Persistent Postoperative Opioid Prescription Fulfillment and Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Retrospective Cohort Study

Background There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. Methods This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors’ exposure was the receipt of a peripheral nerve block. Results The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. Conclusions This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Drug Enforcement Agency 2014 Hydrocodone Rescheduling Rule and Opioid Dispensing after Surgery

Anesthesiology ◽

10.1097/aln.0000000000003188 ◽

2020 ◽

Vol 132 (5) ◽

pp. 1151-1164

Author(s):

Mark D. Neuman ◽

Sean Hennessy ◽

Dylan S. Small ◽

Craig Newcomb ◽

Lakisha Gaskins ◽

...

Keyword(s):

Absolute Risk ◽

Oral Morphine ◽

Risk Difference ◽

Opioid Prescription ◽

Drug Enforcement ◽

Oral Morphine Equivalent ◽

Drug Enforcement Agency ◽

Absolute Decrease ◽

Morphine Equivalent

Abstract Background In 2014, the U.S. Drug Enforcement Agency reclassified hydrocodone from Schedule III to Schedule II of the Controlled Substances Act, resulting in new restrictions on refills. The authors hypothesized that hydrocodone rescheduling led to decreases in total opioid dispensing within 30 days of surgery and reduced new long-term opioid dispensing among surgical patients. Methods The authors studied privately insured, opioid-naïve adults undergoing 10 general or orthopedic surgeries between 2011 and 2015. The authors conducted a differences-in-differences analysis that compared overall opioid dispensing before versus after the rescheduling rule for patients treated by surgeons who frequently prescribed hydrocodone before rescheduling (i.e., patients who were functionally exposed to rescheduling’s impact) while adjusting for secular trends via a comparison group of patients treated by surgeons who rarely prescribed hydrocodone (i.e., unexposed patients). The primary outcome was any filled opioid prescription between 90 and 180 days after surgery; secondary outcomes included the 30-day refill rate and the amount of opioids dispensed initially and at 30 days postoperatively. Results The sample included 65,136 patients. The percentage of patients filling a prescription beyond 90 days was similar after versus before rescheduling (absolute risk difference, −1.1%; 95% CI, −2.3% to 0.1%; P = 0.084). The authors estimated the rescheduling rule to be associated with a 45.4-mg oral morphine equivalent increase (difference-in-differences estimate; 95% CI, 34.2–56.7 mg; P < 0.001) in initial opioid dispensing, a 4.1% absolute decrease (95% CI, −5.5% to −2.7%; P < 0.001) in refills within 30 days, and a 37.7-mg oral morphine equivalent increase (95% CI, 20.6–54.8 mg; P = 0.008) in opioids dispensed within 30 days. Conclusions Among patients treated by surgeons who frequently prescribed hydrocodone before the Drug Enforcement Agency 2014 hydrocodone rescheduling rule, rescheduling did not impact long-term opioid receipt, although it was associated with an increase in opioid dispensing within 30 days of surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty

Anesthesiology ◽

10.1097/aln.0000000000002267 ◽

2018 ◽

Vol 129 (4) ◽

pp. 689-699 ◽

Cited By ~ 13

Author(s):

Lukas Pichler ◽

Jashvant Poeran ◽

Nicole Zubizarreta ◽

Crispiana Cozowicz ◽

Eric C. Sun ◽

...

Keyword(s):

Length Of Stay ◽

Peripheral Nerve ◽

Resource Utilization ◽

Nerve Block ◽

Knee Arthroplasty ◽

Peripheral Nerve Block ◽

Total Knee Arthroplasties ◽

Opioid Prescription ◽

Liposomal Bupivacaine ◽

Total Knee

Abstract Editor’s Perspective What We Already Know about This Topic What This Manuscript Tells Us That Is New Background Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes. Methods The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of −15% in outcomes was assumed to be clinically important. Results Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect −9.3% CI −11.1%, −7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect −8.8% CI −10.1%, −7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications. Conclusions Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.

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ESRA19-0218 ‘Fast-track’ patients to phase II recovery and decrease pacu duration in ambulatory arthroscopic shoulder surgery with combined peripheral nerve block and monitored anesthesia care

10.1136/rapm-2019-esraabs2019.184 ◽

2019 ◽

Author(s):

N Treanor ◽

V Vezina ◽

A Lui

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Phase Ii ◽

Fast Track ◽

Peripheral Nerve Block ◽

Shoulder Surgery ◽

Anesthesia Care ◽

Monitored Anesthesia Care ◽

Arthroscopic Shoulder Surgery

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6 - "Fast-track" patients to Phase II recovery and decrease PACU duration in Ambulatory Arthroscopic Shoulder Surgery with combined peripheral nerve block and monitored anesthesia care

10.26226/morressier.5d1cc24957558b317a173394 ◽

2019 ◽

Author(s):

Nuala Treanor ◽

Virginia Vezina ◽

Dr. Anne Lui

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Phase Ii ◽

Fast Track ◽

Peripheral Nerve Block ◽

Shoulder Surgery ◽

Anesthesia Care ◽

Monitored Anesthesia Care ◽

Arthroscopic Shoulder Surgery

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Peripheral nerve block use in inpatient and outpatient shoulder arthroplasty: a population-based study evaluating utilization and outcomes

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101522 ◽

2020 ◽

Vol 45 (10) ◽

pp. 818-825

Author(s):

Jimmy J Chan ◽

Carl M Cirino ◽

Luilly Vargas ◽

Jashvant Poeran ◽

Nicole Zubizarreta ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Shoulder Arthroplasty ◽

Peripheral Nerve Block ◽

Oral Morphine ◽

Population Based ◽

National Study ◽

Population Based Study ◽

Outpatient Procedures ◽

Shoulder Arthroplasties

BackgroundPeripheral nerve block (PNB) is an effective pain management option after shoulder arthroplasty with increasing popularity over the past decade. Large-scale US data in shoulder arthroplasties are lacking, especially regarding impacts on opioid utilization. This population-based study aimed to evaluate PNB utilization patterns and their effect on outcomes after inpatient and outpatient shoulder arthroplasty.MethodsThis retrospective cohort study used data from the nationwide Premier Healthcare claims database (2006–2016). This study includes n=94 787 and n=3293 inpatient and outpatient (total, reverse and partial) shoulder arthroplasty procedures. Multivariable mixed-effects models estimated associations between PNB use and opioid utilization in oral morphine equivalents and cost of hospitalization/stay. For the inpatient group, additional outcome measures were length of stay (LOS), admission to a skilled nurse facility, 30-day readmission, combined complications and naloxone use (as a proxy for opioid-related complications). We report OR (or % change for continuous variables) and 95% CIs.ResultsOverall, PNB was used in 19.1% (n=18 144) and 20.8% (n=685) of inpatient and outpatient shoulder arthroplasties, respectively, with an increasing trend for inpatient procedures. PNB utilization was consistently associated with lower (up to −14.0%, 95% CI −15.4% to −12.5% decrease, with median 100 and 90 oral morphine equivalents for inpatient and outpatient procedures) opioid utilization on the day of surgery with more potent effects seen for inpatient shoulder arthroplasties. Other outcomes were minimally impacted.DiscussionIn this first national study on PNB use in shoulder arthroplasty, we found increasing PNB use among specifically, inpatient procedures, resulting in particularly reduced opioid use on the day of surgery. While our findings may support PNB use in shoulder arthroplasty, its current low utilization and trends towards more outpatient procedures necessitate continuous monitoring of more extensive benefits.

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Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00316 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0031

Author(s):

Jason A. Lauf ◽

Pearson N. Huggins ◽

Mohammed Al-Issa ◽

Brian M. Byrne ◽

Bryan Large ◽

...

Keyword(s):

Risk Factors ◽

Regression Analysis ◽

Peripheral Nerve ◽

Nerve Block ◽

Odds Ratio ◽

Peripheral Nerve Block ◽

Individual Factors ◽

Complication Rates ◽

Foot And Ankle ◽

Diabetes Status

Category: Other; Ankle; Ankle Arthritis; Bunion Introduction/Purpose: Foot and ankle surgeries are often be accompanied by a peripheral nerve block as a method of reducing post-operative pain. The major nerve targeted is the popliteal nerve. The nerve can be supplemented with a target of the adductor canal or saphenous nerve. Higher than expected complication rates with peripheral nerve blocks has led to increased concern among both surgeons as well as patients. To our knowledge, no study has been able to identify risk factors that may predispose a patient to one of these complications. Our goal was to attempt to identify those risk factors. Methods: We reviewed patient charts who underwent a foot and ankle procedure between 2014 and 2018 as performed by the senior author. The review yielded 992 procedures performed across four surgical locations. Of these, 137 procedures were removed because no regional block was used. The remaining cases were analyzed for nerve complications, defined as sensory (paresthesia, numbness, tingling, or burning pain) or motor (weakness or paralysis) deficits along the distribution of a peripheral nerve. The patients were divided into blocked patients with and without complications. The groups were evaluated for demographic differences. The categories consisted of age, sex, diabetic status, smoking, previous procedures, previously diagnosed neuropathies, surgical location, body mass index (BMI), race, and insurance provider. Statistical analysis was performed using SAS software. To determine significance of these different factors, Chi-square values were obtained for each data set. Additionally, a regression analysis was performed to identify odds ratio for individual factors. Results: The overall complication rate was 10.1% with a total of 855 blocks given. The significant factors associated with a complication were age (p=0.0061), BMI (p=0.0031), location (p=0.0016), and smoking status (p=0.0026). Factors that were not significantly associated with complications were sex, diabetes status, previous procedures requiring a block, previously diagnosed neuropathies, race, and insurance provider. A regression analysis was performed to determine odds ratio for individual factors. Those with significant higher odds ratio were age between 40-65 years, normal or underweight BMI, surgery occurring at an Outpatient Surgery Center, and current smoker. Conclusion: Current literature has reviewed operative variables such as tourniquet time and epinephrine use, while others have looked at diabetes and age as predictors of nerve block complications. Our study focuses more on epidemiological factors that can predict an increased risk. Our study helped to reinforce the findings previous literature has found in regards to age and diabetes status. This study has also introduced some new factors that can help the surgeon decide if a nerve block is necessary for each surgical patient. [Table: see text]

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Examining the burden of opioid prescribing for non-cancer pain considering socio-economic differences, in Wales. A retrospective database study examining trends between 2005 – 2015

10.1101/19012625 ◽

2019 ◽

Author(s):

Emma Davies ◽

Bernadette Sewell ◽

Mari Jones ◽

Ceri Phillips ◽

Jaynie Rance

Keyword(s):

Primary Care ◽

Cancer Pain ◽

Oral Morphine ◽

Equivalent Dose ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Proxy Measure ◽

General Practices ◽

Oral Morphine Equivalent ◽

Morphine Equivalent

AbstractObjectivesTo use a proxy-measure of oral morphine equivalent dose (OMED) to determine trends in opioid burden in people with non-cancer pain and explore differences related to deprivation status.Design, setting and participantsRetrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from 78% of Welsh Primary Care General Practices, whose data is shared with the Secure Anonymised Information Linkage (SAIL) databank. Anonymised data for the period 2005 to 2015, for people aged 18 or over, without a recorded cancer diagnosis and who received at least one prescription for an opioid medicine was included.Primary and Secondary outcomesA proxy-measure of oral morphine equivalence dose (OMED) was used to describe trends in opioid burden over the study period. OMED burden was stratified by 8 drug groups and deprivation, based on the quintile measures of the Welsh Index of Multiple Deprivation 2011 (WIMD2011).ResultsIn the 11 years examined, 22 641 424 prescriptions for opioids were issued from 345 primary care general practices in Wales. Daily OMED per 1000 population increased by 94.7% (from 16 266 mg to 31 665 mg). Twenty-eight percent of opioid prescribing occurred in the most deprived quintile. More than 100 000 000mg more OMED was prescribed in the most deprived areas of Wales, compared to the least deprived. Codeine prescribing accounted for 35% of the OMED burden in Wales over the study period.ConclusionsWhilst opioid prescription numbers increased 44% between 2005 and 2015, the OMED burden nearly doubled, with a disproportionate OMED load in the most deprived communities in Wales. Using OMED provides an insightful representation of opioid burden, more so than prescription numbers alone. Socio-economic differences are likely to affect pain presentation, access to support services and increase the likelihood of receiving an opioid prescription.Strengths and limitations of this studyThis study forms part of the first large-scale examination of opioid prescribing in Wales and is the first to use oral morphine equivalent dose as an outcome measure.Access to anonymously linked data allows more detailed examination of demographic influences on opioid prescribing.The study used a proxy-measure for oral morphine equivalent dose due to unavailability of anonymously linked prescription dispensing data.Disproportionate levels of prescribing in particular populations have been reported in many countries; further research should seek to understand the reasons for the differences and develop means to address any inequality noted.

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