OPEN examines data, clinical practices and strategies to support better pain management, opioid stewardship, policy, treatment and care.
A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgeryKeller DS, Kenney BC, Harbaugh CM, Waljee JF, Brummett CM. A national evaluation of opioid prescribing and persistent use after ambulatory anorectal surgery. Surgery. Published Online 4 December 2020. DOI: https://doi.org/10.1016/j.surg.2020.11.006
- 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.
New Persistent Opioid Use After Inguinal Hernia RepairHoward RA; Gunaseelan, V; Brummett CM; Waljee, JF; Englesbe MJ; Telem D. New Persistent Opioid Use After Inguinal Hernia Repair. Annals of Surgery. Published Online 15 October 2020 DOI: 10.1097/SLA.0000000000004560
- 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 and Mortality After Minor Outpatient SurgerySantosa KB, Lai Y, Oliver JD, et al. Preoperative Opioid Use and Mortality After Minor Outpatient Surgery. JAMA Surg. Published online October 21, 2020. doi:10.1001/jamasurg.2020.3623
- 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.
Surgeon Experience and Opioid PrescribingSantosa KB, Wang CS, Hu H, Brummett CM, Englesbe MJ, Waljee JF. Surgeon Experience and Opioid Prescribing. Am J Surg. 2020; 220(4): 823-827.
- 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).
Does Surgical Intensity Correlate With Opioid Prescribing? Classifying Common Surgical ProceduresCho HE, Hu H, Gunaseelan V, Chen J, Englesbe MJ, Chung KC, Waljee JF. Does Surgical Intensity Correlate With Opioid Prescribing? Classifying Common Surgical Procedures. Ann Surg: July 24, 2020. Publish Ahead of Print doi: 10.1097/ SLA.0000000000004299
- 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.
Association of State Opioid Duration Limits with Postoperative Opioid PrescribingAgarwal S, Bryan JD, Hu HM, et al. Association of State Opioid Duration Limits With Postoperative Opioid Prescribing. JAMA Netw Open. 2019;2(12):e1918361. Published 2019 Dec 2. doi:10.1001/jamanetworkopen.2019.18361
- 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.
New Persistent Opioid Use after Acute Opioid Prescribing in PregnancyPeahl AF, Morgan DM, Dalton VK, et al. New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis [published online ahead of print, 2020 Mar 23]. Am J Obstet Gynecol. 2020;S0002-9378(20)30342-2. doi:10.1016/j.ajog.2020.03.020
- 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.