At-a-glance - Concurrent monitoring of opioid prescribing practices and opioid-related deaths: the context in Nova Scotia, Canada

Timely public health surveillance is required to understand trends in opioid use and harms. Here, opioid dispensing data from the Nova Scotia Prescription Monitoring Program are presented alongside fatality data from the Nova Scotia Medical Examiner Service. Concurrent monitoring of trends in these data sources is essential to detect population-level effects (whether intended or unintended) of interventions related to opioid prescribing.

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Attributes, Attitudes, and Practices of Clinicians Concerned with Opioid Prescribing

Pain Medicine ◽

10.1093/pm/pny204 ◽

2018 ◽

Vol 20 (10) ◽

pp. 1934-1941 ◽

Cited By ~ 1

Author(s):

Zayd Razouki ◽

Bushra A Khokhar ◽

Lindsey M Philpot ◽

Jon O Ebbert

Keyword(s):

Monitoring Program ◽

Program Review ◽

Opioid Misuse ◽

Opioid Use ◽

Prescribing Practices ◽

Chronic Noncancer Pain ◽

Opioid Prescribing ◽

Attitudes And Practices ◽

Urine Drug ◽

Noncancer Pain

Abstract Background Many clinicians who prescribe opioids for chronic noncancer pain (CNCP) express concerns about opioid misuse, addiction, and physiological dependence. We evaluated the association between the degree of clinician concerns (highly vs less concerned), clinician attributes, other attitudes and beliefs, and opioid prescribing practices. Methods A web-based survey of clinicians at a multispecialty medical practice. Results Compared with less concerned clinicians, clinicians highly concerned with opioid misuse, addiction, and physiological dependence were more confident prescribing opioids (risk ratio [RR] = 1.34, 95% confidence interval [CI] = 1.08–1.67) but were more reluctant to do so (RR = 1.13, 95% CI = 1.03–1.25). They were more likely to report screening patients for substance use disorder (RR = 1.18, 95% CI = 1.01–1.37) and to discontinue prescribing opioids to a patient due to aberrant opioid use behaviors (RR = 1.30, 95% CI = 1.13–1.50). They were also less likely to prescribe benzodiazepines and opioids concurrently (RR = 0.40, 95% CI = 0.25–0.65). Highly concerned clinicians were more likely to work in clinics which engage in “best practices” for opioid prescribing requiring urine drug screening (RR = 4.65, 95% CI = 2.51–8.61), prescription monitoring program review (RR = 2.90, 95% CI = 1.84–4.56), controlled substance agreements (RR = 4.88, 95% CI = 2.64–9.03), and other practices. Controlling for clinician concern, prescribing practices were also associated with clinician confidence, reluctance, and satisfaction. Conclusions Highly concerned clinicians are more confident but more reluctant to prescribe opioids. Controlling for clinician concern, confidence in care and reluctance to prescribe opioids were associated with more conservative prescribing practices.

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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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Understanding Opioid Prescribing Practices of Resident Physicians

The American Surgeon ◽

10.1177/00031348211060412 ◽

2021 ◽

pp. 000313482110604

Author(s):

Julia M. Coughlin ◽

Samantha L. Terranella ◽

Ethan M. Ritz ◽

Thomas Q. Xu ◽

John F. Tierney ◽

...

Keyword(s):

Best Practice ◽

Monitoring Program ◽

Resident Training ◽

Prescribing Practices ◽

Exact Test ◽

Opioid Prescribing ◽

Resident Physicians ◽

Order Sets ◽

Patient’S History ◽

Safe Opioid Prescribing

Background To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. Methods An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher’s exact test assessed differences in prescribing practices between specialties. Results Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient’s history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills ( P < .001). Discussion The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.

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Implementation of an Evidence-Based Protocol Significantly Reduces Opioid Prescribing After Ventral Hernia Repair

The American Surgeon ◽

10.1177/0003134820942207 ◽

2020 ◽

Vol 86 (11) ◽

pp. 1602-1606

Author(s):

Diana E. Peterman ◽

Bryan P. Knoedler ◽

Joseph A. Ewing ◽

Alfredo M. Carbonell ◽

William S. Cobb ◽

...

Keyword(s):

South Carolina ◽

Hernia Repair ◽

Ventral Hernia ◽

Program Analysis ◽

Ventral Hernia Repair ◽

Monitoring Program ◽

Trend Test ◽

Evidence Based ◽

Opioid Use ◽

Opioid Prescribing

Background Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use. Methods A standardized protocol for discharge prescribing was implemented in March 2018. Patients were prescribed ibuprofen, acetaminophen, and opioids based on milligram morphine equivalent (MME) use the 24 hours prior to discharge. We retrospectively reviewed prescriptions of opioids for two 6-month periods—July-December 2017 (PRE) and July-December 2018 (POST)—for comparison using EPIC report and the South Carolina Prescription Monitoring Program. Analysis performed included Mann-Kendall linear trend test and Student’s t-test for continuous variables. Results VHR was performed in 105 patients in the PRE and 75 patients in the POST group. Total MME prescribed decreased significantly from mean 322.7 + 261.3/median 225 (IQR 150-400) MME to 141.6 + 150.4/median 100 (50-184) MME ( P < .001). This represents a 57% reduction in mean opioid MME prescriptions. Acetaminophen prescribing increased from 10% to 65%, and ibuprofen from 7.6% to 61.3%. Refills were prescribed in 21 patients (20%) during the PRE period, which decreased to 10.7% during the POST group ( P = .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR. Discussion A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.

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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 Use After Common Sports Medicine Procedures: A Systematic Review

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120913293 ◽

2020 ◽

Vol 12 (3) ◽

pp. 225-233 ◽

Cited By ~ 1

Author(s):

Ujash Sheth ◽

Mitesh Mehta ◽

Fernando Huyke ◽

Michael A. Terry ◽

Vehniah K. Tjong

Keyword(s):

Systematic Review ◽

Sports Medicine ◽

Management Strategies ◽

Opioid Consumption ◽

Opioid Use ◽

Prescribing Practices ◽

Eligibility Criteria ◽

Level Of Evidence ◽

Opioid Prescribing ◽

Arthroscopic Procedures

Context: The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. Objective: To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. Data Sources: A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. Study Selection: Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. Results: A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. Conclusion: Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

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Effect of Florida’s prescription monitoring Program and pill-mill Laws on Opioid prescribing and Utilization

Value in Health ◽

10.1016/j.jval.2015.03.1767 ◽

2015 ◽

Vol 18 (3) ◽

pp. A304

Author(s):

M. Daubresse ◽

L. Rutkow ◽

H. Chang ◽

E. Stuart ◽

D. Webster ◽

...

Keyword(s):

Monitoring Program ◽

Opioid Prescribing ◽

Prescription Monitoring

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Can we use medical examiners’ records for suicide surveillance and prevention research in Nova Scotia?

Chronic Diseases and Injuries in Canada ◽

10.24095/hpcdp.31.4.05 ◽

2011 ◽

Vol 31 (4) ◽

pp. 165-171 ◽

Cited By ~ 1

Author(s):

LA Campbell ◽

L Jackson ◽

R Bassett ◽

MJ Bowes ◽

M Donahue ◽

...

Keyword(s):

Health Care ◽

Nova Scotia ◽

Policy Development ◽

Data Extraction ◽

Population Level ◽

Health Care Use ◽

Administrative Databases ◽

Medical Examiner ◽

Targeted Prevention ◽

Medical Examiners

Introduction Medical examiners’ records can contribute to our understanding of the extent of suicide in a population, as well as associated sociodemographic and other factors. Methods Using a mixed methods approach, the key objective of this pilot study was to determine the sources and types of information found in the Nova Scotia Medical Examiner Service (NSMES) records that might inform suicide surveillance and targeted prevention efforts. A secondary objective was to describe the one-year cohort of 108 individuals who died by suicide in 2006 in terms of available sociodemographic information and health care use in the year prior to death. Results Data extraction revealed inconsistencies both across and within files in terms of the types and amounts of sociodemographic and other data collected, preventing correlational analyses. However, linkage of the records to administrative databases revealed frequent health care use in the month prior to death. Conclusion The introduction of systematic data collection to NSMES investigations may yield a comprehensive dataset useful for policy development and population level research.

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Qualitative insights into the opioid prescribing practices of Australian GP

Family Practice ◽

10.1093/fampra/cmz083 ◽

2019 ◽

Vol 37 (3) ◽

pp. 412-417

Author(s):

Pallavi Prathivadi ◽

Chris Barton ◽

Danielle Mazza

Keyword(s):

Chronic Pain ◽

Research Network ◽

World Health ◽

Evidence Based ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Attitudes And Practices ◽

Factors Influencing ◽

Age Related

Abstract Background Over the last three decades, Australian opioid-prescribing rates and related morbidity and mortality have dramatically increased. Opioids are frequently prescribed by general practitioners (GPs) to manage chronic non-cancer pain, despite evidence-based recommendations from the Centre for Disease Control, National Institute for Health and Care Excellence and World Health Organization widely cautioning their use. Little is known about the factors influencing the opioid prescribing decisions of Australian GPs, especially when not evidence based. Objective To explore the opioid prescribing knowledge, attitudes and practices of Australian GPs. Methods Semi-structured interviews with 20 GPs recruited from the Monash University practice-based research network in metropolitan, southeastern Melbourne. Thematic analysis was used to identify emergent themes. Data were managed using QSR NVivo. Ethics approval was granted by Monash University. Results Three key themes emerged. GP attitudes towards opioid use for chronic pain varied by age of patient and goals for therapy. Use of opioids for elderly patients was positively perceived. GPs were reluctant to use opioids in younger patients due to fears of addiction and difficulty weaning. GPs felt obliged to prescribe opioids recommended by specialists, even if they believed the opioids were unsafe. Conclusion This study identified and described the patient-centred nature of GP opioid prescribing decisions. Patient age and perceived age-related opioid harm were important factors influencing prescribing decisions. Future work should inform interventions that value GP autonomy while still encouraging a collaborative inter-speciality approach to managing chronic pain patients with opioids.

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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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