Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience

Objective: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries.Design: Retrospective observational.Setting: Urban, tertiary care, academic orthopedic hospital.Patients: Pediatric, sports knee surgery, 23-month period.Interventions: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries.Main outcome measure: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. Results: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient.Conclusions: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

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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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868 Guideline for Discharge Opioid Prescription Management in Adult and Pediatric Burn Patients

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.434 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S273-S273 ◽

Cited By ~ 1

Author(s):

An Bui ◽

Felicia N Williams ◽

Lori Chrisco ◽

Sanja Sljivic ◽

Rabia Nizamani ◽

...

Keyword(s):

Adult Patients ◽

Burn Patients ◽

Prescribing Practices ◽

Opioid Dependency ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Pain Scores ◽

Burn Survivors ◽

Before And After ◽

Surgical Standard

Abstract Introduction Pediatric and adult burn survivors are at risk for chronic opioid dependency. Conversely, undertreatment of pain can negatively affect mental health and patient compliance. Overtreatment has arguably led to the current opioid legislation. Despite an opioid-limiting mandate, there has been little direction for streamlining prescribing practices and there has been no guideline established to facilitate prescribing practices for burn patients. We evaluated the efficacy of a standard opioid prescribing schedule (SOPS) for surgical patients admitted greater than four days, based on pain scores, in our adult and pediatric burn patients. Methods This was a retrospective review conducted between June 2018 to June 2019 of our prescribing practices compared to a newly established standardized prescribing schedule. All patients admitted to the burn center were included if they had a length of stay longer than 4 days, and were prescribed oxycodone doses between 0-60mg within the last 24 hours of their stay. The primary outcome was amount of oxycodone prescribed upon discharge compared to the doses they received within their last 24hrs before and after the SOPS was established. Results The year before the SOPS was developed, we prescribed an average of 140mg of oxycodone to our pediatric patients upon discharge, even when they used 0mg within 24 hours of discharge. We prescribed an average of 165mg of oxycodone to adult patients who required 0mg 24hrs prior to discharge. We prescribed an average of 200mg to adult patients who required 15mg. We prescribed an average of 235mg to adult patients who required 35mg. We prescribed 310mg to adult patients that required the maximum of 60mg within their last 24 hours. This represented 0% compliance. After adopting the surgical standard opioid prescribing schedule to determine doses, we became 87.5% complaint with all patients and saw no increased in readmissions for pain. Conclusions An institutional guideline for discharge opioid prescribing practices has reduced the number of opioid pills patients take home, and the risk for overtreatment. A Standardized Opioid Prescribing schedule for burn patients is feasible and merits further investigation. Applicability of Research to Practice This study demonstrates the benefits of a standardized prescribing schedule and its applicability to burn patients.

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Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery

PEDIATRICS ◽

10.1542/peds.2020-001487 ◽

2021 ◽

Author(s):

Kerwyn Jones ◽

Laurie Engler ◽

Elizabeth Fonte ◽

Ibrahim Farid ◽

Michael T. Bigham

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Control Charts ◽

Postoperative Pain Management ◽

Prescribing Practices ◽

Opioid Prescription ◽

Orthopedic Surgical Procedures ◽

Pediatric Orthopedic ◽

Over Time ◽

Order Set

OBJECTIVES Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. METHODS Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. RESULTS Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). CONCLUSIONS The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

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P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective

CJEM ◽

10.1017/cem.2020.319 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S105-S106

Author(s):

P. Doran ◽

G. Sheppard ◽

B. Metcalfe

Keyword(s):

Emergency Department ◽

Acute Pain ◽

Oral Morphine ◽

Prescribing Patterns ◽

Evidence Based ◽

Emergency Physicians ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Ensure Patient Safety ◽

Evidence Based Guidelines

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.

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Opioid Prescribing Patterns for Low Back Pain Among Commercially Insured Children

Neurosurgery ◽

10.1093/neuros/nyz310_203 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Tej D Azad ◽

Michael D Harries ◽

Daniel Vail ◽

Yi Jonathan Zhang ◽

John K Ratliff

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Pediatric Patients ◽

Pediatric Population ◽

Prescribing Patterns ◽

Low Back ◽

Age Group ◽

Newly Diagnosed ◽

Opioid Prescription ◽

Opioid Prescribing

Abstract INTRODUCTION Low back pain (LBP) may affect up to 20% of the pediatric population. No specific guidelines exist regarding pharmacotherapy for acute LBP in the pediatric population. Given this observation and the lack of data available regarding pharmacotherapy for pediatric LBP, we sought to characterize patterns of opioid prescribing in the pediatric population. METHODS We used a national database to identify pediatric patients (age 5-17) with newly diagnosed with 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. We used logistic regression to model the association between sex, geographic region, categorical age, and our primary outcome, receipt of an opioid prescription in the year following diagnosis. RESULTS Our sample included 268 228 opioid-naïve pediatric patients diagnosed with LBP between 2008 and 2015. We observed that 47 631 (17.8%) patients received physical therapy, 29 903 (11.2%) patients received chiropractic manipulative therapy, 658 (0.25%) patients received epidural steroid injection, and 281 (0.10%) patients received surgery. A total of 35 274 (13.2%) pediatric LBP patients were prescribed opioids within 12 mo from their diagnosis. Opioid prescribing decreased in all age groups over the study period age group 5 to 9 decreased from 4.2% to 2.7%, age group 10 to 14 decreased from 10.3% to 7.7%, and age group 15 to 18 yr decreased from 20.9% to 17.1%. Female pediatric patients were more likely than male patients to receive an opioid prescription (OR, 1.12, P < .0001). Patients ages 10 to 14 (OR, 2.89, P < .0001) and 15 to 18 (OR, 6.98, P < .0001) were significantly more likely to be prescribed opioids compared to patients in the youngest age group. CONCLUSION To our knowledge, we report the first observational cohort study of opioids and LBP in the pediatric population. Our findings indicate that opioids are being used for newly diagnosed LBP and receipt of opioids are associated with patient demographic factors.

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MP58: Have opioid prescription by emergency physicians changed significantly over five years?

CJEM ◽

10.1017/cem.2020.206 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S63-S63

Author(s):

M. Wei ◽

M. Da Silva ◽

J. Perry

Keyword(s):

Emergency Department ◽

Abdominal Pain ◽

Tertiary Care ◽

Opioid Analgesia ◽

Emergency Physicians ◽

Prescribing Practices ◽

Chi Square ◽

Opioid Prescription ◽

Emergency Department Care ◽

Undetermined Etiology

Introduction: It is believed by some that emergency physicians prescribe more opioids than required to manage patients’ pain, and this may contribute to opioid misuse. The objective of our study was to assess if there has been a change in opioid prescribing practices by emergency physicians over time for undifferentiated abdominal pain. Methods: A medical record review for adult patients presenting at two urban academic tertiary care emergency departments was conducted for two distinct time periods; the years of 2012 and 2017. The first 500 patients within each time period with a discharge diagnosis of “abdominal pain” or “abdominal pain not yet diagnosed” were included. Data were collected regarding analgesia received in the emergency department and opioid prescriptions written. Opioids were standardized into morphine equivalent doses to compare quantities of opioids prescribed. Analyses included t-test for continuous and chi-square for categorical data. Results: 1,000 patients were included in our study. The mean age was 42.0 years and 69.6% of patients were female. Comparing 2017 to 2012, there was a non-significant decrease in opioid prescriptions written for patients discharged directly by emergency physicians, from 17.8% to 14.4% (p = 0.14). Mean opioid quantities per prescription decreased from 130.4 milligrams of morphine equivalents per prescription to 98.9 milligrams per prescription (p = 0.002). 13.9% of opioid prescriptions in 2017 were for more than 3 days, which is a decrease from 28.1% in 2012. During the emergency department care, there was an increase in foundational analgesia use prior to initiating opioids from 17.6% to 26.8% (p = 0.001). There was also a decrease for within ED opioid analgesia use from 40.0% to 32.8% (p = 0.018). Conclusion: Opioid prescription rates did not change significantly during our study. However, physicians reduced the quantity of opioids per prescription and used less opioid analgesia in the emergency department for abdominal pain of undetermined etiology.

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Opioid-prescribing practices in chronic cancer pain in a tertiary care pain clinic

Indian Journal of Palliative Care ◽

10.4103/0973-1075.92340 ◽

2011 ◽

Vol 17 (3) ◽

pp. 222 ◽

Cited By ~ 6

Author(s):

RaghuS Thota ◽

SumitraG Bakshi ◽

PN Jain ◽

ChhayaN Dhanve

Keyword(s):

Cancer Pain ◽

Tertiary Care ◽

Pain Clinic ◽

Prescribing Practices ◽

Opioid Prescribing ◽

Chronic Cancer Pain

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Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study

Journal of Medical Internet Research ◽

10.2196/24360 ◽

2021 ◽

Vol 23 (4) ◽

pp. e24360

Author(s):

Benjamin Heritier Slovis ◽

Jeffrey M Riggio ◽

Melanie Girondo ◽

Cara Martino ◽

Bracken Babula ◽

...

Keyword(s):

The United States ◽

Prescribing Patterns ◽

Duration Of Treatment ◽

Opioid Prescription ◽

Hospital System ◽

Opioid Prescribing ◽

Before And After ◽

Control And Prevention ◽

Prescribing Practice ◽

Quasi Experimental

Background The United States is in an opioid epidemic. Passive decision support in the electronic health record (EHR) through opioid prescription presets may aid in curbing opioid dependence. Objective The objective of this study is to determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system. Methods We performed a quasi-experimental retrospective pre–post analysis of a 24-month period before and after modifications to our EHR’s opioid prescription presets to match Centers for Disease Control and Prevention guidelines. We included all opioid prescriptions prescribed at our institution for nonchronic pain. Our modifications to the EHR include (1) making duration of treatment for an opioid prescription mandatory, (2) adding a quick button for 3 days’ duration while removing others, and (3) setting the default quantity of all oral opioid formulations to 10 tablets. We examined the quantity in tablets, duration in days, and proportion of prescriptions greater than 90 morphine milligram equivalents/day for our hospital system, and compared these values before and after our intervention for effect. Results There were 78,246 prescriptions included in our study written on 30,975 unique patients. There was a significant reduction for all opioid prescriptions pre versus post in (1) the overall median quantity of tablets dispensed (54 [IQR 40-120] vs 42 [IQR 18-90]; P<.001), (2) median duration of treatment (10.5 days [IQR 5.0-30] vs 7.5 days [IQR 3.0-30]; P<.001), and (3) proportion of prescriptions greater than 90 morphine milligram equivalents/day (27.46% [10,704/38,976; 95% CI 27.02%-27.91%] vs 22.86% [8979/39,270; 95% CI 22.45%-23.28%]; P<.001). Conclusions Modifications of opioid prescribing presets in the EHR can improve prescribing practice patterns. Reducing duration and quantity of opioid prescriptions could reduce the risk of dependence and overdose.

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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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