RESUMO
There is growing concern about the over-prescription of opioids and the risks of long-term use. This study examined the relationship between initial need (pre-operative, post-operative, and discharge pain) and dosage of opioids in the first prescription after surgery with continued opioid use through opioid refills over 12 months, while considering patient-level characteristics. A total of 9262 opioid-naïve patients underwent elective surgery, 7219 of whom were prescribed opioids following surgery. The results showed that 17% of patients received at least one opioid refill within one year post-surgery. Higher initial opioid doses, measured in morphine milligram equivalent (MME), were associated with a greater likelihood of continued use. Patients receiving a dose greater than 90 MME were 1.57 times more likely to receive a refill compared to those receiving less than 90 MME (95% confidence interval: 1.30-1.90, p < 0.001). Additionally, patients who experienced pain before or after surgery were more likely to receive opioid refills. Those experiencing moderate or severe pain were 1.66 times more likely to receive a refill (95% confidence interval: 1.45-1.91, p < 0.001). The findings highlight the need to consider surgery-related factors when prescribing opioids and the importance of developing strategies to balance the optimization of pain management with the risk of opioid-related harms.
Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Humanos , Estados Unidos , Dor Pós-Operatória/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Prescrições , Estudos Retrospectivos , Padrões de Prática MédicaRESUMO
OBJECTIVES: Overprescribing to opioid-naive surgical patients substantially contributes to opioid use disorders, which have become increasingly prevalent. Opioid stewardship programs (OSPs) within healthcare settings provide an avenue for introducing interventions to regulate prescribing. This study examined the association of OSP policies limiting exposure on changes in surgery-related opioid prescriptions and patient pain. METHODS: We evaluated policies implemented by an OSP in a large American healthcare system between 2016 and 2018: nonopioid medication during surgery, decrease of available opioid dosage vials in operating rooms, standardization of opioid in-patient practices through electronic health record alerts, and limit to postsurgery opioid supply. Generalized linear mixed effects models examined the association of interventions with outcome changes in 9262 opioid-naive patients undergoing elective surgery. Outcomes were discharge pain, morphine milligram equivalent in the first prescription postsurgery, and opioid prescription refills. RESULTS: Decreases in all prescription outcomes and discharge pain were observed following onset of OSP interventions ( P 's < 0.001). Among individual policies, standardization of in-patient prescribing practices was associated with the strongest decrease in prescribed morphine milligram equivalent. Importantly, there was no evidence of an increase in discharge pain related to any intervention. CONCLUSIONS: This study promotes the potential of OSP formation and policies to reduce opioid prescribing without compromising patient pain. The most effective policy, standardization of in-patient prescribing practices through alerts, suggests that reminding prescribers to re-evaluate the patient's need is effective in changing behavior. The findings offer considerations for OSP formation and policy implementation across health systems to improve quality and safety in opioid prescribing.
Assuntos
Analgésicos Opioides , Dor Pós-Operatória , Humanos , Estados Unidos , Analgésicos Opioides/efeitos adversos , Dor Pós-Operatória/induzido quimicamente , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Derivados da Morfina/uso terapêutico , Prescrições de MedicamentosRESUMO
BACKGROUND: Major abdominal operations often requires postoperative opioid analgesia. However, there is growing recognition of the potential for abuse. We previously reported a significant reduction in opioid consumption after implementation of an Enhanced Recovery after Surgery protocol after ventral hernia repair focusing on opioid reduction. Epidural use was routine for postoperative pain control in this protocol. Recently, we have transitioned to transversus abdominis plane (TAP) block instead of epidural analgesia. We hypothesize that this modification reduces length of stay and lowers opioid use in ventral hernia repair. METHODS: All patients undergoing open ventral hernia repair were recorded prospectively in the Americas Hernia Society Quality Collaborative database. All patients receiving either TAP or epidural between February 2015 and March 2018 were identified. Additional review was performed to quantify opioid use in morphine milligram equivalents (MMEs). Primary outcomes were length of stay and opioid use. RESULTS: Epidural was used in 172 patients and TAP block in 74. There were no significant comorbidity differences between groups. The TAP group had a slightly higher BMI (33.6 kg/m2 vs 28.3 kg/m2) and slightly smaller hernias (8.8 cm vs 10.8 cm). There was no difference in 30-day surgical site infections. Hospital length of stay was significantly shorter with TAP block (2.4 vs 4.5 days; p < 0.001). Total MME requirements for patients receiving TAP block were lower than those with epidural during postoperative days 1 and 2 (mean 40 vs 54.1 MMEs; p = 0.033 and 36.1 vs 52.5 MMEs; p = 0.018). CONCLUSIONS: Use of TAP block significantly reduces length of stay and decreases opioid dose requirements in the early postoperative period compared with epidural analgesia.
Assuntos
Analgesia Epidural , Analgésicos Opioides/administração & dosagem , Hérnia Ventral/cirurgia , Herniorrafia , Tempo de Internação/estatística & dados numéricos , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Músculos Abdominais/inervação , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Relação Dose-Resposta a Droga , Recuperação Pós-Cirúrgica Melhorada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: There is limited data on enhanced recovery after surgery (ERAS) protocols after ventral hernia repair (VHR). This study reports the impact of multimodal analgesia on opioid use after open VHR. METHODS: Retrospective review of open VHR treated during the initial 6 months after ERAS implementation. Protocol focused on opioid sparing using intraoperative ketamine and/or lidocaine infusion, selective epidural anesthesia, and postoperative ketamine infusion, ketorolac, and acetaminophen. Four groups were analyzed: 1-ERAS protocol with epidural analgesia, 2-historical controls with epidural analgesia prior to ERAS, 3-ERAS protocol without epidural, and 4-historical controls without epidural analgesia, prior to ERAS. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests, and subgroup analysis using Student's t test or Mann-Whitney U test. Discrete variables were analyzed using Pearson's chi-square test or Fisher's exact test. RESULTS: Patients differed in hernia width, but were similar in comorbidity and operative technique. There was no difference in length of stay or readmission. Use of ERAS nearly eliminated patient-controlled analgesia use (group 1, 2.7%; group 2, 68.4%; group 3, 0%; group 4, 65.7%; p < 0.001). ERAS significantly reduced narcotic requirements on postoperative days 0, 1, and 2 (p < 0.001). To account for the bias of selective epidural analgesia, groups 1 and 2 (epidural) and groups 3 and 4 (no epidural) were compared separately. Opioid requirement and PCA use remained significantly lower in patients in the ERAS pathway. CONCLUSION: Implementation of multimodal analgesia in the perioperative and postoperative setting significantly reduced opioid use after VHR.