Publications

OBJECTIVE: Thoracic surgery is known to lead to post-operative opioid dependence in countries with high opioid consumption; however, there are limited reports from countries with moderate to low opioid consumption, such as Japan. This study aimed to investigate the prevalence and risk factors for persistent opioid use after thoracic surgery in Japan.

DESIGN: A retrospective cohort study using linked medical claims data from the National Health Insurance in Ibaraki Prefecture, Japan.

PATIENTS: Patients aged ≥18 who underwent thoracic (mediastinal or lung) surgery between October 2012 and September 2021 were included in this study.

MAIN OUTCOME MEASURES: Persistent opioid use was defined as prescription from 0 to 14 days after surgery and 91 to 180 days after surgery. We evaluated associated factors using multivariable logistic regressions.

RESULTS: Among the 6,041 patients who underwent thoracic surgery during the study period, 3,924 were included in the final analysis. The median age was 68 years (range, 64-71 years), and 2,316 (61.0 percent) were male. Persistent opioid use was recorded in 130 (3.3 percent). Multivariable analyses identified neoadjuvant therapy (chemotherapy or radiotherapy) (odds ratio [OR], 2.02; 95 percent confidence interval [CI], 1.09-3.77; p = 0.027) and thoracotomy (vs video-assisted thoracoscopic surgery) (OR, 1.50; 95 percent CI, 1.01-2.24; p = 0.046) as independent risk factors for persistent opioid use.

CONCLUSIONS: In a prefecture of Japan, 3.3 percent of patients who underwent thoracic surgery developed persistent opioid use. Neoadjuvant therapy (chemotherapy or radiotherapy) and thoracotomy were independent factors associated with persistent opioid use. Individualized perioperative pain management strategies should be considered for high-risk patients.

OBJECTIVE: The effects of opioid use disorder (OUD) are devastating and wide-ranging. Although the information in the >43,000 manuscripts on OUD are searchable, gaining a comprehensive grasp of this information is out of reach to most persons. We present a pilot study to use published data on OUD, repurpose it for rapid comprehension and distribution to the world.

DESIGN: Data from articles on OUD were entered into a data-tree and evaluated to achieve integration of information using the least number of notes.

SETTING: Literature on OUD. Experimental units: A total of 752 articles were selected from PubMed searches. Review articles, case reports, and short series with samples of less than ten were excluded.

OUTCOME MEASURES: The frequency of descriptive note types, and the total number of notes used with and without note sharing.

RESULTS: Four types of notes were found sufficient to describe extracted numeric data from an article; topic (20.1 percent), population (26.2 percent), description of numeric value (28.4 percent), and numeric value (25.3 percent). Notes were entered in parent-child relationships across hierarchical levels, descriptive analyses showed smooth expansion and reduction of notes across the database. Entry rules allowed sharing of parent notes across different numeric values, which reduced that total number of notes by 72.9 percent.

CONCLUSIONS: These results demonstrate a method of data extraction and integration that allows for readily understandable grouping of large amounts of data. This strategy yields a method to extract and make accessible all published data on OUD. We expect that common understanding will improve outcomes for patients and research objectives.

BACKGROUND: Opioid prescribing to post-operative patients in the acute hospital setting is well described; however, little is known about use of opioids in inpatient rehabilitation (IPR) settings. Understanding how opioids are prescribed across all inpatient settings is important to optimize opioid stewardship. The aim of this study was to determine the percentage of post-operative orthopedic patients prescribed opioids and prescribing patterns on discharge from an IPR ward.

DESIGN: Single-center retrospective audit.

SETTING: Tertiary metropolitan hospital.

PATIENTS: Patients who underwent an orthopedic surgical procedure between January and July 2020 and were subsequently transferred to an IPR center under the same health service.

MAIN OUTCOME MEASURES: Opioid prescribing data were obtained at three time points: on admission to the acute hospital, at the time of transfer from the acute hospital to IPR, and at the time of discharge from IPR. Doses were reported in oxycodone equivalent doses.

RESULTS: Of the 117 patients who were included in the audit (median age 84 years, median length of hospital stay 23 days), 115 (98 percent) were prescribed an opioid at the time of discharge from the acute hospital to IPR, and 69 patients (59 percent) were discharged from IPR with a prescription for an opioid.

CONCLUSIONS: A significant proportion of patients admitted to IPR were discharged with a prescription for an opioid. Further research is required to determine the appropriateness of continued opioid use in these patients, and ways to reduce the exposure of patients to opioids during and following IPR should be explored.

OBJECTIVE: To evaluate the effectiveness of an outpatient, interdisciplinary pain management (IPM) program offering individualized opioid tapering as part of flexible, patient-specific care plans, in achieving the dual goals of improved management of chronic nonmalignant pain (CNMP) and substantial reduction of opioid use.

DESIGN: A retrospective cohort study, comprising a cohort of patients who presented on opioid therapy and a cohort who did not.

SETTING: Community outpatient IPM program.

PARTICIPANTS: Patients presenting between April 1, 2016 and September 15, 2019. From an initial pool of 402 patients, inclusion and exclusion criteria identified 300 patients for analyses.

INTERVENTIONS: Engagement in a comprehensive and flexible IPM program with patient-specific care plans that included individualized opioid tapering.

MAIN OUTCOME MEASURE(S): Changes in pain intensity, pain interference, physical therapy (PT) metrics, patient retention, and follow-up of opioid use status at least 3 years after the end of each patient's study episode of care.

RESULTS: Changes in pain intensity and interference, and PT outcomes reflected notable improvements in pain management, with no significant overall differences between cohorts. During study episodes of care, all patients in the opioid cohort reduced opioid use and two-thirds discontinued opioids; patient retention was 90.9 percent. In follow-up of over 80 percent of the opioid cohort up to an average of 4.5 years, opioid use for CNMP decreased to 15.8 percent of patients.

CONCLUSIONS: A flexible, patient-centered IPM program can improve the management of CNMP, substantially reduce opioid use, and maintain a high rate of patient retention. During follow-up, patients further reduced their use of opioids for CNMP.

Pain and addiction are persistent public health issues that can lead to serious and fatal consequences on individuals, families, and communities. With the continued development of the opioid epidemic and the subsequent rise in opioid use and misuse, it is important to recognize the need for intervention at a public health level. Opioid stewardship programs (OSPs) are promising public health interventions that aim to coordinate safe and effective pain management through evidence-based intervention strategies. This narrative literature review examined the current evidence for implementation of OSPs in emergency departments and acute care hospitals to identify best practices and gaps in evidence. We reviewed publications found through PubMed and Embase, and articles were selected for inclusion after being evaluated through the inclusion criteria. One hundred and ninety-six articles were first found via the database search, and a final 24 articles were included in the sample for full review. The results indicated that all but two studies were published within the last 4 years, and one study mentioned a rural location. Most of the studies were pre- and post-OSP implementation studies. On average, the studies implemented four of the 11 total OSP strategies of interest. Twenty-two studies included information on care coordination, with the most prevalent effect being a decrease in total morphine milligram equivalents being prescribed at discharge. Nine studies included data on patient safety measures, including adverse events such as return emergency room visits, need for naloxone administration, and increase in post-operative clinic visits. This narrative review provides us with a preliminary understanding of OSP implementation in hospital settings and provides evidence that they are feasible and accepted with a wide variety of implementation interventions and strategies. It also demonstrates a gap in the literature regarding implementation in rural settings and with some specific implementation strategies.

Despite efforts to reduce abuse, opioids remain a societal concern. Coronavirus disease 2019 (COVID-19) brought new challenges, and research is needed to understand its impact on opioid abuse in the population. Three data sources were used to investigate trends in misuse and abuse of XTAMPZA® ER compared to extended-release (ER) and single-entity immediate-release (SE-IR) oxycodone from 2019Q3 through 2022. Changes in trends over 6-month intervals were investigated using linear spline models with a breakpoint at 2020Q3 to measure the impact of COVID-19. Poison center call rates for misuse or abuse of ER and SE-IR oxycodone showed significant changes during COVID-19 (both p < 0.001), reversing trends and significantly decreasing (201327.56 percent change and -12.91 percent change, respectively). In contrast, XTAMPZA ER trend rates showed no change during COVID-19, remaining fairly stable. The odds of abuse of ER oxycodone among those entering opioid use disorder treatment significantly changed during COVID-19 (p = 0.025), resulting in a stabilization of the trend. For SE-IR oxycodone, no change was observed in the decreasing trend (-12.88 percent change during COVID-19). XTAMPZA ER had no significant change during COVID-19 (p = 0.200) and appeared stable. Since 2021Q3, among the general adult population, the prevalence of past-year nonmedical use of XTAMPZA ER was rare (0.04 percent), as was the case for other oxycodone products (<1 percent). Overall, there is no evidence that oxycodone misuse and abuse worsened during COVID-19 in these populations, and XTAMPZA ER was consistently lower than other oxycodone products. Low rates and improving trends in oxycodone misuse and abuse may signify an ongoing reduction in prescription opioid contributions to the opioid crisis.

OBJECTIVES: To investigate post-operative opioid use, functionality, and overall survival following internal fixation for pathologic or impending fractures at 3 and 6 months.

BACKGROUND: Pathologic and impending fractures commonly occur in the proximal femur, and patients may be prescribed opioids prior to surgery and often require opioids for post-operative pain relief. This study compared post-operative opiate usage and ambulatory functional status in patients with impending versus pathologic fractures in the proximal femur.

DESIGN: This was a retrospective case-control study of patients using opioids post-operatively who underwent internal fixation for a pathologic or impending fracture between 2016 and 2022. Preoperative and post-operative opioid usage as well as ambulation status and risk factors at 3 and 6 months associated with post-operative opioid use were recorded.

RESULTS: Twenty-four pathologic fractures and 23 impending fractures were included. Preoperative opioid daily morphine milligram equivalent was significantly higher in the pathologic fracture group, but there were no significant differences at 3 or 6 months. There was statistically significant post-operative improvement in ambulation status in the combined cohort and impending fracture cohort at 3 months and 6 months.

CONCLUSIONS: Although patients did not experience a significant post-operative change in opioid use, patients with pathologic fractures notably required higher opioid dosages preoperatively, and there was overall improvement in function following fixation. Future studies should examine post-operative opioid use with careful consideration of concurrent pain management pain therapies and tumor characteristics.

OBJECTIVE: To examine associations between race, comorbidity, opioid and nonopioid treatment burden, and socioeconomic status (SES) in patients with chronic low back pain (CLBP).

DESIGN: A case-control study.

SETTING: Tertiary academic system.

PARTICIPANTS: A total of 4,193 subjects with CLBP and 4,193 age-, sex-, race-, and region-matched subjects with nonchronic low back pain participated in this study.

MAIN OUTCOME MEASURE(S): The primary outcome measures were prescription frequencies of opioid and nonopioid medications as well as nonpharmaceutical interventions. Secondary measures pertained to the prevalence of comorbidities, race, and SES traits.

RESULTS: The median age of the subjects was 55.50 years, with 61.75 percent female distribution, 48.84 percent Black or African American, 30.65 percent White non-Hispanic, and 15.93 percent non-White Hispanic or Latino among the subjects. Black or African American and non-White Hispanic or Latino identity was associated with higher hardship compared to patients identifying as White non-Hispanic (Tukey-Kramer adjusted p-value < 0.0001). Opioid use was significantly higher in the CLBP group (Cochran-Armitage trend test p-value < 0.0001), and there was a significant positive trend between the number of comorbidities and opioids used. As hardship index group (HIG) increased by 1, the expected number of comorbidities increased by a factor of 1.09 (95 percent confidence interval [CI]: 1.06-1.11), and the expected number of treatments increased by a factor of 1.07 (95 percent CI: 1.04-1.09). Physical therapy and spine procedures had a significant negative relationship with hardship.

CONCLUSIONS: Higher opioid prescribing behavior, particularly for morphine, hydrocodone, and tramadol, exists in patients with CLBP, especially in patients facing hardship and identifying as Black or African American and non-White Hispanic or Latino. Further prospective studies are needed to strengthen causality.

AIM: This study aims to assess the application of opioids for pain control in patients following a cesarean section (CS) at a tertiary referral obstetric hospital.

METHODS: A retrospective cohort audit of CSs in September 2022 was conducted. Medical records were reviewed to capture patient demographics, opioid used, and discharge medications.

RESULTS: Medical records of 46 patients were reviewed. Of those, 46 percent (n = 21) had a non-elective lower uterine CS (NELUSCS), 43 percent (n = 20) had an elective lower uterine CS (ELUSCS), and the remainder had a nonelective classical CS (NEClassicalCS). NEClassicalCS had higher total morphine equivalent opioid use with an average of 245.7 mg, compared with 92.4 mg and 60.1 mg for NELUSCS and ELUSCS, respectively. Tramadol was the most common opioid supplied on discharge (85 percent), followed by buprenorphine (17 percent) and oxycodone/naloxone (15 percent). An average discharge medication supply of 3 days was provided.

CONCLUSIONS: NEClassicalCS procedures had higher use of opioid pain medications. All patients were initiated on opioids post-CS, with 93 percent (n = 43) discharged with at least one opioid.