Association of opioid exposure during intensive care unit stays with post-discharge opioid use: A retrospective study and literature review

Objective: To evaluate whether pain management strategies within intensive care unit (ICU) settings contribute to chronic opioid use upon hospital discharge in opioid-naive patients requiring invasive mechanical ventilation. Design: A retrospective, observational study.Setting: An 18-bed mixed ICU at a community teaching hospital located in Brooklyn, New York.Participants: This study included mechanically ventilated patients requiring continuous opioid infusion from April 25, 2017 to May 16, 2019. Patients were excluded if they received chronic opioid therapy at home or expired during this hospital admission. Eligible patients were identified using an electronic health record data query.Main outcome measure(s): The proportion of ICU patients who continued to require opioids upon ICU and hospital discharge. Results: A total of 196 ICU patients were included in this study. Of these, 22 patients were transferred to a regular floor while receiving a fentanyl transdermal patch. However, the fentanyl patch treatment was continued only for three patients (2 percent) at hospital discharge.Conclusions: This retrospective study suggested that high-dose use of opioids in mechanically ventilated, opioid-naive ICU patients was not associated with continued opioid use upon hospital discharge.

Systematic review and meta-analysis of opioid use at 3, 6 and 12 months post-operatively by opioid naïve orthopaedic surgery patients

Background and objective: There is evidence that opioid initiation post-surgery is contributing to the problem of chronic misuse and/or abuse of over the counter medications in the community, and that orthopedic patients may be particularly at risk. The aim of the systematic review with meta-analysis was to identify research that examined opioid use at 3, 6, and 12 months post-operatively by previously opioid naïve orthopedic surgery patients.Design, databases, and data treatment: A searched review with meta-analysis was undertaken. Eight databases were search. Meta-analyses conducted at all three time points (3 months, 6 months, and 12 months).Results: The search yielded 779 records, and after screening, 13 papers were included in meta-analysis. Results provide strong evidence that post-operative opioid use amongst the opioid naïve is a real effect (7 percent at 3 months, 4 percent at 6 months, and 2 percent at 12 months). A Z-test for overall effect revealed strong evidence that this proportion was nonzero for opioid use at 3, 6, and 12 months (p 0.001 for all time points). A small but significant proportion of opioid naïve patients who are prescribed opioids remain on these medications up to 12 months post-operatively.Conclusions: The nature of the studies included in the meta-analysis were varied, hence subanalyses regarding surgery type, characteristics of the patient group or other potential factors that might influence the progression to longer term opioid use after these surgeries could not be explored. Given this, further research in this area should explore such specific orthopedic subgroups.

System intervention in community pharmacy setting: Leading to better patient care through reducing harm associated with coprescribing benzodiazepines and opioids

Objective: The opioid epidemic is frequently discussed including the staggering numbers involved with coprescribing opioids and benzodiazepines associated with death. Community pharmacists, with the help of a system intervention, have a unique opportunity to help reduce the coprescribing of benzodiazepines and opioids and reduce the associated risk of death.Design: A single center retrospective chart review was conducted after a system intervention was placed, as a quality improvement project, from November 2019 to May 2020.Setting: Independent community pharmacy.Patients/participants: Data included demographics, dosing of each medication pre- and post-intervention, and naloxone status.Main outcome(s) measures: The primary outcome evaluated was reduction in dose/discontinuation of these prescriptions. The secondary outcome evaluated was the number of naloxone prescriptions ordered per protocol and picked up.Results: The primary outcome did not show statistical difference; however, the secondary outcomes showed statistical significance.Conclusion: In conclusion, community pharmacists, with the help of evolving technologies, can reduce harm associated with the coprescribing of benzodiazepines and opioids.

How opioid prescribing policies influence primary care clinicians’ treatment decisions and conversations with patients with chronic pain

Objective: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain.Design: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies.Results: Opioid prescribing policies influenced clinicians’ treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3).Conclusions: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.

Telehealth acceptability and opioid prescribing patterns of providers of painful chronic diseases during the COVID-19 pandemic: A survey of sickle cell providers

Objective: The coronavirus disease 2019 (COVID-19) has led to a rapid transition to telehealth services. It is unclear how subspecialists managing painful chronic diseases—such as sickle cell disease (SCD), an inherited hemoglobinopathy with significant disparities in access and outcomes—have viewed the transition to telehealth or altered their pain management practices. This study elicits the views of sickle cell providers regarding their transition to telehealth and their opioid prescribing patterns during the COVID-19 pandemic.Design: An anonymous online survey was sent to eligible sickle cell providers.Setting: Comprehensive sickle cell centers and/or clinics across the United States. Participants: Physicians and advanced practice providers providing care to SCD patients.Main outcome measures: Respondents answered questions regarding their (1) views of telehealth compared to in-person encounters and (2) opioid prescribing practices during the early months of the pandemic.Results: Of the 130 eligible participants, 53 respondents from 35 different sickle cell centers completed at least 90 percent of the survey. Respondents reported a significant increase in telehealth encounters for routine and acute appointments (mean difference and standard deviation: 57.6 ± 31.9 percent, p 0.001 and 24.4 ± 34.1 percent, p 0.001, respectively) since COVID-19. The overwhelming majority of respondents reported no changes in their opioid prescribing patterns since COVID-19, despite increased telehealth use. Only a minority coprescribed naloxone as a risk mitigation strategy.Conclusion: The rapid uptake of telehealth has not suppressed ambulatory providers’ prescribing of opioids for SCD. Studies assessing the impact of the COVID-19 pandemic and telehealth on opioid prescribing practices in other painful chronic diseases are needed to ensure health equity for vulnerable pain patients.

Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study

Objective: Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients’ perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.Design: We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.Setting: All participants underwent surgery at a single, academic tertiary-care center.Participants: Adult patients who had a general surgery operation in the prior 60 days.Outcome measure: Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.Results: Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.Conclusions: Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

A retrospective study evaluating the trend of opioid prescribing in low back pain at a UK teaching hospital

Introduction: Current data suggest that the chronic use of strong opioids in low back pain (LBP) is increasing. There is evidence for the use of opioids in the initial management of LBP, but the efficacy in the long term is unknown. This article intends to examine the use of opioids in patients with chronic LBP over a period of three doctor-led clinics.Methods: Single-center retrospective cohort study following 200 patients through the pain clinic at a UK teaching hospital for more than two clinic visits, up to a maximum of three. Data concerning demographics, pain scores, medication changes, and clinic outcome.Results: Data collected showed that there was a significant correlation between baseline morphine equivalent amount (MEA) and final clinic MEA; initial pain scores and final clinic MEA; cause of LBP and final clinic LBP; and traumatic LBP and absolute change in MEA. There was no association between number of physical interventions and MEA. The sample also showed an average absolute change in MEA by 2.93 ± 57.86 mg. The proportion of patients with a MEA of 50 mg/d increased from 24 to 29 percent. The proportion of patients on opioids at least one opioid increased by 10 percent.Conclusions: Significant predictors of final clinic MEA were initial pain scores, baseline MEA, and the cause of LBP. Duration of pain was a poor predictor of MEA. There was no association between MEA and number of interventions. In this cohort, the trend seems to be increasing the number and dose of opioids in patients with LBP.

Volume 17, Number 6

November/December 2021

Analgesia vs. addiction

Includes Author's response.

Guideline adherence and reasons for recommending dose reduction in a primary care-based opioid management clinic

Background: To provide Centers for Disease Control and Prevention (CDC) guideline-recommended practices for patients on long-term opioid therapy (LTOT) including individualized decisions about opioid dose reduction, we developed the Power Over Pain (POP) Clinic.Objective: To describe frequency and reasons for opioid dose reduction and pre–post adherence to CDC guideline-recommended practices.Design: Retrospective chart review with qualitative and pre–post analysis.Patients and setting: Patients at an urban internal medicine teaching practice-prescribed LTOT were seen at POP Clinic at least once.Methods: Opioid dose reduction was defined by reduction in morphine-equivalent daily dose (MEDD) at 6 and 12 months after the first POP Clinic visit compared to baseline using paired t-tests. Among patients with a dose reduction, reasons documented in POP Clinic notes were qualitatively examined. Dichotomous measures of receiving four CDC guideline-recommended practices (controlled substance agreement [CSA], urine drug testing [UDT], prescription monitoring program review, and naloxone dispensing) at baseline versus 6 and 12 months were compared using McNemar's tests.Results: Of the 70 patients, most were female (66 percent) and Hispanic (54 percent). Forty-three patients (61 percent) had an opioid dose reduction in 12 months after the first POP Clinic visit. The most frequent reason was low or unclear benefit of continuing the current dose (49 percent). Mean MEDD was reduced from 69 mg to 57 mg at 6 months (p 0.01) and to 56 mg at 12 months (p 0.01). Completing a CSA, UDT, and naloxone distribution increased at 6 and 12 months (p 0.01). Conclusions: Individualized risk assessment in a primary care-based opioid management clinic is feasible and can result in opioid dose reduction and guideline adherence.