Opioid Prescribing Practices Before and After Initiation of Palliative Care in Outpatients

Objectives: This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states. Design: This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018. Methods: Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum t tests for OMEs and χ2 t tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). Results: In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (p < 0.0001). The opioid refill rate remained unchanged at 7.4% (p = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (p < 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; p = 0.739). Limitations: Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design. Conclusions: Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.

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Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs

Neurosurgery ◽

10.1093/neuros/nyab061 ◽

2021 ◽

Author(s):

Karam Asmaro ◽

Hassan A Fadel ◽

Sameah A Haider ◽

Jacob Pawloski ◽

Edvin Telemi ◽

...

Keyword(s):

Clinical Decision Making ◽

Tumor Resection ◽

Educational Interventions ◽

Prescribing Patterns ◽

Prescribing Practices ◽

Post Intervention ◽

Intracranial Surgery ◽

Opioid Prescribing ◽

Before And After ◽

Craniotomy For Tumor Resection

Abstract BACKGROUND Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P < .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105). CONCLUSION A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns.

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868 Guideline for Discharge Opioid Prescription Management in Adult and Pediatric Burn Patients

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.434 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S273-S273 ◽

Cited By ~ 1

Author(s):

An Bui ◽

Felicia N Williams ◽

Lori Chrisco ◽

Sanja Sljivic ◽

Rabia Nizamani ◽

...

Keyword(s):

Adult Patients ◽

Burn Patients ◽

Prescribing Practices ◽

Opioid Dependency ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Pain Scores ◽

Burn Survivors ◽

Before And After ◽

Surgical Standard

Abstract Introduction Pediatric and adult burn survivors are at risk for chronic opioid dependency. Conversely, undertreatment of pain can negatively affect mental health and patient compliance. Overtreatment has arguably led to the current opioid legislation. Despite an opioid-limiting mandate, there has been little direction for streamlining prescribing practices and there has been no guideline established to facilitate prescribing practices for burn patients. We evaluated the efficacy of a standard opioid prescribing schedule (SOPS) for surgical patients admitted greater than four days, based on pain scores, in our adult and pediatric burn patients. Methods This was a retrospective review conducted between June 2018 to June 2019 of our prescribing practices compared to a newly established standardized prescribing schedule. All patients admitted to the burn center were included if they had a length of stay longer than 4 days, and were prescribed oxycodone doses between 0-60mg within the last 24 hours of their stay. The primary outcome was amount of oxycodone prescribed upon discharge compared to the doses they received within their last 24hrs before and after the SOPS was established. Results The year before the SOPS was developed, we prescribed an average of 140mg of oxycodone to our pediatric patients upon discharge, even when they used 0mg within 24 hours of discharge. We prescribed an average of 165mg of oxycodone to adult patients who required 0mg 24hrs prior to discharge. We prescribed an average of 200mg to adult patients who required 15mg. We prescribed an average of 235mg to adult patients who required 35mg. We prescribed 310mg to adult patients that required the maximum of 60mg within their last 24 hours. This represented 0% compliance. After adopting the surgical standard opioid prescribing schedule to determine doses, we became 87.5% complaint with all patients and saw no increased in readmissions for pain. Conclusions An institutional guideline for discharge opioid prescribing practices has reduced the number of opioid pills patients take home, and the risk for overtreatment. A Standardized Opioid Prescribing schedule for burn patients is feasible and merits further investigation. Applicability of Research to Practice This study demonstrates the benefits of a standardized prescribing schedule and its applicability to burn patients.

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Effect of a Standardized Electronic Medical Record Order Set on Opioid Prescribing after Tonsillectomy

Otolaryngology ◽

10.1177/0194599820911721 ◽

2020 ◽

Vol 163 (2) ◽

pp. 216-220 ◽

Cited By ~ 1

Author(s):

Joshua D. Horton ◽

Corinne Corrigan ◽

Terral Patel ◽

Caroline Schaffer ◽

Robert A. Cina ◽

...

Keyword(s):

Medical Record ◽

Electronic Medical Record ◽

Pain Control ◽

Retrospective Chart Review ◽

Postoperative Hemorrhage ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Before And After ◽

Order Set

Objective Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)–based order set. Methods Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission. Results Analysis of 276 preorder set and 128 post–order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post–order set cohort. Variability between prescriptions and providers was significantly decreased in the post–order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified. Discussion An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels. Implications for Practice A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

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Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?

Journal of General Internal Medicine ◽

10.1046/j.1525-1497.2002.10837.x ◽

2002 ◽

Vol 17 (8) ◽

pp. 625-631 ◽

Cited By ~ 38

Author(s):

Wayne A. Ury ◽

Maike Rahn ◽

Victorio Tolentino ◽

Monica G. Pignotti ◽

Janet Yoon ◽

...

Keyword(s):

Palliative Care ◽

Pain Management ◽

Medical Residents ◽

Prescribing Practices ◽

Opioid Prescribing

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Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention to Reduce Opioid Overprescribing

JAMA Network Open ◽

10.1001/jamanetworkopen.2018.2908 ◽

2018 ◽

Vol 1 (5) ◽

pp. e182908 ◽

Cited By ~ 31

Author(s):

Barry R. Meisenberg ◽

Jennifer Grover ◽

Colson Campbell ◽

Daniel Korpon

Keyword(s):

Health System ◽

Prescribing Practices ◽

Opioid Prescribing ◽

System Intervention ◽

Before And After ◽

Health System Intervention

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Opioid-prescribing Practices in a Graduate Endodontic Clinic before and after Implementation of the Federal Schedule II Prescribing Mandate

Journal of Endodontics ◽

10.1016/j.joen.2019.07.011 ◽

2019 ◽

Vol 45 (11) ◽

pp. 1314-1320.e1

Author(s):

Andrew M. Broadsword ◽

Christine M. Sedgley ◽

Richie Kohli ◽

Al M. Best ◽

Karan J. Replogle

Keyword(s):

Prescribing Practices ◽

Opioid Prescribing ◽

Before And After

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Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience

Journal of Opioid Management ◽

10.5055/jom.2021.0660 ◽

2021 ◽

Vol 17 (4) ◽

pp. 284-288

Author(s):

Jeffrey G. Stepan, MD, MSc ◽

Christine Goodbody, MD ◽

Kanupriya Kumar, MD ◽

Kathryn DelPizzo, MD ◽

Peter Fabricant, MD, MPH ◽

...

Keyword(s):

Sports Medicine ◽

Pediatric Patients ◽

Tertiary Care ◽

Oral Morphine ◽

Knee Surgery ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Before And After ◽

Pediatric Orthopedic

Objective: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries.Design: Retrospective observational.Setting: Urban, tertiary care, academic orthopedic hospital.Patients: Pediatric, sports knee surgery, 23-month period.Interventions: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries.Main outcome measure: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. Results: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient.Conclusions: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

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Impact of Michigan’s new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative

Journal of Neurosurgery Spine ◽

10.3171/2020.7.spine20729 ◽

2020 ◽

pp. 1-6

Author(s):

Paul Park ◽

Victor Chang ◽

Hsueh-Han Yeh ◽

Jason M. Schwalb ◽

David R. Nerenz ◽

...

Keyword(s):

Spine Surgery ◽

Spinal Surgery ◽

Readmission Rate ◽

Rating Scale ◽

Short Term ◽

Readmission Rates ◽

Opioid Prescribing ◽

Number Of Patients ◽

Before And After ◽

The Impact

OBJECTIVEIn 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.METHODSPatient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.RESULTSPatients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).CONCLUSIONSThere was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

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Impact of legalization of Medical Assistance in Dying on the Use of Palliative Sedation in a Tertiary Care Hospital: A Retrospective Chart Review

American Journal of Hospice and Palliative Medicine® ◽

10.1177/10499091211030443 ◽

2021 ◽

pp. 104990912110304

Author(s):

Amy Nolen ◽

Rawaa Olwi ◽

Selby Debbie

Keyword(s):

Palliative Care ◽

Acute Care ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Palliative Sedation ◽

Palliative Care Unit ◽

Care Hospital ◽

Medical Assistance ◽

Medical Assistance In Dying ◽

Before And After

Background: Patients approaching end of life may experience intractable symptoms managed with palliative sedation. The legalization of Medical Assistance in Dying (MAiD) in Canada in 2016 offers a new option for relief of intolerable suffering, and there is limited evidence examining how the use of palliative sedation has evolved with the introduction of MAiD. Objectives: To compare rates of palliative sedation at a tertiary care hospital before and after the legalization of MAiD. Methods: This study is a retrospective chart analysis of all deaths of patients followed by the palliative care consult team in acute care, or admitted to the palliative care unit. We compared the use of palliative sedation during 1-year periods before and after the legalization of MAiD, and screened charts for MAiD requests during the second time period. Results: 4.7% (n = 25) of patients who died in the palliative care unit pre-legalization of MAiD received palliative sedation compared to 14.6% (n = 82) post-MAiD, with no change in acute care. Post-MAiD, 4.1% of deaths were medically-assisted deaths in the palliative care unit (n = 23) and acute care (n = 14). For patients who requested MAiD but instead received palliative sedation, the primary reason was loss of decisional capacity to consent for MAiD. Conclusion: We believe that the mainstream presence of MAiD has resulted in an increased recognition of MAiD and palliative sedation as distinct entities, and rates of palliative sedation increased post-MAiD due to greater awareness about patient choice and increased comfort with end-of-life options.

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