OPEN examines data, clinical practices and strategies to support better pain management, opioid stewardship, policy, treatment and care.
- Over 2% of ambulatory anorectal procedures develop new persistent opioid use.
- Logistic regression found new persistent opioid use was associated with perioperative opioid fills, increased comorbidity, tobacco use, and pain disorders; there was no significant association with procedure performed.
- Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed.
- This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.
- 1.5% of patients develop new persistent opioid use after inguinal hernia repair.
- The strongest risk factor for this complication was filling an opioid prescription in the 30 days prior to surgery, which was most commonly provided by a surgeon.
- Other risk factors for new persistent opioid use included receiving a larger opioid prescription, having more comorbidities, having a major postoperative complication, and certain mental health disorders and pain disorders.
- Preoperative opioid use was correlated with an increased mortality within 90 days after surgery
- Patients with high and medium preoperative opioid exposure were more likely to die within 90 days after outpatient surgery compared with opioid-naïve patients
- Mortality did not differ between opioid-naïve patients and patients with low preoperative opioid exposure.
Assessment of a Quality Improvement Intervention to Decrease Opioid Prescribing in a Regional Health SystemBrown CS, Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee JF, Englesbe MJ. Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system. BMJ Quality & Safety. Published Online First: 16 September 2020. doi: 10.1136/bmjqs-2020-011295
- The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50%.
- Opioid consumption also decreased, while satisfaction and postoperative pain remained unchanged.
- Leveraging the continuous quality improvement infrastructure to implement evidence-based opioid prescribing guidelines has had a meaningful impact on opioid prescription.
- Among opioid naïve Medicare patients aged 65 and older who underwent major/minor surgery, 53.8% of patients filled an opioid prescription within seven days of discharge.
- Opioid prescription size was largest for patients whose surgeons were early in practice (<7 years: 292 OMEs), with decreasing amounts of opioids filled among patients with surgeons who had been in practice longer (8-15 years: 279 OMEs; 16-25 years: 265 OMEs).
- Surgical intensity, classified as 5 ordinal clusters – low, mid-low, mid, mid-high, and high, is positively associated with initial opioid prescribing and rates of refill.
- Median amount of opioid prescribed increased as the cluster-order increased: 150 oral morphine equivalents (OME) for low-intensity, 225 OME for mid-intensity, and 300 OME for high-intensity surgeries.
- Rates of refill increased as surgical intensity also increased, from 17.4% for low, 26.4% for mid, and 48.9% for high-intensity procedures.
Higher Amounts of Opioids Filled After Surgery Increase Risk of Serious Falls and Fall-Related Injuries Among Older AdultsSantosa KB, Lai YL, Brummett CM, et al. Higher Amounts of Opioids Filled After Surgery Increase Risk of Serious Falls and Fall-Related Injuries Among Older Adults [published online ahead of print, 2020 Aug 3]. J Gen Intern Med. 2020. doi:10.1007/s11606-020-06015-6
- Among opioid naïve Medicare patients aged 65 and older who underwent elective outpatient surgery, 76.3% filled a perioperative opioid prescription, and 0.62% suffered a serious fall or fall-related injury within 30 days after surgery.
- Higher amount of opioid filled over 30 days prior to surgery through to 30 days after surgery was strongly associated with increased risk of serious falls after surgery; patients who filled ≥ 225 OMEs after surgery were over twice as likely to fall after surgery compared with the group who filled < 150 OME (RR 2.29, 95% CI 1.72–3.07).
- Older age, being female, and dual Medicaid eligibility were also associated with higher risk of serious falls and fall-related injuries.
- In Massachusetts, the implementation of 7-day limits on initial opioid prescriptions for acute pain was associated with a decrease in prescription size (−38 OMEs) and additional reduction of 1.5 OMEs per month. The implementation was also associated with an average decrease of 0.4 days supplied and the proportion of prescriptions exceeding a 7-day supply (−5.9 percentage points).
- In contrast, the 7-day limit implementation in Connecticut was not associated with significant changes in opioid prescription.
Association between Insurance Cost-sharing Subsidy and Postoperative Opioid Prescription Refills among Medicare PatientsKirsch M, Montgomery JR, Hu HM, et al. Association between insurance cost-sharing subsidy and postoperative opioid prescription refills among Medicare patients. Surgery. 2020;168(2):244-252. doi:10.1016/j.surg.2020.04.013
- 6% of Medicare patients in Michigan who underwent orthopedic procedures filled an opioid prescription after the procedure, and 66.4% of patients who filled a prescription refilled another opioid prescription within 90 days of discharge.
- Among patients with full low-income subsidy, the odds of filling an initial postoperative prescription were 1.29 times higher, and the odds of refilling another prescription were 1.39 times higher than patients without low-income subsidy.
- 0% of pregnant women filled an opioid prescription during pregnancy, and 4.0% of the women who filled developed new persistent opioid use.
- Having a non-delivery procedure in pregnancy and having an emergency room visit during pregnancy are factors associated with filling an opioid in pregnancy
- Filling a peripartum opioid prescription (1 week prior to or 3 days post-discharge) was significantly associated with new persistent opioid use.