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The Annals of Otology, Rhinology, and... Oct 2022Little data is available on opioid usage in the adult population for benign oropharyngeal surgery. The objective here is to evaluate opioid prescribing patterns, opioid... (Observational Study)
Observational Study
OBJECTIVES
Little data is available on opioid usage in the adult population for benign oropharyngeal surgery. The objective here is to evaluate opioid prescribing patterns, opioid consumption, and patient pain patterns following benign oropharyngeal surgery, specifically tonsillectomy and adenoidectomy, tonsillectomy alone, and expansion sphincter pharyngoplasty.
METHODS
Patients aged ≥18 years old and received a tonsillectomy, tonsillectomy and adenoidectomy, or expansion sphincter pharyngoplasty between November 2019 and August 2020 were included. Patients were provided a survey which included a visual analog scale for recording their pain postoperatively and the amount of opioid they had remaining.
RESULTS
About 103 patients completed the post-operative questionnaire. Patients were prescribed 38 837 morphine milligram equivalents and used 28 644: approximately 26% went unused, which is the equivalent of 1346 5 mg oxycodone pills. Opioid consumption correlated with the initial dosage: patients consumed 12% more narcotic on average as the initial prescription went upwards by 50 morphine milligram equivalents. Obstructive sleep apnea, history of smoking, and being female predicted increased opioid usage in this cohort. Pain was reported the highest on postoperative day 1. A prescription of approximately 225 morphine milligram equivalents (150 mg oxycodone) was associated with decreased opioid use in this cohort. Larger initial prescriptions did not result in fewer requests for refills.
CONCLUSION
A significant amount of opioid medication went unused in this study. A prescription of 225 morphine milligram equivalents (or 150 mg oxycodone) provided appropriate analgesia for the majority of patients. Larger prescriptions may result in increased opioid consumption and may not reduce the amount of refills. More study is needed to confirm these findings.
Topics: Adolescent; Adult; Analgesics, Opioid; Female; Humans; Male; Oxycodone; Pain, Postoperative; Practice Patterns, Physicians'; Prospective Studies
PubMed: 34694150
DOI: 10.1177/00034894211053290 -
JTCVS Open Dec 2022Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing...
OBJECTIVE
Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing multimodal pain control regimens that include both opioid and nonopioid components. We investigated the effects of an Enhanced Recovery After Surgery protocol at our institution on postoperative outcomes with particular focus on analgesia.
METHODS
Single-center retrospective study comparing perioperative opioid use before and after implementation of an Enhanced Recovery After Surgery protocol at our institution. Subjects were divided into 2 cohorts: Enhanced Recovery After Surgery (study group from year 2020) and pre-Enhanced Recovery After Surgery (control group from year 2018). Baseline and perioperative variables including total opioid use from the day of surgery to postoperative day 5 were collected. Opioid use was calculated as morphine milligram equivalents and compared between the 2 cohorts.
RESULTS
A total of 466 patients were included: 250 in the Enhanced Recovery After Surgery group and 216 in the pre-Enhanced Recovery After Surgery group. Both groups had similar baseline characteristics, but the Enhanced Recovery After Surgery group had significantly more subjects with intravenous drug use history ( < .0001), endocarditis ( < .0001), and liver disease ( = .007) compared with the pre-Enhanced Recovery After Surgery group. Every day from the day of surgery to postoperative day 5, the Enhanced Recovery After Surgery group had significant reduction (57%) in opioid use compared with the pre-Enhanced Recovery After Surgery group. Total opioid use for the entire length of stay was 259 morphine milligram equivalents in the Enhanced Recovery After Surgery group versus 452 morphine milligram equivalents in the pre-Enhanced Recovery After Surgery group ( < .0001). Subgroup analysis of subjects with intravenous drug use history did not demonstrate a significant reduction in opioid use.
CONCLUSIONS
Enhanced Recovery After Surgery protocols with an emphasis on multimodal pain management throughout perioperative care are associated with a significant reduction in the postoperative use of opioid analgesics.
PubMed: 36590721
DOI: 10.1016/j.xjon.2022.08.008 -
American Journal of Preventive Medicine May 2022Increases in opioid prescribing contributed to the opioid epidemic in the U.S. Subsequent efforts to promote safer use of opioids for treating pain included augmenting...
INTRODUCTION
Increases in opioid prescribing contributed to the opioid epidemic in the U.S. Subsequent efforts to promote safer use of opioids for treating pain included augmenting prescription drug monitoring programs and prescribing guidelines. The purpose of this study is to characterize the distribution of opioids dispensed in the U.S. by specialty.
METHODS
Data from the IQVIA National Prescription Audit were analyzed (in 2019). Prescriptions were standardized to morphine milligram equivalents using the 2018 Centers for Disease Control and Prevention conversion file. The annual number of prescriptions and total dose (morphine milligram equivalents) of opioids dispensed, overall and by specialty (provider type or physician specialty), were calculated for 2012-2017.
RESULTS
The number of prescriptions for opioids dispensed declined by 26.6% overall from 2012 to 2017. However, the number of prescriptions dispensed increased for pain medicine (8.8%) and advanced practice providers (nurse practitioners: 34.8%, physician assistants: 5.4%). Similarly, total morphine milligram equivalents for opioids dispensed declined by 28.6% from 2012 to 2017. Despite an increase in the number of prescriptions, total morphine milligram equivalents of opioids dispensed declined by nearly 20% in pain medicine. Higher total morphine milligram equivalents of dispensed opioids were observed in 2017 than in 2012 for advanced practice providers (nurse practitioners: 19.1%, physician assistants: 1.8%), although a decline in morphine milligram equivalents was observed from 2016 to 2017.
CONCLUSIONS
During a period in which prescribing interventions were expanded, opioid prescribing declined overall, although not uniformly by specialty.
Topics: Analgesics, Opioid; Drug Prescriptions; Humans; Morphine; Pain; Practice Patterns, Physicians'; Prescription Drug Monitoring Programs
PubMed: 35151524
DOI: 10.1016/j.amepre.2021.10.022 -
Surgery Aug 2022Adherence to opioid prescribing protocols after operations remains challenging despite published guidelines. Integration of these guidelines with the electronic health...
BACKGROUND
Adherence to opioid prescribing protocols after operations remains challenging despite published guidelines. Integration of these guidelines with the electronic health record could potentially improve their adoption. We hypothesize that implementing an electronic health record order set containing prepopulated tablet quantities tailored to surgical procedures based on published guidelines will decrease postoperative opioid prescription.
METHODS
We conducted a 12-month prepost intervention study on adult patients who underwent appendectomy, cholecystectomy, inguinal or umbilical hernia repair, thyroidectomy, or parathyroidectomy at a single institution. An electronic health record order set was developed with prepopulated opioid tablet quantities reflecting the upper limit of published recommendations. The primary endpoint was change in morphine milligram equivalent prescribed postintervention and was analyzed using linear regression adjusting for age, race, procedure, and prescriber training level. Secondary endpoints were emergency department visits for pain-related issues and opioid refill rates.
RESULTS
We identified 524 patients (mean age = 53, 51% male) in our baseline cohort and 433 patients (mean age = 52, 58% male) in our postintervention group. The mean morphine milligram equivalent prescribed was 62.6 and 50.4 for the preintervention and postintervention cohorts, respectively (P = .049). Thyroidectomies and parathyroidectomies achieved the largest decrease after intervention, which decreased to 42.6 morphine milligram equivalent from 79.7 morphine milligram equivalent preintervention (P < .001). Refill rate was 1.6% postintervention compared to 3.1% preintervention (P = .20), and emergency department visit for pain control rate was 0.2% post intervention and 2.5% preintervention (P = .005).
CONCLUSION
An electronic health record tailored order set based on prescription guidelines is a safe, effective, and scalable intervention for decreasing opioid prescriptions after operations.
Topics: Adult; Analgesics, Opioid; Drug Prescriptions; Electronic Health Records; Female; Humans; Male; Middle Aged; Morphine Derivatives; Pain, Postoperative; Practice Patterns, Physicians'; Retrospective Studies; Tablets
PubMed: 35430051
DOI: 10.1016/j.surg.2022.03.018 -
American Journal of Obstetrics and... Apr 2024Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have...
BACKGROUND
Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have mostly focused on the immediate postpartum period when patients are still admitted to the hospital. At discharge, most providers prescribe a fixed number of opioid tablets. Most patients do not use all the opioids that they are prescribed at hospital discharge. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion.
OBJECTIVE
This study aimed to determine whether a transition from universal opioid prescribing to a personalized, patient-specific protocol decreases morphine milligram equivalents prescribed at hospital discharge after cesarean delivery while adequately controlling pain.
STUDY DESIGN
This was a prospective cohort study of patients undergoing cesarean delivery before and after the implementation of a personalized opioid-prescribing practice at the time of hospital discharge. Each patient was prescribed scheduled ibuprofen and acetaminophen, with a prescription for oxycodone tablets equal to 5 times the morphine milligram equivalents used in the 24 hours before discharge, calculated via an electronic order set. The previous traditional cohorts were routinely prescribed 30 tablets of acetaminophen-codeine 300/30 mg. The primary outcome was morphine milligram equivalents prescribed at discharge. A hotline to address pain control issues after discharge was established, and calls, emergency department visits, and readmissions were examined. Statistical analyses was performed using chi-square and Wilcoxon rank-sum test, with a P value of <.05 considered statistically significant.
RESULTS
Overall, 412 patients underwent cesarean delivery in the 6 weeks after initiation of the personalized prescribing protocol and were compared with 367 patients before the change. The median morphine milligram equivalents prescribed at discharge was lower with personalized prescribing (37.5 [interquartile range, 0-75] vs 135 [interquartile range, 135-135]; P<.001). Moreover, 176 patients (43%) were not prescribed opioids at discharge, which was a substantial change as all 367 patients in the traditional cohort received opioids at discharge (P<.001). Of note, 9 hotline phone calls were received; none required additional opioids after a 24-hour trial of scheduled ibuprofen, which none had taken before the call. In addition, 11 patients (2.7%) presented to the emergency department for pain evaluation, of which none required readmission or an outpatient prescription of opioids.
CONCLUSION
A personalized protocol for opioid prescriptions after cesarean delivery decreased the total morphine milligram equivalents and the number of opioid tablets at discharge, without hospital readmissions or need for rescue opioid prescriptions after discharge. Opioids released into our community will be reduced by more than 90,000 tablets per year, without demonstrable adverse effect.
Topics: Pregnancy; Female; Humans; United States; Analgesics, Opioid; Acetaminophen; Ibuprofen; Prospective Studies; Outpatients; Electronic Health Records; Pain, Postoperative; Practice Patterns, Physicians'; Oxycodone; Prescriptions
PubMed: 37778679
DOI: 10.1016/j.ajog.2023.09.092 -
Surgery Aug 2021Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused...
BACKGROUND
Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing.
METHODS
Prospective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017-2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty.
RESULTS
Overall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period.
CONCLUSION
A small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Analgesics, Opioid; Female; Humans; Male; Middle Aged; Motivation; Pain Management; Pain, Postoperative; Practice Patterns, Physicians'; Prescription Drug Monitoring Programs; Prospective Studies
PubMed: 33676733
DOI: 10.1016/j.surg.2021.01.016 -
Obstetrics and Gynecology Jul 2017To characterize postdischarge opioid use and examine factors associated with variation in opioid prescribing and consumption. (Observational Study)
Observational Study
OBJECTIVE
To characterize postdischarge opioid use and examine factors associated with variation in opioid prescribing and consumption.
METHODS
We conducted a prospective observational cohort study by recruiting all women undergoing cesarean delivery during an 8-week period, excluding those with major postoperative morbidities or chronic opioid use. Starting on postoperative day 14, women were queried weekly regarding number of opioid pills used, amount remaining, and their pain experience until they had stopped opioid medication. Demographic and delivery information and in-hospital opioid use were recorded. The state Substance Monitoring Program was accessed to ascertain prescription-filling details. Morphine milligram equivalents were calculated to perform opioid use comparisons. Women in the highest quartile of opioid use (top opioid quartile use) were compared with those in the lowest three quartiles (average opioid use).
RESULTS
Of 251 eligible patients, 246 (98%) agreed to participate. Complete follow-up data were available for 179 (71% of eligible). Most women (83%) used opioids after discharge for a median of 8 days (interquartile range 6-13 days). Of women who filled their prescriptions (165 [92%]), 75% had unused tablets (median per person 75 morphine milligram equivalents, interquartile range 0-187, maximum 630) and the majority (63%) stored tablets in an unlocked location. This amounts to an equivalent of 2,540 unused 5-mg oxycodone tablets over our study period. Women who used all prescribed opioids (n=40 [22%]) were more likely to report that they received too few tablets than women who used some (n=109 [61%]) or none (n=30 [17%]) of the prescribed opioids (33% compared with 4% compared with 5%, P<.001). The top quartile was more likely to be smokers than average users and consumed more opioid morphine milligram equivalents per hour of inpatient stay than average opioid users (1.6, interquartile range 1.1-2.3 compared with 1.0, interquartile range 0.5-1.4, P<.001).
CONCLUSION
Most women-especially those with normal in-hospital opioid use-are prescribed opioids in excess of the amount needed.
Topics: Adult; Analgesics, Opioid; Cesarean Section; Female; Humans; Obstetrics; Opioid-Related Disorders; Pain, Postoperative; Patient Discharge; Patient Safety; Practice Patterns, Physicians'; Pregnancy; Prospective Studies; Tennessee
PubMed: 28594766
DOI: 10.1097/AOG.0000000000002095 -
American Journal of Physical Medicine &... Apr 2023The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients...
OBJECTIVE
The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients admitted with osteoarthritis or spine disorders.
DESIGN
This is a retrospective study of 12,747 adult patients admitted to six private community hospitals from 2017 to 2020. Opioid use during hospitalization and risk factors for hospital-acquired adverse events and nonhome discharge were investigated.
RESULTS
The total number of patients using opioids decreased; however, the daily morphine milligram equivalent use for patients on opioids increased from 2017 to 2020. Increased odds of nonhome discharge were associated with older age, Medicaid, Medicare insurance, and increased lengths of stay, increased body mass index, daily morphine milligram equivalent, and electrolyte replacement in the osteoarthritis group. In the spine group, older age, Black race, Medicaid, Medicare, no insurance, increased Charlson Comorbidity Index, lengths of stay, polypharmacy, and heparin use were associated with nonhome discharge. Adverse events were associated with increased age, lengths of stay, Medicare, polypharmacy, antiemetic, and benzodiazepine use in the osteoarthritis group and increased Charlson Comorbidity Index, lengths of stay, and electrolyte replacement in the spine group.
CONCLUSIONS
Despite the decreasing number of patients using opioids over the years, patients on opioids had an increased daily morphine milligram equivalent over the same period.
Topics: Adult; Humans; Aged; United States; Analgesics, Opioid; Retrospective Studies; Inpatients; Medicare; Hospitalization; Hospitals; Osteoarthritis; Electrolytes; Morphine Derivatives
PubMed: 36095159
DOI: 10.1097/PHM.0000000000002101 -
Angewandte Chemie (International Ed. in... Oct 2017A 24-step synthesis of (±)-forskolin is presented, which delivered hundred milligram quantities of this complex diterpene in one pass. Transformations key to our...
A 24-step synthesis of (±)-forskolin is presented, which delivered hundred milligram quantities of this complex diterpene in one pass. Transformations key to our approach include: a) a strategic allylic transposition, b) stepwise assembly of a sterically encumbered isoxazole ring, and c) citric acid-modified Upjohn dihydroxylation of a resilient tetrasubstituted olefin. The developed route has exciting potential for the preparation of new forskolin analogues inaccessible by semisynthesis.
PubMed: 28782270
DOI: 10.1002/anie.201706809 -
Advances in Colloid and Interface... Jul 2016This review summarizes the current state of knowledge regarding interfacial properties of very complex biological colloids, specifically, human meibum and tear lipids,... (Review)
Review
This review summarizes the current state of knowledge regarding interfacial properties of very complex biological colloids, specifically, human meibum and tear lipids, and their interactions with proteins similar to the proteins found in aqueous part of human tears. Tear lipids spread as thin films over the surface of tear-film aqueous and play crucial roles in tear-film stability and overall ocular-surface health. The vast majority of papers published to date report interfacial properties of meibum-lipid monolayers spread on various aqueous sub-phases, often containing model proteins, in Langmuir trough. However, it is well established that natural human ocular tear lipids exist as multilayered films with a thickness between 30 and 100nm, that is very much disparate from 1 to 2nm thick meibum monolayers. We employed sessile-bubble tensiometry to study the dynamic interfacial and rheological properties of reconstituted multilayered human tear-lipid films. Small amounts (0.5-1μg) of human tear lipids were deposited on an air-bubble surface to produce tear-lipid films in thickness range 30-100nm corresponding to ocular lipid films. Thus, we were able to overcome major Langmuir-trough method limitations because ocular tear lipids can be safely harvested only in minute, sub-milligram quantities, insufficient for Langmuir through studies. Sessile-bubble method is demonstrated to be a versatile tool for assessing conventional synthetic surfactants adsorption/desorption dynamics at an air-aqueous solution interface. (Svitova T., Weatherbee M., Radke C.J. Dynamics of surfactant sorption at the air/water interface: continuous-flow tensiometry. J. Colloid Interf. Sci. 2003;261:1170-179). The augmented flow-sessile-bubble setup, with step-strain relaxation module for dynamic interfacial rheological properties and high-precision syringe pump to generate larger and slow interfacial area expansions-contractions, was developed and employed in our studies. We established that this method is uniquely suitable for examination of multilayered lipid-film interfacial properties. Recently it was compellingly proven that chemical composition of human tear lipids extracted from whole tears is substantially different from that of meibum lipids. To be exact, healthy human tear lipids contain 8-16% of polar lipids, similar to lung lipids, and they are mostly double-tailed phospholipids, with C16 and longer alkyl chains. Rationally, one would assume that the results obtained for meibum lipids, devoid of surface-active components such as phospholipids, and, above all, in a form of monolayers, are not pertinent or useful for elucidating behavior and stability of an averaged 60-nm thick ocular tear-lipid films in vivo. The advantage of sessile-bubble technique, specifically, using a small amount of lipids required to attain multilayered films, unlocks the prospect of evaluating and comparing the interfacial properties of human tear lipids collected from a single individual, typically 100-150μg. This is in sharp contrast with several milligrams of lipids that would be required to build equally thick films for Langmuir-trough experiments. The results of our studies provided in-depth understanding of the mechanisms responsible for properties and stability of human tear-lipid films in vivo. Here we summarize recent publications and our latest findings regarding human tear-lipid interfacial properties, their chemical composition, and their interaction with model proteins mimicking the proteins found in human tear-aqueous phase.
Topics: Eye Proteins; Humans; Lacrimal Apparatus; Lipids; Meibomian Glands; Rheology; Surface Tension; Tears; Viscosity
PubMed: 26830077
DOI: 10.1016/j.cis.2015.12.009