Identifying patterns of pain, depression, anxiety, interpersonal trauma exposure, and nonmedical prescription opioid use: Latent class analysis among patients with chronic pain.

BACKGROUND: Chronic pain in the context of certain factors may be associated with potential for nonmedical prescription opioid use; however, identifying this risk can be challenging and complex. Several variables alone have been associated with non-prescribed opioid use, including depression, anxiety, pain interference, and trauma exposure. Prior research has often failed to integrate these assessments together, which is important as these factors may cluster together in important and complex ways. The current study aimed to identify classes of patients with chronic pain who have differential risk for use of nonmedical prescription opioid use, depression and anxiety, and pain severity, interference, and catastrophizing, and interpersonal violence exposure. METHODS: Self-report and medical record data from patients (N = 211; Mage = 48, 69.0% women, 69.0% white) at a pain management center were collected. RESULTS: Latent class analysis revealed 3 classes with (1) low probability of clinically significant depression, anxiety, pain, and nonmedical prescription opioid use (44.7%), (2) high probability of clinically significant depression, anxiety, pain, pain catastrophizing, trauma, and nonmedical prescription opioid use (41.3%), and (3) high probability of severe pain and nonmedical prescription opioid use (14.0%). CONCLUSIONS: High-risk classes had either high levels of depression and anxiety, pain catastrophizing, and interpersonal violence exposure, or pain severity and interference. Future research should continue to explore these classes in large, diverse samples, and prospective study designs. Finally, results underscore that opioid use is complex, not easily identified by a single factor, and may be motivated by complex unmet clinical needs.

"My Goal is to get Through the Day Without Pain": A Qualitative Study on Chronic Pain Experiences and Treatment Needs Among Child Caregiving Women.

INTRODUCTION: We aimed to understand connections between pain, caregiving, physical and behavioral health treatment needs, and motivations for prescription opioid use among child caregiving women with chronic pain. METHODS: We conducted in-depth, semi-structured interviews with 12 women (average age 48 years; 58% Black) in child caregiving roles, including women who were pregnant or trying to become pregnant and were caring for children or grandchildren < 18 years, and who received treatment at an outpatient pain management clinic. We used thematic text analysis to identify qualitative themes related to caregiving, pain, treatment, substance use, coping strategies, and sources of support. RESULTS: A diverse sample of women reported high levels of stress and pain, substance use, interpersonal violence, depression, and financial strain. Most described difficulties at work, interacting with children or grandchildren, and engaging routine, daily activities due to their pain. Most indicated that they spent less time with family and friends due to their pain and had limited sources of support to help them navigate both caregiving and pain. Many described barriers to receiving appropriate healthcare, including prescription opioids, due to stigma or logistics, though most also reported positive healthcare experiences. Women also reported added daily-life, physical, mental health, and interpersonal stressors and difficulty navigating the healthcare system to receive needed care. DISCUSSION: For women with chronic pain in child caregiver roles, results highlight the importance of care tailored to the physical needs of child caregiving and of trauma-informed approaches given the prevalence of comorbid conditions and trauma.

Impacts of Initial Prescription Length and Prescribing Limits on Risk of Prolonged Postsurgical Opioid Use.

BACKGROUND: In response to concerns about opioid addiction following surgery, many states have implemented laws capping the days supplied for initial postoperative prescriptions. However, few studies have examined changes in the risk of prolonged opioid use associated with the initial amount prescribed. OBJECTIVE: The objective of this study was to estimate the risk of prolonged opioid use associated with the length of initial opioid prescribed and the potential impact of prescribing limits. RESEARCH DESIGN: Using Medicare insurance claims (2007-2017), we identified opioid-naive adults undergoing surgery. Using G-computation methods with logistic regression models, we estimated the risk of prolonged opioid use (≥1 opioid prescription dispensed in 3 consecutive 30-d windows following surgery) associated with the varying initial number of days supplied. We then estimate the potential reduction in cases of prolonged opioid use associated with varying prescribing limits. RESULTS: We identified 1,060,596 opioid-naive surgical patients. Among the 70.0% who received an opioid for postoperative pain, 1.9% had prolonged opioid use. The risk of prolonged use increased from 0.7% (1 d supply) to 4.4% (15+ d). We estimated that a prescribing limit of 4 days would be associated with a risk reduction of 4.84 (3.59, 6.09)/1000 patients and would be associated with 2255 cases of prolonged use potentially avoided. The commonly used day supply limit of 7 would be associated with a smaller reduction in risk [absolute risk difference=2.04 (-0.17, 4.25)/1000]. CONCLUSIONS: The risk of prolonged opioid use following surgery increased monotonically with increasing prescription duration. Common prescribing maximums based on days supplied may impact many patients but are associated with relatively low numbers of reduced cases of prolonged use. Any prescribing limits need to be weighed against the need for adequate pain management.

Postsurgical Opioid Prescriptions and Risk of Long-term Use: An Observational Cohort Study Across the United States.

OBJECTIVE: The aim of this study was to evaluate differences in risk of long-term opioid therapy after surgery among an opioid-naive population using varying cutoffs based on days supplied (DS), total morphine milligram equivalents (MME) dispensed, and quantity of pills (QTY) dispensed. BACKGROUND: In response to the US opioid crisis, opioid prescription (Rx) limits have been implemented on a state-by-state basis beginning in 2016. However, there is limited evidence informing appropriate prescribing limits, and the effect of these policies on long-term opioid therapy. METHODS: Using the MarketScan claims databases, we identified all opioid-naive patients undergoing outpatient surgery between July 1, 2006 and June 30, 2015. We identified the initial postsurgical opioid prescribed, examining the DS, total MME, and QTY dispensed. We used Poisson to estimate adjusted risk differences and risk ratios of long-term opioid use comparing those receiving larger versus smaller volume of opioids. RESULTS: We identified 5,148,485 opioid-naive surgical patients. Overall, 55.5% received an opioid for postoperative pain, with median days supply = 5 and median total MME = 240. The proportion of patients receiving prescriptions above 7 DS increased from 11% in 2006 to 19% in 2015. Among those receiving postoperative opioids, 8% had long-term opioid use, and risk of long-term use was 1.16 times [95% confidence interval (CI), 1.10-1.25] higher among those receiving >7 days compared with those receiving ≤7 days. Those receiving >400 total MME (15% of patients) were at 1.17 times (95% CI, 1.10-1.25) the risk of long-term use compared with those receiving ≤400 MME. CONCLUSIONS: Between 2005 and 2015, the amounts of opioids prescribed for postoperative pain increased dramatically, and receipt of larger volume of opioids was associated with increased risk of long-term opioid therapy.

Pre-Visit Education on Pain Management Options Prior to the First Clinic Visit Improves Chronic Pain Patient Satisfaction with Proposed Treatment Plans.

OBJECTIVE: This study sought to evaluate if actively informing new chronic pain patients about treatment options and setting realistic expectations for care, through the use of a pre-visit informational handout prior to the first clinic visit, improved patient satisfaction with subsequently proposed treatment plans. METHODS: The study was divided into two 3-month periods. During the first 3 months, with our current pain clinic practices in place, new patients (n = 147) were given surveys to establish a baseline of patient satisfaction with treatment plans proposed on their first visit. During the second 3 months, a different group of new patients (n = 156) was given a detailed informational handout which described our clinic's multimodal approach to pain management and therapeutic expectations prior to their visit with a provider. Patient satisfaction with subsequently proposed treatment plans was then assessed and compared with the baseline group. RESULTS: The average patient satisfaction score for the group of patients given the informational handout was 4.21 (on a 5-point Likert scale), compared to an average score of 3.25 for the baseline group (P < .0001, unpaired t-test). 77.6% of patients given the informational handout said their proposed treatment plan met their expectations compared to 46.3% of patients in the baseline group (χ2= 31.61, two-tailed P < .0001). CONCLUSIONS: Patient satisfaction with proposed chronic pain treatment plans was improved when clinic approaches to pain were explicitly outlined and therapeutic expectations were clearly established in the form of an informational handout at the outset of the first visit.

Day-of-Surgery Gabapentinoids and Prolonged Opioid Use: A Retrospective Cohort Study of Medicare Patients Using Electronic Health Records.

BACKGROUND: While preoperative gabapentinoids are commonly used in surgical multimodal analgesia protocols, little is known regarding the effects this therapy has on prolonged postsurgical opioid use. In this observational study, we used data from a large integrated health care system to estimate the association between preoperative day-of-surgery gabapentinoids and the risk of prolonged postsurgical opioid use. METHODS: We identified adults age ≥65 years undergoing major therapeutic surgical procedures from a large integrated health care system from 2016 to 2019. Exposure to preoperative gabapentinoids on the day of surgery was measured using inpatient medication administration records, and the outcome of prolonged opioid use was measured using outpatient medication orders. We used stabilized inverse probability of treatment-weighted log-binomial regression to estimate risk ratios and 95% confidence intervals (CIs) of prolonged opioid use, comparing patients who received preoperative gabapentinoids to those who did not and adjusting for relevant clinical factors. The main analysis was conducted in the overall surgical population, and a secondary analysis was conducted among procedures where at least 30% of all patients received a preoperative gabapentinoid. RESULTS: Overall, 13,958 surgical patients met inclusion criteria, of whom 21.0% received preoperative gabapentinoids. The observed 90-day risk of prolonged opioid use following surgery was 0.91% (95% CI, 0.77-1.08). Preoperative gabapentinoid administration was not associated with a reduced risk of prolonged opioid use in the main analysis conducted in a broad surgical population (adjusted risk ratio [adjRR], 1.19 [95% CI, 0.67-2.12]) or in the secondary analysis conducted in patients undergoing colorectal resection, hip arthroplasty, knee arthroplasty, or hysterectomy (adjRR, 1.01 [95% CI, 0.30-3.33]). CONCLUSIONS: In a large integrated health system, we did not find evidence that preoperative gabapentinoids were associated with reduced risk of prolonged opioid use in patients undergoing a broad range of surgeries.

Evidence-Based Medicine and Regulatory Oversight: Opioid Prescribing for Treatment of Pain.

It is no secret that our country is in the midst of an opioid crisis. With hundreds of Americans dying everyday due to opioid use, it is hard to ignore. Closely related, though not as often talked about, is another crisis providers are facing: chronic pain and its treatment. The treatment approach to this problem is multifaceted. Evidence-based studies are the hallmark of appropriate treatment; however, increasing patient concerns and regulatory oversight have added an additional layer that physicians and other prescribers have to incorporate. Navigating a balance between evidence-based treatment, regulatory pressures, and patient concerns is now at the forefront of pain management and patient care.

Family Anesthesia Experience: Improving Social Support of Residents Through Education of Their Family and Friends.

Introduction: The prevalence of burnout among anesthesiology residents is 41%-51%. Burnout is associated with medical errors, physician turnover, and substance use disorder. Social support and wellness may reduce burnout, but a barrier is support persons' lack of understanding of an anesthesiologist's work demands. We developed the Family Anesthesia Experience (FAX) to help support persons best support their resident. Methods: FAX consisted of a 4-hour event with hands-on experience, didactics portion, and panel discussion. Participants learned about a typical day in the life of an anesthesiology resident, wellness, burnout, substance use disorder, and available support resources, and had hands-on experience with procedures. The panel discussion offered logistical information about anesthesiology residency and allowed support persons to ask panel members questions. A postevent survey collected feedback on the event. Results: Fifty-one participants (first-year anesthesiology residents and their support persons) attended the event. Eight of 11 residents (73%) and 32 of 40 support persons (80%) completed the survey. All enjoyed the event, would recommend it to other anesthesiology resident support persons, and felt the event would improve communication and support. Most learned a moderate (35%) to large amount (50%) from the event. Qualitative feedback suggested most support persons found the event helpful in improving their understanding of anesthesiology residents' work demands. Discussion: The FAX was well liked by participants. Although we did not assess specific knowledge gained and long-term effects of the 2022 event, evaluations of previous years' events suggest that the event improved participants' understanding of anesthesiology residents' work and stressors.

Examining Age and Postoperative Opioid Use in the Urogynecology Population: A Prospective Study.

IMPORTANCE: Surgeons must individualize postoperative pain management while also reducing the amount of unused prescribed opioids. OBJECTIVES: This study compared postoperative opioid use in younger versus older women following urogynecologic surgery. We also assessed the likelihood of women returning unused opioids for safe disposal. STUDY DESIGN: This was a prospective study of women undergoing pelvic reconstructive surgery divided into 2 cohorts: younger (<65 years) and older (≥65 years). Our primary outcome was total opioid use, measured in morphine milligram equivalents (MME). We also assessed the average pain score during the first week after surgery measured by a numerical pain scale (range, 0-10). Our secondary outcome was the rate of return of unused prescribed opioids at the 6-week postoperative visit utilizing a disposable drug deactivation system. RESULTS: From April 2019 to September 2021, 152 participants were enrolled: 92 (61%) in the younger cohort (mean age, 51 ± 8 years) and 60 (39%) in the older cohort (mean age, 72 ± 6 years). For our primary outcome, younger women used significantly more opioids during the first postoperative week compared with older women (49 ± 71 vs 28 ± 40 MME, respectively, P = 0.04), despite no difference in average pain scores (4 ± 2 younger vs 3 ± 2 older, P = 0.05). For our secondary outcome, 23% of participants returned their opioids for disposal with the drug deactivation system. CONCLUSIONS: Younger women had higher postoperative opioid use despite similar pain scores after urogynecologic surgery. Among those prescribed opioids, a quarter of participants returned their opioids for disposal at their postoperative visit.

Inches, Centimeters, and Yards: Overlooked Definition Choices Inhibit Interpretation of Morphine Equivalence.

OBJECTIVE: Morphine-standardized doses are used in clinical practice and research to account for molecular potency. Ninety milligrams of morphine equivalents (MME) per day are considered a "high dose" risk threshold in guidelines, laws, and by payers. Although ubiquitously cited, the "CDC definition" of daily MME lacks a clearly defined denominator. Our objective was to assess denominator-dependency on "high dose" classification across competing definitions. METHODS: To identify definitional variants, we reviewed literature and electronic prescribing tools, yielding 4 unique definitions. Using Prescription Drug Monitoring Programs data (July to September 2018), we conducted a population-based cohort study of 3,916,461 patients receiving outpatient opioid analgesics in California (CA) and Florida (FL). The binary outcome was whether patients were deemed "high dose" (>90 MME/d) compared across 4 definitions. We calculated I2 for heterogeneity attributable to the definition. RESULTS: Among 9,436,640 prescriptions, 42% overlapped, which led denominator definitions to impact daily MME values. Across definitions, average daily MME varied 3-fold (range: 17 to 52 [CA] and 23 to 65 mg [FL]). Across definitions, prevalence of "high dose" individuals ranged 5.9% to 14.2% (FL) and 3.5% to 10.3% (CA). Definitional variation alone would impact a hypothetical surveillance study trying to establish how much more "high dose" prescribing was present in FL than CA: from 39% to 84% more. Meta-analyses revealed strong heterogeneity (I2 range: 86% to 99%). In sensitivity analysis, including unit interval 90.0 to 90.9 increased "high dose" population fraction by 15%. DISCUSSION: While 90 MME may have cautionary mnemonic benefits, without harmonization of calculation, its utility is limited. Comparison between studies using daily MME requires explicit attention to definitional variation.

The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review.

BACKGROUND: Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. METHODS: This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan-Jun 2018) versus postintervention (Jan-Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. RESULTS: A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5-36.5). There was no significant difference in 2019 (-8 morphine milligram equivalents, 95% confidence interval -20.5 to 4.6). CONCLUSION: Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

Implementation of Postoperative Standard Opioid Prescribing Schedules Reduces Opioid Prescriptions Without Change in Patient-reported Pain Outcomes.

OBJECTIVE: To implement Standard Opioid Prescribing Schedules (SOPS) based on opioid use following urologic surgeries and to evaluate how evidence-based prescribing schedules affect opioid use and patient reported outcomes. METHODS: Patients who underwent urologic surgeries within 6 procedure subtypes at UNC Health during the 2 study time periods ("pre-SOPS": 7/2017-1/2018, "post-SOPS": 7/2018-1/2019) were invited to complete a survey analyzing postoperative opioid usage, storage and disposal, and patient reported outcomes (including pain interference using a validated questionnaire). A pharmacy database provided medication prescribing data and patient demographics. During the pre-SOPS time period, baseline outcomes were measured. Following the pre-SOPS period, usage amounts were analyzed and Standard Opioid Prescribing Schedules were developed to guide prescriptions during the post-SOPS period. Descriptive summary statistics and appropriate t test or r2 were calculated. RESULTS: A total of 438 patients within 6 procedure types completed the survey (pre-SOPS: 282 patients, post-SOPS: 156 patients). Pre-SOPS, patients were prescribed significantly more 5-mg oxycodone tablets than used (20.9 vs 7.8, P <.001). Post-SOPS, compared to pre-SOPS amounts, patients were prescribed significantly fewer tablets (12.7 vs 20.9, P <.001) and used fewer tablets (5.3 vs 7.8, P = .003). No difference was observed in pain interference (average t-score (standard deviation): 54.33 (10.9) pre-SOPS vs 55.89 (9.1) post-SOPS, P = .125) or patient satisfaction (95% pre-SOPS vs 94% post-SOPS). CONCLUSION: Adherence to data-driven postoperative opioid prescribing schedules reduce opioid prescriptions and use without compromising pain interference or patient satisfaction. These results have important implications for urologists' ability to decrease opioid prescriptions and fight the opioid epidemic.

Should Surgeons or Anesthesiologists Manage Perioperative Pain Protocols?

Enhanced recovery after surgery (ERAS®) protocols vary by surgery type. This article examines benefits of ERAS pathways, compares ERAS pathways to traditional protocols from clinical and ethical standpoints, and discusses formal recommendations of the American College of Surgeons, the American Society of Anesthesiologists, and other groups.

Family Comes First: A Pilot Study of the Incorporation of Social Support Into Resident Well-being.

BACKGROUND: Recent work has shown that understanding of work-related stress by family and friends is associated with increased resident well-being. However, it is often difficult for residents to communicate with their support persons (SPs), especially those who have minimal understanding of the medical field, regarding even the most basic functions of their role in the health care system. This study aimed to pilot test an innovative wellness event focusing on the social relatedness component of resident well-being. METHODS: The target population included 30 new residents at 2 anesthesiology residency programs and their SPs in 2017. The Family Anesthesia Experience (FAX) began with didactic presentations and a panel discussion about wellness topics. It concluded with a multifaceted simulation experience. Participants were surveyed before and after the event. Measures included SPs' understanding of residents' work and residents' stress, burnout, resilience, and social support levels. Student t tests, Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated measures analysis of variance were used to examine the impact of the event. RESULTS: Twenty-two (84.6%) of the 26 intervention clinical anesthesia year 1 residents who attended FAX completed the postevent surveys, and all intervention SPs (100%, n = 33) completed both pre-event and postevent surveys. The event was well received by the residents (100%) and their SPs (100%). Improvement in perceived understanding in the intervention SPs group (Pre: 1.44 ± 0.63, Post: 2.69 ± 0.33, P < .0001) was observed. Not all metrics of well-being for the residents achieved significance in change; however, decreased stress was observed compared with historical controls (Control: 1.91 ± 0.61, Intervention: 1.54 ± 0.42, P = .019). CONCLUSION: The event led to improved SPs' understanding of the role of an anesthesiology resident.

Opioid Stewardship in Urology: Quality Improvement Summit 2018.

INTRODUCTION: We summarize the 2018 AUA (American Urological Association) Quality Improvement Summit, Opioid Stewardship in Urology, highlighting appropriate urological opioid use as well as reviewing programs that have been successful in reducing opioid prescribing. The AUA brought together nearly 100 attendees from across the United States, including clinicians who specialize in urology and other specialties, as well as researchers, government officials and others. METHODS: The 2018 AUA Quality Improvement Summit was a 1-day meeting held at AUA headquarters in Linthicum, Maryland. Talks and panels highlighted opioid stewardship programs and emphasized research on the nature and management of postoperative pain. RESULTS: The impact of the opioid epidemic is profound and the contribution of postoperative prescribing is noteworthy (eg 6% of opioid naïve patients demonstrate new persistent use habits after surgery and up to 70% of opioid pills prescribed after surgery go unused). Speakers raised awareness of these facts and detailed opportunities to improve, including prudent prescribing, opioid reclamation, use of nonopioid alternatives, and outreach and education. CONCLUSIONS: The 2018 AUA Quality Improvement Summit provided a platform for urologists to discuss the opioid epidemic and to learn strategies for combatting this issue from multidisciplinary experts. Physician led opioid stewardship and research, facilitated by this Summit, may enhance the quality and safety of medical care and improve the lives of patients, their families and their communities.

The Use of Simulation to Improve Family Understanding and Support of Anesthesia Providers.

Introduction  Burnout in medical providers is associated with work dissatisfaction, reduction in patient safety, and provider depression. Simulation is a tool effectively used for specific task training but has not been broadly used as a means to combat medical professional stress and enhance wellness. The authors created a medical simulation program targeted at those involved in the social support of medical providers. The hypothesis was that education of non-medical persons involved in social support would translate into an enhanced understanding of the demands among medical providers in anesthesiology. This understanding would thereby open communication pathways within the social support system and contribute to enhanced wellness among providers. Methods To assess effectiveness and benefits of the event, survey data were obtained from anesthesia providers and their adult support persons before and after the event. The anesthesia providers were queried on their perception regarding the benefit of the event for their support persons. Support persons were asked questions regarding their understanding of the role of an anesthesia provider. Results Sixty-three family members and friends (adult=30, child=33) participated in a two-hour simulation event including activities for participants of all ages. Twenty-nine (96.7%) adult participants (age ≥ 14) completed the support person surveys before and/or after the event. The post-event survey results revealed participants' satisfaction with the event (n=26, 100%). This simulation event also demonstrated an improved understanding of the demands among anesthesia providers by their support persons (seven items, P values range from less than .0001 to .0313). Most anesthesia providers who attended the event enjoyed it a significant amount (n=19, 82.6%). Most providers whose primary work-related support persons attended the event believed that it would be easier to communicate work-related issues (n=12, 85.7%). Conclusion We outline "The Family Anesthesia Experience Day" as a wellness initiative for anesthesia providers. Our study demonstrated improved understanding of support persons' knowledge about anesthesia providers' work-related stress via an immersive two-hour simulation-based learning experience. The event was well-received and may be a useful approach to provide support persons with an opportunity to learn about and better support their beloved anesthesia provider.