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

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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580 Assessing Opioid Use After Discharge in Pediatric Burn Patients

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.230 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S141-S142

Author(s):

Victoria Owens ◽

Kathleen S Romanowski ◽

Tina L Palmieri ◽

David G Greenhalgh ◽

Soman Sen

Keyword(s):

Burn Injury ◽

Total Body Surface Area ◽

Outpatient Setting ◽

Prescription Opioid ◽

Burn Patients ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescription ◽

Mean Values ◽

Pain Scores

Abstract Introduction Opioids are frequently prescribed after burn injury. Prolonged use of opioids can increase dependence and potential for life threatening complications. For burn-injured children, optimizing opioid prescriptions in the outpatient setting can reduce these risks. Our aim for this study was to assess and analyze the outpatient opioid prescription use in children with burn injuries. Methods After approval from the institutional review board, pediatric patients admitted to our institution with £20% total body surface area (TBSA) burn were included. Data collected included age, gender, % TBSA burn, mechanism of injury, length of stay, surgical procedures, total morphine milligram equivalent (MME) given in last 24 hours prior to discharge and discharge pain prescriptions. 7 days after discharge, families tracked and provided daily usage of prescription opioids, acetaminophen, and ibuprofen, as well as daily pain scores. Families were given a follow up questionnaire about whether a prescription opioid was prescribed and filled, daily medication needs, pain scores, storage of opioids, quantity of medications remaining, and disposal of any remaining opioids. All mean values are mean±standard deviation, all median values are median(interquartile range). Results Twenty-nine patients were enrolled with a mean age of 7±5.8 years and mean TBSA of 10±6%. Daily outpatient pain scores ranged from 0–2. 18 patients underwent skin graft surgery (SUR) and 11 did not (NOSUR). The mean % of opioids that were not used was 50%±38% and 52% of families kept the left-over opioids for future use. For the SUR group, a median % of opioids that were not used was 64(14–90)% and for the NOSUR the median was 35(17.5–56)% and 56% of SUR families and 45% of NOSUR families kept the left-over opioids for future use. Conclusions For pediatric burn patients, opioids prescribed at discharge may be overestimating pain needs. In our study, half of the opioids were not used, and this was even more pronounced in patients who underwent surgery. More concerning is that the majority of families did not dispose the opioids and instead kept the medication for future use. We recommend optimizing opioid prescribing practices to reduce over-prescribing opioids to burn injured children and educating families on the need for proper disposal of left-over opioids.

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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 Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida

Gynecologic and Obstetric Investigation ◽

10.1159/000519517 ◽

2021 ◽

pp. 1-9

Author(s):

Aakriti R. Carrubba ◽

Amy E. Glasgow ◽

Elizabeth B. Habermann ◽

Amanda P. Stanton ◽

Megan N. Wasson ◽

...

Keyword(s):

Statistical Analysis ◽

Cohort Analysis ◽

Oral Morphine ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Before And After ◽

Legislative Changes

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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Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study

Journal of Medical Internet Research ◽

10.2196/24360 ◽

2021 ◽

Vol 23 (4) ◽

pp. e24360

Author(s):

Benjamin Heritier Slovis ◽

Jeffrey M Riggio ◽

Melanie Girondo ◽

Cara Martino ◽

Bracken Babula ◽

...

Keyword(s):

The United States ◽

Prescribing Patterns ◽

Duration Of Treatment ◽

Opioid Prescription ◽

Hospital System ◽

Opioid Prescribing ◽

Before And After ◽

Control And Prevention ◽

Prescribing Practice ◽

Quasi Experimental

Background The United States is in an opioid epidemic. Passive decision support in the electronic health record (EHR) through opioid prescription presets may aid in curbing opioid dependence. Objective The objective of this study is to determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system. Methods We performed a quasi-experimental retrospective pre–post analysis of a 24-month period before and after modifications to our EHR’s opioid prescription presets to match Centers for Disease Control and Prevention guidelines. We included all opioid prescriptions prescribed at our institution for nonchronic pain. Our modifications to the EHR include (1) making duration of treatment for an opioid prescription mandatory, (2) adding a quick button for 3 days’ duration while removing others, and (3) setting the default quantity of all oral opioid formulations to 10 tablets. We examined the quantity in tablets, duration in days, and proportion of prescriptions greater than 90 morphine milligram equivalents/day for our hospital system, and compared these values before and after our intervention for effect. Results There were 78,246 prescriptions included in our study written on 30,975 unique patients. There was a significant reduction for all opioid prescriptions pre versus post in (1) the overall median quantity of tablets dispensed (54 [IQR 40-120] vs 42 [IQR 18-90]; P<.001), (2) median duration of treatment (10.5 days [IQR 5.0-30] vs 7.5 days [IQR 3.0-30]; P<.001), and (3) proportion of prescriptions greater than 90 morphine milligram equivalents/day (27.46% [10,704/38,976; 95% CI 27.02%-27.91%] vs 22.86% [8979/39,270; 95% CI 22.45%-23.28%]; P<.001). Conclusions Modifications of opioid prescribing presets in the EHR can improve prescribing practice patterns. Reducing duration and quantity of opioid prescriptions could reduce the risk of dependence and overdose.

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Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489419877912 ◽

2019 ◽

Vol 129 (2) ◽

pp. 142-148 ◽

Cited By ~ 2

Author(s):

Molly N. Huston ◽

Rouya Kamizi ◽

Tanya K. Meyer ◽

Albert L. Merati ◽

John Paul Giliberto

Keyword(s):

The United States ◽

Opioid Abuse ◽

Prescribing Patterns ◽

Opioid Analgesia ◽

Opioid Use ◽

Prescribing Practices ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Opioid Prescription ◽

Opioid Prescribing

Background: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. Objective: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. Methods: A cross-sectional survey of otolaryngologists at a national laryngology meeting. Results: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. Conclusions: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

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

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2012.06.006 ◽

2013 ◽

Vol 45 (6) ◽

pp. 1107-1111 ◽

Cited By ~ 6

Author(s):

J. Cameron Muir ◽

Carl Scheffey ◽

Heidi M. Young ◽

Agustin O. Vilches ◽

Malene S. Davis ◽

...

Keyword(s):

Palliative Care ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Before And After

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Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed

BMJ Open ◽

10.1136/bmjopen-2020-047928 ◽

2021 ◽

Vol 11 (8) ◽

pp. e047928

Author(s):

Christopher W Shanahan ◽

Olivia Reding ◽

Inga Holmdahl ◽

Julia Keosaian ◽

Ziming Xuan ◽

...

Keyword(s):

Chronic Pain ◽

High Risk ◽

Drug Use ◽

Opioid Analgesic ◽

Safety Net ◽

Opioid Consumption ◽

Secondary Outcome ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Prescribing

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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Trends in opioid prescribing practices in South Korea, 2009–2019: Are we safe from an opioid epidemic?

PLoS ONE ◽

10.1371/journal.pone.0250972 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0250972

Author(s):

Noo Ree Cho ◽

Young Jin Chang ◽

Dongchul Lee ◽

Ji Ro Kim ◽

Dai Sik Ko ◽

...

Keyword(s):

South Korea ◽

Extended Release ◽

Population Based ◽

Prescription Opioid ◽

Prescribing Practices ◽

Geographic Variations ◽

Cross Sectional ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Long Acting

Opioid prescribing data can guide regulation policy by informing trends and types of opioids prescribed and geographic variations. In South Korea, the nationwide data on prescribing opioids remain unclear. We aimed to evaluate an 11-year trend of opioid prescription in South Korea, both nationally and by administrative districts. A population-based cross-sectional analysis of opioid prescriptions dispensed nationwide in outpatient departments between January 1, 2009, and December 31, 2019, was conducted for this study. Data were obtained from the Health Insurance Review & Assessment Service. The types of opioids prescribed were categorized into total, strong, and extended-release and long-acting formulation. Trends in the prescription rate per 1000 persons were examined over time nationally and across administrative districts. There are significant increasing trends for total, strong, and extended-release and long-acting opioid prescriptions (rate per 1000 persons in 2009 and 2019: total opioids, 347.5 and 531.3; strong opioids, 0.6 and 15.2; extended-release and long-acting opioids, 6.8 and 82.0). The pattern of dispensing opioids increased from 2009 to 2013 and slowed down from 2013 to 2019. The rate of opioid prescriptions issued between administrative districts nearly doubled for all types of opioids. Prescription opioid dispensing increased substantially over the study period. The increase in the prescription of total opioids was largely attributed to an increase in the prescription of weak opioids. However, the increase in prescriptions of extended-release and long-acting opioids could be a future concern. These data may inform government organizations to create regulations and interventions for prescribing opioids.

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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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Select practice behaviors of clinicians on the use of opioids for adolescents with subacute and chronic nonmalignant pain

Journal of Opioid Management ◽

10.5055/jom.2011.0055 ◽

2018 ◽

Vol 7 (2) ◽

pp. 123-134 ◽

Cited By ~ 2

Author(s):

John M. Saroyan, MD ◽

Wendy Y. Cheng, MPH ◽

Damani C. Taylor, BA ◽

Amna Afzal, MD ◽

Nomita Sonty, MPhil, PhD ◽

...

Keyword(s):

Nurse Practitioners ◽

Reference Group ◽

Self Report ◽

Prescribing Practices ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Practice Behaviors ◽

Scoliosis Correction ◽

Nonmalignant Pain ◽

Chronic Nonmalignant Pain

Objectives: To characterize the opioid prescribing and monitoring practices of providers for chronic nonmalignant pain (CNP) and subacute postoperative pain (SAPOP) in adolescents.Design: Web-based cross-sectional self-report survey.Setting: Free-standing pediatric tertiary academic center.Participants: A total of 183 physicians and nurse practitioners were eligible. Of 115 (62.8 percent) participants who responded, 108 (93.9 percent) completed the survey.Main outcome measures: Self-reported frequency of opioid prescription for SAPOP and CNP conditions and frequency of associated monitoring practices.Results: For 10 of the 13 pain conditions included, some participants endorsed “monthly or more opioid prescriptions” while others endorsed “opioids do not represent appropriate management.” Opioid prescribing is present for almost all pain conditions but is substantially more common for nonacute vaso-occlusive-related sickle cell disease, scoliosis correction, and video-assisted pectus excavatumrelated pains. When compared with the reference group, CNP with no identifiable pathology, the odds ratio (OR) of an opioid being prescribed for CNP states with identifiable pathology was not significantly higher. The OR for SAPOP was significantly higher (p 0.0001). None of the opioid prescribers reported collecting urine toxicology before or during opioid therapy.Conclusions: This survey identifies a diversity of self-reported clinician opioid prescribing practices for adolescents with CNP and SAPOP. Urine collection for drug toxicology screening is not utilized by opioid prescribers. Surveys of similar clinician practice behaviors at other institutions are warranted to replicate this finding and to establish common clinical practice for usage and monitoring of opioids in conditions where guidelines do not yet exist.

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