Perioperative Opioid-Related Harms: Opportunities to Minimize Risk.

Although substantial attention has been given to opioid prescribing in the United States, opioid-related mortality continues to climb due to the rising incidence and prevalence of opioid use disorder. Perioperative care has an important role in the consideration of opioid prescribing and the care of individuals at risk for poor postoperative pain- and opioid-related outcomes. Opioids are effective for acute pain management and commonly prescribed for postoperative pain. However, failure to align prescribing with patient need can result in overprescribing and exacerbate the flow of unused opioids into communities. Conversely, underprescribing can result in the undertreatment of pain, complicating recovery and impairing well-being after surgery. Optimizing pain management can be particularly challenging for individuals who are previously exposed to opioids or have critical risk factors, including opioid use disorder. In this review, we will explore the role of perioperative care in the broader context of the opioid epidemic in the United States, and provide considerations for a multidisciplinary, comprehensive approach to perioperative pain management and optimal opioid stewardship.

Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan.

Importance: There is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption. Objective: To describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery. Design, Setting, and Participants: A retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients. Exposures: Opioid prescription size in the initial postoperative prescription. Main Outcomes and Measures: Patient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors. Results: In this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills; P < .001). The quantity of opioid prescribed had the strongest association with patient-reported opioid consumption, with patients using 0.53 more pills (95% CI, 0.40-0.65; P < .001) for every additional pill prescribed. Patient-reported pain in the week after surgery was also significantly associated with consumption but not as strongly as prescription size. Compared with patients reporting no pain, patients used a mean (SD) 9 (1) more pills if they reported moderate pain and 16 (2) more pills if they reported severe pain (P < .001). Other significant risk factors included history of tobacco use, American Society of Anesthesiologists class, age, procedure type, and inpatient surgery status. After adjusting for these risk factors, patients in the lowest quintile of opioid prescribing had significantly lower mean (SD) opioid consumption compared with those in the highest quintile (5 [2] pills vs 37 [3] pills; P < .001). Conclusions and Relevance: The quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.

Acute Care Surgery Model and Outcomes in Emergency General Surgery.

BACKGROUND: Annually, more than 2 million patients are admitted with emergency general surgery (EGS) conditions. Emergency general surgery cases comprise 11% of all general surgery operations, yet account for 47% of mortalities and 28% of complications. Using the statewide general surgery Michigan Surgical Quality Collaborative (MSQC) data, we previously confirmed that wide variations in EGS outcomes were unrelated to case volume/complexity. We assessed whether patient care model (PCM) affected EGS outcomes. STUDY DESIGN: There were 34 hospitals that provided data for PCM, resources, surgeon practice patterns, and comprehensive MSQC patient data from January 1, 2008 to December 31, 2016 (general surgery cases = 126,494; EGS cases = 39,023). Risk and reliability adjusted outcomes were determined using hierarchical multivariable logistic regression analysis with multiple clinical covariates and PCM. RESULTS: The general surgery service (GSS) model was more common (73%) than acute care surgery (ACS, 27%). Emergency general surgery 30-day mortality was 4.1% (intestinal resections 11.6%). The ACS model was associated with a reduction of 31% in mortality (odds ratio [OR] 0.69; 95% CI 0.52-0.92] for EGS cases, related to decreased mortality in the intestinal resection cohort (8.5% ACS vs 12% GSS, p < 0.0001). Morbidity in EGS was 17.4% (9.7% elective); highest (40%) in intestinal resection, and PCM did not affect morbidity. We identified specific variables for an optimal EGS risk adjustment model. CONCLUSIONS: This is the first multi-institutional study to identify that an ACS model is associated with a significant 31% mortality reduction in EGS using prospectively collected, clinically obtained, research-quality collaborative data. We identified that new risk adjustment models are necessary for EGS outcomes evaluations.