Postoperative Opioid-Prescribing Practice in Limb Preservation Surgery.

BACKGROUND: Limb preservation surgery affects more than 100,000 Americans annually. Current postoperative pain management prescribing practices of podiatric physicians in the United States are understudied. We examined prescribing practices for limb preservation surgery to identify prescriber characteristics' that may be associated with postoperative opioid-prescribing practices. METHODS: We administered an anonymous online questionnaire consisting of five patient scenarios with limb preservation surgery commonly performed by podiatric physicians. Respondents provided information about their prescription choice for each surgery. Basic provider demographics were collected. We developed linear regression models to identify the strength and direction of association between prescriber characteristics and quantity of postoperative opioid "pills" (dosage units) prescribed at surgery. Logistic regression models were used to identify the odds of prescribing opioids for each scenario. RESULTS: One hundred fifteen podiatric physicians completed the survey. Podiatric physicians reported using regional nerve blocks 70% to 88% of the time and prescribing opioids 43% to 67% of the time across all scenarios. Opioids were more commonly prescribed than nonsteroidal anti-inflammatory drugs and anticonvulsants. Practicing in the Northeast United States was a significant variable in linear regression (P = .009, a decrease of 9-10 dosage units) and logistic regression (odds ratio, 0.23; 95% confidence interval, 0.07-0.68; P = .008) models for the transmetatarsal amputation scenario. CONCLUSIONS: Prescribing practice variation exists in limb preservation surgery by region. Podiatric physicians reported using preoperative regional nerve blocks more than prescribing postoperative opioids for limb preservation surgeries. Through excess opioid prescribing, the diabetes pandemic has likely contributed to the US opioid epidemic. Podiatric physicians stand at the intersection of these two public health crises and are equipped to reduce their impact via preventive foot care and prescribing nonopioid analgesics when warranted.

Opioid-Prescribing Approaches-One-Size-Fits-All versus Patient-Centric and Procedure-Focused-Among Podiatric Physicians: A Cross-Sectional Study.

BACKGROUND: More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir maintained by variable prescription rates and, notably, excessive postoperative prescription. We examined the postoperative opioid-prescribing approaches among podiatric physicians. METHODS: We administered a scenario-based, anonymous, online questionnaire via an online survey platform. The questionnaire consisted of five patient-foot surgery scenarios aimed at discerning opioid-prescribing approaches. Respondents were asked how many opioid "pills" (dosage units) that they would prescribe at the time of surgery. We divided respondents into two opioid-prescribing approach groups: one-size-fits-all (prescribed the same dosage units regardless of the scenario) and patient-centric and procedure-focused (prescribed varied amounts of opioid dosage units based on the patient's opioid history and the procedure provided in each scenario). We used the Mann-Whitney U test to determine the difference between the opioid dosage units prescribed at the time of surgery by the two groups. RESULTS: Approximately half of the respondents used a one-size-fits-all postoperative opioid-prescribing approach. Podiatric physicians who used a patient-centric and procedure-focused approach reported prescribing significantly fewer opioid dosage units in scenarios 1 (partial toe amputation; -9.1; P = .0087) and 2 (incision and drainage with partial fifth-ray resection; -12.3; P = .0024), which represented minor procedures with opioid-naive patients. CONCLUSIONS: Podiatric physicians who used a one-size-fits-all opioid-prescribing approach prescribed more postoperative opioid dosage units regardless of the scenario. Given that the patient population requiring foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is suited to limit excess prescribing while defending the physician-patient relationship.

Cognitive Bias in Postoperative Opioid-Prescribing Practice.

BACKGROUND: Given that excess opioid prescriptions contribute to the US opioid epidemic and there are few national opioid-prescribing guidelines for the management of acute pain, it is pertinent to determine whether prescribers can sufficiently assess their own prescribing practice. We investigated podiatric surgeons' ability to evaluate whether their own opioid-prescribing practice is less than, near, or above that of an "average" prescriber. METHODS: We administered a scenario-based, voluntary, anonymous, online questionnaire consisting of five surgery-based scenarios commonly performed by podiatric surgeons. Respondents were asked the quantity of opioids they would prescribe at the time of surgery. Respondents were also asked to rate their prescribing practice compared with the average (median) podiatric surgeon. We compared self-reported behavior to self-reported perception ("I prescribe less than average," "I prescribed about average," and "I prescribe more than average"). Analysis of variance was used for univariate analysis among the three groups. We used linear regression to adjust for confounders. Data restriction was used to account for restrictive state laws. RESULTS: One hundred fifteen podiatric surgeons completed the survey in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences among podiatric surgeons who reported that they "prescribe less," "prescribe about average," and "prescribe more." Paradoxically, there was a flip in scenario 5: respondents who reported they "prescribe more" actually prescribed the least and respondents who believed they "prescribe less" actually prescribed the most. CONCLUSIONS: Cognitive bias, in the form of a novel effect, occurs in postoperative opioid-prescribing practice; in the absence of procedure-specific guidelines or an objective standard, podiatric surgeons, more often than not, were unaware of how their own opioid-prescribing practice measured up to that of other podiatric surgeons.

Inclusion of Social and Structural Determinants of Health to Advance Understanding of their Influence on the Biology of Chronic Disease.

Social Determinants of Health (SDOH) consider social, political, and economic factors that contribute to health disparities in patients and populations. The most common health-related SDOH exposures are food and housing insecurity, financial instability, transportation needs, low levels of education, and psychosocial stress. These domains describe risks that can impact health outcomes more than health care. Epidemiologic and translational research demonstrates that SDOH factors represent exposures that predict harm and impact the health of individuals. International and national guidelines urge health professionals to address SDOH in clinical practice and public health. The further implementation of these recommendations into basic and translational research, however, is lagging. Herein, we consider a precision health framework to describe how SDOH contributes to the exposome and exacerbates physiologic pathways that lead to chronic disease. SDOH factors are associated with various forms of stressors that impact physiological processes through epigenetic, inflammatory, and redox regulation. Many SDOH exposures may add to or potentiate the pathologic effects of additional environmental exposures. This overview aims to inform basic life science and translational researchers about SDOH exposures that can confound associations between classic biomedical determinants of disease and health outcomes. To advance the study of toxicology through either qualitative or quantitative assessment of exposures to chemical and biological substances, a more complete environmental evaluation should include SDOH exposures. We discuss common approaches to measure SDOH factors at individual and population levels and review the associations between SDOH risk factors and physiologic mechanisms that influence chronic disease. We provide clinical and policy-based motivation to encourage researchers to consider the impact of SDOH exposures on study results and data interpretation. With valid measures of SDOH factors incorporated into study design and analyses, future toxicological research may contribute to an evidence base that can better inform prevention and treatment options, to improve equitable clinical care and population health. © 2022 Wiley Periodicals LLC.

In their own words: a qualitative study of factors promoting resilience and recovery among postpartum women with opioid use disorders.

BACKGROUND: Opioid use disorder (OUD) is associated with substantial morbidity and mortality for women, especially during the perinatal period. Opioid overdose has become a significant cause of maternal death in the United States, with rates highest in the immediate postpartum year. While pregnancy is a time of high motivation for healthcare engagement, unique challenges exist for pregnant women with OUD seeking both substance use treatment and maternity care, including managing change after birth. How women successfully navigate these barriers, engage in treatment, and abstain from substance use during pregnancy and postpartum is poorly understood. The aim of this study is to explore the experiences of postpartum women with OUD who successfully engaged in both substance use treatment and maternity care during pregnancy, to understand factors contributing to their ability to access care and social support. METHODS: We conducted semi-structured, in-depth interviews with postpartum women in sustained recovery (n = 10) engaged in a substance use treatment program in northern New England. Interviews were analyzed using grounded theory methodology. RESULTS: Despite multiple barriers, women identified pregnancy as a change point from which they were able to develop self-efficacy and exercise agency in seeking care. A shift in internal motivation enabled women to disclose need for OUD treatment to maternity care providers, a profoundly significant moment. Concurrently, women developed a new capacity for self-care, demonstrated through managing relationships with providers and family members, and overcoming logistical challenges which had previously seemed overwhelming. This transformation was also expressed in making decisions based on pregnancy risk, engaging with and caring for others, and providing peer support. Women developed resilience through the interaction of inner motivation and their ability to positively utilize or transform external factors. CONCLUSIONS: Complex interactions occurred between individual-level changes in treatment motivation due to pregnancy, emerging self-efficacy in accessing resources, and engagement with clinicians and peers. This transformative process was identified by women as a key factor in entering recovery during pregnancy and sustaining it postpartum. Clinicians and policymakers should target the provision of services which promote resilience in pregnant women with OUD.

Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement.

The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.

Reporting Military Sexual Trauma: A Mixed-Methods Study of Women Veterans' Experiences Who Served From World War II to the War in Afghanistan.

Since 2004, there has been increased effort to reduce military sexual trauma (MST) in the U.S. military. Although MST covers a range of inappropriate behaviors, the majority of research, treatment, and outreach are focused on sexual assault and the experiences of individuals serving in Afghanistan and Iraq. During a study on veterans' involvement in a national peace organization, participants were asked about their military experiences. Veterans served from World War II to current conflicts in Iraq and Afghanistan. Emerging out of the responses were descriptions of women's experiences with MST, barriers to reporting incidents of sexual misconduct and sexual assault, and the challenges they faced when seeking care. Data were gathered using anonymous questionnaires and semi-structured interviews. Out of 52 female veterans, the majority (90%) was subjected to at least one form of MST, and 15% (8) attempted to report the incident(s). Over half of the assailants were of a higher rank than the survivors. The majority of veterans remained silent due to lack of options to report, the status of perpetrators, and fear of retaliation. These data provide a glimpse into the challenges many women veterans faced when seeking assistance reporting incidents or obtaining health care for their MST.

Gender Differences in Service Utilization among OEF/OIF Veterans with Posttraumatic Stress Disorder after a Brief Cognitive-Behavioral Intervention to Increase Treatment Engagement: A Mixed Methods Study.

PURPOSE: Women veterans who served in Iraq and Afghanistan (Operation Enduring Freedom and Operation Iraqi Freedom [OEF/OIF]) have a moderately higher risk of developing posttraumatic stress disorder (PTSD) than male veterans. However, gender disparities in treatment engagement may prevent women veterans from initiating the care they need. Understanding gender differences in predictors of and barriers to treatment is essential to improving engagement and mental health outcomes. The purpose of this study was to examine gender differences in treatment utilization after a brief, cognitive-behavioral therapy (CBT) intervention among male and female OEF/OIF veterans. METHODS: Participants were assigned randomly to either the intervention or control conditions. Intervention participants received the telephone-based CBT intervention. Participants were 35 female and 238 male OEF/OIF veterans who screened positive for PTSD and had never initiated PTSD treatment. Participants were asked about treatment utilization, beliefs about PTSD treatment, and symptoms at months 1, 3, and 6 months subsequent to the baseline telephone assessment. The PTSD Checklist-Military Version was used to assess PTSD and the Patient's Health Questionnaire was used to assess symptoms of depression. FINDINGS: Female veterans who received an intervention were significantly more likely to have attended treatment over the 6-month follow-up period than male veterans who received an intervention (χ(2) = 7.91; df = 3; odds ratio, 3.93; p = .04). CONCLUSIONS: The CBT intervention may be a critical mechanism to engage female veterans in treatment. Further research is needed to understand how to engage male veterans with PTSD in treatment.

Change IS Possible: Reducing High-Risk Drinking Using a Collaborative Improvement Model.

OBJECTIVE: To describe the adoption of public health and improvement methodologies to address college students' high-risk drinking behaviors and to aid in prevention efforts. PARTICIPANTS: Members of 32 colleges and universities, content experts, and staff members of the National College Health Improvement Program (NCHIP). METHODS: A 2-year learning collaborative developed by NCHIP trained individuals from 32 different college and universities in using the Plan-Do-Study-Act cycle as a method to create and implement initiatives aimed at reducing students' high-risk drinking behaviors and related harms. RESULTS: Participants experienced success ranging from noteworthy increases in type and amount of interventions directed at reducing high-risk drinking, to creating collaboratives across campus, the local community, and stakeholders. Challenges related to data collection and creating lasting cultural change remain. CONCLUSIONS: The use of quality improvement methodologies and creation of a national collaborative successfully effected meaningful change in high-risk drinking behaviors on college campuses.

Screening for substance abuse in women's health: a public health imperative.

Alcohol and drug use is a significant public health problem with particular implications for the health and safety of women. Women who abuse these substances are more likely to have untreated depression and anxiety and are at higher risk for intimate partner violence, homelessness, incarceration, infectious disease, and unplanned pregnancy. Substance abuse during pregnancy places both mother and fetus at risk for adverse perinatal outcomes. Data regarding the prevalence of substance abuse in women are conflicting and difficult to interpret. On the clinical level, strong arguments exist against routine urine drug testing and in favor of the use of validated instruments to screen women for drug and alcohol use both in primary women's health care and during pregnancy. A number of sex-specific screening tools are available for clinicians, some of which have also been validated for use during pregnancy. Given the risks associated with untreated substance abuse and dependence in women, the integration of drug and alcohol screening into daily clinical practice is imperative. This article reviews screening tools available to providers in both the prenatal and primary women's health care settings and addresses some of the challenges raised when women screen positive for drug and alcohol abuse.