Trends in Opioid Prescribing and New Persistent Opioid Use After Surgery in the United States.

OBJECTIVE: To define recent trends in opioid prescribing after surgery and new persistent opioid use in the United States. SUMMARY BACKGROUND DATA: New persistent opioid use after surgery among opioid-naïve individuals has emerged as an important postoperative complication. In response, initiatives to promote more appropriate post-operative opioid prescribing have been adopted in recent years. However, current estimates of opioid prescribing and new persistent opioid use following surgery remain unknown. METHODS: A retrospective cohort study of opioid-naïve privately insured adult patients undergoing 17 common surgical procedures between 2013 and 2021 was conducted utilizing multi-payer claims data from the Health Care Cost Institute (HCCI). Initial opioid prescription size in oral morphine equivalents and new persistent opioid use were the outcomes of interest. Trends in opioid prescribing and rates of new persistent opioid use were evaluated across the study period. Mixed effects logistic regression was performed to evaluate independent predictors of new persistent opioid use while adjusting for patient-level factors and year. RESULTS: Among 989,354 opioid-naïve individuals, the adjusted initial opioid prescription size decreased from 282 mg OME to 164 mg OME, a reduction of 118 mg OME (95% CI: 116-120). The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%-2.8%) to 1.1% in 2021 (95% CI: 1.0%-1.2%). For every 30 OME increase in initial opioid prescription size, new persistent opioid use increased by 3.1%. Other predictors of new persistent opioid use included preoperative non-opioid controlled substances fills (31-365 days: aOR=1.78, 95% CI: 1.70-1.86; 0-30 days: aOR=2.71, 95% CI: 2.59-2.84) and undergoing orthopedic procedures (total knee arthroplasty (aOR=3.43, 95% CI: 3.15-3.72); shoulder arthroscopy (aOR=2.39, 95% CI: 2.24-2.56)). CONCLUSIONS: Both opioid prescription size after surgery and new persistent opioid use decreased over the last decade, suggesting that opioid stewardship practices had favorable effects on the risk of long-term opioid use.

Epidemiology of Opioid Prescribing After Discharge From Surgical Procedures Among Adults.

Importance: Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs. Objective: To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States. Design, Setting, and Participants: This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023. Main Outcomes and Measures: The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years. Results: Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]). Conclusions and Relevance: In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.

Pediatric Surgical Opioid Prescribing by Procedure, 2020-2021.

BACKGROUND AND OBJECTIVES: Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing. METHODS: We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years. RESULTS: Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%). CONCLUSIONS: Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control.

Worth the Risk? Standardized Screening to Identify Substance Use Among Patients Prior to Surgery.

OBJECTIVE: We sought to compare identification of unhealthy substance use before surgery using The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS), a standardized 4-item instrument, versus routine clinical documentation in the electronic medical record (EHR). SUMMARY BACKGROUND DATA: Over 20% of individuals exhibit unhealthy substance use before elective surgery. Routine EHR documentation is often based on non-standard questions that may not fully capture the extent of substance use and is subject to bias. In contrast, brief standardized screening could provide a more efficient and systematic approach. METHODS: We conducted a cross-sectional study among adults (≥18 y) at a preoperative clinic from August to September, 2021. Positive screens for unhealthy substances by TAPS were compared to data from the EHR. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were reported. Receiver operating characteristic curves (ROCs) were used to assess diagnostic ability. Multivariable logistic regression was used to estimate the predictors of positive screens by TAPS. RESULTS: The cohort included 240 surgical patients. TAPS screening identified significantly more positive screens than EHR documentation (43.3% vs. 14.2%). Patients with unhealthy substance use were younger (50.8 vs. 56.7 y; P=0.003), and TAPS revealed alcohol misuse in 30.8% of cases, contrasting with 0% in clinician documentation (P<0.001). Of the 104 TAPS-positive patients, 69.2% were missed by EHR documentation. Sensitivity (31%) and accuracy (AUC=0.65) of clinician documentation for any unhealthy substance use were lower compared to TAPS. CONCLUSION: Standardized TAPS screening detected preoperative unhealthy substance use more frequently than routine clinician documentation, emphasizing the need for integrating standardized measures into surgical practice to ensure safer perioperative care and outcomes.

Association Between Prescription Drug Monitoring Program Use Mandate and Opioid Prescribing and Patient-Reported Outcomes After Surgery.

OBJECTIVE: To evaluate changes in opioid prescribing and patient-reported outcomes after surgery following implementation of Michigan's prescription drug monitoring program (PDMP) use mandate in June 2018. BACKGROUND: Most states mandate clinicians to query prescription drug monitoring program (PDMP) databases before prescribing controlled substances. Whether these PDMP use mandates affect opioid prescribing and patient-reported outcomes after surgery is unclear, especially among patients with elevated "Narx" scores, a risk score for overdose death used in most PDMPs. METHODS: We conducted an interrupted time series analysis of a statewide surgical registry linked to Michigan's PDMP database. Analyses included adults undergoing general surgical procedures during January 2017-October 2019. Outcomes included monthly mean days supplied in dispensed opioid prescriptions (those filled within 3 days of discharge) and monthly mean scores for 3 patient-reported outcomes (pain in the week after surgery, care satisfaction, regret undergoing surgery). Segmented regression models were used to assess for level and slope changes in outcomes in June 2018. Analyses were repeated among patients with Narx scores ≥200, a threshold that defines the top quartile. RESULTS: Analyses included 21,897 patients. The mandate was associated with a -0.5 (95% CI: -0.8, -0.2) level decrease in mean days supplied in dispensed opioid prescriptions, but not with worsened patient-reported outcomes. Findings were similar among patients with Narx scores ≥200. CONCLUSIONS: Following implementation of Michigan's PDMP use mandate, the duration of opioid prescriptions decreased, but patient-reported outcomes did not worsen. Findings suggest PDMP use mandates may not be associated with worsened experience among general surgical patients.

Medicaid Insurance Predicts Increased Postoperative Care Encounters Among Patients on Long-Term Opioid Therapy.

OBJECTIVE: This study examined the association between insurance type and postoperative unplanned care encounters among patients on long-term opioid therapy prior to surgery. SUMMARY BACKGROUND DATA: Preoperative long-term opioid therapy is associated with unique risks and poorer outcomes following surgery. To date, the extent to which insurance coverage influences postoperative outcomes in this population remains unclear. METHODS: Among individuals receiving a supply of greater than 120 total days or at least 10 opioid prescriptions in the year prior to surgery, we examined patients with Medicaid or private insurance who underwent abdominopelvic surgery from 2017 to 2021 across 70 hospitals in the state of Michigan. The primary outcome was unplanned care encounters, defined as an emergency department visit or unplanned readmission within 30 days of discharge from surgery. Multivariable logistic regression was used to assess the likelihood of acute care events with insurance type as the primary covariate of interest. RESULTS: Among 1212 patients on long-term opioid therapy prior to surgery, 45.6% (n = 553) had Medicaid insurance. Overall, one in eight (n=151) patients met criteria for a postoperative unplanned care encounter within 30 days. The probability of an unplanned encounter was 4.5 percentage points higher among patients with Medicaid insurance compared to private insurance (95% CI: 0.5%, 8.4%). CONCLUSIONS: Among patients on preoperative long-term opioid therapy, unplanned care encounters were higher among patients with Medicaid when compared to private insurance. While this is likely multifactorial, differences by insurance status may point to disparities in underlying social determinants of health and suggest the need for postoperative care pathways that address these gaps.

The Association of Preoperative Opioid Use with Post-Discharge Outcomes: A Cohort Study of the Michigan Surgical Quality Collaborative.

OBJECTIVE: To examine the association of prescription opioid fills over the year prior to surgery with postoperative outcomes. BACKGROUND: Nearly one third of patients report opioid use in the year preceding surgery, yet an understanding of how opioid exposure influences patient-reported outcomes after surgery remains incomplete. Therefore, this study was designed to test the hypothesis that preoperative opioid exposure may impede recovery in the postoperative period. METHODS: This retrospective cohort study used a statewide clinical registry from 70 hospitals linked to opioid fulfillment data from the state's prescription drug monitoring program to categorize patients' preoperative opioid exposure as none (naïve), minimal, intermittent, or chronic. Outcomes were patient-reported pain intensity (primary), as well as 30-day clinical and patient-reported outcomes (secondary). RESULTS: Compared to opioid-naïve patients, opioid exposure was associated with higher reported pain scores at 30 days after surgery. Predicted probabilities was higher among the opioid exposed versus naive group for reporting moderate pain (43.5% [95% CI 42.6 - 44.4%] vs 39.3% [95% CI 38.5 - 40.1%]) and severe pain (13.% [95% CI 12.5 - 14.0%] vs 10.0% [95% CI 9.5 - 10.5%]), and increasing probability was associated increased opioid exposure for both outcomes. Clinical outcomes (incidence of ED visits, readmissions, and reoperation within 30-days) and patient-reported outcomes (reported satisfaction, regret, and quality of life) were also worse with increasing preoperative opioid exposure for most outcomes. CONCLUSIONS: This study is the first to examine the effect of presurgical opioid exposure on both clinical and non-clinical outcomes in a broad cohort of patients, and shows that exposure is associated with worse postsurgical outcomes. A key question to be addressed is whether and to what extent opioid tapering before surgery mitigates these risks after surgery.

Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions: A Randomized Clinical Trial.

Importance: Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective: To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants: This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions: In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures: The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results: There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance: In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration: ClinicalTrials.gov NCT05070338.

The Association of Cannabis Use After Discharge From Surgery With Opioid Consumption and Patient-reported Outcomes.

OBJECTIVE: To compare outcomes of patients using versus not using cannabis as a treatment for pain after discharge from surgery. BACKGROUND: Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes. METHODS: Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing 16 procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included postdischarge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life, and regret to undergo surgery (secondary). RESULTS: Of 11,314 included patients (58% females, mean age: 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI: 0.4-1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (adjusted odds ratio: 1.7, 95% CIL 1.4-2.1) and 1 month (adjusted odds ratio: 2.1, 95% CI: 1.7-2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs 82.6%), best quality of life (46.7% vs 63.0%), and no regret (87.6% vs 92.7%) (all P < 0.001). CONCLUSIONS: Patient-reported cannabis use, to treat postoperative pain, was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes.

What evidence is needed to inform postoperative opioid consumption guidelines? A cohort study of the Michigan Surgical Quality Collaborative.

INTRODUCTION: To balance adequate pain management while minimizing opioid-related harms after surgery, opioid prescribing guidelines rely on patient-reported use after surgery. However, it is unclear how many patients are required to develop precise guidelines. We aimed to compare patterns of use, required sample size, and the precision for patient-reported opioid consumption after common surgical procedures. METHODS: We analyzed procedure-specific 30-day opioid consumption data reported after discharge from 15 common surgical procedures between January 2018 and May 2019 across 65 hospitals in the Michigan Surgical Quality Collaborative. We calculated proportions of patients using no pills and the estimated number of pills meeting most patients' needs, defined as the 75th percentile of consumption. We compared several methods to model consumption patterns. Using the best method (Tweedie), we calculated sample sizes required to identify opioid consumption within a 5-pill interval and estimates of pills to meet most patients' needs by calculating the width of 95% CIs. RESULTS: In a cohort of 10,688 patients, many patients did not consume any opioids after all types of procedures (range 20%-40%). Most patients' needs were met with 4 pills (thyroidectomy) to 13 pills (abdominal hysterectomy). Sample sizes required to estimate opioid consumption within a 5-pill wide 95% CI ranged from 48 for laparoscopic appendectomy to 188 for open colectomy. The 95% CI width for estimates ranged from 0.7 pills for laparoscopic cholecystectomy to 7.0 pills for ileostomy/colostomy. CONCLUSIONS: This study demonstrates that profiles of opioid consumption share more similarities than differences for certain surgical procedures. Future investigations on patient-reported consumption are required for procedures not currently included in prescribing guidelines to ensure surgeons and perioperative providers can appropriately tailor recommendations to the postoperative needs of patients.

Financial model for a transitional pain service at a large tertiary academic center in the USA.

Approximately 1 in 10 patients undergoing surgery is considered at high risk for poor pain and opioid-related outcomes due to chronic pain or persistent opioid use prior to surgery, leading to increased hospital lengths of stay, emergency department visits, hospital readmissions, and worse long-term outcomes. Multidisciplinary transitional pain services (TPSs) have been shown to effectively identify and optimize high-risk patients before surgery, leading to a reduction in healthcare utilization. We conducted a series of semistructured interviews, a literature search, and a financial analysis to develop a reproducible business case for establishing a TPS. These interviews involved discussions with clinicians and administrators at Michigan Medicine, as well as leaders of TPS initiatives at peer institutions across the USA and Canada. The aim was to understand possible operational structures and potential sources of revenue and cost savings that needed inclusion in our model. Subsequently, the authors developed a modifiable financial modeling tool, which is freely available for download and adaptable to any healthcare institution. The model suggests that the primary source of cost savings can be attributed to a reduction in length of stay. Furthermore, several operational options exist for incorporating a TPS that performs at breakeven or positive net profit. This tool and these findings are important for informing health systems of operational and financial considerations when implementing a TPS program. Future research should evaluate this financial tool's reproducibility in community health system contexts.

Perioperative opioid prescribing and iatrogenic opioid use disorder and overdose: a state-of-the-art narrative review.

BACKGROUND/IMPORTANCE: Considerable attention has been paid to identifying and mitigating perioperative opioid-related harms. However, rates of postsurgical opioid use disorder (OUD) and overdose, along with associated risk factors, have not been clearly defined. OBJECTIVE: Evaluate the evidence connecting perioperative opioid prescribing with postoperative OUD and overdose, compare these data with evidence from the addiction literature, discuss the clinical impact of these conditions, and make recommendations for further study. EVIDENCE REVIEW: State-of-the-art narrative review. FINDINGS: Nearly all evidence is from large retrospective studies of insurance claims and Veterans Health Administration (VHA) data. Incidence rates of new OUD within the first year after surgery ranged from 0.1% to 0.8%, while rates of overdose events ranged from 0.01% to 0.8%. Higher rates were seen among VHA patients, which may reflect differences in data completeness and/or risk factors. Identified risk factors included those related to substance use (preoperative opioid use; non-opioid substance use disorders; preoperative sedative, anxiolytic, antidepressant, and gabapentinoid use; and postoperative new persistent opioid use (NPOU)); demographic attributes (chiefly male sex, younger age, white race, and Medicaid or no insurance coverage); psychiatric comorbidities such as depression, bipolar disorder, and PTSD; and certain medical and surgical factors. Several challenges related to the use of administrative claims data were identified; there is a need for more granular retrospective studies and, ideally, prospective cohorts to assess postoperative OUD and overdose incidence with greater accuracy. CONCLUSIONS: Retrospective data suggest an incidence of new postoperative OUD and overdose of up to 0.8% during the first year after surgery, but prospective studies are lacking.

Changes in Surgical Opioid Prescribing and Patient-Reported Outcomes After Implementation of an Insurer Opioid Prescribing Limit.

Importance: Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain. Objective: To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan. Design, Setting, and Participants: This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019. Exposure: Policy limiting opioid prescriptions to a 5-day supply in February 2018. Main Outcomes and Measures: Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume. Results: Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone. Conclusions: This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.

Epidemiologic Questionnaire (EPI-Q) - a scalable, app-based health survey linked to electronic health record and genotype data.

The Epidemiologic Questionnaire (EPI-Q) was established to collect broad, uniform, self-reported health data to supplement electronic health record (EHR) and genotype information from participants in the University of Michigan (UM) Precision Health cohorts. Recruitment of EPI-Q participants, who were already enrolled in 1 of 3 ongoing UM Precision Health cohorts-the Michigan Genomics Initiative, Mental Health Biobank, and Metabolism, Endocrinology, and Diabetes cohorts-began in March 2020. Of 54,043 retrospective invitations, 5,577 individuals enrolled, representing a 10.3% response rate. Of these, 3,502 (63.7%) were female, and the average age was 56.1 years (standard deviation, 15.4). The baseline survey comprises 11 modules on topics including personal and family health history, lifestyle, and cancer screening and history. Additionally, 11 optional modules cover topics including financial toxicity, occupational exposure, and life meaning. The questions are based on standardized and validated instruments used in other cohorts, and we share resources to expedite development of similar surveys. Data are collected via the MyDataHelps platform, which enables current and future participants to share non-Michigan Medicine EHR data. Recruitment is ongoing. Cohort data are available to those with institutional review board approval; for details, contact the Data Office for Clinical and Translational Research (DataOffice@umich.edu).

Prescribed Opioid Dosages, Payer Type, and Self-Reported Outcomes After Surgical Procedures in Michigan, 2018-2020.

Importance: Collaborative quality improvement (CQI) models, often supported by private payers, create hospital networks to improve health care delivery. Recently, these systems have focused on opioid stewardship; however, it is unclear whether reduction in postoperative opioid prescribing occurs uniformly across health insurance payer types. Objective: To evaluate the association between insurance payer type, postoperative opioid prescription size, and patient-reported outcomes in a large statewide CQI model. Design, Setting, and Participants: This retrospective cohort study used data from 70 hospitals within the Michigan Surgical Quality Collaborative clinical registry for adult patients (age ≥18 years) undergoing general, colorectal, vascular, or gynecologic surgical procedures between January 1, 2018, and December 31, 2020. Exposure: Insurance type, classified as private, Medicare, or Medicaid. Main Outcomes and Measures: The primary outcome was postoperative opioid prescription size in milligrams of oral morphine equivalents (OME). Secondary outcomes were patient-reported opioid consumption, refill rate, satisfaction, pain, quality of life, and regret about undergoing surgery. Results: A total of 40 149 patients (22 921 [57.1%] female; mean [SD] age, 53 [17] years) underwent surgery during the study period. Within this cohort, 23 097 patients (57.5%) had private insurance, 10 667 (26.6%) had Medicare, and 6385 (15.9%) had Medicaid. Unadjusted opioid prescription size decreased for all 3 groups during the study period from 115 to 61 OME for private insurance patients, from 96 to 53 OME for Medicare patients, and from 132 to 65 OME for Medicaid patients. A total of 22 665 patients received a postoperative opioid prescription and had follow-up data for opioid consumption and refill. The rate of opioid consumption was highest among Medicaid patients throughout the study period (16.82 OME [95% CI, 12.57-21.07 OME] greater than among patients with private insurance) but increased the least over time. The odds of refill significantly decreased over time for patients with Medicaid compared with patients with private insurance (odds ratio, 0.93; 95% CI, 0.89-0.98). Adjusted refill rates for private insurance remained between 3.0% and 3.1% over the study period; adjusted refill rates among Medicare and Medicaid patients decreased from 4.7% to 3.1% and 6.5% to 3.4%, respectively, by the end of the study period. Conclusions and Relevance: In this retrospective cohort study of surgical patients in Michigan from 2018 to 2020, postoperative opioid prescription size decreased across all payer types, and differences between groups narrowed over time. Although funded by private payers, the CQI model appeared to have benefitted patients with Medicare and Medicaid as well.

Evidence-based opioid prescribing guidelines after lung resection: a prospective, multicenter analysis.

Background: Opioid prescribing guidelines have significantly decreased overprescribing and post-discharge use after cardiac surgery; however, limited recommendations exist for general thoracic surgery patients, a similarly high-risk population. We examined opioid prescribing and patient-reported use to develop evidence-based, opioid prescribing guidelines after lung cancer resection. Methods: This prospective, statewide, quality improvement study was conducted between January 2020 to March 2021 and included patients undergoing surgical resection of a primary lung cancer across 11 institutions. Patient-reported outcomes at 1-month follow-up were linked with clinical data and Society of Thoracic Surgery (STS) database records to characterize prescribing patterns and post-discharge use. The primary outcome was quantity of opioid used after discharge; secondary outcomes included quantity of opioid prescribed at discharge and patient-reported pain scores. Opioid quantities are reported in number of 5-mg oxycodone tablets (mean ± standard deviation). Results: Of the 602 patients identified, 429 met inclusion criteria. Questionnaire response rate was 65.0%. At discharge, 83.4% of patients were provided a prescription for opioids of mean size 20.5±13.1 pills, while patients reported using 8.2±13.0 pills after discharge (P<0.001), including 43.7% who used none. Those not taking opioids on the calendar day prior to discharge (32.4%) used fewer pills (4.4±8.1 vs. 11.7±14.9, P<0.001). Refill rate was 21.5% for patients provided a prescription at discharge, while 12.5% of patients not prescribed opioids at discharge required a new prescription before follow-up. Pain scores were 2.4±2.5 for incision site and 3.0±2.8 for overall pain (scale 0-10). Conclusions: Patient-reported post-discharge opioid use, surgical approach, and in-hospital opioid use before discharge should be used to inform prescribing recommendations after lung resection.

Predicting chronic postsurgical pain: current evidence and a novel program to develop predictive biomarker signatures.

ABSTRACT: Chronic pain affects more than 50 million Americans. Treatments remain inadequate, in large part, because the pathophysiological mechanisms underlying the development of chronic pain remain poorly understood. Pain biomarkers could potentially identify and measure biological pathways and phenotypical expressions that are altered by pain, provide insight into biological treatment targets, and help identify at-risk patients who might benefit from early intervention. Biomarkers are used to diagnose, track, and treat other diseases, but no validated clinical biomarkers exist yet for chronic pain. To address this problem, the National Institutes of Health Common Fund launched the Acute to Chronic Pain Signatures (A2CPS) program to evaluate candidate biomarkers, develop them into biosignatures, and discover novel biomarkers for chronification of pain after surgery. This article discusses candidate biomarkers identified by A2CPS for evaluation, including genomic, proteomic, metabolomic, lipidomic, neuroimaging, psychophysical, psychological, and behavioral measures. Acute to Chronic Pain Signatures will provide the most comprehensive investigation of biomarkers for the transition to chronic postsurgical pain undertaken to date. Data and analytic resources generatedby A2CPS will be shared with the scientific community in hopes that other investigators will extract valuable insights beyond A2CPS's initial findings. This article will review the identified biomarkers and rationale for including them, the current state of the science on biomarkers of the transition from acute to chronic pain, gaps in the literature, and how A2CPS will address these gaps.

Association Between Payer Type and Risk of Persistent Opioid Use After Surgery.

OBJECTIVE: To assess whether the risk of persistent opioid use after surgery varies by payer type. BACKGROUND: Persistent opioid use is associated with increased health care utilization and risk of opioid use disorder, opioid overdose, and mortality. Most research assessing the risk of persistent opioid use has focused on privately insured patients. Whether this risk varies by payer type is poorly understood. METHODS: This cross-sectional analysis of the Michigan Surgical Quality Collaborative database examined adults aged 18 to 64 years undergoing surgical procedures across 70 hospitals between January 1, 2017 and October 31, 2019. The primary outcome was persistent opioid use, defined a priori as 1+ opioid prescription fulfillment at (1) an additional opioid prescription fulfillment after an initial postoperative fulfillment in the perioperative period or at least 1 fulfillment in the 4 to 90 days after discharge and (2) at least 1 opioid prescription fulfillment in the 91 to 180 days after discharge. The association between this outcome and payer type was evaluated using logistic regression, adjusting for patient and procedure characteristics. RESULTS: Among 40,071 patients included, the mean age was 45.3 years (SD 12.3), 24,853 (62%) were female, 9430 (23.5%) were Medicaid-insured, 26,760 (66.8%) were privately insured, and 3889 (9.7%) were covered by other payer types. The rate of POU was 11.5% and 5.6% for Medicaid-insured and privately insured patients, respectively (average marginal effect for Medicaid: 2.9% (95% CI 2.3%-3.6%)). CONCLUSIONS: Persistent opioid use remains common among individuals undergoing surgery and higher among patients with Medicaid insurance. Strategies to optimize postoperative recovery should focus on adequate pain management for all patients and consider tailored pathways for those at risk.