Association between Initial Opioid Prescription and Patient Pain with Continued Opioid Use among Opioid-Naïve Patients Undergoing Elective Surgery in a Large American Health System.

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.

Evaluation of Policies Limiting Opioid Exposure on Opioid Prescribing and Patient Pain in Opioid-Naive Patients Undergoing Elective Surgery in a Large American Health System.

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.

Intrapleural tissue plasminogen activator for the treatment of parapneumonic effusion.

Intrapleural tissue plasminogen activator (t-PA) has emerged over the past several years as a treatment option for patients with complicated parapneumonic effusion that does not respond to medical management and drainage. Fibrinolytics are thought to dissolve fibrin deposits and loculations within the pleural space, facilitating drainage of the trapped pleural fluid surrounding the lungs. Whereas older fibrinolytics (streptokinase and urokinase) have been studied for intrapleural use with conflicting results, t-PA is currently the agent most commonly used in adults for this indication. However, the literature describing t-PA therapy for complicated parapneumonic effusion and empyema is sparse, and studies have been highly variable in their methods. Several articles report use of this drug at doses ranging from 2-100 mg at daily intervals or more frequently. Surgical treatment options associated with good outcomes are also available to these patients. As a result, the indications for intrapleural t-PA (especially compared with surgical management) in patients with effusions resistant to conventional drainage are not fully clear. The usefulness of t-PA in all patients with resistant parapneumonic effusions or empyema before surgical intervention remains undetermined, but several studies have taken this approach. Sufficient evidence is available to indicate that this therapy does have potential in patients for whom surgery is not a safe or desired option. Further study is needed to better understand the role of t-PA and its optimal dosage in patients with complicated parapneumonic effusion.