scholarly journals De-Implementing Opioid Use and Implementing Optimal Pain Management Following Dental Extractions (DIODE): Trial rationale, protocol, and progress to date (Preprint)

2020 ◽  
Author(s):  
D. Brad Rindal ◽  
Stephen E. Asche ◽  
Jan Gryczynski ◽  
Sheryl M. Kane ◽  
Anjali R. Truitt ◽  
...  
Keyword(s):  
United States ◽  
Pain Management ◽  
Patient Education ◽  
Randomized Trial ◽  
Primary Outcome ◽  
Opioid Analgesics ◽  
The United States ◽  
Prescribing Patterns ◽  
Opioid Prescribing ◽  
Patient Level

BACKGROUND Overdose deaths from prescription opioid analgesics are a continuing crisis in the United States. Opioid analgesics are among the most frequently prescribed drugs by dentists. An estimated 5 million people undergo third-molar extractions in the United States each year, resulting in postoperative pain. Studies show that in most cases the combination of ibuprofen and acetaminophen is an effective alternative to commonly-prescribed opioid analgesics for the management of post-extraction pain. Nevertheless, many dentists routinely prescribe opioids after dental extractions. OBJECTIVE We describe the rationale, design, and methods for a randomized trial of interventions designed to de-implement opioid prescribing by dentists while implementing effective non-opioid analgesics following dental extractions. METHODS Using a prospective, 3-arm cluster randomized trial design with dentists as the unit randomized and patient-level prescribing data as the primary outcome, we will compare different strategies to reduce the reliance on opioids and increase the use of alternative pain management approaches utilizing information support tools aimed at both providers and their patients. The study will test the efficacy of two interventions to decrease opioid prescribing following dental extractions: Clinical Decision Support (CDS), and CDS with Patient Education (CDS-E). Providers will be randomized to CDS, CDS-E, or standard practice. Patient-level outcomes will be determined via review of comprehensive electronic health records. We will compare study arms on differential change in prescribing patterns from pre- to post-implementation of the intervention. The primary outcome of interest is a binary indicator of whether or not the patient received an opioid prescription on the day of the extraction encounter. We will also examine recommendations or prescriptions for non-opioid analgesics, patients’ perception of shared decision making, and patients’ pain experiences following the extraction. RESULTS The HealthPartners Institutional Review Board has approved the study. All study materials including the CDS and patient education materials have been developed and pilot tested and the protocol has been approved by National Institute of Dental and Craniofacial Research (NIDCR). The intervention was implemented in February 2020 and data collection has begun. CONCLUSIONS If the intervention strategies are shown to be effective, they could be implemented more broadly in dental settings with high levels of opioid prescribing. CLINICALTRIAL ClinicalTrials.gov Identifier: NCT03584789

scholarly journals Opioid Prescribing Patterns of the American Orthopaedic Foot & Ankle Society

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0023
Author(s):  
Noortje Hagemeijer ◽  
Gabrielle Donahue ◽  
Gijs Helmerhorst ◽  
Daniel Guss ◽  
Gino Kerkhoffs ◽  
...  
Keyword(s):  
United States ◽  
Pain Management ◽  
Postoperative Pain ◽  
Management Practices ◽  
Postoperative Pain Management ◽  
The United States ◽  
Prescribing Patterns ◽  
Foot And Ankle ◽  
Opioid Prescribing ◽  
American Orthopaedic

Category: Other Introduction/Purpose: Amid the current opioid epidemic in the United States, surgeons are forced to more carefully manage postoperative pain prescriptions. Despite the enthusiastic engagement of physicians, politicians and the general public, however, clear guidelines for opioid prescribing postoperatively still do not exist, including after foot and ankle surgery. Given the ablity to improve patient outcomes by decreasing treatment variability in other realms of medicine, this study sought to quantify the postoperative opioid prescribing regimens of American foot and ankle surgeons as an initial step towards understanding prescription patterns and establishing a baseline regimen from which future guidelines may stem. Methods: A total of 1235 active and candidate members of the American Orthopaedic Foot & Ankle Society (AOFAS) from the United States and Canada were invited to fill out a postoperative pain management survey using a Research Electronic Data Capture (REDCap) web-based application. Surgeons were asked to report on their pain prescription regimens, including type and number of pills, after nine common foot and ankle procedures rated as minor, moderate, or major in severity. The presence of a regional block anesthesia was also recorded. Opioid prescriptions were then converted to the equivalent of 5 mg oxycodone pills for standardization and inter-prescriber comparison. Results: Two hundred twenty-four (18%) surgeons completed the survey. Because of highly skewed data results are reported as medians and the range. Postoperative opioid prescriptions, given in oxycodone 5 mg pill equivalents, were as follows: 39 (8-133) pills for minor procedure, 45 (10-180) pills for a moderate soft tissue procedure, 53 (16-186) pills for a moderate bony procedure, and 60 (20-200) pills for a major bony procedure. Conclusion: Wide variation between surgeons was noted in postoperative pain management. Median prescription opioid doses vary from 39 to 60 oxycodone pills depending on procedure type. It is likely that the amount of opioids prescribed is excessive for adequate pain management, especially for smaller procedures. We propose a post-operative pain regimen that limits the number of pills prescribed based on studies from other surgical specialties. Future studies are necessary to assess the efficacy of current postoperative pain management practices and to guide improved pain management that limits the use of opioids where possible.

scholarly journals The Role of the Medical School Training on Physician Opioid Prescribing Practices: Evidence from Ontario, Canada: Le rôle de la formation à la faculté de médecine à l’égard des pratiques de prescription d’opioïdes des médecins: données probantes d’Ontario, Canada

2020 ◽  
Vol 65 (10) ◽  
pp. 710-720
Author(s):  
Claire de Oliveira ◽  
Tomisin Iwajomo ◽  
Tara Gomes ◽  
Paul Kurdyak
Keyword(s):  
United States ◽  
Medical School ◽  
Medical Schools ◽  
The United States ◽  
Prescribing Patterns ◽  
Opioid Epidemic ◽  
Opioid Prescribing ◽  
Medical School Training ◽  
School Training

Background: Recent research found that physicians who completed medical school training at top-ranked U.S. medical schools prescribed fewer opioids than those trained at lower ranked schools, suggesting that physician training may play a role in the opioid epidemic. We replicated this analysis to understand whether this finding holds for Ontario, Canada. Methods: We used data on all opioid prescriptions written by Ontario physicians between 2013 and 2017 from the Narcotics Monitoring System. Using the Corporate Provider Database and ICES Physician Database, which contain medical school of training, we linked patients who filled opioid prescriptions with their respective prescribing physician. Available data on Canadian medical school rankings were obtained from Maclean’s news magazine. We used regression analysis to assess the relationship between number of opioid prescriptions and medical school ranking. Results: Compared to the United States, average annual number of opioid prescriptions per physician was lower in Ontario (236 vs. 78). Unlike the United States, we found little evidence that physicians trained at lower ranked medical schools prescribed more than their top-ranked school counterparts after controlling for specialty and location of practice. However, primary care physicians trained at non-English-speaking foreign schools prescribed the most opioids even after excluding opioid maintenance therapy–related prescriptions. Conclusion: The role of medical school training on opioid prescribing patterns among Ontario physicians differs from that in the United States likely due to greater homogeneity of curricula among Canadian schools. Ensuring physicians trained abroad receive additional pain management/addiction training may help address part of the opioid epidemic in Ontario.

scholarly journals Opioid Prescribing Among Adults With Disabilities in the United States After the 2014 Federal Hydrocodone Rescheduling Regulation

2019 ◽  
Vol 135 (1) ◽  
pp. 114-123
Author(s):  
Victor Liaw ◽  
Yong-Fang Kuo ◽  
Mukaila A. Raji ◽  
Jacques Baillargeon
Keyword(s):  
United States ◽  
High Risk ◽  
The United States ◽  
Prescribing Patterns ◽  
Prescription Opioid ◽  
High Dose ◽  
Medicare Beneficiaries ◽  
Persons With Disabilities ◽  
Adults With Disabilities ◽  
Opioid Prescribing

Objectives: Deaths from prescription opioid overdoses have reached an epidemic level in the United States, particularly among persons with disabilities. The 2014 federal rescheduling regulation is associated with reduced opioid prescribing in the general US population; however, to date, no data have been published on this regulation’s effect on persons with disabilities. We examined whether the 2014 hydrocodone rescheduling change was associated with reduced opioid prescribing among adult Medicare beneficiaries with disabilities. Methods: We identified 680 876 Medicare beneficiaries with disabilities aged 21-64 in 2013 and 657 687 in 2015 from a 20% national sample. We examined changes in the monthly opioid-prescribing rates from January 1, 2013, through December 31, 2015. We also compared opioid-prescribing rates in 2013 with rates in 2015. Results: In 2014, the percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased by 0.154% per month (95% confidence interval [CI], –0.186 to –0.121, P < .001). The percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased from 32.2% in 2013 to 27.7% in 2015, whereas rates of any opioid prescribing, prolonged prescribing (≥90-day supply), and high-dose prescribing (≥100 morphine milligram equivalents per day for >30 days) decreased only modestly, from 50.2% to 49.0%, from 27.4% to 26.5%, and from 7.5% to 7.0%, respectively. Conclusions: The 2014 federal rescheduling of hydrocodone was associated with only minor changes in overall and potentially high-risk opioid-prescribing rates. Neither state variation in long-term prescribing nor beneficiary characteristics explained the changes in persistently high opioid-prescribing rates among adults with disabilities after the 2014 regulation. Future studies should examine patient and provider characteristics underlying the persistent high-risk prescribing patterns in this population.

scholarly journals Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study

BMJ ◽  
2020 ◽  
pp. l6968 ◽  
Author(s):  
Mathew V Kiang ◽  
Keith Humphreys ◽  
Mark R Cullen ◽  
Sanjay Basu
Keyword(s):  
United States ◽  
Observational Study ◽  
The United States ◽  
Prescribing Patterns ◽  
Retrospective Observational Study ◽  
Washington Dc ◽  
Medical Providers ◽  
Opioid Prescribing ◽  
One Year ◽  
Improving Patient Care

AbstractObjectiveTo examine the distribution and patterns of opioid prescribing in the United States.DesignRetrospective, observational study.SettingNational private insurer covering all 50 US states and Washington DC.ParticipantsAn annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.Main outcome measuresStandardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.ResultsIn 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs—nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.ConclusionsMost prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

Maximizing the Value of Electronic Prescription Monitoring Programs

2003 ◽  
Vol 31 (1) ◽  
pp. 41-54 ◽  
Author(s):  
David B. Brushwood
Keyword(s):  
United States ◽  
Pain Management ◽  
Public Health Problem ◽  
Opioid Analgesics ◽  
The United States ◽  
Deterrent Effect ◽  
Electronic Prescription ◽  
Significant Public Health Problem ◽  
Significant Public Health ◽  
Controlled Substance

There is general agreement that the “principle of balance” should guide controlled substance policy and regulation in the United States. Although the diversion of controlled substances from medical to nonmedical purposes is a significant public health problem, overly aggressive controlled substance regulation has been shown to have an unintended deterrent effect on appropriate controlled substance use, including pain management with opioid analgesics. The promotion of effective pain management and the reduction of substance abuse are equally important regulatory objectives. Neither regulatory objective need be sacrificed to achieve the other. Rather, the two objectives must be balanced with each other to assure that necessary pain management is encouraged while drug abuse is curtailed.Approximately 75 million people in the United States suffer from severe pain. Fifty million of these suffer chronic pain, and 25 million suffer acute pain from trauma or surgery. Pain is not merely an uncomfortable symptom.

Developing opioid prescribing recommendations in the postoperative orthopedic setting

2019 ◽  
Vol 15 (4) ◽  
pp. 333-341
Author(s):  
Daniel K. Haddad, PharmD ◽  
Orrin H. Sherman, MD
Keyword(s):  
Postoperative Pain ◽  
Best Practice ◽  
Opioid Analgesics ◽  
Postoperative Pain Management ◽  
The United States ◽  
Opioid Use Disorder ◽  
Prescribing Patterns ◽  
Opioid Use ◽  
High Quality Research ◽  
Opioid Prescribing

Background: The use of opioid analgesics in the United States has increased nearly fourfold since 1999 resulting in a similar increase in opioid-related overdose deaths. Although the Centers for Disease Control published guidelines for prescribing chronic opioids, there is a lack of guidance for prescribing postoperative opioids. Objective: To offer an evidence-based approach to prescribing opioids for postoperative pain management in the orthopedic setting.Methods: A narrative review was performed of studies evaluating and quantifying opioid use in orthopedic patients in the postoperative setting, as well as studies analyzing patient satisfaction and perception with regards to opioid use.Results: Studies show that postoperative pain may not be the largest contributing factor to developing an opioid use disorder, but rather patient factors such as tobacco and substance use disorder, mental health disorders, anxiety, mood disorders, pre-existing chronic pain, and recent opioid use may play a role. The review also found that most patients do not utilize significant portions of prescribed opioids and most do not require a refill. This trend leaves patients with thousands of unused pills, which are either retained, shared, or diverted. Although there is no guideline for prescribing opioids postoperatively, data suggest that clinicians can prescribe smaller dosages and fewer quantities of opioids initially. There are also non-opioid strategies that can be employed to reduce opioid consumption.Conclusion: There is a need for more high quality research to be conducted to standardize postoperative opioid prescribing patterns and create best practice guidelines to guide clinicians. Orthopedic practices should consider creating institutional guidelines to reduce the amount of opioids prescribed.

scholarly journals What are Future Pain Physicians Learning? A Survey of Opioid Prescribing Practices Among US Pain Fellowship Programs

2019 ◽  
Vol 6 (22;6) ◽  
pp. 549-554 ◽  
Author(s):  
Ferdinand Iannaccone
Keyword(s):  
United States ◽  
Pain Management ◽  
Clinical Training ◽  
The United States ◽  
Prescribing Practices ◽  
Chronic Noncancer Pain ◽  
Opioid Prescribing ◽  
Prescribe Opioid ◽  
Fellowship Programs ◽  
Noncancer Pain

Background: Pain physicians have long been seen as subspecialists that commonly prescribe opioid medications, but the reality exists that primary care, oncologists, and surgical subspecialists find themselves embroiled in these clinical decisions just as frequently. It is a reasonable hope that pain physicians emerge as leaders in navigating these muddy waters, and the most important time to engrave practice standards is during clinical training. Objectives: It was our hope to survey Accreditation Council for Graduate Medical Education (ACGME) pain fellowship programs throughout the United States in regard to practice behaviors for opioid prescribing in chronic noncancer pain (CNCP), and to assess what future pain physicians are learning during their training. Study Design: We developed a succinct, 8-question survey that attempted to gauge several aspects of opioid prescribing practices for CNCP. A survey was prepared in electronic format and e-mailed to each program director or chair of every ACGME accredited pain program in the United States. Methods: Our results were anonymously collected and percentage of response to each question was presented in bar graph format. The survey was prepared and initially sent out in November 2017 and intermittently redistributed through April 2018. Results: Of the 117 surveys sent through Survey Monkey, 42 responses were returned and collected, 39 fully completed surveys, and 3 partial completions, an estimate of roughly one-third of US ACGME pain fellowship programs. Limitations: Completion of our survey was voluntary, roughly 35% of ACGME programs submitted a response. Conclusions: Data displayed in collected responses illustrate that although there is variance in opioid prescribing practices for CNCP, many programs are limiting what they use opioids for and have substantial nonopioid pharmacologic and or interventional aspects to their practice. Future pain physicians throughout the country are learning diverse methods of pain management, with opioids being only a part of their toolbox. Key words: Opioids, ACGME, pain management fellowship, guidelines, teaching

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