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Introduction: It is unknown whether certain dentists account for disproportionate shares of dental opioid prescriptions and high-risk prescriptions. Identifying and characterizing such dentists could inform the targeting of initiatives to improve the appropriateness and safety of dental opioid prescribing.Methods: In May 2021, the authors conducted a cross-sectional analysis using the IQVIA Longitudinal Prescription Database, which reports dispensing from 92% of U.S. pharmacies, and 2 provider databases (IQVIA OneKey, National Plan and Provider Enumeration System). Analyses included opioid prescriptions from dentists dispensed in 2019 to patients aged >12 years. High-risk prescriptions were those considered high risk by any of 3 metrics (prescriptions to opioid-naïve patients exceeding a 3-day supply, prescriptions with daily opioid dosage ≥50 morphine milligram equivalents, opioid prescriptions with benzodiazepine overlap). Among all prescriptions and high-risk prescriptions, the authors calculated the proportion accounted for by high-volume dentists -- those with prescription counts in the 95th percentile or higher. Using logistic regression, the characteristics associated with being a high-volume dentist were identified.Results: In 2019, a total of 141,345 dentists accounted for 10,736,743 opioid prescriptions dispensed to patients aged >12 years; 4,242,634 (39.5%) were high-risk prescriptions. The 7,079 high-volume dentists, a group representing 5.0% of the 141,345 dentists, accounted for 46.9% of all prescriptions and 47.5% of high-risk prescriptions. Male sex, younger age, non‒Northeast location, and specialization in oral and maxillofacial surgery were associated with a higher risk of being a high-volume dentist.Conclusions: In 2019, high-volume dentists accounted for almost half of dental opioid prescriptions and high-risk prescriptions. Quality improvement initiatives targeting these dentists may be warranted. [ABSTRACT FROM AUTHOR]

To determine the rate and risk factors for new persistent opioid use after ophthalmic surgery in the United States. Retrospective claims-based cohort analysis. Opioid-naive patients 13 years of age and older who underwent incisional ophthalmic surgery between January 1, 2012, and June 30, 2017, and were included in Optum's de-identified Clinformatics Data Mart database. New persistent opioid use was defined as filling an opioid prescription in the 90-day and the 91- to 180-day periods after the surgical procedure. The outcome variable was an initial perioperative opioid prescription fill. Rates of new persistent opioid use were calculated, and multivariate logistic regression models were used to identify variables increasing the risk of new persistent use and refill of an opioid prescription after the initial perioperative prescription in first 30 days. New persistent opioid use and refill. A total of 327 379 opioid-naive patients (mean age, 67 years [standard deviation, 16 years]; 178 067 women [54.4%]) who underwent ophthalmic surgery were examined. Among these patients, 14 841 (4.5%) had an initial perioperative opioid fill. The rate of new persistent opioid use was 3.4% (498 of 14 841 patients) compared with 0.6% (1833 of 312 538 patients) in patients who did not have an initial perioperative opioid fill. After adjusting for patient characteristics, initial perioperative opioid fill was associated independently with increased odds of new persistent use (adjusted odds ratio [OR], 6.21; 95% confidence interval [CI], 5.57–6.91; P < 0.001). Among patients who had filled an initial perioperative prescription, a prescription size of 150 morphine milligram equivalents or more was associated with an increased odds of refill (adjusted OR, 1.87; 95% CI, 1.58–2.22; P < 0.001). Exposure to opioids in the perioperative period is associated with new persistent use in patients who were previously opioid-naive. This suggests that exposure to opioids is an independent risk factor for persistent use in patients undergoing incisional ophthalmic surgery. Surgeons should be aware of those risks to identify at-risk patients given the current national opioid crisis and to minimize prescribing opioids when possible. [ABSTRACT FROM AUTHOR]

Objective: To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery.Methods: Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS.Results: In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03).Conclusion: Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns. [ABSTRACT FROM AUTHOR]

Importance: Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs., Objective: To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States., Design, Setting, and Participants: This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023., Main Outcomes and Measures: The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years., Results: Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs])., Conclusions and Relevance: In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.

Objective: Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance., Background: Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance., Methods: In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber., Results: Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402)., Conclusions: Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess whether the risk of persistent opioid use after surgery varies by payer type., Background: Persistent opioid use is associated with increased health care utilization and risk of opioid use disorder, opioid overdose, and mortality. Most research assessing the risk of persistent opioid use has focused on privately insured patients. Whether this risk varies by payer type is poorly understood., Methods: This cross-sectional analysis of the Michigan Surgical Quality Collaborative database examined adults aged 18 to 64 years undergoing surgical procedures across 70 hospitals between January 1, 2017 and October 31, 2019. The primary outcome was persistent opioid use, defined a priori as 1+ opioid prescription fulfillment at (1) an additional opioid prescription fulfillment after an initial postoperative fulfillment in the perioperative period or at least 1 fulfillment in the 4 to 90 days after discharge and (2) at least 1 opioid prescription fulfillment in the 91 to 180 days after discharge. The association between this outcome and payer type was evaluated using logistic regression, adjusting for patient and procedure characteristics., Results: Among 40,071 patients included, the mean age was 45.3 years (SD 12.3), 24,853 (62%) were female, 9430 (23.5%) were Medicaid-insured, 26,760 (66.8%) were privately insured, and 3889 (9.7%) were covered by other payer types. The rate of POU was 11.5% and 5.6% for Medicaid-insured and privately insured patients, respectively (average marginal effect for Medicaid: 2.9% (95% CI 2.3%-3.6%))., Conclusions: Persistent opioid use remains common among individuals undergoing surgery and higher among patients with Medicaid insurance. Strategies to optimize postoperative recovery should focus on adequate pain management for all patients and consider tailored pathways for those at risk., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To evaluate differences in presentation and outcomes of surgery for colorectal cancer., Background: Although racial and socioeconomic disparities in colorectal cancer outcomes are well documented, disparities in access affecting disease presentation are less clear., Methods: We conducted a statewide retrospective study of patients who underwent resection for colorectal cancer between January 1, 2015, and April 30, 2021. The primary outcome was undergoing emergency surgery. Secondary outcomes included preoperative evaluation and postoperative outcomes. Covariates of interest included race/ethnicity, social deprivation index, and insurance type., Results: A total of 4869 patients underwent surgery for colorectal cancer, of whom 1122 (23.0%) underwent emergency surgery. Overall, 28.1% of Black non-Hispanic patients and 22.5% of White non-Hispanic patients underwent emergency surgery. On multivariable logistic regression, Black non-Hispanic race was independently associated with a 5.8 (95% CI, 0.3-11.3) percentage point increased risk of emergency surgery compared with White non-Hispanic race. Patients who underwent emergency surgery were significantly less likely to have preoperative carcinoembryonic antigen measurement, staging for rectal cancer, and wound/ostomy consultation. Patients who underwent emergency surgery had a higher incidence of 30-day mortality (5.5% vs 1.0%, P <0.001), positive surgical margins (11.1% vs 4.9%, P <0.001), complications (29.2% vs 16.0%, P <0.001), readmissions (12.5% vs 9.6%, P =0.005), and reoperations (12.2% vs 8.2%, P <0.001)., Conclusions: Among patients with colorectal cancer, Black non-Hispanic patients were more likely to undergo emergency surgery than White non-Hispanic patients, suggesting they may face barriers to timely screening and evaluation. Undergoing emergency surgery was associated with incomplete oncologic evaluation, increased incidence of postoperative complications including mortality, and increased surgical margin positivity. These results suggest that racial and ethnic differences in the diagnosis and treatment of colorectal cancer impact near-term and long-term outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery., Background: Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use., Methods: We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates., Results: In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90]., Conclusions: Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The association between surgeon prescribing practices and new persistent postoperative opioid use is not well understood. We examined the association between surgeon prescribing and new persistent use among total hip arthroplasty (THA) patients., Methods: A retrospective analysis of Medicare claims in Michigan was performed. The study cohort consisted of orthopedic surgeons performing THAs from 2013 to 2016 and their opioid-naïve patients, aged >65 years. High-risk prescribing included high daily doses, overlapping benzodiazepine prescriptions, concurrent opioid prescriptions, prescriptions from multiple providers, or long-acting opioid prescriptions. The occurrence of a preoperative prescription, initial prescription size, and 30-day prescription dosage were examined as individual exposures. Surgeons were categorized into quartiles by prescribing practices, and multilevel hierarchical logistic regression was used to examine associations with postoperative new persistent opioid use., Results: Surgeons exhibited high-risk prescribing for 66% of encounters. Patients of surgeons with the highest rates of high-risk prescribing were more likely to develop persistent use compared with patients of surgeons with the lowest rates (adjusted rates: 9.7% vs 4.6%, P = .011). Patients of surgeons with initial prescription sizes in the "high" (third) quartile (adjusted odds ratio, 2.91; 95% confidence interval, 1.53-5.51), and of surgeons in the "highest" (fourth) quartile of 30-day prescription dosage (adjusted odds ratio, 1.93; 95% confidence interval, 1.03-3.61), were more likely to develop persistent opioid use compared with patients of surgeons with low initial and 30-day prescription sizes, respectively., Conclusion: The development of persistent opioid use after surgery is multifactorial, and surgeon prescribing patterns play an important role. Reducing prescribing and encouraging opioid alternatives could minimize postoperative persistent opioid use., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use., Summary of Background Data: Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown., Methods: We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates., Results: In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month., Conclusion: Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.

Objective: We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery., Background: Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use., Methods: We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group., Results: Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001)., Conclusion: Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.

Background: Opioid misuse occurs commonly among obese patients and after bariatric surgery. However, the risk of new persistent use following postbariatric body contouring procedures remains unknown., Methods: The authors examined insurance claims from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minn.) between 2001 and 2015 for opioid-naive patients undergoing five body contouring procedures: abdominoplasty/panniculectomy, breast reduction, mastopexy, brachioplasty, and thighplasty (n = 11,257). Their primary outcomes included both new persistent opioid use, defined as continued prescription fills between 90 and 180 days after surgery, and the prevalence of high-risk prescribing. They used multilevel logistic regression to assess the risk of new persistent use, adjusting for relevant covariates., Results: In this cohort, 6.1 percent of previously opioid-naive patients developed new persistent use, and 12.9 percent were exposed to high-risk prescribing. New persistent use was higher in patients with high-risk prescribing (9.2 percent). New persistent use was highest after thighplasty (17.7 percent; 95 percent CI, 0.03 to 0.33). Increasing Charlson comorbidity indices (OR, 1.11; 95 percent CI, 1.05 to 1.17), mood disorders (OR, 1.27; 95 percent CI, 1.05 to 1.54), anxiety (OR, 1.41; 95 percent CI, 1.16 to 1.73), tobacco use (OR, 1.22; 95 percent CI, 1.00 to 1.49), neck pain (OR, 1.23; 95 percent CI, 1.04 to 1.46), arthritis (OR, 1.30; 95 percent CI, 1.08 to 1.58), and other pain disorders (OR, 1.36; 95 percent CI, 1.16 to 1.60) were independently associated with persistent use., Conclusions: Similar to other elective procedures, 6 percent of opioid-naive patients developed persistent use, and 12 percent were exposed to high-risk prescribing practices. Plastic surgeons should remain aware of risk factors and offer opioid alternatives., Clinical Question/level of Evidence: Risk, III.

Objective: To evaluate the impact of postprescription review of broad-spectrum antimicrobial (study-ABX) agents on rates of antimicrobial use., Design: Quasi-experimental before-after study., Setting: Five academic medical centers., Patients: Adults receiving at least 48 hours of study-ABX., Methods: The baseline, intervention, and follow-up periods were 6 months each in 2 units at each of 5 sites. Adults receiving at least 48 hours of study-ABX entered the cohort as case-patients. During the intervention, infectious-diseases physicians reviewed the cases after 48 hours of study-ABX. The provider was contacted with alternative recommendations if antimicrobial use was considered to be unjustified on the basis of predetermined criteria. Acceptance rates were assessed 48 hours later. The primary outcome measure was days of study-ABX per 1,000 study-patient-days in the baseline and intervention periods., Results: There were 1,265 patients in the baseline period and 1,163 patients in the intervention period. Study-ABX use decreased significantly during the intervention period at 2 sites: from 574.4 to 533.8 study-ABX days/1,000 patient-days (incidence rate ratio [IRR], 0.93; 95% confidence interval [CI], 0.88-0.97; P = .002) at hospital B and from 615.6 to 514.4 study-ABX days/1,000 patient-days (IRR, 0.83; 95% CI, 0.79-0.88; P < .001) at hospital D. Both had established antimicrobial stewardship programs (ASP). Study-ABX use increased at 2 sites and stayed the same at 1 site. At all institutions combined, 390 of 1,429 (27.3%) study-ABX courses were assessed as unjustified; recommendations to modify or stop therapy were accepted for 260 (66.7%) of these courses., Conclusions: Postprescription review of study-ABX decreased antimicrobial utilization in some of the study hospitals and may be more effective when performed as part of an established ASP.