Opioid Reduction After Orthopedic Surgery (OREOS): A Scoping Review Protocol

Background. Faced with the current opioid epidemic, alternative methods to managing postoperative pain are being investigated that could eliminate or substantially reduce opioid prescription and use. Prescribing opioids peri- and post-operatively has been shown to trigger chronic abuse independent of previous drug use and increase the risk of long-term use. The postoperative pain experienced in orthopedic surgery is substantial and it is not surprising that the highest incidence of long-term opioid use occurs after total knee and total hip arthroplasty. Despite the numbers of abuse continuing to rise, there remains a need for high quality and reproducible evidence to support protocols that reduce or eliminate opioid prescription. The goal of this scoping review is to identify the current literature and on opioid reduction after orthopedic surgery, 2) describe the interventions used 3) describe the author’s conclusion on opioid use and postoperative outcomes and 4) synthesize the results of included studies to highlight patterns seen with different interventions.Methods. This is a protocol for a scoping review of opioid sparing analgesic strategies that eliminate or significantly reduce opioid prescription after orthopedic surgery. We will include studies of all designs, excluding expert opinions. We will search Cochrane Library, Embase and Medline. Literature will be managed using Rayyan QCRI software. Two reviewers will independently screen the studies for inclusion, and extract information surrounding the effectiveness of alternative strategies and reduction in opioid prescription. Our analysis will be descriptive in nature. We will group studies based on type of orthopedic procedure and nature of intervention used to report study outcomes.Discussion. Our study will consolidate the current literature on opioid-sparing analgesia after orthopedic surgery and describe the effectiveness of current alternative options. It will look to reveal gaps in our knowledge surrounding our current treatment alternatives to establish areas of interest for future research. Registration. This review was registered prospectively on PROSPERO (registration number CRD42020153418).

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A Biofeedback Enhanced Adaptive Virtual Reality Environment for Managing Surgical Pain and Anxiety

International Journal of Semantic Computing ◽

10.1142/s1793351x20400152 ◽

2020 ◽

Vol 14 (03) ◽

pp. 375-393

Author(s):

Vishnunarayan Girishan Prabhu ◽

Laura Stanley ◽

Robert Morgan

Keyword(s):

Virtual Reality ◽

Pain Management ◽

Postoperative Pain ◽

Low Frequency ◽

Preoperative Anxiety ◽

Opioid Use ◽

Opioid Prescription ◽

Attention Restoration ◽

Increased Risk

Pain and anxiety are common accompaniments of surgery, and opioids have been the mainstay of pain management for decades, with about 80% of the surgical population leaving the hospital with an opioid prescription. Moreover, patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk of long-term opioid use, and about one in 16 surgical patients becomes a long-term user. Current opioid abuse and addiction now place the US in an “opioid epidemic,” and calls for alternative pain management mechanisms. To mitigate the preoperative anxiety and postoperative pain, we developed a virtual reality (VR) experience based on Attention Restoration Theory (ART) and integrated the user’s heart rate variability (HRV) biofeedback to create an adaptive environment. A randomized control trial among 16 Total Knee Arthroplasty (TKA) patients undergoing surgery at Patewood Memorial Hospital, Greenville, SC demonstrated that patients experiencing the adaptive VR environment reported a significant decrease in preoperative anxiety ([Formula: see text]) and postoperative pain ([Formula: see text]) after the VR intervention. These results were also supported by the physiological measures where there was a significant increase in RR Interval (RRI) ([Formula: see text]) and a significant decrease in the low frequency (LF)/high frequency (HF) ratio ([Formula: see text]) and respiration rate (RR) ([Formula: see text]).

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Long-term postoperative opioid prescription after cholecystectomy or gastric by-pass surgery: a retrospective observational study

Scandinavian Journal of Pain ◽

10.1515/sjpain-2020-0150 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Viktoria Larsson ◽

Cecilia Nordenson ◽

Pontus Karling

Keyword(s):

Observational Study ◽

Postoperative Period ◽

Medical Records ◽

Early Postoperative Period ◽

Retrospective Observational Study ◽

Opioid Use ◽

Opioid Prescription ◽

Post Surgery ◽

Gastric By Pass

Abstract Objectives Opioids are commonly prescribed post-surgery. We investigated the proportion of patients who were prescribed any opioids 6–12 months after two common surgeries – laparoscopic cholecystectomy and gastric by-pass (GBP) surgery. A secondary aim was to examine risk factors prior to surgery associated with the prescription of any opioids after surgery. Methods We performed a retrospective observational study on data from medical records from patients who underwent cholecystectomy (n=297) or GBP (n=93) in 2018 in the Region of Västerbotten, Sweden. Data on prescriptions for opioids and other drugs were collected from the patients` medical records. Results There were 109 patients (28%) who were prescribed opioids after discharge from surgery but only 20 patients (5%) who still received opioid prescriptions 6–12 months after surgery. All 20 of these patients had also been prescribed opioids within three months before surgery, most commonly for back and joint pain. Only 1 out of 56 patients who were prescribed opioids preoperatively due to gallbladder pain still received prescriptions for opioids 6–12 months after surgery. Although opioid use in the early postoperative period was more common among patients who underwent cholecystectomy, the patients who underwent GBP were more prone to be “long-term” users of opioids. In the patients who were prescribed opioids within three months prior to surgery, 8 out of 13 patients who underwent GBP and 12 of the 96 patients who underwent cholecystectomy were still prescribed opioids 6–12 months after surgery (OR 11.2; 95% CI 3.1–39.9, p=0,0002). Affective disorders were common among “long-term” users of opioids and prior benzodiazepine and amitriptyline use were significantly associated with “long-term” opioid use. Conclusions The proportion of patients that used opioids 6–12 months after cholecystectomy or GBP was low. Patients with preoperative opioid-use experienced a significantly higher risk of “long-term” opioid use when undergoing GBP compared to cholecystectomy. The indication for being prescribed opioids in the “long-term” were mostly unrelated to surgery. No patient who was naïve to opioids prior surgery was prescribed opioids 6–12 months after surgery. Although opioids are commonly prescribed in the preoperative and in the early postoperative period to patients with gallbladder disease, there is a low risk that these prescriptions will lead to long-term opioid use. The reasons for being prescribed opioids in the long-term are often due to causes not related to surgery.

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The association between initial opioid type and long-term opioid use after hip fracture surgery in elderly opioid-naïve patients

Scandinavian Journal of Pain ◽

10.1515/sjpain-2019-0170 ◽

2020 ◽

Vol 20 (4) ◽

pp. 755-764

Author(s):

Amalie H. Simoni ◽

Lone Nikolajsen ◽

Anne E. Olesen ◽

Christian F. Christiansen ◽

Søren P. Johnsen ◽

...

Keyword(s):

Hip Fracture ◽

Pain Treatment ◽

Population Based ◽

Opioid Use ◽

Calendar Time ◽

Opioid Prescription ◽

Hip Fracture Surgery ◽

Opioid Users ◽

Fracture Surgery

AbstractObjectivesLong-term opioid use after hip fracture surgery has been demonstrated in previously opioid-naïve elderly patients. It is unknown if the opioid type redeemed after hip surgery is associated with long-term opioid use. The aim of this study was to examine the association between the opioid type redeemed within the first three months after hip fracture surgery and opioid use 3–12 months after the surgery.MethodsA nationwide population-based cohort study was conducted using data from Danish health registries (2005–2015). Previously opioid-naïve patients registered in the Danish Multidisciplinary Hip Fracture Registry, aged ≥65 years, who redeemed ≥1 opioid prescription within three months after the surgery, were included. Long-term opioid use was defined as ≥1 redeemed prescription within each of three three-month periods within the year after hip fracture surgery. The proportion with long-term opioid use after surgery, conditioned on nine-month survival, was calculated according to opioid types within three months after surgery. Adjusted odds ratios (aOR) for different opioid types were computed by logistic regression analyses with 95% confidence intervals (CI) using morphine as reference. Subgroup analyses were performed according to age, comorbidity and calendar time before and after 2010.ResultsThe study included 26,790 elderly, opioid-naïve patients with opioid use within three months after hip fracture surgery. Of these patients, 21% died within nine months after the surgery. Among the 21,255 patients alive nine months after surgery, 15% became long-term opioid users. Certain opioid types used within the first three months after surgery were associated with long-term opioid use compared to morphine (9%), including oxycodone (14%, aOR; 1.76, 95% CI 1.52–2.03), fentanyl (29%, aOR; 4.37, 95% CI 3.12–6.12), codeine (13%, aOR; 1.55, 95% CI 1.14–2.09), tramadol (13%, aOR; 1.56, 95% CI 1.35–1.80), buprenorphine (33%, aOR; 5.37, 95% CI 4.14–6.94), and >1 opioid type (27%, aOR; 3.83, 95% CI 3.31–4.44). The proportion of long-term opioid users decreased from 18% before 2010 to 13% after 2010.ConclusionsThe findings suggest that use of certain opioid types after hip fracture surgery is more associated with long-term opioid use than morphine and the proportion initiating long-term opioid use decreased after 2010. The findings suggest that some elderly, opioid-naïve patients appear to be presented with untreated pain conditions when seen in the hospital for a hip fracture surgery. Decisions regarding the opioid type prescribed after hospitalization for hip fracture surgery may be linked to different indication for pain treatment, emphasizing the likelihood of careful and conscientious opioid prescribing behavior.

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Scoping review protocol: the use of telemedicine in providing opioid agonist treatment and related psychosocial supports

BMJ Open ◽

10.1136/bmjopen-2020-040556 ◽

2020 ◽

Vol 10 (12) ◽

pp. e040556

Author(s):

Des Crowley ◽

Robyn Homeniuk ◽

Ide Delargy

Keyword(s):

Scoping Review ◽

Psychosocial Support ◽

Descriptive Analysis ◽

Cochrane Library ◽

Opioid Use ◽

Opioid Agonist ◽

Opioid Agonist Treatment ◽

Search Terms ◽

Medical Librarian ◽

The Cochrane Library

IntroductionThe global opioid-related disease burden is significant. Opioid agonist treatment (OAT) can be effective in reducing illicit opioid use and fatal overdose, and improving multiple health and social outcomes. Despite evidence for its effectiveness, there are significant deficits in OAT globally. COVID-19 has required rapid adaptation of remote models of healthcare. Telemedicine is not used routinely in OAT, and little is known about the current levels of use and effectiveness. The objective of this review is to describe models of telemedicine and their efficacy.Methods and analysisThis scoping review uses the review methodology described by Arksey and O’Malley and adapted by Levac et al. The search strategy developed by the medical librarian at the Irish College of General Practitioners in conjunction with the research team will involve five databases (PubMed, EMBASE, the Cochrane Library, PsycInfo and OpenGrey) and the hand searching of reference lists. A limited initial search of two databases will be completed to refine search terms, followed by a second comprehensive search using newly refined search terms of all databases and finally hand searching references of included studies. To be included, studies must report on remote ways of providing OAT (including assessment, induction and monitoring) or related psychosocial support; be published in English after 2010. Two researchers will independently screen titles, abstracts and full-text articles considered for inclusion. Data will be extracted onto an agreed template and will undergo a descriptive analysis of the contextual or process-oriented data and simple quantitative analysis using descriptive statistics.Ethics and disseminationResearch ethics approval is not required for this scoping review. The results of this scoping review will inform the development of a national remote model of OAT. The results will be published in peer-reviewed journals and presented at relevant conferences.

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Early opioid prescription and risk of long-term opioid use among US workers with back and shoulder injuries: a retrospective cohort study

Injury Prevention ◽

10.1136/injuryprev-2015-041630 ◽

2015 ◽

Vol 22 (3) ◽

pp. 211-215 ◽

Cited By ~ 4

Author(s):

Sara E Heins ◽

Dorianne R Feldman ◽

David Bodycombe ◽

Stephen T Wegener ◽

Renan C Castillo

Keyword(s):

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Shoulder Injuries ◽

Opioid Use ◽

Opioid Prescription

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Patterns of Long-Term Prescription Opioid Use Among Older Adults in the United States: A Study of Medicare Administrative Claims Data

January 2018 - Pain Physician ◽

10.36076/ppj.2021.24.31-40 ◽

2020 ◽

Vol 1;24 (1;1) ◽

pp. 31-40

Keyword(s):

Older Adults ◽

Claims Data ◽

The United States ◽

Prescription Opioid ◽

Administrative Claims ◽

Medicare Beneficiaries ◽

Opioid Use ◽

Opioid Prescription ◽

Administrative Claims Data

BACKGROUND: Long-term opioid therapy was prescribed with increasing frequency over the past decade. However, factors surrounding long-term use of opioids in older adults remains poorly understood, probably because older people are not at the center stage of the national opioid crisis. OBJECTIVES: To estimate the annual utilization and trends in long-term opioid use among older adults in the United States. STUDY DESIGN: Retrospective cohort study. SETTING: Data from Medicare-enrolled older adults. METHODS: This study utilized a nationally representative sample of Medicare administrative claims data from the years 2012 to 2016 containing records of health care services for more than 2.3 million Medicare beneficiaries each year. Medicare beneficiaries who were 65 years of age or older and who were enrolled in Medicare Parts A, B, and D, but not Part C, for at least 10 months in a year were included in the study. We measured annual utilization and trends in new long-term opioid use episodes over 4 years (2013–2016). We examined claims records for the demographic characteristics of the eligible individuals and for the presence of chronic non-cancer pain (CNCP), cancer, and other comorbidities. RESULTS: From 2013 to 2016, administrative claims of approximately 2.3 million elderly Medicare beneficiaries were analyzed in each year with a majority of them being women (~56%) and white (~82%) with a mean age of approximately 75 years. The proportion of all eligible beneficiaries with at least one new opioid prescription increased from 6.64% in 2013, peaked at 10.32% in 2015, and then decreased to 8.14% in 2016. The proportion of individuals with long-term opioid use among those with a new opioid prescription was 12.40% in 2013 and 10.20% in 2016. Among new long-term opioid users, the proportion of beneficiaries with a cancer diagnosis during the study years increased from 13.30% in 2013 to 15.67% in 2016, and the proportion with CNCP decreased from 30.25% in 2013 to 27.36% in 2016. Across all years, long-term opioid use was consistently high in the Southern states followed by the Midwest region. LIMITATIONS: This study used Medicare fee-for-service administrative claims data to capture prescription fill patterns, which do not allow for the capture of individuals enrolled in Medicare Advantage plans, cash prescriptions, or for the evaluation of appropriateness of prescribing, or the actual use of medication. This study only examined long-term use episodes among patients who were defined as opioid-naive. Finally, estimates captured for 2016 could only utilize data from 9 months of the year to capture 90-day long-term-use episodes. CONCLUSIONS: Using a national sample of elderly Medicare beneficiaries, we observed that from 2013 to 2016 the use of new prescription opioids increased from 2013 to 2014 and peaked in 2015. The use of new long-term prescription opioids peaked in 2014 and started to decrease from 2015 and 2016. Future research needs to evaluate the impact of the changes in new and long-term prescription opioid use on population health outcomes. KEY WORDS: Long-term, opioids, older adults, trends, Medicare, chronic non-cancer pain, cancer, cohort study

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Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00339 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0033

Author(s):

Matthew Pate ◽

Jacob Hall ◽

John Anderson ◽

Donald Bohay ◽

John Maskill ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Ankle Fracture ◽

Management Practices ◽

Opioid Analgesic ◽

The United States ◽

Ankle Fractures ◽

Opioid Use ◽

Opioid Prescription ◽

Opioid Medication

Category: Ankle, Bunion, Trauma Introduction/Purpose: Chronic opioid abuse is one of the greatest public health challenges in the United States. The most common first exposure to opioids comes from acute care prescriptions, such as those after surgery. Moreover, opioids are often prescribed excessively, with current estimates suggesting ˜75% of the pills prescribed are unused. Ankle fractures are the most common operatively treated fracture in orthopaedic surgery, and management of acute pain following surgery is challenging. The optimal perioperative pain regimen is still a point of controversy, as there is limited data available regarding appropriate amount of opioid to prescribe. This study evaluates opioid prescribing techniques of multiple foot and ankle surgeons, and associated patient outcomes. We aim to help surgeons improve their pain management practices and to limit opioid overprescription. Methods: Chart review and phone survey were performed on forty two adult patients within three to six months of ankle fracture fixation at our institution. These patients were offered to voluntarily participate in a standardized questionnaire regarding pain scores, opioid use, non-opioid analgesic use, pain management satisfaction, and patient prescription education. Results: 57% of patients reported that they were given “more” or ”much more” opioid medication than needed, 38% stated that they were given the “right amount”, and 5% reported that they were given ”less” or “much less” than needed. 40.0% were on opioids prior to operation. 53.5% did not require refill of discharge opioid prescriptions, 30.2% of patients did not fill any posteroperative opioid prescription. 16.3% of patients filled their discharge prescription and at least one additionall refill (mean refill = 2.22). Mean number of reported opioid pills taken after surgery was 17.4. Mean satisfaction with overall pain management at phone follow up was 8.6/10. Conclusion: While postoperative pain and management vary substantially, a majority of patients feel that they are given more opioid medication than necessary following ankle fracture repair, and a majority of opioid prescriptions are not completely used. Going forward, it is likely that a majority of patients could experience the same beneficial results with less prescription opioid pain medication, which would reduce overpresciption and potential misuse.

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THE OPIOID EPIDEMIC IN LONG-TERM CARE: A STAFF PERSPECTIVE

Innovation in Aging ◽

10.1093/geroni/igz038.2604 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S709-S709

Author(s):

Rachael Hemmert ◽

Gabriella E Dull ◽

Linda S Edelman

Keyword(s):

Pain Management ◽

Long Term Care ◽

Adverse Drug Events ◽

Well Being ◽

Educational Needs ◽

Opioid Use ◽

Term Care ◽

Opioid Prescription ◽

The Impact

Abstract Opioid-based analgesic therapy is a common treatment for moderate to severe pain among long term care (LTC) residents. It has been estimated that 60% of LTC residents have an opioid prescription. Of these, 14% use opioids as part of a long term pain management strategy. LTC residents are particularly vulnerable to opioid misuse, exhibiting higher rates of adverse drug events. However, addressing pain, polypharmacological needs and resident well-being in the LTC setting is challenging. More research and education regarding opioid use in LTC is needed. The Utah Geriatric Education Consortium conducted interprofessional focus groups with LTC partners to 1) determine educational needs of staff regarding opioid use, and 2) gather qualitative data about the pain management experiences of staff when working with residents and families. Staff identified the following training needs: pain manifestation and assessment; certified nurse assistant education on opioid use; non-pharmacological options for pain management. Review of staff’s perception of the intersection of opioids, family and staff in a LTC setting revealed that 1) family is concerned about opioid use; 2) conversely, staff may not see opioid use as a problem; and 3) non-pharmacological options for pain management are often costly and unavailable to those in LTC. Identifying educational needs of LTC staff will help guide the development of educational materials and provide baseline data for future assessments of the impact of opioid education on long-term care patient outcomes.

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Patterns of Opioid and Benzodiazepine Use in Opioid-Naïve Patients With Newly Diagnosed Low Back and Lower Extremity Pain

Neurosurgery ◽

10.1093/neuros/nyz310_101 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Tej D Azad ◽

Yi J Zhang ◽

Martin N Stienen ◽

Daniel Vail ◽

Jason Bentley ◽

...

Keyword(s):

Lower Extremity ◽

Medical Community ◽

National Database ◽

Low Back ◽

Newly Diagnosed ◽

Opioid Use ◽

Opioid Prescription ◽

Lower Extremity Pain ◽

Benzodiazepine Use

Abstract INTRODUCTION The morbidity and mortality associated with opioid and benzodiazepine co-prescribing is a pressing national concern. The aim of this work was to characterize patterns of opioid and benzodiazepine prescribing among opioid-naïve, newly-diagnosed low back and lower extremity pain patients and to investigate the relationship between benzodiazepine prescribing and long-term opioid use. METHODS We used a national database to identify adult patients newly diagnosed with low back pain (LBP) between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6 mo prior to diagnosis, and had 12-mo of continuous enrollment after diagnosis. Among patients receiving at least 1 opioid prescription within 12 mo of diagnosis, we defined discrete patterns of benzodiazepine prescribing continued use, new use, stopped use, and never use. We tested the association of these prescription patterns with long-term opioid use, defined as 6or more fills within 12 mo. RESULTS We identified 2 497 653 opioid-naïve patients with newly diagnosed LBP or lower extremity pain. Between 2008 and 2015, 31.9% and 11.5% of these patients received opioid and benzodiazepine prescriptions, respectively, within 12 mo of diagnosis. Rates of opioid prescription decreased from 34.8% in 2008 to 27.0% in 2015; however, prescribing of benzodiazepines was unchanged (2008, 11.6%; 2015, 10.8%). Patients with continued or new benzodiazepine use consistently used more opioids than patients who never used or stopped using benzodiazepines during the study period (one-way ANOVA, P < .0001). For patients with continued and new benzodiazepine use, the odds ratio of long-term opioid use compared to those never prescribed a benzodiazepine was 2.99 (95% CI, 2.89-3.08) and 2.68 (95% CI, 2.62-2.75), respectively. CONCLUSION Overall opioid prescribing for LBP decreased substantially during the study period, indicating a shift in management within the medical community. Rates of benzodiazepine prescribing, however, remained unchanged. Patterns of benzodiazepine prescribing were associated with long-term opioid use.

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Psychological and social consequences of non-invasive prenatal testing (NIPT): a scoping review

BMC Pregnancy and Childbirth ◽

10.1186/s12884-019-2518-x ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 3

Author(s):

Valérie Labonté ◽

Dima Alsaid ◽

Britta Lang ◽

Joerg J. Meerpohl

Keyword(s):

Psychological Distress ◽

Scoping Review ◽

Social Consequences ◽

Cochrane Library ◽

Psychological Consequences ◽

Short Term ◽

Cell Free Fetal Dna ◽

Distress Scale ◽

Decisional Regret

Abstract Background Genomics-based noninvasive prenatal tests (NIPT) allow screening for chromosomal anomalies such as Down syndrome (trisomy 21). The technique uses cell-free fetal DNA (cffDNA) that circulates in the maternal blood and is detectable from 5 weeks of gestation onwards. Parents who choose to undergo this relatively new test (introduced in 2011) might be aware of its positive features (i.e. clinical safety and ease of use); however, they might be less aware of the required decisions and accompanying internal conflicts following a potential positive test result. To show the evidence on psychological and social consequences of the use of NIPT, we conducted a scoping review. Methods We systematically searched four electronic databases (MEDLINE (Ovid), Cochrane Library (Wiley), CINAHL (EBSCO) and PsychINFO (EBSCO)) for studies that investigated the psychological or social consequences of the use of NIPT by pregnant women or expecting parents. The search was limited to studies published between 2011 and August 8, 2018. We identified 2488 studies and, after removal of duplicates, screened 2007 titles and abstracts, and then assessed 99 articles in full text (both screenings were done independently in duplicate). We included 7 studies in our analysis. Results Five studies assessed anxiety, psychological distress and/or decisional regret among women with validated psychological tests like the Spielberger State Trait-Anxiety Inventory (STAI), the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R), the Kessler Psychological Distress Scale (K6) or the Decisional Regret Scale (DRS). Two studies assessed women’s experiences with and feelings after NIPT in interviews or focus groups. The included studies were heterogeneous in location, study setting, inclusion criteria, outcome assessment, and other characteristics. Conclusions Only few studies on psychological consequences of NIPT have been identified. The studies assessed only short-term psychological consequences of NIPT at baseline and/or after receiving the results or after giving birth. Studies show that short term anxiety decreased when women received negative NIPT results and that decisional regret was generally low. We could not identify studies on long term consequences of NIPT, as well as studies on women’s partners’ short and long term outcomes, nor on social consequences of NIPT.

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