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Background: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. Methods: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. Results: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without ( P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without ( P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men ( P = .0048), and Hispanics were prescribed 16.6 MME more than whites ( P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare ( P < .0001), but 25.0 MME less than those with Medicaid ( P < .0001). There were no differences across age groups. Conclusions: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.

Objectives Opioid prescription rates worldwide suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Findings from cognitive science show that risk perceptions can differ systematically depending on whether people learn about risks by description or experience. We investigated the effects of descriptive and simulated experience risk formats on patients’ risk perceptions and behavior regarding long-term strong opioid use. Methods 300 German patients with chronic noncancer pain were randomly assigned in an exploratory randomized controlled trial to either a descriptive format (fact box) or a simulated experience format (interactive simulation). Primary endpoints were subjective and objective risk perceptions and intended intake behavior. Results Both formats significantly improved patients’ objective risk perception; patients who saw the fact box estimated some outcomes more accurately (p = .031). Formats were equally effective in improving patients’ subjective risk perception in terms of opioids’ harms; however, patients receiving the simulation showed a greater reduction and termination of their opioid intake (p = .030) and a higher uptake of alternative therapies. Conclusions Descriptive and simulated experience risk formats improve risk perceptions and behavior regarding potent but highly risky drugs. Practice implications To eliminate risky behavior, simulated experience formats may be superior to descriptive formats.

Background Given the national opioid crisis, postoperative analgesia at discharge must be thoughtfully prescribed. Data specifically related to thoracic procedures remain scarce. This study assessed adequacy of pain control with standardized and limited opioids after thoracic procedures. Methods A standardized prescription comprised 15 hydromorphone tabs, 7 days of acetaminophen, and 3 days of ibuprofen was provided on discharge to elective thoracic surgery patients. On the first postoperative visit, patients completed a questionnaire regarding the number of hydromorphones used, use of additional opioids, pain-related limitation to function, and adequacy of pain control. Results A total of 122 patients undergoing thoracic surgery procedures were surveyed. Twelve underwent open procedures and were excluded. An additional 6 patients who used opioids chronically preoperatively were also excluded. The remaining 104 patients were included in the study. Median age was 66 years (age range, 17-90 years) and median length of stay was 2 days (range, 1-15 days). Seventeen (16%) patients used all prescribed hydromorphone and 56 (54%) used none, 18 (17%) asked for additional or other opioid, and 14 (13%) felt that their pain significantly limited their function. Nine (9%) felt that that their pain was inadequately controlled. Conclusions Pain after thoracic procedures, especially video-assisted thoracoscopic surgery, is adequately controlled with minimal opioid doses (combined with adjuncts), with less than 1 in 5 patients requiring additional prescriptions and very few patients complaining of pain that significantly limited their function. This study shows that a standardized limited opioid prescription is safe, is adequate, and can easily be implemented for the majority of thoracic surgery patients.

Background Opioid misuse continues to be a major concern in the United States, affecting both adults and adolescents. Unfortunately, even legitimate prescription opioid misuse in adolescence increases the risk for misuse later in life. Although adolescence is a critical period for learning, little is known about adolescents’ preferences for opioid safety education. One potential avenue for prescription opioid education is the use of serious games. Serious games can result in better health outcomes and understanding for adolescents and allow them to safely experience real-life scenarios. However, few studies have examined the use of serious games for adolescent opioid education. Objective This study explored adolescents’ preferences for prescription opioid education and design of a serious game focused on opioid safety education. Methods A focus group guide was adapted from 2 statewide surveys about participants’ perspectives on opioids. Recruitment packets with consent documents and an introduction to the study were sent home to eligible students. Ten focus groups were conducted with 68 middle and high school students in Wisconsin. Adolescents were asked to discuss their preferences for prescription opioid safety education and to design a serious game to educate teens about opioid safety. Focus groups were audio-recorded, professionally transcribed, and underwent content and thematic analyses using NVivo 12 software. Results Three preferred approaches for opioid safety education were identified, including the use of presentations, videos and websites, and serious games. Adolescents desired short presentations delivering personal stories to smaller audiences. They preferred websites and brief, engaging videos from reliable sources because of ease of access. Adolescents also preferred serious games for opioid education that were realistic and relatable. Conclusion When educating adolescents on prescription opioids, the use of presentations, particularly personal stories, brief and engaging websites and videos, or serious games with realistic and relatable scenarios should be incorporated.

Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.

Background The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA. Methods Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). Results We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies. Conclusion Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.

Objectives. The objectives of this study were (1) to assess the impact of the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (GPOCP) on tramadol and opioid prescription rates in patients with chronic kidney disease (CKD), (2) to identify if tramadol was being properly dosed based on kidney function, and (3) to identify the number of clinically relevant drug-drug interactions related to tramadol. Design. Retrospective cohort study. Setting and Participants. Patients with a diagnosis of CKD stage IV or V or end-stage renal disease (ESRD) with a hospital discharge were identified. Participants were distributed into a pre-GPOCP cohort (January to December 2015) and post-GPOCP cohort (January 2017 to May 31, 2018) based on their hospital discharge date. Participants were then further divided into three categories: those who were discharged with a new prescription for tramadol, those who were discharged with a prescription for another opioid product, or those who were discharged with no new opioid or tramadol prescription. Outcome Measures. The primary outcome was incidence of new outpatient tramadol and opioid hospital discharge prescriptions. The secondary outcomes were the number of correctly dosed tramadol discharge prescriptions based on kidney function and incidence of clinically significant drug-drug interactions with tramadol. Results. New tramadol and opioid prescription rates upon hospital discharge for CKD stage IV and V and ESRD patients decreased from 76 (2.5%) to 54 (1.1%) and from 145 (4.7%) to 119 (2.5%), respectively ( P

The study examined the relationship between dispensing patterns of prescription opioids, neighborhood-disadvantage-index, and standardized doses dispensed. Three-year&rsquo, s dispensing data drawn from 80 local government areas (LGAs) within Victoria, Australia&rsquo, s second most populous state, was analyzed. Quantities dispensed in defined daily dose (DDD)/1000-people/day were computed for LGAs of low, moderate, high, and very high socio-economic disadvantage. LGAs with various levels of dispensing, and neighborhood disadvantage were identified and mapped. A multivariable regression model examined the effect of neighborhood level disadvantage and identified other factors that are associated with standardized doses dispensed. More women were dispensed opioids than men. Dispensing increased with increasing age. Most of the LGAs with relatively high dispensing were socioeconomically disadvantaged and located outside the major cities. Dispensing gradually increased from low disadvantage to very high disadvantage areas. Dispensing of standardized doses were consistently higher in rural areas than in urban areas. Neighborhood level disadvantage, age, sex, and urbanization were significant factors in the standardized doses dispensed. As inappropriate dispensing of opioids is a major public health problem, research should facilitate understanding of utilization in small areas to enable tailored public health programs. Nationwide and consistent introduction of real-time prescription drug-monitoring programs, and structural interventions to reduce the fundamental causes of socioeconomic disadvantage and isolation are recommended.

Introduction Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia. Methods Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020. Results Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states. Conclusions Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.

Long-term opioid therapy (LTOT) is associated with increased risk for depression. It is not known if the frequency of opioid use during LTOT is associated with new onset depression. We used Optum's de-identified Integrated Claims-Clinical dataset (2010-2018) to create a cohort of 5,146 patients, 18 - 80 years of age with an encounter or claims in the year before new LTOT. New LTOT was defined by > 90 day opioid use after remaining 6-months opioid free. Opioid use frequency during the first 90 days of LTOT was categorized into occasional use (< 50% days covered), intermittent use (50% to < 80% days covered), frequent use (80% to < 90% days covered) and daily use (≥ 90% days covered). Propensity scores and inverse probability of exposure weighting controlled for confounding in models estimating risk for new onset depression. Patients were on average, 54.5 (SD±13.6) years of age, 55.7% were female, 72.5% were white and 9.5% were African-American. After controlling for confounding, daily users (HR=1.40; 95%CI:1.14-1.73) and frequent users (HR=1.34; 95%CI:1.05-1.71) were significantly more likely to develop new onset depression compared to occasional users. This association remained after accounting for the contribution of post-index pain diagnoses and opioid use disorder. In LTOT, risk for new depression episodes is up to 40% greater in near daily users compared to occasional users. Patients could reduce depression risk by avoiding opioid use on as many low pain days as possible. Repeated screening for depression during LTOT is warranted.

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.

Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.

Background Significant and sustained weight loss resulting from bariatric surgery have demonstrated clinical reduction in severe obesity-related pain. Subsequentially, post-surgical pain reduction may reduce pain medication use. However, clear evidence regarding use of prescribed pain medications before and after bariatric surgery is absent. Methods Linking two state-wide databases, patients who underwent bariatric surgery between July 1, 2013 and December 31, 2015 were identified. Proportion tests were used to compare percent of patients with pain medication prescriptions 1 year before and 1 year after bariatric surgery. Logistic regression was used to identify baseline factors that were associated with pain medication use 1-year following surgery. Results A total of 3535 bariatric surgical patients aged 18-64 years at surgery were identified. Of these patients, 1339 patients met the following study criteria: covered by private insurance; known pre-surgical BMI; and continuous enrollment with health plan(s) from 12-month pre-surgery to 13-month post-surgery. While comparison of average number of overall pain medication prescriptions before and after surgery did not change, from 3.46 to 3.32 prescriptions (p value = 0.26), opioid prescription use increased from 1.62 vs. 2.05 (p value Conclusion While comparison of average number of overall pain medication prescriptions before and after bariatric surgery did not decrease, opioid prescription increased post-surgery. Further studies are needed to examine whether post-surgery opioids are prescribed in lieu of or in tandem with other pain medication prescriptions.

BACKGROUND Opioid use in the treatment of musculoskeletal injuries is a complex decision where benefits must be balanced with risk. Previous research has shown an association between higher opioid doses and adverse health effects. The study's objective was to investigate whether opioid prescriptions are associated with increased costs and deaths through an injury mechanism or as a direct result of the opioid prescription. METHODS Data for 144,553 deidentified Ohio Bureau of Workers' Compensation claims from 2010 to 2014 with shoulder, knee, and low back injuries were obtained and followed until 2016. Each claim had associated prescription information. Injury claims were further classified using the allowed diagnoses by single or multiple body areas affected and injury severity ("simple" or "complex"). The outcome variables were medical and indemnity costs, lost days, MaxMED (maximum claim-prescribed daily morphine equivalent dose), and death status. Association between maximum opioid dose with deaths was determined by logistic regression analysis. RESULTS Several outcome variables, including claim medical and indemnity costs, and the likelihood of claimant death, showed significant associations with the MaxMED. In the analysis of claim deaths, these associations held for all claim types (except complex), even after adjusting for age, gender, surgery, and lost time. CONCLUSION The association between increasing opioid doses and deaths for low-severity diagnoses was disturbing given the lack of demonstrated efficacy of opioids for treatment of minor injuries. A focus on provider education, increased utilization of non-opioids, and early intervention for minor soft-tissue injuries could reduce claims costs, disability, and future deaths.

STUDY OBJECTIVES: The aim of this study was to estimate the association between insufficient sleep and prescription opioid misuse among US high school students. METHODS: Participants were 6,884 high school students who self-reported on sleep duration and prescription opioid misuse in the 2019 Youth Risk Behavior Survey. Sleep duration was categorized by the Youth Risk Behavior Survey according to the American Academy of Sleep Medicine guidelines as follows: recommended sleep duration (8–9 hours) vs insufficient sleep (< 8 hours). Participants also reported whether they had any prescription opioid misuse during their lifetime and whether they had prescription opioid misuse within the past 30 days. RESULTS: Most (79.4%) participants reported sleeping less than 8 hours per night. Among all youth, 12.9% reported lifetime prescription opioid misuse and 6.2% reported current prescription opioid misuse. Prevalence of both lifetime and current opioid medication misuse was higher among those also reporting insufficient sleep compared to those reporting recommended sleep duration (14.3% vs 7.7%, P < .0001 for lifetime misuse and 6.6% vs 4.3%, P = .0091 for current misuse). In multivariate models, insufficient sleep was associated with an increased odds of lifetime prescription opioid misuse (adjusted odds ratios = 1.4; 95% confidence interval, 1.1–1.2; P = .006); however, we did not find an association between sleep duration and current prescription opioid misuse in multivariate analysis. CONCLUSIONS: Sleep duration is associated with lifetime opioid misuse among US youth. Longitudinal studies are needed to test whether causal relationships exist, and to understand biobehavioral mechanisms that underlie associations between sleep deficiency and opioid misuse in adolescents. CITATION: Groenewald CB, Rabbitts JA, Tham SW, Law EF, Palermo TM. Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. J Clin Sleep Med. 2021;17(11):2205–2214.

The United States is facing an opioid epidemic that has only worsened with the COVID-19 pandemic. There is little evidence regarding patterns of opioid use among patients with total hip replacement (THR). Although the Centers for Disease Control and Prevention has put forward guidelines for prescribing opioids, it does not include guidance specifically for THR patients suffering from presurgical and postsurgical pain. The purpose of this study was to (1) compare presurgical and postsurgical opioid rates, (2) compare presurgical and postsurgical morphine milligram equivalents (MME), and (3) determine whether having a presurgical opioid prescription predicts the receipt of postsurgical opioid prescriptions among patients undergoing THR surgery. Retrospective cohort analysis of 4,405 patients undergoing THR at a major academic medical center in the United States from April 30, 2015, to April 30, 2018, was done. Patient characteristics, opioid rates, and average MME/day/person were described. Logistic regression was used to determine whether presurgical opioid prescription and opioid risk level predicted postsurgical opioid prescribing. Median age was 64 years (range = 18-85 years); patients were primarily Caucasian/White (78.8%) and female (54.7%). Opioid prescription rates in this sample for the 12-month presurgical and postsurgical periods were 66.1% and 95.6%, respectively. Oxycodone was the most common opioid prescribed in both periods. Among those prescribed an opioid, moderate/high risk for overdose and/or death was 6.3% presurgery and 19.8% postsurgery. Patients with a comorbidity were two times more likely to receive an opioid prescription in the postsurgical period. The median average MME/day/person was 26.5 (range = 0.3-180.0) for patients with an opioid prescribed during the presurgery period and 40.4 (range = 1.5-270.0) during the postsurgery period. Opioid use, regardless of strength, in the presurgical period as well as having one or more comorbidities predicted opioid use in the postsurgical period.

BACKGROUND Every day, more than 190 people in the United States die from opioid overdose. Unused opioid medications pose a risk to the patient and the community as they increase the potential for abuse or misuse. A contributing factor is lack of education on the proper disposal methods of unused opioid medications. PURPOSE The purpose of this quasi-experimental nursing study was to examine whether providing education on proper disposal of opioid medications would increase the proportion of patients who properly dispose of unused opioids. METHODS The study site's mandatory orthopaedic preoperative class was used for consenting patients. The control group did not receive targeted education on opioid disposal, whereas the intervention group did receive targeted education. A total of 86 patients were consented during Months 1 and 2 of the study. Forty-one patients were in the control group and 45 were in the intervention group. Demographic variables such as age, gender, and marital status were collected to determine whether certain demographic factors had an influence over whether or not opioids would be disposed of properly. FINDINGS Those in the intervention group who attended the class were slightly younger than those in the control group (68.2 ± 9.9 years vs. 70.3 ± 10.6 years, p = .5098), primarily male (57.5% vs. 35.0%, p = .0436), and more likely to live with a significant other (94.7% vs. 74.4%, p = .0249). Of those who had medication left over, 62.5% disposed of their unused opioid prescription in the intervention group compared with 40.7% in the control group (p = .1208). In the intervention group, 86.7% of the individuals with leftover medication disposed of it correctly compared with 63.5% in the control group (p = .3478). CONCLUSION Those who received education on appropriate opioid disposal were more likely to dispose of it in general as well as dispose of it correctly. Although not statistically significant, the findings from this study are clinically significant in that they provide direction on the importance of standardized and focused patient education on proper opioid disposal.

Background Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. Methods Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. Results Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. Conclusion There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.

Background and aims Over the past decades, people who inject drugs (PWID) have been impacted by the development of combination antiretroviral therapy (cART) to combat HIV/AIDS, the prescription opioid crisis, and increased use of lethal synthetic opioids. We measured how these dynamics have impacted mortality among PWID in an urban U.S. city. Design Prospective cohort study using data from the AIDS Linked to the Intravenous Experience (ALIVE) SETTING: Baltimore, Maryland, USA from 1988-2018. Participants 5,506 adult PWIDs (median age at baseline 37 years). Measurements Mortality was identified by linkage to National Death Index-Plus (NDI-Plus) and categorized into HIV/infectious disease (HIV/ID) deaths, overdose and violence-related (drug-related) deaths, and chronic-disease deaths. Person-time at risk accrued from baseline, and ended at the earliest of death or study period. All-cause and cause-specific mortality were calculated annually. Fine and Gray method was used to estimate the sub-distribution hazards of cause-specific deaths accounting for competing risks. Findings Among 5,506 participants with 84,011 person-years of follow-up, 43.9% were deceased by 2018. Among all deaths, 30.5% were HIV/ID-deaths, 24.4% drug-related deaths, and 33.3% chronic-disease deaths. Age-standardized all-cause mortality increased from 23 to 45 per 1000-person-years from 1988-1996, declined from 1996 through 2012, then trended upward through 2018. HIV/ID-deaths peaked in 1996 coincident with the availability of cART, then continuously declined. Chronic-disease deaths increased continuously as the cohort aged. Drug-related deaths declined until 2011, but increased over 4-fold by 2018. HIV/HCV infection and active injecting were independently associated with HIV/ID and drug-related deaths. Female and Black participants had higher risk of dying from HIV/ID deaths and a lower risk of dying from drug-related deaths than male and non-Black participants. Conclusions Deaths in Baltimore, Maryland, USA attributable to HIV/ID appear to have declined following the widespread use of combination antiretroviral therapy. Increases in the rates of drug-related deaths in Baltimore were observed prior to and continue in conjunction with national mortality rates associated with the opiate crisis.

OBJECTIVE The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries. SETTING Five percent sample of Medicare administrative claims obtained for years 2011-2015. PARTICIPANTS A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI. DESIGN Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI. MAIN MEASURES TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file. RESULTS The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02). CONCLUSIONS Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.

Community pharmacists have significant opportunity to contribute to prevention and treatment of opioid use disorders, but barriers to implementation still exist. Understanding their viewpoints is critical to designing future interventions.To qualitatively explore experiences and beliefs of community pharmacists regarding the misuse of prescription opioids in the United States.The study was part of a larger project that utilized a survey questionnaire to evaluate the relationships between knowledge, attitudes, and practices of community pharmacists in substance use disorders. The survey included an open-ended item on pharmacist views regarding the prescription opioid epidemic. The responses were used for inductive content analysis. Axial coding of themes was conducted to analyze underlying relationships: associations, consequences, intervening relationships, and action strategies regarding a central phenomenon. A model describing pharmacist experiences in the opioid epidemic was conceptualized.The open-ended question resulted in 50 (37.3%) usable responses. Final abstraction resulted in six themes including (1) overprescribing opioids: inappropriate prescribing as a contributor to the epidemic, (2) policy and practice recommendations: potential action strategies against the epidemic, (3) poor prescriber-pharmacist relationship: barrier to addressing the epidemic, (4) negative attitudes: intervening condition affecting roles of the pharmacist, (5) personal experience: facilitator to improve pharmacist roles and (6) decreased access to opioids: consequence of strict prescribing laws.The study identified themes that described pharmacist views, attitudes, barriers, and experiences related to their perceived role in prevention and treatment of opioid use disorders. Future research should consider the implications of the barriers and facilitators identified.

Objective The objective of this work was to develop a risk prediction model for opioid overdose and opioid use disorder for patients at first opioid prescription and compare the predictive accuracy of morphine equivalent total dosage with the predictive accuracy of daily dosage . Design Records from patients 18–79 years of age with opioid prescriptions between January 1, 2016, and June 30, 2019, no prior history of adverse outcomes, and no malignant cancer diagnoses were collected from the electronic health record system of a medium-sized central Ohio health care system (n = 219,276). A Cox proportional-hazards model was developed to predict the adverse outcomes of opioid overdose and opioid use disorder from patient sociodemographic, pharmacological, and clinical diagnosis factors. Results During the study time frame, 573 patients experienced overdoses, and 2,571 patients were diagnosed with opioid use disorder. Morphine equivalent total dosage of opioid prescriptions was identified as a stronger predictor of adverse outcomes (C = 0.797) than morphine equivalent daily dosage (C = 0.792), with the best predictions coming from a model that includes both predictors (C = 0.803). In the model with both daily and total dosage predictors, patients receiving a high total / low daily dosage experienced a higher risk (hazard ratio [HR] = 2.17) than those receiving a low total / high daily dosage (HR = 2.02). Those receiving a high total / high daily dosage experienced the greatest risk of all (HR = 3.09). Conclusions These findings demonstrate the value of including morphine equivalent total dosage as a predictor of adverse opioid outcomes and suggest that total dosage may be more strongly correlated with increased risk than daily dosage.

Prescription opioid misuse is an unintended consequence of acute pain management. Opioid-induced euphoria (OIE) with first therapeutic opioid exposure may influence opioid misuse. OIE is not assessed in clinical care and self-report measures of OIE have not been validated in adolescents. We (1) determined adolescents' ability to understand existing self-reported OIE measures, (2) revised measures for better understanding by this population, and (3) established initial content validity of revised measures with adolescents. Using runner's euphoria to simulate OIE in Study 1, 29 adolescents' (14 males) understanding of the Drug Effects Questionnaire (DEQ-5), the Addiction Resource Center Inventory Morphine Benzedrine Group scale (ARCI-MBG), and the ARCI Lysergic Acid Diethylamide scale (ARCI-LSD) were tested. In Study 2, 29 additional adolescents (9 males) participated in a modified Delphi study with focus groups to revise survey items to improve understanding by peers. In Study 1, runners understood40% of ARCI-MBG and ARCI-LSD statements. In Study 2, all but 7 survey items were revised. Revised measures of OIE for adolescents may help define at-risk OIE phenotypes and validate risk assessments using survey methodology. Additional studies are needed to validate the revised OIE self-report measures with opioid-naive adolescents receiving opioids to treat acute pain.

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid ‘epidemic’ and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients. Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

Background In response to the opioid epidemic, Florida recently passed the opioid prescription limiting law, effective since July 1st, 2018. However, its impact on opioid prescription after total joint arthroplasty (TJA) has not been elucidated. Thus, our objective was to assess if this new law led to reduced opioid prescription after TJA and to determine its impact on perioperative clinical outcomes. Methods A retrospective chart review was conducted on a consecutive series of 658 primary TJAs (618 patients), performed by four surgeons in a single institution [1/2/2018-10/23/2018]. Based on effective date of the law, cases were divided into: prelaw (327 cases; 168 hips/159 knees) and postlaw (331 cases; 191 hips/140 knees) phases. Baseline demographics and surgical characteristics were compared. The effect of the law on perioperative outcomes: length of stay, complications, emergency department/office visits, patient phone calls, reoperation or readmission (90 days), and total morphine equivalents prescribed was investigated. Independent sample t-tests and chi-square analyses were performed. Results Prelaw and postlaw phases had no significant difference in baseline demographics and characteristics. No difference was found in length of stay. Opioid law implementation led to significantly lower total oral morphine equivalents after TJAs [Prelaw: 1059.9 ± 825.4 vs postlaw: 942.8 ± 691.7; P = .04], but did not result in a significant increase in 90-day complications, patient visits (office or emergency) or phone calls, and reoperation or readmission. Conclusion Our data suggest that Florida state opioid prescription limiting law has resulted in a marked decline in opioid prescription without any increase in rates of patient visits, phone calls, or readmission after TJA.

BACKGROUND Hundreds of laws aimed at reducing inappropriate prescription opioid dispensing have been implemented in the United States, yet heterogeneity in provisions and their simultaneous implementation have complicated evaluation of impacts. We apply a hypothesis-generating, multistage, machine-learning approach to identify salient law provisions and combinations associated with dispensing rates to test in future research. METHODS Using 162 prescription opioid law provisions capturing prescription drug monitoring program (PDMP) access, reporting and administration features, pain management clinic provisions, and prescription opioid limits, we used regularization approaches and random forest models to identify laws most predictive of county-level and high-dose dispensing. We stratified analyses by overdose epidemic phases-the prescription opioid phase (2006-2009), heroin phase (2010-2012), and fentanyl phase (2013-2016)-to further explore pattern shifts over time. RESULTS PDMP patient data access provisions most consistently predicted high-dispensing and high-dose dispensing counties. Pain management clinic-related provisions did not generally predict dispensing measures in the prescription opioid phase but became more discriminant of high dispensing and high-dose dispensing counties over time, especially in the fentanyl period. Predictive performance across models was poor, suggesting prescription opioid laws alone do not strongly predict dispensing. CONCLUSIONS Our systematic analysis of 162 law provisions identified patient data access and several pain management clinic provisions as predictive of county prescription opioid dispensing patterns. Future research employing other types of study designs is needed to test these provisions' causal relationships with inappropriate dispensing and to examine potential interactions between PDMP access and pain management clinic provisions. See video abstract at, http://links.lww.com/EDE/B861.

To evaluate current opioid prescription practices following a cesarean delivery. Women were asked to participate in a prospective observational cohort study following a cesarean delivery. Participants were asked about their opioid use after discharge, amount leftover, subjective pain score, and satisfaction. A total of 344 women had cesarean deliveries during the study period, 242 were approached, 171 met eligibility criteria, and 109 were included in the analysis. Women in our study were predominantly African American (66.1%), high school graduates (32.1%), publicly insured (65.1%), single (55%) working mothers (68.8%). Most had been previously prescribed opioids (70.6%), of which 58.4% had a prior cesarean delivery. Only 78.8% of study participants took their opioid prescriptions, and 89.6% had an average of 17 pills leftover. The number of pills taken correlated with those prescribed in the study. Improved satisfaction in pain control with opioid and non-opioid alternatives was associated with a decrease in opioids used. Similarly, the participants’ perception of their abundant prescription quantity was associated with a decrease in prescription taken. Women were prescribed excess opioids. Excess opioids accounted for 63.3% of all pills filled, a total of 1670 pills leftover, most of which were stored in an unlocked location (75.6%). Our data showed a discrepancy of pills prescribed (24) compared to those used (10), which was also perceived as enough or too many by our participants. Our study demonstrates that women would benefit from fewer opioid pills and a discussion based on their pain perception.

Background Prescription opioid misuse and suicide among adolescents are significant health challenges. Purpose This study investigated whether effects of prescription opioid misuse on depressive symptoms and suicidality are greater among female than male students. Methods Using the 2017 Youth Risk Behavior Survey (N = 14,765), this research estimated additive interactions using risk differences as well as multiplicative interactions using odds ratios. Discussion Results showed prescription opioid misuse was associated with significantly greater risks among females than males for depressive symptoms (31.1% vs. 20.8%), suicidal ideation (27.3% vs. 19.1%), suicide attempts (18.1% vs. 11.9%) and suicide attempts requiring treatment (8.5% vs. 4.4%). In contrast, multiplicative interactions using odds ratios were all nonsignificant. Conclusions Among students who misused prescription opioids, females compared to males had much higher average predicted margins of depressive symptoms, suicidal ideation, suicide attempts, and suicide attempts requiring treatment. Screening for depression and suicidality among adolescents who misuse prescription opioids, and vice versa, is paramount.

Objective To describe opioid prescribing patterns for patients undergoing kidney cancer surgery and evaluate associations with medical resource utilization in the postoperative setting. Methods Linked Surveillance, Epidemiology, and End Results - Medicare data were used to identify patients with kidney cancer who underwent partial or radical nephrectomy (open vs. minimally invasive) from 2007 to 2015. Total dose of discharge opioid prescriptions was quantified into 3 exposure groups based on observed tertiles: 1-199 (low), 200-300 (moderate), and >300 (high) oral morphine milligram equivalents. Associations between exposure groups and patient demographics, clinical factors, and hospital volumes were measured using multivariate logistic regression. Additionally, we identified associations with prior opioid exposure and postoperative medical resource utilization. Results Of 4538 patients meeting inclusion criteria, exposure group distributions were 35% (low), 43.5% (moderate) and 21.6% (high). Over one-third of patients (39.5%) received an opioid prescription within 6 months preceding surgery. High opioid prescriptions were associated with prior exposure, younger age, rural residence and open surgery (P Conclusion Prescribing patterns after kidney cancer surgery vary widely. Higher prescribed dose of post-surgical opioids is associated with 90-day hospital readmissions and long-term exposure. Prior opioid exposure conveys a higher risk of medical resource utilization. More judicious opioid prescribing may limit medical resource utilization and help combat the opioid epidemic.

Objectives To evaluate patient, provider, and facility factors associated with variation in opioid prescribing after endoscopic procedures for benign prostatic hyperplasia across a large academic health system to drive improvement efforts. Methods Opioids prescribed at discharge for patients who underwent an endoscopic prostate procedure March 2018-November 2019 were analyzed. Multivariable logistic and linear regression were used to evaluate the relationship between patient, provider, and facility factors and the receipt of any opioid prescription and the quantity prescribed. Results We included 724 patients who had surgery with one of 26 urologists across five facilities. 222 (30.7%) received an opioid prescription, and the average morphine milligram equivalents (MMEs) prescribed was 97.9±33.5. We found wide variation in the proportion of patients who received an opioid prescription across surgeons (range 0%-88.9%) and facilities (range 19.9%-66.7%) and the average MMEs prescribed (range 25-188.5). Outpatient surgery (OR 2.32; 95% confidence interval [CI] 1.22-4.40, P = .010) and preoperative opioid use (OR 15.04; CI 9.65-23.45, P Conclusions Opioid prescribing following endoscopic prostate procedures varied widely. Targeted interventions tailored to younger patients, those taking opioids preoperatively, recipients of outpatient surgery and those undergoing surgery at satellite facilities may be particularly high yield given the association between these factors and increased postoperative prescribing.

The U.S. opioid crisis necessitates that health care providers of all types work collaboratively to manage patients taking prescription opioid medications and manage those who may be misusing prescription opioids. Musculoskeletal conditions are the most common diagnoses associated with an opioid prescription. Physical therapists commonly manage patients with musculoskeletal conditions and chronic pain. Some patients who attend physical therapy for pain management take prescription opioid medications for pain and some of these patients may be misusing prescription opioids. Physical therapists who manage patients with musculoskeletal conditions are well-positioned to help address the opioid crisis. Historically, physical therapists have not been adequately engaged in efforts to manage persons with co-occurring musculoskeletal pain and opioid misuse or OUD. The American Physical Therapy Association (APTA) has emphasized physical therapy over the use of prescription opioids for the management of painful conditions. The APTA, however, does not highlight the important role that physical therapists could play in monitoring opioid use among patients receiving treatment for pain, nor the role that physical therapists should play in screening for opioid misuse. Such screening could facilitate referral of patients suspected misuse to an appropriate provider for formal assessment and treatment. This commentary presents simulated musculoskeletal patient presentations depicting 2 common opioid use states; chronic opioid use and opioid misuse. The cases highlight and interactions that physical therapists could have with these patients and actions that the physical therapist could take when working inter-disciplinarily. Recommendations are provided that aim to increase physical therapists’ knowledge and skills related to managing patients taking prescription opioid medications for pain.

There has been a dramatic rise in opioid-related deaths over the past decade. Most of the reduction strategies have focused on outpatient use; however, recent studies have demonstrated an association between inpatient opioid use and consumption following discharge across a variety of surgical procedures. The objective of this study is to evaluate the association of inpatient use of opioids as well as the consumption of opioids after discharge following endovascular aortic aneurysm repair (EVAR).A prospectively maintained database was reviewed for cases between 2015 and 2018. Patients were included in the study if they underwent an elective EVAR, had an intensive care unit stay less than 1 day and total length of stay less than 3 days. Patients were contacted to participate in a survey of opioid use if they received a prescription at discharge. The primary outcome was percent of prescribed opioids consumed following discharge. Multivariate analyses were performed to determine predictors of receiving an opioid prescription.One hundred seventy-one patients were included in the analysis; 95% patients were white and 85% male. 59% of patients responded to the survey. Seventy-one (42%) received an opioid prescription at discharge. Patients that received a discharge prescription tended to be younger (71 vs. 75 years, P = 0.005) and more likely to have received opioids while in the hospital (79% vs. 45%, P0.001). Additionally, patients who received opioids at discharge received a significantly greater amount of milligram oral morphine equivalents (OME) while in the hospital (27.76 ± 38.91 vs. 10.05 ±29.43, P0.001). Multivariate analysis demonstrated age, estimated blood loss (EBL), and OME per day to be significant inpatient predictors of requiring an outpatient opioid prescription. Open femoral access (27%) was not a predictor of opioid prescription at discharge. A total of 1185 pills were prescribed (29.6 ± 2.06 per patient), but only 208 pills consumed (5.2 ± 1.27 per patient). Around 82% of total pills prescribed were not consumed.This study evaluates inpatient opioid use and postdischarge consumption following EVAR. These data identify key factors associated with receiving an opioid prescription at discharge and demonstrate that patients consume far fewer opioids than prescribed. These findings provide insight as to which patients may not require an outpatient prescription following EVAR, leading to potential practice-changing opioid reduction strategies.

Key Points Question With recent increases in buprenorphine treatment for opioid use disorder (OUD), is buprenorphine misuse increasing in the US? Findings In this survey study of 214 505 respondents to the National Survey on Drug Use and Health Data, nearly three-fourths of adults reporting buprenorphine use did not misuse their prescribed buprenorphine in 2019. Among adults with OUD, prevalence of buprenorphine misuse trended downward during the period from 2015 to 2019, and “because I am hooked” and “to relieve physical pain” were the most common motivations for the most recent buprenorphine misuse. Meaning These findings underscore the need to expand access to buprenorphine-based OUD treatment while monitoring and implementing strategies to reduce buprenorphine misuse., This survey study examines buprenorphine misuse among US adults with and without opioid use disorder., Importance There is a lack of empirical research regarding misuse of buprenorphine hydrochloride. Objective To identify prescription opioids that are most frequently misused, assess differences in motivations for misuse between buprenorphine and nonbuprenorphine prescription opioids, and examine trends in and factors associated with buprenorphine misuse among individuals with or without opioid use disorder (OUD). Design, Setting, and Participants This survey study used nationally representative data on past-year prescription opioid use, misuse, OUD, and motivations for the most recent misuse from the 2015-2019 National Survey on Drug Use and Health (NSDUH). Participants included 214 505 civilian, noninstitutionalized adult NSDUH respondents. Data were collected from January 2015 to December 2019 and analyzed from February 15 to March 15, 2021. Main Outcomes and Measures Buprenorphine use, misuse, and OUD. Misuse was defined as use “in any way that a doctor [physician] did not direct you to use them, including (1) use without a prescription of your own; (2) use in greater amounts, more often, or longer than you were told to take them; or (3) use in any other way a doctor did not direct you to use them.” Results The 214 505 respondents included in the analysis represented an estimated annual average 246.7 million US adults during 2015-2019 (51.7% [95% CI, 51.4%-52.0%] women; 13.9% [95% CI, 13.7%-14.1%] aged 18-25 y; 40.6% [95% CI, 40.3%-41.0%] aged 26-49 y; 45.5% [95% CI, 45.0-45.9%] aged ≥50 y). In 2019, an estimated 2.4 (95% CI, 2.2-2.7) million US adults used buprenorphine, and an estimated 0.7 (95% CI, 0.5-0.9) million misused buprenorphine compared with an estimated 4.9 (95% CI, 4.4-5.4) million and an estimated 3.0 (95% CI, 2.7-3.2) million who misused hydrocodone and oxycodone, respectively. Prevalence of OUD with buprenorphine misuse trended downward during the period from 2015 to 2019. “Because I am hooked” (27.3% [95% CI, 21.6%-33.8%]) and “to relieve physical pain” (20.5% [95% CI, 14.0%-29.0%]) were the most common motivations for the most recent buprenorphine misuse among adults with OUD. Adults who misused buprenorphine were more likely to report using prescription opioids without having their own prescriptions than those who misused nonbuprenorphine prescription opioids (with OUD: 71.8% [95% CI, 66.4%-76.6%] vs 53.2% [95% CI, 48.5%-57.8%], P

Harms caused by prescription opioid analgesics (POAs) have been identified as a major international public health concern. Recent statistics show rising numbers of opioid-related deaths across Canada. However, Canadian family physicians appear to have inadequate resources to safely and effectively prescribe opioid analgesics to treat chronic non-cancer pain (CNCP).We completed a qualitative study of the barriers and facilitators to safe and effective prescribing of opioid analgesics for CNCP through semi-structured interviews with eight family physicians in Nova Scotia. Thematic analysis was used to identify the barriers and facilitators.Family physicians identified challenges in prescribing opioid analgesics for CNCP: the complexity of CNCP management, addictions risks and prescribing tools, physician training, the physician-patient relationship, prescription monitoring and control, and systemic factors.Family physicians described themselves as inadequately supported in their prescribing of opioid analgesics for CNCP and could benefit from an integrated and coordinated approach to prescriber support.Les méfaits causés par les analgésiques opioïdes sur ordonnance constituent un grave problème de santé publique à l’échelle internationale. Des statistiques récentes font état d’une augmentation du nombre de décès associés à la prise d’opioïdes à travers le Canada. Or les médecins de famille canadiens semblent ne pas disposer des ressources suffisantes pour prescrire efficacement et sans risque les analgésiques opioïdes destinés au traitement de la douleur chronique non cancéreuse (DCNC).Au moyen d’entrevues semi-structurées avec huit médecins de famille en Nouvelle-Écosse, nous avons réalisé une étude qualitative sur les facteurs qui entravent et ceux qui facilitent une prescription d’opioïdes efficace et sans risque par les médecins de famille aux patients atteints de DCNC. Une analyse thématique a permis de dégager ces facteurs.Les médecins de famille interrogés ont mis en évidence plusieurs enjeux posés par la prescription d’analgésiques opioïdes pour le traitement de la DCNC : la complexité du traitement de la DCNC, le risque de dépendance et les outils de prescription, la formation des médecins, la relation médecin-patient, le suivi et le contrôle des ordonnances et enfin certains facteurs systémiques.Les médecins de famille disent ne pas recevoir de soutien adéquat quant à la prescription d’analgésiques opioïdes pour le traitement de la DCNC et pensent qu’une approche intégrée et coordonnée visant à soutenir les médecins prescripteurs pourrait les aider.There is a complex intersection of challenges in prescribing opioid analgesics for chronic non-cancer pain (CNCP): the complexity of chronic pain management, addictions risks, physician training, the physician–patient relationship, prescription monitoring and control, and systemic factors. Family physicians and patients need timely access to experts in pain management. A comprehensive integrated system of support for CNCP management that provides peer-to-peer communications tools and access to a team of pain specialists is needed to support family physicians and patients.La prescription d’analgésiques opioïdes pour soulager la douleur chronique non cancéreuse (DCND) représente un ensemble complexe d’enjeux : la complexité du traitement de la DCNC, le risque de dépendance, la formation des médecins, la relation médecin-patient, le suivi et le contrôle des ordonnances ainsi que certains facteurs systémiques. Les médecins de famille et les patients doivent avoir accès rapidement à des spécialistes du traitement de la douleur. Un système intégré complet destiné à soutenir le traitement de la DCNC, qui fournirait des outils de communication entre pairs et qui donnerait accès à une équipe de spécialistes du traitement de la douleur, est nécessaire pour appuyer les médecins de famille et les patients.

BACKGROUND: Florida's House Bill 21 (HB21), implemented into law on July 1, 2018, limited opioid prescriptions for acute pain to a 3-day supply. While the law has been associated with a decrease in opioid prescribing for acute pain, its effect on opioid volume dispensed at the plan level remains unknown. OBJECTIVES: To assess the impact of HB21 on the total volume dispensed of oral Schedule II opioids. We evaluated the change from before to after the law's implementation in (1) total number of opioid units dispensed per month and (2) total morphine milligram equivalent (MMEs) dispensed per month. METHODS: Pharmacy claims from July 2017 to June 2019 were analyzed from a private health plan serving a large Florida employer. We summed the number of units and the total MMEs dispensed for each month per 1,000 enrollees. Units were defined as the total quantity of tablets/capsules dispensed for each Schedule II oral opioid prescription. We used interrupted time series (ITS) models, accounting for autocorrelation, to determine any immediate change after the policy implementation and to estimate trends before and after the policy. RESULTS: We identified 16,226 prescriptions of oral Scheduled II opioids dispensed to 6,315 enrollees over a 2-year period. The HB21 law was associated with an immediate but not statistically significant decrease of 110.25 units dispensed per 1,000 enrollees in the month after implementation (95% CI: -218.84, -1.67; P = 0.06). There was an immediate but not statistically significant decrease of 1,456.29 MMEs dispensed per 1,000 enrollees following HB21 implementation (95% CI: -2,983.87, 71.29; P = 0.07). There were no significant changes in the slopes of the trends for total number of opioid units and total MMEs dispensed after HB21. CONCLUSIONS: Despite substantial lower quantities, there were no significant immediate reductions in total opioid units and MMEs dispensed in the year following the implementation of HB21. Our findings can inform other health plans on the potential effect of such restrictive laws and policies in other states where preexisting declining trends might have a higher impact than restriction policies. Future studies are needed to evaluate long-term intended and unintended consequences, including effects on patients' access to care, resulting from this type of restrictive law. DISCLOSURES: No outside funding supported this study. The authors report no conflicts of interest. Preliminary results of this study were presented at the Virtual ISPOR 2020 Conference held May 18-20, 2020.

Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data...

Introduction Between 2013 and 2019, opioid prescriptions in the US declined by about 7% per year. However, little is known about the health and economic impacts of this decline on common dental diseases in adults (i.e. periodontitis, untreated dental caries and edentulism). We sought to assess relationships between prescription opioid use and indicated dental diseases, and to estimate associated epidemiologic and economic impacts of the decline in opioid prescriptions. Methods We evaluated NHANES data (2009, 2011, 2013 and 2015 cycles) to measure associations between recent prescription opioid use and indicated dental diseases. We then used an empirical modeling approach to estimate: a) the number of patients directly affected by withheld opioid prescriptions, b) associated changes in the number of patients with indicated dental diseases, and c) associated changes in direct and indirect costs of care. Results Estimated one-year risks of untreated caries and edentulism were 1.5% (95% CI: 0.2–2.8, p

In the past decade, health authorities in various jurisdictions have reported an upsurge in prescription opioid utilisation and an unprecedented rise in opioid-related mortality. In this scoping re...

Introduction Total hip arthroplasty and total knee arthroplasty account for over 1 million procedures annually. Opioids are the mainstay of postoperative pain management for these patients. In this context, the objective of this study was to determine patterns of use and factors associated with early discontinuation of opioids after total joint arthroplasty (TJA). Methods TRICARE claims data (2006-2014) were queried for adult (18-64 years) patients who underwent total hip arthroplasty or total knee arthroplasty. Prescription opioid use was identified from 6 months before and 6 months after surgical intervention. Prior opioid use was categorized as naïve, exposed (with non-sustained use), and sustained (6 month continuous use before surgery). Cox proportional-hazards models were used to identify factors associated with opioid discontinuation following TJA. Results Among the 29,767 patients included in the study, 15,271 (51.3%) had prior opioid exposure and 3,740 (12.5%) were sustained opioid users. At 6 months after the surgical intervention, 3,171 (10.6%) continued opioid use, 3.3% were among opioid naïve, 10.2% among exposed, and 33.3% among sustained users. In risk-adjusted models, prior opioid exposure (hazards ratio: 0.65, 95% CI: 0.62-0.67) and sustained prior use (hazards ratio: 0.33, 95% CI: 0.31-0.35) were the strongest predictors of lower likelihood of opioid discontinuation. Lower socio-economic status, depression, and anxiety were also strong predictors. Conclusion Prior opioid exposure was strongly associated with continued opioid dependence after TJA. Although one-third of prior sustained users continued use after surgery, approximately 10% of previously exposed patients became sustained users, making them the prime candidates for targeted interventions to reduce the likelihood of sustained opioid use after TJA.

Background:. Opioids are commonly prescribed after ureteroscopy. With an increasing adoption of ureteroscopy for management of urolithiasis, this subset of patients is at high risk for opioid dependence. We sought to pilot an opioid-free discharge protocol for patients undergoing ureteroscopy for urolithiasis. Materials and methods:. A prospective cohort study was performed of all patients undergoing ureteroscopy for urolithiasis and compared them to a historical control group. An opioid-free discharge protocol was initiated targeting all areas of surgical care from June 20th, 2019 to September 20th, 2019 as part of an institutional quality improvement initiative. Demographic and surgical data were collected as were morphine equivalent doses (MEDs) prescribed at discharge, postoperative measures including phone calls, clinic visits, and emergency room visits for pain. Results:. Between October 1st, 2017 and February 1st, 2018, a total of 54 patients who underwent ureteroscopy were identified and comprised the historical control cohort while 54 prospective patients met the inclusion criteria since institution of the quality improvement initiative. There were no statistically significant differences in baseline patient demographics or surgical characteristics between the 2 patient groups. Total 37% of the intervention group had a preexisting opioid prescription versus 42.6% of the control group with no difference in preoperative MED (p = 0.55). The intervention group had a mean MED of 12.03 at discharge versus 110.5 in the control cohort (p ≤ 0.001). At discharge 3.7% of the intervention group received an opioid prescription versus 88.9% of the control group (p

BACKGROUND: Prescription drug monitoring programs (PDMPs) exist in 49 states to guide opioid prescribing. In 40 states, clinicians must check the PDMP prior to prescribing an opioid. Data on mandated PDMP checks show mixed results on opioid prescribing. OBJECTIVES: This study sought to examine the impact of the Massachusetts mandatory PDMP check on opioid prescribing for discharges from an urban tertiary emergency department (ED). METHODS: This was a retrospective cohort study of discharges from one ED from 7/1/2010–10/15/2018. The primary outcome was the monthly percentage of patients discharged from the ED with an opioid prescription. The intervention was Massachusetts mandating a PDMP check for all opioid prescriptions. Prescribing was compared pre- and post-mandate. Interrupted time series (ITS) analysis accounted for known declining trends in opioid prescribing. RESULTS: Of 273,512 ED discharges, 35,050 (12.8%) received opioid prescriptions. Mean monthly opioid prescribing decreased post-intervention from 15.1% (SD ± 3.5%) to 5.1% (SD ± 0.9%; p < 0.001). ITS showed equal pre and post-intervention slopes (−0.002, p = 0.819). A small immediate decrease occurred in prescribing around the mandated check: a 3-month level effect decrease of 0.018 (p = 0.039), 6-month level effect 0.019 (p = 0.023), and a 12-month level effect of 0.020 (p = 0.019). The 24-month level effect was not decreased. CONCLUSION: Prior to the mandated PDMP check, ED opioid prescribing was declining. The mandate did not change the rate of decline but was associated with a non-sustained drop in opioid prescribing immediately following enactment. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13181-021-00837-4.

As the opioid crisis in the United States evolved, so did the relationship between prescribers and pharmaceutical companies that manufacture prescription opioids, with policymakers at both the state and national levels focused on the issue of prescription opioid misuse. This article discusses the role of the prescriber-pharmaceutical company relationship with respect to opioid over- and underprescribing, the evolution of that relationship over time, and its contribution to what is now commonly known as the U.S. opioid crisis or overdose epidemic. The United States saw several "waves" of prescription opioid misuse, and this article characterizes the relationship between prescribers and pharmaceutical companies in similar waves. The article proposes several prescriber- and manufacturer-focused "solutions" that can be implemented to address and lessen the effects of the ongoing crisis. Changes directed at prescribers and manufacturers must be implemented in tandem to ensure such solutions do not, in attempting to fill the existing cracks in the system, create even more.

Prescription opioid misuse remains a serious public health concern in the United States. While considerable research attention is paid to this issue, a relatively small number of studies focus spec...

In a 2018 report titled, Quantifying the Epidemic of Prescription Opioid Overdose Deaths, four senior analysts of the Centers for Disease Control and Prevention (CDC), including the head of the Epidemiology and Surveillance Branch, acknowledged for the first time that the number of prescription opioid overdose deaths reported by the CDC in 2016 was erroneous. The error, they said, was caused by miscoding deaths involving illicitly manufactured fentanyl (IMF) as deaths involving prescribed fentanyl. To understand what caused this error, the authors examined the CDC’s methodology for compiling drug-related mortality data, beginning with the source data obtained from approximately 2.8 million death certificates received each year from state vital statistics registrars. Systemic problems often begin outside the CDC, with a surprisingly high rate of errors and omissions in the source data. Using the CDC’s explanation for what caused the error, the authors show why an international program used by the CDC for reporting mortality is ill-suited for compiling and reporting drug overdose deaths. Except for heroin, methadone, and opium, each of which has an individual program code, all other opioids are separated in just two program codes according to whether they are synthetic or semisynthetic/opiates. Methadone-involved deaths pose a special problem for the CDC because methadone has dual indications for treating pain and for treating opioid use disorder (OUD). In 2019, more than seven times more methadone was administered or dispensed for OUD treatment than was prescribed for pain, yet all methadone-involved deaths are coded by the CDC as involving the prescribed form of the drug. The authors conclude that the CDC was at fault for failing to recognize and correct this problem before 2016. Public policy consequences of this failure are briefly mentioned.

Purpose of review The number of opioid-related overdose deaths has rapidly increased since 2000, increasing more than five-fold from 1999 to 2016. Although surgeons only write 10% of opioid prescriptions annually, with ophthalmologists writing only a fraction of this amount, all physicians need to be cognizant of the current opioid epidemic and ways to decrease unnecessary opioid prescriptions. Recent findings Previous work within ophthalmology has shown that retrobulbar anesthesia along with peri-operative intravenous or oral nonopioid analgesics can lead to decreased postoperative opioid use following ophthalmic surgery. Recent literature has shifted focus towards the use of opioid prescription guidelines in managing postoperative pain and decreasing the number of unnecessary opioids being prescribed by ophthalmologists. Overall, the frequency of opioid prescriptions may have gradually declined the past few years with such efforts, increased awareness, and new healthcare policies to monitor opioid prescriptions. However, ophthalmologists still continue to prescribe a substantial number of opioid medications, much of which may not be necessary. Summary This review serves as a tool to aid all ophthalmologists in managing postoperative pain. There is a recent trend in addressing the opioid epidemic and efforts are being made to limit the overprescribing of opioids. Continued efforts are still required by all ophthalmologists to address the current opioid epidemic.

BACKGROUND/OBJECTIVES Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes. DESIGN Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016. SETTING Beneficiaries enrolled in the Medicare hospice benefit. PARTICIPANTS Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022). MAIN OUTCOME Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing. RESULTS 70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics. CONCLUSIONS Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.