Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations.

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Postoperative Pain and Opioid Use after Facial Feminization Surgery.

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Factors Predicting Chronic Opioid Use after Orthopedic Surgical Procedures.

BACKGROUND: Opioid abuse has been an increasing problem since the 1990s. With over 47,000 opioid related deaths recorded in 2017 alone, concerns have been raised regarding the dangers of introducing opioids perioperatively to patients undergoing major surgeries. OBJECTIVES: The present study proposes to examine the frequency, amount, and trends in post-operative opioid consumption in patients undergoing orthopedic surgical procedures. STUDY DESIGN: This was a randomized, retrospective questionnaire-based study. SETTING: Patients who underwent any type of orthopedic surgery at the University of Pennsylvania Presbyterian Hospital from 1/1/2018 to 3/12/2019 were randomly selected and called during the summer of 2019. METHODS: In this retrospective questionnaire-based study, 828 patients were called by telephone in the summer of 2019. These patients were asked a variety of questions involving opioid consumption behavior post-surgery. The study ended after receiving responses from 200 patients. RESULTS: Nineteen (9.5%) patients reported positively for experiencing euphoria while taking opioids post-surgery. Of the 200 patients contacted, 6 patients (3%) reported switching to marijuana instead of opioids. Thirty-eight (19%) patients preferred to take no opioids at all post-surgery, and one patient was found to have given their prescription to a family member or friend. Twenty-one patients (10.5%) were found to have been taking opioids for non-severe pain. Blacks and whites were the most common racial demographics, making up 84 and 109 of the totals, respectively. The odds ratios for all of the predictors showed that the relative risk for opioid misuse was higher for black patients than white patients (OR = 3.034). There was no relationship between the intra- and post-operative opioid administration and long-term opioid misuse. LIMITATIONS: Patients are self-selected and had the option to opt out of the study when contacted. Some patients may not have been available to answer the phone when our study was being conducted. This study was only conducted for orthopedic patients and for patients who received surgery at the University of Pennsylvania Presbyterian Hospital, thus affecting the demographics for our research. CONCLUSIONS: Prescription opioid misuse is more common among the black population. The total opioid consumption is frequently lower than the quantity prescribed. Patients frequently use opioids even though they feel that pain is insufficient to deserve such an intervention. Euphoria is experienced by a significant number of patients taking prescription opioids Often patients do not take any opioids, although they had prescriptions.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities.

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

The development of a nomogram to determine the frequency of elevated risk for non-medical opioid use in cancer patients.

OBJECTIVE: Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center. METHOD: 3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. "+risk" was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk. RESULTS: 731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1. SIGNIFICANCE OF RESULTS: We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.

Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study.

OBJECTIVES: This prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing. METHODS: Data analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use. RESULTS: Among 14 221 patients, 9% had prescriptions with an average MEDD ≥90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD ≥90 (high-dose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P < .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change. CONCLUSIONS: EMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.

Substitution of marijuana for opioids in a national survey of US adults.

Opioid prescriptions for chronic pain and subsequent opioid-related complications have risen dramatically in the US. Recent data suggest that medical marijuana laws have been associated with lower state-level opioid overdose mortality. In a national survey, we examined the prevalence of substitution of marijuana for opioids among US adults taking opioids for pain.Using GfK's KnowledgePanel, we conducted an Internet-based survey of a nationally representative sample of 16,280 adults in 2017 about individual perceptions and use of marijuana. We developed questions designed to assess the extent and reasons for substitution of marijuana for opioids. We examined opioid substitution among respondents with a history of ever using marijuana who used opioids in the past 12 months. There were 9,003 respondents, corresponding to a 55.3% response rate. The mean age was 48 years. Among the 5% (n = 486) who reported ever using marijuana and using opioids in the past year, 43% used opioids daily, and 23% reported current (past 30 day) marijuana use. Forty-one percent reported a decrease or cessation of opioid use due to marijuana use; 46% reported no change in opioid use; and 8% reported an increase in opioid use. We found that a substantial number of US adults reported that they substituted marijuana for opioids.

BU10038 as a safe opioid analgesic with fewer side-effects after systemic and intrathecal administration in primates.

BACKGROUND: The marked increase in mis-use of prescription opioids has greatly affected our society. One potential solution is to develop improved analgesics which have agonist action at both mu opioid peptide (MOP) and nociceptin/orphanin FQ peptide (NOP) receptors. BU10038 is a recently identified bifunctional MOP/NOP partial agonist. The aim of this study was to determine the functional profile of systemic or spinal delivery of BU10038 in primates after acute and chronic administration. METHODS: A series of behavioural and physiological assays have been established specifically to reflect the therapeutic (analgesia) and side-effects (abuse potential, respiratory depression, itch, physical dependence, and tolerance) of opioid analgesics in rhesus monkeys. RESULTS: After systemic administration, BU10038 (0.001-0.01 mg kg-1) dose-dependently produced long-lasting antinociceptive and antihypersensitive effects. Unlike the MOP agonist oxycodone, BU10038 lacked reinforcing effects (i.e. little or no abuse liability), and BU10038 did not compromise the physiological functions of primates including respiration, cardiovascular activities, and body temperature at antinociceptive doses and a 10-30-fold higher dose (0.01-0.1 mg kg-1). After intrathecal administration, BU10038 (3 µg) exerted morphine-comparable antinociception and antihypersensitivity without itch scratching responses. Unlike morphine, BU10038 did not cause the development of physical dependence and tolerance after repeated and chronic administration. CONCLUSIONS: These in vivo findings demonstrate the translational potential of bifunctional MOP/NOP receptor agonists such as BU10038 as a safe, non-addictive analgesic with fewer side-effects in primates. This study strongly supports that bifunctional MOP/NOP agonists may provide improved analgesics and an alternative solution for the ongoing prescription opioid crisis.

Autonomic and affective mediators of the relationship between mindfulness and opioid craving among chronic pain patients.

Prescription opioid misuse among chronic pain patients is undergirded by self-regulatory deficits, affective distress, and opioid-cue reactivity. Dispositional mindfulness has been associated with enhanced self-regulation, lower distress, and adaptive autonomic responses following drug-cue exposure. We hypothesized that dispositional mindfulness might serve as a protective factor among opioid-treated chronic pain patients. We examined heart-rate variability (HRV) during exposure to opioid cues and depressed mood as mediators of the association between dispositional mindfulness and opioid craving. Data were obtained from a sample of chronic pain patients (N = 115) receiving long-term opioid pharmacotherapy. Participants self-reported opioid craving and depression, and HRV was measured during an opioid-cue dot-probe task. Dispositional mindfulness was significantly positively correlated with HRV, and HRV was significantly inversely associated with opioid craving. Dispositional mindfulness was significantly negatively correlated with depression, and depression was significantly positively correlated with opioid craving. Path analysis revealed significant indirect effects of dispositional mindfulness on craving through both HRV and depression. Dispositional mindfulness may buffer against opioid craving among chronic pain patients prescribed opioids; this buffering effect may be a function of improved autonomic and affective responses. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Self-Reported Marijuana Use Is Associated with Increased Use of Prescription Opioids Following Traumatic Musculoskeletal Injury.

BACKGROUND: Cannabinoids are among the psychoactive substances considered as alternatives to opioids for the alleviation of acute pain. We examined whether self-reported marijuana use was associated with decreased use of prescription opioids following traumatic musculoskeletal injury. METHODS: Our analysis included 500 patients with a musculoskeletal injury who completed a survey about their marijuana use and were categorized as (1) never a user, (2) a prior user (but not during recovery), or (3) a user during recovery. Patients who used marijuana during recovery indicated whether marijuana helped their pain or reduced opioid use. Prescription opioid use was measured as (1) persistent opioid use, (2) total prescribed opioids, and (3) duration of opioid use. Persistent use was defined as the receipt of at least 1 opioid prescription within 90 days of injury and at least 1 additional prescription between 90 and 180 days. Total prescribed opioids were calculated as the total morphine milligram equivalents (MME) prescribed after injury. Duration of use was the interval between the first and last opioid prescription dates. RESULTS: We found that 39.8% of patients reported never having used marijuana, 46.4% reported prior use but not during recovery, and 13.8% reported using marijuana during recovery. The estimated rate of persistent opioid use ranged from 17.6% to 25.9% and was not associated with marijuana use during recovery. Marijuana use during recovery was associated with increases in both total prescribed opioids (regression coefficient = 343 MME; 95% confidence interval [CI] = 87 to 600 MME; p = 0.029) and duration of use (coefficient = 12.5 days; 95% CI = 3.4 to 21.5 days; p = 0.027) compared with no previous use (never users). Among patients who reported that marijuana decreased their opioid use, marijuana use during recovery was associated with increased total prescribed opioids (p = 0.008) and duration of opioid use (p = 0.013) compared with never users. CONCLUSIONS: Our data indicate that self-reported marijuana use during injury recovery was associated with an increased amount and duration of opioid use. This is in contrast to many patients' perception that the use of marijuana reduces their pain and therefore the amount of opioids used. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center.

BACKGROUND: Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) was compared with that of the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool as instruments for identifying patients at risk for ADB. METHODS: In total, 751 consecutive patients with cancer who were referred to a supportive care clinic were reviewed. Patients were eligible if they had diagnosis of cancer and had received opioids for pain for at least 1 week. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), the SOAPP-14, and the CAGE-AID. SOAPP scores ≥7 (SOAPP-positive) were used to identify patients who were at risk of ADB. RESULTS: Among the 729 of 751 (97%) evaluable consults, 143 (19.6%) were SOAPP-positive, and 73 (10.5%) were CAGE-AID-positive. Multivariate analysis revealed that the odds ratio of a positive SOAPP score was 2.3 for patients who had positive CAGE-AID scores (P < .0001), 2.08 for men (P = .0013), 1.10 per point for ESAS pain (P = .014), 1.13 per point for ESAS anxiety (P = .0015), and 1.09 per point for ESAS financial distress (P = .012). A CAGE-AID cutoff score of 1 in 4 had 43.3% sensitivity and 90.93% specificity for screening patients with a high risk of ADB. CONCLUSIONS: The current results indicate a high frequency of an elevated risk of ADB among patients with cancer. Men and patients who have anxiety, financial distress, and a prior history of alcoholism/illicit drug use are at increased risk of ADB.

Persistent Opioid Use Following Total Knee Arthroplasty: A Signal for Close Surveillance.

BACKGROUND: Prolonged opioid use following total knee arthroplasty (TKA) has not been extensively studied. METHODS: A cohort study of primary TKA for osteoarthritis using an integrated healthcare system and Total Joint Replacement Registry (January 2008-December 2011) was conducted. Opioid use during the first year after TKA was the exposure of interest and cumulative daily oral morphine equivalent (OME) amounts were calculated. Total postsurgical OME per 90-day exposure periods were categorized into quartiles. The end point was aseptic revision surgery. Survival analyses were conducted and hazard ratios (HRs) were adjusted for age, gender, prior analgesic use, opioid-related comorbidities, and chronic pain diagnoses. RESULTS: A total of 24,105 patients were studied. After the initial 90-day postoperative period, 41.5% (N = 9914) continued to use opioids. Also, 155 (0.6%) revisions occurred within 1 year and 377 (1.6%) within 5 years. Compared to patients not taking any opioids, patients using medium-low to high OME after the initial 90-day period had a higher adjusted risk of 1-year revision, ranging from HR = 2.4 (95% confidence interval, 1.3-4.5) to HR = 33 (95% confidence interval, 10-110) depending on the OME and time period. CONCLUSION: Patients who require opioids beyond 90 days after TKA warrant close follow-up.

Codeine and opioid metabolism: implications and alternatives for pediatric pain management.

PURPOSE OF REVIEW: Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. RECENT FINDINGS: Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY: Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative pain management is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety.

Key Data Gaps Regarding the Public Health Issues Associated with Opioid Analgesics.

Most pharmaceutical opioids are used to treat pain, and they have been demonstrated to be effective medications for many. Their abuse and misuse pose significant public health concerns in the USA. Research has provided much insight into the prevalence, scope, and drivers of opioid abuse, but a holistic understanding is limited by a lack of available data regarding key aspects of this public health problem. Twelve data gaps were revealed during the creation of a systems-level computer model of medical use, diversion, nonmedical use, and the adverse outcomes associated with opioid analgesics in the USA. Data specific to these gaps would enhance the validity and real-world applications of systems-level models of this public health problem and would increase understanding of the complex system in which use and abuse occur. This paper provides an overview of these gaps, argues for the importance of closing them, and provides specific recommendations for future data collection efforts.

Buprenorphine in the workers' compensation setting.

Buprenorphine is approved by the Food and Drug Administration for the treatment of chronic pain in low-dose transdermal patch formulations and for the treatment of addiction in high-dose sublingual tablets and films. Clinicians often prescribe these high-dose preparations "off label" for pain management. In the workers' compensation setting, it is particularly important to consider factors such as a) if the injured person has, and is being treated for co-occurring addiction as well as pain; b) if alternative therapies, including opioid withdrawal, were considered prior to initiating buprenorphine treatment; and c) the anticipated duration of treatment. This article reviews buprenorphine's approved indications, formulations, pharmacology, clinical efficacy, and special considerations in the workers' compensation setting.

Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial.

OBJECTIVE: Opioid pharmacotherapy is now the leading treatment for chronic pain, a problem that affects nearly one third of the U.S. population. Given the dramatic rise in prescription opioid misuse and opioid-related mortality, novel behavioral interventions are needed. The purpose of this study was to conduct an early-stage randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention designed to simultaneously target mechanisms underpinning chronic pain and opioid misuse. METHOD: Chronic pain patients (N = 115; mean age = 48 ± 14 years; 68% female) were randomized to 8 weeks of MORE or a support group (SG). Outcomes were measured at pre- and posttreatment, and at 3-month follow-up. The Brief Pain Inventory was used to assess changes in pain severity and interference. Changes in opioid use disorder status were measured by the Current Opioid Misuse Measure. Desire for opioids, stress, nonreactivity, reinterpretation of pain sensations, and reappraisal were also evaluated. RESULTS: MORE participants reported significantly greater reductions in pain severity (p = .038) and interference (p = .003) than SG participants, which were maintained by 3-month follow-up and mediated by increased nonreactivity and reinterpretation of pain sensations. Compared with SG participants, participants in MORE evidenced significantly less stress arousal (p = .034) and desire for opioids (p = .027), and were significantly more likely to no longer meet criteria for opioid use disorder immediately following treatment (p = .05); however, these effects were not sustained at follow-up. CONCLUSIONS: Findings demonstrate preliminary feasibility and efficacy of MORE as a treatment for co-occurring prescription opioid misuse and chronic pain. (PsycINFO Database Record (c) 2014 APA, all rights reserved).