshiaris, and Nav Persaud. "Relation between opioid consumption and inclusion of opioids in 137 national essential medicines lists." BMJ Global Health 5, no. 11 (November 2020): e003563. http://dx.doi.org/10.1136/bmjgh-2020-003563.
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IntroductionOpioids are deemed essential medicines by the World Health Organization (WHO). However, many countries have inadequate access to them. Whether including opioids in national essential medicines lists (EMLs) influences national opioid consumption has not been evaluated.MethodsWe conducted a cross-sectional study to determine whether the listing of opioids in national EMLs was associated with consumption. We quantified the numbers and types of all opioids included in 137 national EMLs, for comparison with opioids in the WHO’s Model List of Essential Medicines. Using the International Narcotics Control Board (INCB) consumption statistics for 2015–2017, we assessed the relation between annual mean opioid consumption (mg/person) and the numbers of opioids included in EMLs, controlling for region, population, healthcare expenditure, life expectancy, gross domestic product, human development and corruption.ResultsFive opioids were included in the 20th edition of the WHO’s Model List of Essential Medicines: codeine, fentanyl, loperamide, methadone and morphine. On average, countries’ lists included significantly (p<0.05) more opioids than the WHO’s Model List. However, there were wide variations in the numbers (median 6 opioids; IQR: 5–9) and types (n=33) of opioids included in national EMLs. Morphine (95%), fentanyl (83%) and codeine (69%) were the most commonly included opioids. Most national EMLs were out of date (median publication date: 2011, IQR: 2009–2013). After adjusting for country characteristics, there was no relation between mean opioid consumption and the number of opioids in EMLs.ConclusionsIncluding opioids in national EMLs was not associated with consumption. National EMLs should be regularly updated to reflect the availability of opioids and the populations’ needs for managing pain.
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Miller, Andrew, Nayoung Kim, Benjamin Zmistowski, Asif M. Ilyas, and Jonas L. Matzon. "Postoperative Pain Management Following Carpal Tunnel Release: A Prospective Cohort Evaluation." HAND 12, no. 6 (November 1, 2016): 541–45. http://dx.doi.org/10.1177/1558944716677535.
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Background: Managing postoperative pain in hand surgery is important for both patients and surgeons. However, there is growing concern over prescription opioid abuse. We hypothesized: (1) that pain medications after carpal tunnel release (CTR) surgery are over-prescribed; and (2) that opioids are unnecessary in the majority of patients. Methods: We prospectively studied 2 demographically similar patient cohorts receiving either opioid or tramadol for CTR performed by 2 hand surgery fellowship-trained orthopedic surgeons over a 1-year period. The first cohort of patients undergoing CTR received opioids pills postoperatively. The second cohort of patients received a standard prescription of 10 tramadol pills postoperatively. Student t tests were performed to evaluate statistically significant differences between the tramadol and opioid cohorts in total pill consumption and number of postoperative days the medication was used. Results: The opioid cohort consisted of 159 patients with a mean opioid consumption of 4.9 pills for 2.3 days. Eleven of these patients declined the use of opioids postoperatively and instead substituted for nonsteroidal anti-inflammatories and/or acetaminophen. The tramadol cohort consisted of 110 patients with a mean tramadol consumption of 3.3 pills for 1.8 days. Seven of these patients requested opioids postoperatively, and 14 substituted for nonsteroidal anti-inflammatory drugs and/or acetaminophen. When comparing the postoperative consumption of opioids and tramadol for CTR, there was a statistically significant difference in total pill consumption based on both intention to treat as well as the medication ultimately prescribed. There was no difference in the duration of postoperative utilization. Conclusion: Following CTR, pain medications are being over-prescribed, with patients receiving more than double the amount of pills than they consume. Tramadol appears to be equally effective in managing postoperative pain compared with opioids.
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Rogero, Ryan, Daniel Fuchs, Kristen Nicholson, Rachel J. Shakked, Brian S. Winters, David I. Pedowitz, Steven M. Raikin, and Joseph N. Daniel. "Postoperative Opioid Consumption in Opioid-Naïve Patients Undergoing Hallux Valgus Correction." Foot & Ankle International 40, no. 11 (July 18, 2019): 1267–72. http://dx.doi.org/10.1177/1071100719862606.
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Background: Postoperative pain management following orthopedic surgeries can be challenging, and the opioid epidemic has made it essential to better individualize opioid prescriptions by patient and procedure. The purpose of this subgroup analysis of a prospective study was to investigate immediate postoperative opioid pill consumption and prolonged use in patients undergoing operative correction of hallux valgus (HV). Methods: Patients undergoing outpatient HV correction procedures with 5 fellowship-trained foot and ankle surgeons over a 1-year period were included. Patients were excluded if they were being prescribed chronic opioid analgesics for an underlying condition prior to the date of initial injury or if they underwent concomitant nonforefoot procedures. At the patient’s first postoperative visit, opioid pills were counted, and these were standardized to the equivalent number of 5-mg oxycodone pills. Linear regression analysis was performed to determine if any of the procedure categories or patient factors were independently associated with postoperative opioid consumption. Prolonged use of opioids 90 to 180 days after the procedure was also examined using our state’s online Prescription Drug Monitoring Program (PDMP). One-hundred thirty-seven patients (86% female) were included. Thirty-six patients (26%) underwent primary chevron osteotomies, 78 (57%) underwent primary proximal osteotomies (Ludloff, scarf), 10 (7%) underwent soft tissue–only procedures with or without a first proximal phalanx osteotomy (modified McBride, Akin), and 13 (9%) underwent first metatarsophalangeal arthrodeses. Results: Overall, patients consumed a median of 27 pills. There was no significant difference in postoperative opioid intake between the 4 procedures, including when subdivided into those with and without lesser toe procedures. Higher preoperative visual analog scale pain levels ( P = .028) and younger patient age ( P = .042) were associated with higher opioid pill consumption. A total of 1.5% of patients demonstrated prolonged opioid use. Conclusion: Our study demonstrated a lack of difference between HV procedures in terms of postoperative opioid consumption and an overall low rate of prolonged use in opioid-naïve patients. Level of Evidence: Level III, comparative study.
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Thompson, Samuel F., Zackary P. Burrow, Scott H. Conant, Samantha P. Kelly, Evan S. Fene, Ryan W. Morrisett, and Amgad M. Haleem. "Patient Reported Opioid Consumption Following Outpatient Foot and Ankle Surgery." Foot & Ankle Orthopaedics 4, no. 4 (October 1, 2019): 2473011419S0007. http://dx.doi.org/10.1177/2473011419s00073.
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Category: opioid consumption Introduction/Purpose: The expanding opioid crisis has forced orthopedic surgeons to evaluate their prescribing practices, yet there remains limited evidence to guide providers in achieving safe and effective postoperative analgesia. Our goal was to prospectively evaluate opioid consumption following outpatient foot and ankle surgery and determine predictors of increased narcotic usage. Methods: We prospectively enrolled adult patients scheduled for outpatient foot and ankle surgery and conducted phone and in- person interviews postoperatively to determine pain level, number of pills consumed, satisfaction with pain control, and whether other analgesic medication was used. Interviews were performed at four separate time points: 5 days, 10 days, 2 weeks, and 6 weeks following surgery. Additional data collected included age, gender, payer status, education level, preoperative pain level, procedure performed, whether opioid pain medication had been used by the patient in the 12 months preceding surgery, and the amount of narcotic prescribed postoperatively. Results: Complete data was available for 52 patients (median age, 42 years). The median number of opioids prescribed postoperatively was 45 pills (337.5 morphine milligram equivalents (MMEs)). A refill narcotic prescription was provided for 36.5% of patients. The number of opioid pills consumed following surgery ranged from 0 to 120 (median, 40 pills). Forty-six percent of patients had discontinued the use of opioids by post-op day 10 and 86.5% by post-op day 20. Increased pre-operative pain level (p = 0.02) and an increased quantity of pills prescribed at the first prescription (<0.0001) were significantly associated with increased narcotic consumption. Eighteen (39.1%) patients filled a narcotic prescription in the 12 months prior to surgery, however, narcotic use prior to surgery did not significantly increase total opioid consumption. Conclusion: We found that the median number of opioids consumed following outpatient foot and ankle surgery was 40 pills. Nearly 90% of patients had discontinued narcotic use by 20 days postoperatively. Pre-operative pain level and the number of pills provided at the first prescription were predictive of increased narcotic usage.
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Bergeria, Cecilia L., Sean B. Dolan, Matthew W. Johnson, Claudia M. Campbell, and Kelly E. Dunn. "Evaluating the co-use of opioids and cannabis for pain among current users using hypothetical purchase tasks." Journal of Psychopharmacology 34, no. 6 (April 8, 2020): 654–62. http://dx.doi.org/10.1177/0269881120914211.
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Background: Cannabinoids may potentiate opioid analgesia and therefore could be used to reduce reliance on opioids for analgesia. Aims: The current study evaluated whether the concurrent availability of cannabis influences opioid consumption using a behavioral economic demand framework. Methods: An online survey assessed cannabis and opioid use frequency and dependence measures, pain severity, and demand for both cannabis and opioids alone and when concurrently available using hypothetical purchase tasks. Adults reporting current use of opioids for pain management and past 30-day cannabis exposure ( N=155) completed two hypothetical purchase tasks in which only grams of cannabis or units of participants’ index opioids were available for purchase, and two hypothetical tasks in which both were concurrently available and the price of one drug increased whereas the other was kept constant. Paired-sample t-tests compared the demand of each drug alone with when it was available concurrently with an alternative. Results: Demand intensity was significantly reduced and demand elasticity was significantly increased for both cannabis and opioids when the alternate commodity was available, although the reductions in cannabis consumption were more pronounced than they were for opioid consumption in the presence of the alternate commodity. Conclusions: These data provide behavioral economic evidence that cannabis access may modestly reduce demand for opioids in persons who have pain. Additional clinical studies that evaluate the analgesic effects of cannabis and cannabis-opioid effects on pain are warranted.
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Wong, Kelvin A., and Kanu S. Goyal. "Postoperative Pain Management of Non–“Opioid-Naive” Patients Undergoing Hand and Upper-Extremity Surgery." HAND 15, no. 5 (February 19, 2019): 651–58. http://dx.doi.org/10.1177/1558944719828000.
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Background: Patients with prior opioid use are often difficult to manage postoperatively. We examined potential strategies for managing these patients: (1) prescribing a different opioid; and (2) encouraging the use of nonopioid analgesics over opioids. Methods: A pain control program was implemented at an outpatient hand and upper-extremity center. Patients were recruited before (n = 305) and after (n = 225) implementation. Seventy of them were taking opioids prior to surgery. Information about pain control satisfaction and opioid use was collected. The Fisher exact test was used to compare categorical variables with small expected frequencies. Wilcoxon rank sum test was used to compare nonnormally distributed continuous variables. Results: Opioid users used 28.8 ± 25.6 opioid pills; nonopioid users used 14.5 ± 21.5 pills. Furthermore, 41.4% of opioid users sought more pills after surgery compared with 14.0% among nonopioid users. The pain control program was more effective in reducing opioid consumption and waste and increasing nonopioid consumption for nonopioid users than for opioid users. Prior opioid users who were prescribed a different opioid after surgery used 24.6 ± 22.0 opioid pills. Patients prescribed the same opioid used 37.9 ± 30.8 pills. Conclusions: Patients taking opioids prior to hand and upper-extremity surgery use more opioid pills, seek more pills after surgery, and are less satisfied with their pain control than their nonopioid user counterparts. Furthermore, the comprehensive pain plan was less effective in this patient population. Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management.
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Lee, Wonyong, Dan Prat, Daniel C. Farber, Keith L. Wapner, and Wen Chao. "Prospective Evaluation of Opioid Consumption in Multimodal Analgesia Following Isolated Hallux Valgus Correction or First MTP Joint Arthrodesis." Foot & Ankle Orthopaedics 5, no. 4 (October 1, 2020): 2473011420S0032. http://dx.doi.org/10.1177/2473011420s00327.
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Category: Other; Bunion; Midfoot/Forefoot Introduction/Purpose: There is no standard guideline for prescription opioids for postoperative pain management following outpatient foot and ankle surgery. Multiple previous studies demonstrated that opioids were overprescribed. The purpose of this study was to prospectively investigate opioid consumption using multimodal analgesia regimen after two of the most common forefoot surgeries: isolated hallux valgus correction or 1st metatarsophalangeal (MTP) joint arthrodesis. Methods: We prospectively investigated opioid prescription and consumption of total 21 patients who underwent isolated hallux valgus correction with distal soft tissue procedure and proximal first metatarsal crescentic osteotomy or 1st MTP joint arthrodesis. Postoperative pain was managed using multimodal analgesia including oxycodone, ibuprofen, acetaminophen, and regional ankle block. Patients were instructed to take 5mg of oxycodone every 4 hours as needed, and 600 mg of ibuprofen as well as 1,000 mg of acetaminophen every 8 hours regularly. The number of pills patients consumed for oxycodone was recorded at postoperative follow-up at 1-week, 2-week, 4-week, 8-week, and 12-week. Subgroup analysis was performed to evaluate opioid consumption according to the prescription type: Only oxycodone was prescribed in group A while oxycodone as well as prescription strength ibuprofen and acetaminophen were prescribed in group B. Another subgroup analysis in opioid consumption was performed based on the quantity of opioid prescription and procedure type. Results: The overall mean opioid consumption in 12 weeks of the postoperative period was 16.2 pills per patient with an average of 37.3 pills prescribed. Lower opioid consumption was noted in group B when prescription ibuprofen and acetaminophen were prescribed compared to group A when patients took over-the-counter (OTC) ibuprofen and acetaminophen: 9.0 pills vs 24.1 pills, respectively (P = 0.036). There was a trend showing higher opioid consumption in patients prescribed greater than 30 pills of oxycodone compared to less than or equal to 30 pills: 22.0 pills vs 9.8 pills, respectively (P = 0.099). No significant difference was found in opioid consumption according to the procedure type: 15.8 pills in hallux valgus correction vs 16.5 pills in 1st MTP joint arthrodesis (P = 0.750). Conclusion: This study showed that on the average, patients took 16.2 pills out of 37.3 pills of the prescribed oxycodone after isolated hallux valgus correction or 1st MTP joint arthrodesis using our multimodal analgesia regimen. Patients who were prescribed prescription strength ibuprofen and acetaminophen consumed opioid significantly less than those who took the OTC strength. No significant difference was noted in opioid consumption between isolated hallux valgus correction and 1st MTP joint arthrodesis.
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Sheth, Ujash, Mitesh Mehta, Fernando Huyke, Michael A. Terry, and Vehniah K. Tjong. "Opioid Use After Common Sports Medicine Procedures: A Systematic Review." Sports Health: A Multidisciplinary Approach 12, no. 3 (April 9, 2020): 225–33. http://dx.doi.org/10.1177/1941738120913293.
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Context: The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. Objective: To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. Data Sources: A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. Study Selection: Two 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 Design: Systematic review. Level of Evidence: Level 4. Data Extraction: The 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. Results: A 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. Conclusion: Opioids 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.
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Alsirafy, Samy. "Opioid consumption in Egypt." Research in Oncology 8, Issue 1-2 (January 1, 2012): 2–4. http://dx.doi.org/10.21608/resoncol.2012.459.
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Bromberg, MD, FACS, Warren D., Tracey Emanuel, MSN, RN, FNP-BC, Valerie Zeller, MA, RN, Elizabeth Galloway, BSN, RN, CAPA, Susan Mogan, DNP, ANP-BC, ACHPN, AP-PMN, Justin Diamond, BS, Debra Statler, RN III-C, BC, and Fay Wright, PhD, RN, APRN-BC. "Assessment of post-operative opioid prescribing practices in a community hospital ambulatory surgical center." Journal of Opioid Management 17, no. 3 (July 19, 2021): 241–49. http://dx.doi.org/10.5055/jom.2021.0634.
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Objective: To evaluate the prescribing practices and opioid consumption in an ambulatory setting to inform the development of evidence-based guidelines.Design: A prospective study of adults undergoing outpatient open and laparoscopic surgeries over 3 months. One week after discharge, a telephonic interview quantified the number of opioids prescribed and consumed, degree of pain control and satisfaction, and whether additional pain medication was requested. Setting: Community hospital ambulatory surgery center in Westchester County, New York.Participants: This study included 304 adults undergoing a variety of procedures by surgeons from multiple specialties.Main outcome measures: Quantify surgeons’ postoperative opioid prescribing compared with patient opioid consumption.Results: Eighty-one percent (N = 245) responded to the survey, of which 64 percent were prescribed opioids. Males and females were equally represented with the mean age of 59.4 years. Of those prescribed opioids, 92 percent filled the prescription. The most commonly prescribed opioids reported by the patients that filled their prescription (N = 145) were oxycodone (36.5 percent), oxycodone/acetaminophen (28.9 percent), and tramadol (22.7 percent). The mean number of opioid pills prescribed was 20 and the mean consumption was 6.7 pills, resulting in an average of 13 retained pills. Only 3.8 percent of the patients prescribed opioids at discharge called their provider for additional analgesia. Despite the low opioid consumption patients reported high satisfaction (4.5 on scale of 0-5) with pain control. Only 10.4 percent reported that the surgeon recommended an over the counter (OTC) analgesic option. There was variability in the amount of opioids prescribed within each surgical category.Conclusions: One week after outpatient surgery, patients consumed one-third of physician-prescribed opioids, yet they reported high pain management satisfaction. Our study will inform the development of a patient-centered interdisciplinary perioperative education program to more effectively tailor multimodal pain management in ambulatory surgical patients and collaterally reduce the number of retained opioids.
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Premkumar, A., F. C. Lovecchio, J. G. Stepan, P. K. Sculco, S. A. Jerabek, A. Gonzalez Della Valle, D. J. Mayman, et al. "Characterization of opioid consumption and disposal patterns after total knee arthroplasty." Bone & Joint Journal 101-B, no. 7_Supple_C (July 2019): 98–103. http://dx.doi.org/10.1302/0301-620x.101b7.bjj-2018-1518.r1.
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Aims The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA). Patients and Methods In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform. Results Overall, 103 of 109 patients (94.5%) completed the daily short message service (SMS) surveys. The mean oral morphine equivalents (OME) consumed during the six weeks post-surgery were 639.6 mg (sd 323.7; 20 to 1616) corresponding to 85.3 tablets of 5 mg oxycodone per patient. A total of 66 patients (64.1%) had stopped taking opioids within six weeks of surgery and had the mean equivalent of 18 oxycodone 5 mg tablets remaining. Only 17 patients (25.7%) appropriately disposed of leftover medications. Conclusion These prospectively collected data provide a benchmark for general opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and leftover medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Cite this article: Bone Joint J 2019;101-B(7 Supple C):98–103
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Long, Sallie M., Catherine J. Lumley, Alexander Zeymo, and Bruce J. Davidson. "Prescription and Usage Pattern of Opioids after Thyroid and Parathyroid Surgery." Otolaryngology–Head and Neck Surgery 160, no. 3 (May 29, 2018): 388–93. http://dx.doi.org/10.1177/0194599818779776.
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Objective We seek to characterize the prescribing patterns of opioids, opioid consumption, and pain severity after thyroid and parathyroid surgery. We also aim to determine if a relationship exists between preoperative medication use and postoperative pain or opioid consumption. Study Design Case series with chart review. Setting Academic university hospital. Subjects and Methods Medical records of 237 adult patients undergoing thyroid and parathyroid surgery were included. Clinicopathologic data were collected, including pain scores, preoperative medications, and inpatient pain medications. Results The mean maximum pain score was 5.74 and varied by surgery type (range, 0-10). Mean pain score decreased to 2.61 upon discharge (0-8) and to 0.51 at the first postoperative visit. Patients with a length of stay exceeding 1 day had significantly higher maximum pain scores than those with a length of stay of 0 or 1 day (8 vs 5.58, P < .001). Morphine milligram equivalents while in the hospital averaged 25.4 per day and were significantly influenced by preoperative opioid use (0-202). Acetaminophen/oxycodone was the most commonly prescribed opioid. The mean number of pills prescribed postoperatively was 43.1 (0-120). Conclusion In our population, patients are discharged with opioid prescriptions that may be in excess of their requirements following thyroid and parathyroid surgery. Preoperative opioid use was associated with higher postoperative pain score and, on multivariate analysis, greater inpatient opioid consumption. Further investigation is warranted to ensure that we are prescribing opioids appropriately following thyroid and parathyroid surgery.
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Low, Keysha. "Initiating Buprenorphine/Naloxone for Opioid Use Disorder in the Emergency Department." Canadian Journal of Emergency Nursing 43, no. 1 (May 16, 2020): 12–22. http://dx.doi.org/10.29173/cjen15.
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The opioid crisis continues to affect individuals across the country, and requires a multifaceted approach to minimize the impact of this public health crisis. Through the chronic consumption of opioids, many individuals can become dependent on opioids and develop opioid use disorder. Buprenorphine/naloxone is the recommended treatment for patients living with opioid use disorder. The Emergency Strategic Clinical Network™ within Alberta Health Services is targeting the crisis through emergency departments by implementing a provincially standardized program. The Buprenorphine/Naloxone Initiation in Emergency Departments program includes screening for opioid use disorder, treatment initiation with the medication buprenorphine/naloxone, and providing rapid and reliable referrals to community clinics for titration and continuing patient care. This paper provides an overview of opioids, opioid use disorder, opioid agonist treatments such as buprenorphine/naloxone, and specifically details the program and protocol available in Alberta.
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Gorzelańczyk, E. J., A. Szponar, and P. Walecki. "Increased intake of monosaccharides and disaccharides in opioid-addicts." European Psychiatry 41, S1 (April 2017): s863. http://dx.doi.org/10.1016/j.eurpsy.2017.01.1725.
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IntroductionPersons dependent on opioids often characterized by the coexistence of a whole range of dysfunctional behaviors, which may also lead to eating disorders.ObjectivesImpulsive and risky behavior, conducive to the formation of polysubstance dependence, including food addiction, which manifests itself in the uncontrollable craving substances, that are quickly metabolized and turned into sugar in the bloodstream.AimsAim of the study was to assess the nutritional status and carbohydrates consumption in opioid-dependent individuals treated with methadone substitution therapy.MethodsFourteen opioid addicts during methadone maintenance treatment were examined. Eighteen healthy individuals matched for age and gender were included to the control group. The 24 hour hour diet recalls interview was used. After the dietary recall, a special questionnaire was administered to ascertain frequency of refined carbohydrates consumptions during the past 30 days.ResultsIt was found the nutritional deficiencies in the diet and poor nutritional status in opioid-addicts compared to healthy ones. Opioid-dependent individuals significantly more often snack between meals. It was found increased consumption monosaccharides and disaccharides in foods and beverages in opioid-addicts compared to healthy ones (P < 0.05).ConclusionsInvestigation of dietary behaviors may facilitate understanding of dynamics of addiction, so that we can use more effective methods of treatment.Disclosure of interestThe authors have not supplied their declaration of competing interest.
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Pantazis, Caroline B., Luis A. Gonzalez, Brendan J. Tunstall, Stephanie A. Carmack, George F. Koob, and Leandro F. Vendruscolo. "Cues conditioned to withdrawal and negative reinforcement: Neglected but key motivational elements driving opioid addiction." Science Advances 7, no. 15 (April 2021): eabf0364. http://dx.doi.org/10.1126/sciadv.abf0364.
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Opioid use disorder (OUD) is a debilitating disorder that affects millions of people. Neutral cues can acquire motivational properties when paired with the positive emotional effects of drug intoxication to stimulate relapse. However, much less research has been devoted to cues that become conditioned to the aversive effects of opioid withdrawal. We argue that environmental stimuli promote motivation for opioids when cues are paired with withdrawal (conditioned withdrawal) and generate opioid consumption to terminate conditioned withdrawal (conditioned negative reinforcement). We review evidence that cues associated with pain drive opioid consumption, as patients with chronic pain may misuse opioids to escape physical and emotional pain. We highlight sex differences in withdrawal-induced stress reactivity and withdrawal cue processing and discuss neurocircuitry that may underlie withdrawal cue processing in dependent individuals. These studies highlight the importance of studying cues associated with withdrawal in dependent individuals and point to areas for exploration in OUD research.
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Feinberg, Adina E., Sergio A. Acuna, David Smith, Brian Kashin, Aaron Mocon, Brian Yau, Jenny Chiu, and Sanjho Srikandarajah. "Optimizing opioid prescriptions after laparoscopic appendectomy and cholecystectomy." Canadian Journal of Surgery 64, no. 1 (February 2021): E69—E75. http://dx.doi.org/10.1503/cjs.001319.
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Background: There has been an increase in opioid usage and opioid-related deaths. Opioids prescribed to surgical patients have similarly increased. The aim of this study was to assess opioid consumption in patients undergoing laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC) and to determine whether a standardized prescription could affect opioid consumption without affecting patient satisfaction. Methods: Patients undergoing LA or LC were recruited prospectively during 2 time periods (April to June 2017 and November 2017 to January 2018). In the first phase, surgeons continued their usual postoperative analgesia prescribing patterns. In the second phase, a standardized prescription was implemented. Patients were contacted by telephone and a questionnaire was completed for both phases of the study. The primary outcome was the quantity of opioids prescribed and consumed. Results: In the first phase, 166 patients who underwent LC or LA were recruited. The median number of prescribed opioid tablets was 20 and the median number consumed was 2. Ninety-five percent of patients reported satisfaction with their analgesia. Based on these results, a standardized prescription for multimodal analgesia was implemented for the second phase, consisting of 10 opioid tablets. In the second phase, 129 patients who underwent LA or LC were recruited. There was a significant decrease in the median number of opioid pills filled (10) and consumed (0), with no difference in reported satisfaction with analgesia. Conclusion: Patients are prescribed an excess of opioids after LA or LC. Implementation of a standardized prescription based on a quality improvement intervention was effective at decreasing the number of opioids prescribed and consumed.
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Mandava, Nikhil, Demetris Delos, Katherine Vadasdi, R. Greene, Marc Kowalsky, Francis Alberta, Paul Sethi, and Parth Kamdar. "An Evidence Driven Opioid Prescribing Guideline following Knee Arthroscopy and Anterior Cruciate Ligament Reconstruction." Orthopaedic Journal of Sports Medicine 8, no. 7_suppl6 (July 1, 2020): 2325967120S0039. http://dx.doi.org/10.1177/2325967120s00393.
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Objectives: Opioid prescriptions following knee arthroscopy vary substantially, ranging from 15 to 60 opioid pills.[1-3] Expert panel guidelines recommend up to 30 pills for knee arthroscopy and 60 pills for anterior cruciate ligament reconstruction (ACLR) using an autograft; however, these recommendations are based on consensus rather than evidence.[4] Currently, orthopaedic surgeons do not possess any evidence driven guidelines for opioid prescriptions following knee arthroscopy or ACLR. The purpose of this study was to record patients’ postoperative opioid requirement to develop evidence driven prescription guidelines for knee arthroscopy and ACLR. Tepolt FA, Bido J, Burgess S, Micheli LJ, Kocher MS. Opioid Overprescription After Knee Arthroscopy and Related Surgery in Adolescents and Young Adults. Arthroscopy. 2018;34(12):3236-3243. Gardner V, Gazzaniga D, Shepard M, et al. Monitoring Postoperative Opioid Use Following Simple Arthroscopic Meniscectomy: A Performance-Improvement Strategy for Prescribing Recommendations and Community Safety. JB JS Open Access. 2018;3(4):e0033. Wojahn RD, Bogunovic L, Brophy RH, et al. Opioid Consumption After Knee Arthroscopy. J Bone Joint Surg Am. 2018;100(19):1629-1636. Stepan JG, Lovecchio FC, Premkumar A, et al. Development of an Institutional Opioid Prescriber Education Program and Opioid-Prescribing Guidelines: Impact on Prescribing Practices. J Bone Joint Surg Am. 2019;101(1):5-13. Methods: This prospective multicenter observational study enrolled 50 subjects undergoing outpatient knee arthroscopy for meniscal repair, meniscectomy, or ACLR. Opioid prescriptions, refills, and subject demographics were recorded. All patients followed the same perioperative, multimodal analgesic regimen (Table 1). Subjects were provided a pain journal to record visual analog scale (VAS) pain scores and opioid consumption for one week postoperatively. No changes were made to existing prescribing habits, postoperative physical rehabilitation, or surgical methodology. State databases were reviewed for additional opioid prescriptions. Results: Subjects, on average, consumed 2.5 opioid pills (range 0 to 14 pills) with a median consumption of 0.5 pills after knee arthroscopy. Eighty six percent of subjects (N = 43) consumed ≤ 5 opioid pills and 50% of subjects (N = 25) chose not to consume opioids postoperatively. Ninety two percent of subjects (N = 46) discontinued opioid consumption by the 3rd postoperative day. Subjects specifically undergoing ACLR (N = 18) consumed an average of 41 OME (Figure 1). Subjects consumed only 30% of opioids leaving 2,196 OME (approximately 293 oxycodone 5mg) available for possible distribution or misuse. Conclusion: This study demonstrates that current expert panels recommend an excess of opioids following knee arthroscopy. In contrast to these expert panel guidelines, we suggest a maximum of 5 and 15 oxycodone 5mg pills for knee arthroscopy and ACLR respectively. This evidence driven guideline will greatly assist orthopaedic surgeons in their effort to combat opioid overprescription. [Table: see text][Figure: see text]
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Hozack, Bryan A., Jack Abboudi, Gregory Gallant, Christopher M. Jones, William Kirkpatrick, Frederic E. Liss, Michael Rivlin, et al. "Prospective Evaluation of Opioid Consumption Following Cubital Tunnel Decompression Surgery." HAND 14, no. 1 (September 29, 2018): 42–47. http://dx.doi.org/10.1177/1558944718800732.
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Background: Managing postoperative pain is important for patients and surgeons. However, there is concern over opioid dependency. Cubital tunnel decompression is among the most common upper extremity surgeries. Our study aimed to analyze opioid use after cubital tunnel decompression to guide postoperative opioid prescribing. Methods: We prospectively collected opioid consumption for 16 consecutive months (February 2016 to June 2017) for cubital tunnel decompression patients. Data on demographics, insurance type, surgery performed, functional questionnaires (Quick Disabilities of the Arm, Shoulder and Hand [QuickDASH]), and electrodiagnostics (electromyography) were collected. Opioid consumption was reported at first postoperative visits. Results: One hundred patients consumed a mean of 50 morphine equivalent units (MEUs) (range, 0-300), or 7 oxycodone 5-mg pills, postoperatively. Cubital tunnel release (CuTR) patients consumed fewer than ulnar nerve transposition (UNT) patients (40.4 vs 62.5 MEUs or 5.4 vs 8.3 pills, P = .08). Patients undergoing submuscular UNT consumed more than CuTR (115.0 vs 40.4 MEUs or 15.3 vs 5.4 pills, p = 0.003) and more than subcutaneous UNT patients (37.8 MEU or 5.0 pills, p = 0.03). Medicare patients consumed less than privately insured (42.7 vs 54.1 MEUs, 5.7 vs 7.2 pills, P = .02) and less than workers’ compensation patients (76.8 MEU or 10.2 pills, P = .04). Older patients consumed fewer than younger patients ( P = .03). Postoperative QuickDASH score was positively related to opioid intake ( P = .009). Conclusions: Patients consumed 7 oxycodone 5-mg pills after cubital tunnel decompression. Younger, privately insured, and workers’ compensation patients, and those with worse functional scores and those undergoing UNT (specifically the submuscular technique) consumed more opioids.
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Daoust, R., J. Paquet, J. Morris, A. Cournoyer, E. Piette, J. Lessard, V. Castonguay, S. Gosselin, and J. Chauny. "P026: Opioid use and dependence three months after an emergency department visit for acute pain." CJEM 20, S1 (May 2018): S66. http://dx.doi.org/10.1017/cem.2018.224.
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Introduction: Most studies evaluating prescription opioid dependence or misuse are retrospective and are based on prescription filling rates from pharmaceutical databases. These studies cannot evaluate if opioids are really consumed nor differentiate if used for a new pain, chronic pain, or for misuse/dependence. The aim of this study was to assess the opioid consumption in emergency department (ED) patients three months after discharge with an opioid prescription. Methods: This prospective cohort study was conducted in the ED of a tertiary care centre with a convenience sample of patients aged 18 years and older, recruited 24/7, who consulted and were discharged for an acute pain condition ( 2 weeks). We excluded patients who: did not speak French or English, were using opioid medication prior to their ED visit, with an ED stay > 48 hours, or suffering from cancer or chronic pain. Three months post-ED visit, participants were contacted by phone for a structured interview on their past two-week opioid use, their reasons for consuming them, and also answered the Rapid Opioid Dependence Screen (RODS) questionnaire. Results: In the 524 participants interviewed at three months (mean age ± SD: 51±16 years, 47% women), 44 (8.4%) patients consumed opioids in the previous two weeks. Among those, 72% consumed opioids for their initial pain, 19% for a new unrelated pain, and 9% for another reason. In this entire cohort, only five patients (1%) tested positive to opioid dependence from the RODS test. The low dependence incidence could be affected by a social desirability bias. Conclusion: This study suggests that opioid use at 3-month, for patients initially treated for acute pain, is associated with opioid dependency in 1% or possible misuse in only 9%. Additional prospective studies using multiple methods to measure opioids consumption, misuse, and dependence are needed.
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Shanahan, Christopher W., Olivia Reding, Inga Holmdahl, Julia Keosaian, Ziming Xuan, David McAneny, Marc Larochelle, and Jane Liebschutz. "Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed." BMJ Open 11, no. 8 (August 2021): e047928. http://dx.doi.org/10.1136/bmjopen-2020-047928.
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ObjectivesTo prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management.DesignLongitudinal survey of patients 7 days before and 7–14 days after surgery.SettingAcademic urban safety-net hospital.Participants181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years.InterventionsNone.Primary and secondary outcome measuresTotal morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids.ResultsSurgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (−2.05 to –0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (−0.09% to –0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to –104.82) total MED increase in opioid consumption, and 19% (−0.35% to –0.02%) fewer unused opioids. High-risk drug use was associated with 9% (−0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices.ConclusionsParticipants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.
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Martin, Thomas J., Susy A. Kim, Nancy L. Buechler, Frank Porreca, and James C. Eisenach. "Opioid Self-administration in the Nerve-injured Rat." Anesthesiology 106, no. 2 (February 1, 2007): 312–22. http://dx.doi.org/10.1097/00000542-200702000-00020.
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Background Neuropathic pain is associated with several sensory abnormalities, including allodynia as well as spontaneous pain. Opioid intake in neuropathic pain patients is motivated by alleviation of both pain and allodynia. However, laboratory animal studies rely almost exclusively on reflexive withdrawal measures of allodynia. The authors examined the pharmacology of self-regulated intake of opioids in rats with or without nerve injury and compared the rate of drug intake to reversal of allodynia. Methods Rats were implanted with intravenous catheters, and the L5 and L6 spinal nerves were ligated in half of these animals. Rats were then trained to self-administer a commonly abused opioid (heroin) and commonly prescribed opioids (morphine, fentanyl, hydromorphone, and methadone). In addition, rats trained to self-administer heroin were given either clonidine or adenosine spinally before self-administration sessions to assess opioid-sparing effects. Results Nerve injury significantly decreased the reinforcing effects of low doses of opioids, and only doses of each opioid that reduced mechanical hypersensitivity maintained self-administration after spinal nerve ligation. The rate of drug consumption was correlated with the duration of the antiallodynic effect for each dose of opioid. Intrathecal administration of clonidine or adenosine reversed mechanical hypersensitivity, but only clonidine reduced heroin self-administration in rats with spinal nerve ligation. Conclusion Opioid self-administration is significantly altered by nerve injury, with rate of drug intake being correlated with reversal of allodynia. Intrathecal clonidine, but not adenosine, produces opioid-sparing effects in self-administering rats. The neurobiologic mechanisms that regulate opioid consumption in rats therefore seem to be altered after nerve injury.
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Jarlbaek, L., and P. Joergensen. "Changes in opioid prescribing behaviour in Denmark, Sweden and Norway - 2006-2014." Scandinavian Journal of Pain 12, no. 1 (July 1, 2016): 121. http://dx.doi.org/10.1016/j.sjpain.2016.05.014.
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Abstract Aims A country’s use of opioids is frequently debated in the public, usually based on rough figures from prescription databases made for consumption registration purposes. However, these databases hold much more detailed information that can be processed to increase knowledge and insight into nationally opioid prescribing-behaviour. This study aims to provide a more detailed picture of opioid prescribing and its changes in Denmark, Sweden and Norway during 2006-2014. Methods Data on opioid-use (ATC; N02A) were downloaded from each country’s publically assessable prescription-databases. Consumption-data were converted from defined daily doses (DDDs) to mg oral morphine equivalents (omeqs). Changes in choice of opioid-types, use and number of users were presented using descriptive statistics and compared. Results Opioid users: During the whole period, Norway had the highest, and Denmark the lowest, number of opioid users/1000 inhabitants. In 2006, Norway, Sweden and Denmark had 98, 79, 66 users/1000 inhabitants. In 2014 the numbers were 105, 78, 75 users/1000 inhabitants, respectively. Opioid use/user: During the whole period, Norway had the lowest, and Denmark the highest use/user. In 2006, the mean use/user was 1979, 3615, 6025 mg omeq/user in Norway, Sweden and Denmark respectively. In 2014 the corresponding use was 2426,3473,6361 mg omeq/user. The preferred choices of opioid-types changed during the period for all three countries. The balance between use of weak or strong opioids showed more prominent changes for Norway and Sweden compared to Denmark. Conclusions Three nations, closely related in culture and geo graphically, showed significant differences and changes in opioid prescribing behaviour. This knowledge can easily be overlooked using the traditional way of presenting opioid consumption statistics. More detailed and clinically relevant presentation can increase the knowledge of doctors’ opioid prescribing behaviour, that can be related to changes in the society or health care system, like demography, legislation and guidelines from authorities.
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Choo, Stephanie, Stephen Nogan, and Laura Matrka. "Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy." Otolaryngology–Head and Neck Surgery 161, no. 6 (July 30, 2019): 960–66. http://dx.doi.org/10.1177/0194599819866823.
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Objectives Despite increased concern with the opioid epidemic, literature remains scant regarding narcotic prescription and use following tonsillectomy. Study Design Retrospective cohort study with telephone interview. Subject and Methods A chart review from January to August 2018 evaluated the difference between prescribed amounts of narcotic and patient-reported usage following tonsillectomy ( Current Procedural Terminology codes 42821 and 42826). Patients were excluded if they used opioids for chronic pain, had a history of chronic opioid use or substance abuse, or underwent tonsillectomy to exclude malignancy. A telephone interview assessed opioid and nonopioid usage and pain control postoperatively, including amount and form of narcotics remaining. Results Sixty-four patients were enrolled at a mean 4.47 months after tonsillectomy. The mean ± SD prescribed morphine milligram equivalent (MME) was 456.1 ± 281.7, with only 302.8 ± 206.2 consumed. The mean MME prescribed per day was 74.1 ± 44.8, and average days of narcotic usage postoperatively was 9.6 ± 4.6, correlating with a mean MME per day of 49.2 ± 34.3 if the maximum prescribed dose per day was consumed. Fifty-four (84.4%) patients reported pain as well controlled. Forty-three (67.2%) patients reported residual narcotic medication, with 228.1 ± 208.5 MMEs remaining per patient. Narcotic solutions were more completely consumed than tablet forms, with 23.1% and 44.0% remaining, respectively. Patients cited uncertainty about safe disposal and safeguarding for future use as reasons for keeping residual narcotic. Conclusions Patient-reported narcotic use is significantly lower than the amount prescribed after tonsillectomy for benign disease. Providers can use these data to adjust narcotic-prescribing patterns while maintaining appropriate pain management for patients undergoing tonsillectomy.
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Weinstein, Brielle, Dominique Pagnozzi, Alexa Abitabilo, Lilla Kis, Madeline Carney, and David J. Smith. "815 Outpatient Opioid Use in Burn Injuries Following Hospital Discharge: A Single Institution Evaluation." Journal of Burn Care & Research 41, Supplement_1 (March 2020): S246—S247. http://dx.doi.org/10.1093/jbcr/iraa024.392.
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Abstract Introduction There is a growing concern regarding the unprecedented increase in morbidity and mortality related to the use of opioids. Prescription opioid abuse has been increasing dramatically in recent years. Prescription opioids have been shown to be favorable in perioperative management, however, their impact on chronic usage remains unclear. As an effort to help reduce opioid consumption following hospitalization for burn injuries, we look to evaluate the outpatient opioid consumption following hospital discharge at our institution. Methods After IRB approval, we obtained demographics, medical history, inpatient and outpatient opioid usage, treatment, and length of hospital stay of patients admitted with burn injuries who met study inclusion criteria (age ≥ 12 years and no history of opioid abuse prior to hospitalization) from January 1, 2011 to January 1, 2018. Data was analyzed using SAS v9.4. Results Our preliminary data included 210 patients with average age of 58 years, 75% non-Hispanic Caucasians and average total burn surface area of 18%. Medical histories observed included: hypertension (40%), diabetes (15%), hyperlipidemia (11%), depression (7%), and bipolar disorder (3%) among many others. 79% of patients had surgical intervention including excision and grafting, of which 32% had autografting procedures. All patients were treated with opioids during hospitalization, which included: fentanyl, hydromorphone, oxycodone-acetaminophen, morphine and oxycodone. 6% of patients had pain management consultation during hospitalization. 79% of patients were discharged with an opioid prescription, of which 21% had their opioid refilled during follow-up. There was no statistically significant difference in discharge opioid prescriptions (79% had surgical intervention versus 76% had no surgical intervention, p=0.69) and outpatient opioid prescription refills (17% had surgical intervention versus 17% had no surgical intervention, p=0.99) between patients who had surgical intervention for burn injuries versus those who did not. Conclusions This evaluation shows that there is no statistical difference in opioid usage between patients who had surgical intervention and those who did not for their burn injury treatments. Therefore, prescription opioids may not be necessary in postoperative care following hospital discharge. Applicability of Research to Practice With further research, we hope to evaluate the need for outpatient opioid prescriptions this treatment modality in effort of decreasing the order and use of opioids following hospital discharge in burn patients.
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Taylor, Loryn, Kimberly Maynell, Thanh Tran, and David J. Smith. "589 Methadone in Procedural Care for Burn Injuries of 20–30% Total Burn Surface Area: A Retrospective Chart Review." Journal of Burn Care & Research 42, Supplement_1 (April 1, 2021): S146. http://dx.doi.org/10.1093/jbcr/irab032.239.
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Abstract Introduction Prolonged opioid usage remains a concern in pain management in procedural care. Recent evidence also suggests that a considerable number of patients who were prescribed opioids struggle with transitioning to non-opioid pain medications. As a continuous effort to reduce opioid consumption following burn surgical procedures, our institution recently evaluated methadone administration for burn procedural care in patients with 20–30% total burn surface area (TBSA) requiring excision and grafting. Methods After IRB approval, we performed a retrospective chart review of patients who underwent excision and grafting procedure for 20–30% TBSA burn injuries between January 1, 2019 and June 30, 2020. The following data was evaluated: postoperative opioid consumption, postoperative pain intensity (rated as “No Pain” [NRS=0], “Minor Pain” [NRS 1 to 3], “Moderate Pain” [NRS 4 to 6], “Severe Pain” [NRS 7 to 10]), time to physical therapy and time to hospital discharge. Data was analyzed using chi square/Fisher exact test for categorical variables and t-test/Wilcoxon rank sum test for continuous variables. Results Our preliminary data included 12 patients who met inclusion criteria, of which two patients received methadone administration. Our patient sample consisted of average age of 43 years, 75% male, and 24% TBSA (92% were flame burns). Patients in both methadone and non-methadone groups had no significant differences in medical histories and TBSA (23% TBSA in methadone, 25% TBSA in non-methadone). There was no significant difference in reported preoperative pain intensity between the two groups, rating moderate to severe. Postoperative pain intensity remained the same, rating moderate to severe and controlled with fentanyl, oxycodone, morphine and non-opioid analgesics. While there was no difference in postoperative fentanyl, opioid and non-opioid analgesic consumptions between the two groups, morphine consumption was significantly lower in the methadone group compared to non-methadone group (2±2 mg vs 51±54 mg, respectively, p=0.02). There was no significant difference between average time from surgery to first physical therapy session and time to hospital discharge (about 21 days after surgery) between the two groups. Conclusions This evaluation shows a potential trend in reduction of inpatient postoperative opioid consumption with the conjunctive administration of methadone, although a bigger sample size is needed for further assessment.
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Locketz, Garrett D., Jason D. Brant, Nithin D. Adappa, James N. Palmer, Andrew N. Goldberg, Patricia A. Loftus, Rakesh K. Chandra, et al. "Postoperative Opioid Use in Sinonasal Surgery." Otolaryngology–Head and Neck Surgery 160, no. 3 (October 16, 2018): 402–8. http://dx.doi.org/10.1177/0194599818803343.
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Objective To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Study Design Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Setting Four academic medical centers and 1 private practice institution. Subjects Consecutive adult patients undergoing sinonasal surgery. Results A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02). Conclusions An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.
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McKissack, Haley, Jun Kit He, Sameer Naranje, Joshua L. Washington, Romil K. Patel, Jessyca Ray, Gerald McGwin, Michael D. Johnson, and Ashish Shah. "Does Postoperative Gabapentin Administration Reduce Opioid Consumption after Foot and Ankle Surgery?" Foot & Ankle Orthopaedics 5, no. 2 (April 1, 2020): 2473011420S0001. http://dx.doi.org/10.1177/2473011420s00010.
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Category: Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. The purpose of this study is to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. All patients prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients not taking opioids or gabapentin preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed postoperative gabapentin (177.3 OME) in comparison to those prescribed only opioids (442.2 OME) (p=0.0018) in the 3-6 week postoperative interval. When all patients were analyzed, including those taking preoperative opioids or gabapentin, patients who received postoperative gabapentin were also prescribed significantly fewer OME at weeks 1-2 (p= 0.0270), weeks 3-6 (p = 0.0006), and weeks 7 - 12 (p = 0.0149). Conclusion: Gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Prospective clinical trials are warranted to further validate these results. [Table: see text][Table: see text][Table: see text]
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Wojahn, Robert D., Ljiljana Bogunovic, Robert H. Brophy, Rick W. Wright, Matthew J. Matava, John R. Green, Corinne A. Zalomek, et al. "Opioid Consumption After Knee Arthroscopy." Journal of Bone and Joint Surgery 100, no. 19 (October 2018): 1629–36. http://dx.doi.org/10.2106/jbjs.18.00049.
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Kendall, Mark C. "Opioid Consumption after Plastic Surgery." Plastic and Reconstructive Surgery 145, no. 1 (January 2020): 216e—217e. http://dx.doi.org/10.1097/prs.0000000000006237.
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Balceniuk, Mark D., Peng Zhao, Isabelle V. Chu, Brian C. Ayers, Tianna M. Negron, Kathleen Raman, Jennifer L. Ellis, Adam J. Doyle, Roan J. Glocker, and Michael C. Stoner. "Opioid Consumption Following Carotid Revascularization." Annals of Vascular Surgery 55 (February 2019): 25. http://dx.doi.org/10.1016/j.avsg.2018.12.039.
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Balceniuk, Mark D., Peng Zhao, Isabelle V. Chu, Tianna M. Negron, Brian C. Ayers, Roan J. Glocker, Adam J. Doyle, and Michael C. Stoner. "Opioid Consumption after Carotid Revascularization." Annals of Vascular Surgery 62 (January 2020): 114–18. http://dx.doi.org/10.1016/j.avsg.2019.08.070.
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Jebaraj, Bright, Souvik Maitra, Dalim Kumar Baidya, and Puneet Khanna. "Intravenous Paracetamol Reduces Postoperative Opioid Consumption after Orthopedic Surgery: A Systematic Review of Clinical Trials." Pain Research and Treatment 2013 (November 6, 2013): 1–6. http://dx.doi.org/10.1155/2013/402510.
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Postoperative pain management is one of the most challenging jobs in orthopedic surgical population as it comprises of patients from extremes of ages and with multiple comorbidities. Though effective, opioids may contribute to serious adverse effects particularly in old age patients. Intravenous paracetamol is widely used in the postoperative period with the hope that it may reduce opioid consumption and produce better pain relief. A brief review of human clinical trials where intravenous paracetamol was compared with placebo or no treatment in postoperative period in orthopedic surgical population has been done here. We found that four clinical trials reported that there is a significant reduction in postoperative opioid consumption. When patients received an IV injection of 2 g propacetamol, reduction of morphine consumption up to 46% has been reported. However, one study did not find any reduction of opioid requirement after spinal surgery in children and adolescent. Four clinical trials reported better pain scores when paracetamol has been used, but other three trials denied. We conclude that postoperative intravenous paracetamol is a safe and effective adjunct to opioid after orthopedic surgery, but at present there is no data to decide whether paracetamol reduces opioid related adverse effects or not.
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Andelman, Steven M., Nicholas Debellis, Daniel Bu, University of Connecticut, Chukwuma Nwachukwu, James N. Gladstone, and Alexis Chiang Colvin. "Preoperative Education Significantly Decreases Postoperative Opioid Use after Arthroscopic Meniscectomy." Orthopaedic Journal of Sports Medicine 7, no. 7_suppl5 (July 2019): 2325967119S0035. http://dx.doi.org/10.1177/2325967119s00355.
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Objectives: Arthroscopic meniscectomy is one of the most common procedures in orthopedic surgery and is thus a frequent reason for prescription of post-operative opioid narcotics. Recent emphasis has been placed on limiting the number of opioid pills given for post-operative analgesia, with the goal being to provide adequate post-operative pain control while minimizing the number of unused pills after surgery. A number of modifiable variables have been identified to prevent over-prescription of opioids including prescriber education and identification of patient-specific factors associated with increased opioid use. To date, no study has evaluated the role of patient education to decrease post-operative opioid use. The goal of this study is to determine the utility of pre-operative patient education in decreasing post-operative opioid consumption after arthroscopic meniscectomy. Methods: All patients 18 years and older from a group of five attending surgeons undergoing isolated arthroscopic unicompartmental meniscectomy were prospectively identified for inclusion in this cohort study. Patients were split into two groups: patients in Group 1 did not receive any specific education regarding opioid usage after surgery while patients in Group 2 received a formalized three-minute overview from a physician on both appropriate usage of opioid narcotics as well as options for non-narcotic post-operative analgesia. Patients were assigned to each group consecutively - all patients at the beginning of the study were assigned to Group 1 while all patients at the end of the study were assigned to Group 2. Post-operatively, patients in both groups were surveyed via phone call one, two, three, and four weeks after surgery to determine the number of opioid pills taken each week. Patient descriptive statistics and post-operative opioid consumption were analyzed and compared between the two groups. Results: 62 patients completed the study, with 32 in Group 1 (no pre-operative education) and 24 in Group 2 (received pre-operative education). There were no significant demographic differences between the two groups. Patients in Group 1 used an average of 16.71 (95% CI, 9.67-23.75) opioid pills after surgery while patients in Group 2 used an average 3.21 (95% CI, 1.78-6.06) opioids after surgery. Patients in Group 2 used 13.5 less opioid pills (p = 0.001) representing a 420.0% decrease in post-operative opioid consumption over a four-week course (Figure 1). 7 (21.9%) patients in Group 1 continued to take opioid pills four weeks after surgery, while only 1 (4.2%) patient in Group 2 did the same. Conclusion: Pre-operative patient education regarding appropriate usage of opioid and options for non-narcotic analgesia significantly decreases post-operative opioid consumption and the duration which patients take opioid pills after arthroscopic meniscectomy. Pre-operative education is quick and inexpensive method to decrease post-operative opioid prescription requirements. [Figure: see text]
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Rančić, Nemanja, Dušica Stamenković, and Viktorija Dragojević-Simić. "Opioid analgesic consumption in Serbia during two years period: Opioid analgesic consumption in Serbia." Serbian Journal of Anesthesia and Intensive Therapy 38, no. 5-6 (2016): 145–53. http://dx.doi.org/10.5937/sjait1606145r.
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Herz, Albert. "Opioid reward mechanisms: a key role in drug abuse?" Canadian Journal of Physiology and Pharmacology 76, no. 3 (March 1, 1998): 252–58. http://dx.doi.org/10.1139/y98-017.
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There is increasing evidence to implicate the mesolimbic dopamine system in the rewarding effects of drugs of abuse such as opioids, psychostimulants, and alcohol, and in addition endogenous opioids may play a key role in the underlying adaptive mechanisms. Opioid agonists with affinity for µ and delta opioid receptors are rewarding, whereas opioid agonists with affinity for kappa receptors are aversive. These opposing motivational effects are paralleled by an increase and decrease, respectively, of dopamine release in the nucleus accumbens. Opposite effects are induced in response to selective antagonists for these different receptor types, pointing to tonically active endogenous opioid reward mechanisms. Withdrawal from chronic morphine results in sensitization for opioid reward; an effect that is counteracted by kappa opioid agonists. The rewarding effects of psychostimulants such as cocaine and amphetamine, mediated by the mesolimbic dopamine pathway, are modulated by opioid mechanisms in both directions: sensitization by morphine pretreatment, inhibition by kappa receptor agonists. A modulatory role of endogenous opioids is also suggested from biochemical data, showing increased dynorphin and kappa receptor expression after chronic cocaine treatment. Alcohol reward involves the mesolimbic reward system also, and opioids modulate this behaviour. Naltrexone as well as selective µ and delta opioid receptor antagonists decrease alcohol consumption in operant conditioning models. Biochemical approaches point to a functional deficit of endogenous opioids in genetic models exhibiting high prevalence for alcohol intake. The therapeutic implications of these data are discussed.Key words: reward mechanisms, endogenouos opioid systems, psychostimulants, alcohol.
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Almoghrabi, Omar, Joseph Brungardt, Stephen Helmer, Jared Reyes, and Brett Grizzell. "Efficacy of Intravenous Acetaminophen as Adjunct Post-Operative Analgesic in Cardiac Surgery: A Retrospective Study." Kansas Journal of Medicine 13 (June 25, 2020): 143–46. http://dx.doi.org/10.17161/kjm.v13i.13818.
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Introduction. The dose-dependent adverse events associated with post-operative opioid use may be reduced when opioids are used in conjunction with intravenous acetaminophen. The purpose of this study was to compare outcomes in median sternotomy patients receiving intravenous acetaminophen in addition to intravenous opioids versus intravenous opioids only.
Methods. A retrospective study was conducted on 122 adult patients undergoing median sternotomy at a regional tertiary-referral center. Data collected included patient demographics, length of stay, opioid and intravenous acetaminophen use, adverse effects, and transition time to oral pain medication.
Results. There was no difference between groups in demographics, preoperative risk scores, operative procedures, intravenous opioid consumption, transition time to oral pain medications, or length of stay. Acetaminophen use was associated with lower rates of atrial fibrillation (7.0% vs. 24.6%, p = 0.009) and nausea/vomiting (8.9% vs. 32.3%, p = 0.002), but higher rates of urinary retention (15.8% vs. 3.1%, p = 0.014), constipation (50.0% vs. 20.0%, p = 0.001) and respiratory depression (7.1% vs. 0.0%, p = 0.043).
Conclusion. Intravenous acetaminophen was not associated with a reduction in length of stay or opioid consumption, but was associated with lower rates of atrial fibrillation, nausea, and vomiting. Additional studies are needed to determine if intravenous acetaminophen administration reduces atrial fibrillation in this population.
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Skibicki, Hope, Sundeep Saini, Ryan Rogero, Kristen Nicholson, Rachel J. Shakked, Daniel Fuchs, Brian S. Winters, Steven M. Raikin, David I. Pedowitz, and Joseph N. Daniel. "Opioid Consumption Patterns and the Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Ankle Fracture Surgery." Foot & Ankle Orthopaedics 4, no. 4 (October 1, 2019): 2473011419S0006. http://dx.doi.org/10.1177/2473011419s00068.
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Category: Ankle Introduction/Purpose: Over the past two decades, the number of opioids dispensed in the United States has nearly tripled. Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Statewide Prescription Drug Monitoring Programs (PDMPs) have been implemented to deter overprescribing and help monitor information pertaining to suspected abuse. The purpose of this study was to assess the immediate postoperative opioid consumption patterns as well as the incidence of new prolonged opioid use among opioid naïve patients following ankle fracture surgery. Methods: This was a retrospective review of prospectively collected data. Patients were included if they underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture between October 2016 and September 2017. Patients were excluded if they received any narcotic prescriptions prior to the date of the initial injury. Patient demographics, medical history, fracture pattern, and opioid prescription and consumption details were collected. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone “pill”. The New Jersey PDMP was used to determine all prescriptions of controlled substances filled up to 1 year postoperatively. Prolonged use was defined as filling a postoperative prescription for a controlled substance 90 days after the index procedure. Linear regression analysis was performed to identify independent factors associated with immediate postoperative opioid consumption and repeated to identify factors associated with prolonged use. Results: One-hundred seventy-one patients were included in this study. At the first postoperative visit, patients consumed a median of 24 pills, whereas the median number prescribed was 40. This resulted in an initial utilization rate of 60% and 2,736 pills left unused. Additionally, we found that 18.7% (n=32) of patients required a narcotic prescription after 90 days from the index procedure. There was no statistically significant difference found between specific fracture type (isolated distal fibula, bimalleolar, trimalleolar) and prolonged opioid consumption, however tibial plafond fractures could not be included due to insufficient sample size (n=5). Patients with a self-reported history of depression (p=.094) or diabetes (p=.097) demonstrated marginal correlation with prolonged narcotic use. Conclusion: Our study demonstrated that patients who underwent outpatient surgical fixation of an ankle or tibial plafond fracture were initially overprescribed narcotics by nearly 67%, leaving a significant quantity of pills unused for potential abuse or diversion. 18.7% of originally opioid naïve patients required continued analgesia 90 days after the index procedure, however large variations in consumption rates make it difficult for physicians to predict prolonged narcotic use.