Implementing Prescribing Guidelines for Upper Extremity Orthopedic Procedures: A Prospective Analysis of Postoperative Opioid Consumption and Satisfaction

Hand ◽  
2019 ◽  
pp. 155894471986712 ◽  
Author(s):  
Jenna R. Adalbert ◽  
Asif M. Ilyas
Keyword(s):  
Upper Extremity ◽  
Opioid Analgesic ◽  
Analgesic Efficacy ◽  
Opioid Consumption ◽  
Orthopedic Procedures ◽  
Anatomical Location ◽  
Prospective Evaluation ◽  
Opioid Prescribing ◽  
Request Rate ◽  
Consecutive Period

Background: A lack of established opioid-prescribing guidelines has prompted recent studies to propose preliminary guidelines to mitigate inadvertent overprescribing, diversion, and abuse. The purpose of our study was to assess the efficacy of a specific set of opioid-prescribing guidelines by prospective evaluation of patient consumption and satisfaction. Methods: During a consecutive period, all patients undergoing outpatient upper extremity surgical procedures were postoperatively prescribed opioids based on published guidelines that were specific to the anatomical location and procedure being performed. At the first postoperative visit, surgical details, opioid consumption patterns, and prescription efficacy and satisfaction were recorded. Results: A total of 201 patients reported any amount of prescription use, resulting in a mean consumption of 5.5 pills. Patients who underwent soft tissue procedures reported the lowest requirement (4.2 pills) compared with those who underwent fracture repairs (6.7 pills) or arthroscopy and arthroplasty/fusion procedures (8.7 pills). Patients undergoing hand procedures consumed fewer opioids (3.9 pills) compared with those undergoing wrist (6.3 pills) or elbow (8.1 pills) procedures. Of the patients requiring opioids, 82% reported being satisfied or at least neutral to the prescribed quantity ( P < .001), and 92% reported being satisfied or at least neutral to the prescribed opioid analgesic efficacy ( P < .001). Overall, the study refill request rate was 13%. Conclusions: Although the proposed guidelines tended to exceed patient need, the study confirmed strong patient satisfaction and an overall refill request rate of only 13%. We conclude that following anatomical and procedure-specific opioid-prescribing guidelines is an effective method of prescribing opioids postoperatively after upper extremity.

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

BMJ Open ◽  
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.

scholarly journals Inhibition of Glycine Re-Uptake: A Potential Approach for Treating Pain by Augmenting Glycine-Mediated Spinal Neurotransmission and Blunting Central Nociceptive Signaling

Biomolecules ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. 864
Author(s):  
Christopher L. Cioffi
Keyword(s):  
Spinal Cord ◽  
Dorsal Horn ◽  
Therapeutic Potential ◽  
Opioid Analgesic ◽  
Critical Role ◽  
Analgesic Efficacy ◽  
Standard Of Care ◽  
Current Standard ◽  
Glycine Transporters ◽  
Pathological Pain

Among the myriad of cellular and molecular processes identified as contributing to pathological pain, disinhibition of spinal cord nociceptive signaling to higher cortical centers plays a critical role. Importantly, evidence suggests that impaired glycinergic neurotransmission develops in the dorsal horn of the spinal cord in inflammatory and neuropathic pain models and is a key maladaptive mechanism causing mechanical hyperalgesia and allodynia. Thus, it has been hypothesized that pharmacological agents capable of augmenting glycinergic tone within the dorsal horn may be able to blunt or block aberrant nociceptor signaling to the brain and serve as a novel class of analgesics for various pathological pain states. Indeed, drugs that enhance dysfunctional glycinergic transmission, and in particular inhibitors of the glycine transporters (GlyT1 and GlyT2), are generating widespread interest as a potential class of novel analgesics. The GlyTs are Na+/Cl−-dependent transporters of the solute carrier 6 (SLC6) family and it has been proposed that the inhibition of them presents a possible mechanism by which to increase spinal extracellular glycine concentrations and enhance GlyR-mediated inhibitory neurotransmission in the dorsal horn. Various inhibitors of both GlyT1 and GlyT2 have demonstrated broad analgesic efficacy in several preclinical models of acute and chronic pain, providing promise for the approach to deliver a first-in-class non-opioid analgesic with a mechanism of action differentiated from current standard of care. This review will highlight the therapeutic potential of GlyT inhibitors as a novel class of analgesics, present recent advances reported for the field, and discuss the key challenges associated with the development of a GlyT inhibitor into a safe and effective agent to treat pain.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

2021 ◽  
pp. 1-9
Author(s):  
Marie-Jacqueline Reisener ◽  
Alexander P. Hughes ◽  
Ichiro Okano ◽  
Jiaqi Zhu ◽  
Artine Arzani ◽  
...  
Keyword(s):  
Side Effects ◽  
Spine Surgery ◽  
Effect Size ◽  
Lumbar Fusion ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Chi Square ◽  
Opioid Prescribing ◽  
Pain Scores ◽  
Stewardship Program

OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Safety and Efficacy of the Cyclooxygenase-2 Inhibitors Parecoxib and Valdecoxib after Noncardiac Surgery

2006 ◽  
Vol 104 (3) ◽  
pp. 518-526 ◽  
Author(s):  
Nancy A. Nussmeier ◽  
Andrew A. Whelton ◽  
Mark T. Brown ◽  
Girish P. Joshi ◽  
Richard M. Langford ◽  
...  
Keyword(s):  
Adverse Events ◽  
Artery Bypass ◽  
Opioid Analgesic ◽  
Analgesic Efficacy ◽  
Noncardiac Surgery ◽  
Double Blind ◽  
Related Symptom ◽  
Pain Ratings ◽  
Gastroduodenal Ulceration

Background Valdecoxib and its intravenous prodrug parecoxib are reported to increase thromboembolic risk after coronary artery bypass grafting. The authors conducted a randomized trial to examine their safety and analgesic efficacy in patients recovering from major noncardiac surgical procedures. Methods The trial was randomized and double-blind, with 10 days of treatment and 30 days of follow-up. Patients (n = 1,062) received either parenteral parecoxib for 3 days and oral valdecoxib for the rest of the treatment period or placebo medications throughout. The frequency of predefined adjudicated postrandomization adverse events, including cardiovascular thromboembolism, renal dysfunction, gastroduodenal ulceration, and wound-healing complications, was assessed in each group. Secondary efficacy endpoints included patients' pain ratings, opioid analgesic consumption (recorded as morphine equivalents), and reports of opioid-related adverse effects. Results Predefined adjudicated adverse events had similar frequencies among patients who received parecoxib and valdecoxib (2.7%) and placebo patients (3.2%) (P = 0.58), including cardiovascular thromboembolic events (1.0% in each group; P = 1.0). Placebo patients consumed more morphine equivalents (66.2 +/- 92.4 mg) than did patients receiving parecoxib and valdecoxib (43.2 +/- 65.7 mg) (P &lt; 0.001). Placebo patients had higher mean pain ratings on each of study days 2-10 (P &lt; 0.01) and reported more opioid-related symptom distress on days 2-6 (P &lt; 0.01). Conclusions Parecoxib and valdecoxib are useful adjuncts to opioids for the treatment of postoperative pain in noncardiac surgical patients. Further study will be required to determine the safety profile of parecoxib and valdecoxib administered to patients with known atherosclerotic disease after noncardiac surgery.

Prospective Evaluation of a Tiered Opioid Prescribing Guideline for Inpatient Colorectal Operations

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
David C. Meyer ◽  
Susanna S. Hill ◽  
Richard Pavao ◽  
Adam J. Resnick ◽  
Ayan Purkayastha ◽  
...  
Keyword(s):  
Prospective Evaluation ◽  
Opioid Prescribing

scholarly journals The analgesic efficacy of ultrasound-guided transversus abdominis plane block for retroperitoneoscopic renal surgery: a randomized controlled study

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Xue Li ◽  
Zhen-Zhen Xu ◽  
Xue-Ying Li ◽  
Ting-Ting Jiang ◽  
Zeng-Mao Lin ◽  
...  
Keyword(s):  
Pain Intensity ◽  
Abdominal Wall ◽  
Analgesic Efficacy ◽  
Opioid Consumption ◽  
Transversus Abdominis ◽  
Controlled Study ◽  
Tap Block ◽  
Transversus Abdominis Plane ◽  
Ultrasound Guided ◽  
Renal Surgery

Abstract Background Ultrasound-guided lateral transversus abdominis plane (TAP) block can provide definite analgesia to the anterior abdominal wall. However, whether this method is useful in renal surgery through the lateral abdominal wall pathway remains unknown. The study aimed to evaluate the analgesic efficacy of lateral TAP block for retroperitoneoscopic partial or radical nephrectomy. Method In this prospective, randomized, double-blind, placebo-controlled trial, eligible patients were randomized into two groups. After anaesthesia induction, ultrasound-guided lateral TAP block was performed with either 30 ml of 0.4% ropivacaine (Group T) or an equivalent volume of normal saline (Group C). The primary outcomes were opioid consumption during surgery and in the first 24 h after surgery. Secondary outcomes included postsurgical pain intensity immediately awakening from anaesthesia and at 0.5, 1, 2, 6, 12, and 24 h after surgery, as well as recovery variables including the incidence of postoperative nausea and vomiting (PONV), sleep quality, time to first ambulation, drainage and length of hospital stay. Results A total of 104 patients were enrolled and randomized (53 in Group T and 51 in Group C). Laparoscopic surgery was converted to open surgery in one patient of Group T; this patient was excluded from the outcome analysis. The opioid consumption during surgery (intravenous morphine equivalent dose: median 35.0 mg [interquartile range 18.0, 49.6] in Group C vs. 40.3 mg [20.9, 59.0] in Group T, P = 0.281) and in the first 24 h after surgery (10.8 mg [7.8, 21.7] in Group C vs. 13.2 mg [8.0, 26.6] in Group T, P = 0.311) did not differ significantly between groups. There were no significant differences between groups regarding the pain intensity at all time points after surgery and the recovery variables (all P > 0.05). Conclusions Our results showed that, in patients undergoing retroperitoneoscopic renal surgery, preoperative lateral TAP did not decrease intra- and postoperative opioid consumption, nor did it relieve pain intensity or promote postoperative recovery in the first 24 h after surgery. However, the trial might be underpowered. Trial registration This study was registered on November 4, 2017, in the Chinese Clinical Trail Registry with the identification number ChiCTR-INR-17013244.

An Effective Intervention: Limiting Opioid Prescribing as a Means of Reducing Opioid Analgesic Misuse, and Overdose Deaths

2020 ◽  
Vol 48 (2) ◽  
pp. 249-258 ◽  
Author(s):  
Brandi C. Fink ◽  
Olivier Uyttebrouck ◽  
Richard S. Larson
Keyword(s):  
Opioid Analgesic ◽  
Opioid Analgesics ◽  
Fold Increase ◽  
Prescribing Patterns ◽  
Prescription Opioid ◽  
Heroin Use ◽  
Overdose Death ◽  
Opioid Prescribing ◽  
Prescription Opioid Misuse ◽  
Overdose Deaths

Overdose deaths involving prescription opioids killed more than 17,000 Americans in 2017, marking a five-fold increase since 1999. High prescribing rates of opioid analgesics have been a substantial contributor to prescription opioid misuse, dependence, overdose and heroin use. There was recognition approximately ten years ago that opioid prescribing patterns were contributing to this startling increase in negative opioid-related outcomes, and federal actions, including Medicare reimbursement reform and regulatory actions, were initiated to restrict opioid prescribing. The current manuscript is a description of those actions, the effect of those actions on opioid prescribing and related patient outcomes. We also describe our proposal of methods of expanding these efforts as an important piece to further reduce opioid-related misuse, dependence, and overdose death.

A retrospective cohort review of opioid prescribing and patient-reported consumption patterns following upper extremity surgery

2020 ◽  
Vol 31 (3) ◽  
pp. 240-245
Author(s):  
Justin J. Turcotte ◽  
Andrew C. Palsgrove ◽  
Marcia B. Fowler ◽  
Stephanie A. Adams ◽  
Kevin R. Crowley ◽  
...  
Keyword(s):  
Upper Extremity ◽  
Retrospective Cohort ◽  
Consumption Patterns ◽  
Opioid Prescribing ◽  
Patient Reported

scholarly journals Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan

JAMA Surgery ◽  
2019 ◽  
Vol 154 (1) ◽  
pp. e184234 ◽  
Author(s):  
Ryan Howard ◽  
Brian Fry ◽  
Vidhya Gunaseelan ◽  
Jay Lee ◽  
Jennifer Waljee ◽  
...  
Keyword(s):  
Opioid Consumption ◽  
Opioid Prescribing

Analgesic Efficacy of Nerve Blocks After Abdominoplasty: A Systematic Review

2019 ◽  
Vol 40 (11) ◽  
pp. 1208-1215 ◽  
Author(s):  
Peter M Vonu ◽  
Paul Campbell ◽  
Noah Prince ◽  
Bruce A Mast
Keyword(s):  
Systematic Review ◽  
Rectus Sheath ◽  
Analgesic Efficacy ◽  
Postoperative Pain Management ◽  
Opioid Consumption ◽  
Transversus Abdominis ◽  
Level Of Evidence ◽  
Nerve Blocks ◽  
Quadratus Lumborum ◽  
Meta Analyses

Abstract Background A variety of regional nerve blocks have been utilized in abdominoplasty procedures, including transversus abdominis plane (TAP), intercostal, rectus sheath (RS), pararectus + ilioinguinal/iliohypogastric, quadratus lumborum, and paravertebral blocks. No consensus exists regarding the most effective nerve block modality in optimizing postprocedural comfort levels. Objectives The purpose of this systematic review was to explore the efficacy of the various abdominal nerve blocks employed in abdominoplasty surgery and to draw attention to any modality that may be superior in regards to effectiveness and/or administration. Methods Utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies that have employed regional nerve blocks in abdominoplasty procedures. Opioid consumption, pain scores, time to ambulation, time in the recovery room, and time to first analgesia request were extracted when available. Results A total of 191 articles were reviewed, of which 8 met inclusion criteria. The nerve blocks represented included TAP, RS, pararectus + ilioinguinal/iliohypogastric, intercostal, and quadratus lumborum. All modalities were effective in reducing opioid consumption except quadratus lumborum. Conclusions TAP, RS, pararectus + ilioinguinal/iliohypogastric, and intercostal regional nerve blocks have been shown to optimize postoperative pain management in abdominoplasty procedures. The existing literature suggests that when studied against one another, TAP is more efficacious than RS and pararectus + ilioinguinal/iliohypogastric. When ultrasound guidance is unavailable, consideration should be given to TAP employing the direct visualization approach. Level of Evidence: 2

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