Search

Background: Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice. Aim: To use an estimated oral morphine equivalent (OMEQe) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status. Design & setting: A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank. Method: An OMEQe measure was developed and used to describe trends in opioid burden over the study period. OMEQe burden was stratified by eight drug groups, which was based on usage and deprivation. Results: An estimated 643 436 843 milligrams (mg) OMEQe was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQe per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQe prescribed than the least deprived over the study period. Conclusion: Over the study period, OMEQe burden nearly doubled, with disproportionate OMEQe prescribed in the most deprived communities. Using OMEQe provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.

Objectives: Opioid-related medication errors (MEs) can have a significant impact on patient health and contribute to opioid misuse. The objective of this study was to estimate the incidence of and variables associated with the receipt of an opioid prescription and opioid-related MEs (omissions, duplications, or dose changes) at hospital discharge. We also determined rates of adverse drug events and risks of emergency department visits, readmissions, or death 30 days and 90 days post discharge associated with MEs.Methods: A cohort of hospitalized patients discharged from the McGill University Health Centre between 2014 and 2016 was assembled. The impact of opioid-related MEs was assessed in a propensity score-adjusted logistic regression models. Multivariable logistic regression was used to determine characteristics associated with MEs and discharge opioid prescription.Results: A total of 1530 (43.9%) of 3486 patients were prescribed opioids, of which 13.4% (n = 205) of patients had at least 1 opioid-related ME. Rates of MEs were higher in handwritten prescriptions compared to the electronic reconciliation discharge prescription group (20.6% vs 1.2%). Computer-based prescriptions were associated with a 69% lower risk of opioid-related MEs (adjusted odds ratio: 0.31, 95% confidence interval: 0.14-0.65) as well as 63% lower risk of receiving an opioid prescription. Opioid-related MEs were associated with a 2.3 times increased risk of healthcare utilization in the 30 days postdischarge period (adjusted odds ratio: 2.32, 95% confidence interval: 1.24-4.32).Conclusions: Opioid-related MEs are common in handwritten discharge prescriptions. Our findings highlight the need for computer-based prescribing platforms and careful review of medications during critical periods of care such as hospital transitions. [ABSTRACT FROM AUTHOR]

Background: Multiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload. Objective: To estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes. Design: Quality improvement quasi-experiment, analyzed as interrupted time series. Participants: Adult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers. Intervention: In the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription. Main Measures: Proportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions. Key Results: Across the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards. Conclusions: Autocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress. Trial Registration: www.ClinicalTrials.gov protocol 1710018646 [ABSTRACT FROM AUTHOR]

Background: One strategy to address the high number of U.S. opioid-related deaths is to restrict high-risk or inappropriate opioid analgesic prescribing and dispensing. Federal and state laws and regulations have implemented restrictions but less is known about commercial and public payers' policies aside from clinician anecdotal reports that these policies are increasing. To assess the number and types of policies with temporal trends, we examined commercial and public (Medicaid) payer policies in one state, Michigan, that has high opioid-related deaths and implemented opioid analgesic prescribing laws.Methods: Policies for seven large commercial payers and the public payer for 2012-2018 were reviewed and categorized by actions. Joinpoint regression was used to summarize temporal trends on number of policies for all payers and subgroups.Results: Across the 7 years, there were 529 action policies (75.57 (95% confidence intervals (CI) 35.93, 115.22) actions per year) with a range of 36 to 103 actions by payer. Limitations on number of days for initial prescriptions and prior authorizations were the most frequently implemented policy. The temporal trend showed a decline in new policies from 2012 to 2013 but a steady increase from 2014 to 2018 (average annual percent change or AAPC=29.6% (95% confidence intervals 13.2, 48.5%)). The public payer (n=47 policies) showed no increase in number of policies over time (AAPC=2.9% (95% CI -41.6, 61.6%).Conclusions: The eight commercial and public payers implemented many new policies to restrict opioid analgesic prescribing with a steady increase in the number of such policies implemented from 2014 to 2018. This case study documented that at least in one state with high opioid-related deaths and multiple commercial payers, new and different policies were increasingly implemented creating barriers to patient care. The impact of these policies is understudied, complicating recommendation of best practices. [ABSTRACT FROM AUTHOR]

In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship. [ABSTRACT FROM AUTHOR]

Background: Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice. Aim: To use an estimated oral morphine equivalent (OMEQe) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status. Design & setting: A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank. Method: An OMEQe measure was developed and used to describe trends in opioid burden over the study period. OMEQe burden was stratified by eight drug groups, which was based on usage and deprivation. Results: An estimated 643 436 843 milligrams (mg) OMEQe was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQe per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQe prescribed than the least deprived over the study period. Conclusion: Over the study period, OMEQe burden nearly doubled, with disproportionate OMEQe prescribed in the most deprived communities. Using OMEQe provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden. [ABSTRACT FROM AUTHOR]

Purpose: Abuse‐deterrent formulation (ADF) opioid analgesics have been developed as a means to address prescription opioid abuse. ADF opioid use in clinical practice is not well described in the literature. This study characterizes ADF opioid prescribing patterns in 3 diverse states. Methods: This study used data from prescription drug monitoring programs (PDMPs) in California, Florida, and Kentucky. The sample includes all ADF opioid prescriptions for patients ≥18 years old during the study period (CY 2018). Standardized prescribing rates were calculated by age, sex, and county rurality. The ADF opioid prescribing rate was calculated per 1,000 adult recipients of opioid analgesics. Findings: The rate of ADF prescribing per 1,000 adult recipients of opioid analgesics was nearly twice as high in Florida (14.57; 95% CI: 14.44‐14.69) than in California (8.30; 95% CI: 8.22‐8.37) or Kentucky (8.20; 95% CI: 8.01‐8.39). ADF prescribing rates were highest among adults ages 55‐74 years and among males. ADF opioid prescribing in rural counties represented a greater proportion of total patients using opioid analgesics than in metro counties in California (RR 1.40; CI: 1.28‐1.53). Opposite and less pronounced variation was observed in Kentucky (RR 0.93; 95% CI: 0.88‐0.98), and a significant difference was not observed in Florida (RR 0.68; 95% CI: 0.38‐1.19). Conclusions: There were significant differences in the ADF prescribing rates among the 3 states and in rural versus metro counties within 2 states. ADF opioid prescribing by age and sex showed similar trends within states. Further research is needed to elucidate contextual factors which may lead to prescribing variation. [ABSTRACT FROM AUTHOR]

Background: Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs). Objective: To identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs). Design: Retrospective, cross-sectional analysis of Medicare Part D enrollee prescription data. Participants: Twenty percent national sample of 2015 Medicare Part D enrollees. Main Measures: We identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients. Key Results: Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. Conclusions: Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation. [ABSTRACT FROM AUTHOR]

Purpose Skilled nursing facility (SNF) residents are at increased risk for opioid‐related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs. Methods: This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary‐care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay. Results: Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS‐DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF. Conclusion: Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted. [ABSTRACT FROM AUTHOR]

Many opioid control policies target the prescribing behavior of health care providers. In this paper, we study the first comprehensive state-level policy requiring providers to access patients' opioid history before making prescribing decisions. We compare prescribers in Kentucky, which implemented this policy in 2012, to those in a control state, Indiana. Our main difference-in-differences analysis uses the universe of prescriptions filled in the two states to assess how the information provided affected prescribing behavior. We find that a significant share of low-volume providers stopped prescribing opioids altogether after the policy was implemented, though this change accounted for a small share of the reduction in total volume. The most important margin of response was to prescribe opioids to fewer patients. Although providers disproportionately discontinued treating patients whose opioid histories showed the use of multiple providers, there were also economically meaningful reductions for patients without multiple providers and single-use acute patients. [ABSTRACT FROM AUTHOR]

Background: To the best of our knowledge, the change in opioid prescription patterns upon referral to a palliative care team (PCT) was not previously investigated in the Middle East. Objective: This study aimed to explore the change in the pattern of opioid prescription and the pain scores before and after referring inpatients to a PCT. Methods: We conducted a retrospective review of patients' records including all inpatients ≥15 years newly referred to the PCT over a period of 21 months at King Faisal Specialist Hospital and Research Center, Riyadh. Results: Of 631 patients, 52.3% were females, the median age was 54 years, and 96.7% had cancer. The proportion of patients on opioids before referral (83.4%) increased to 93.3% in the postreferral period, P <.0001. Patients receiving opioids on a regular basis increased from 31.9% before referral to 49.9% after referral to the PCT, P <.0001. Morphine was the most commonly prescribed opioid on a regular basis pre- and postreferral. Upon referral, the administration of opioids through the subcutaneous route increased from 3.7% to 10.9%, P <.0001. On average, pain scores were reduced by 1 point on a 0 to 10 numeric scale within 48 hours of seeing a patient by the PCT, P <.0001. Conclusion: Patients referred to a PCT are likely to get their opioid prescription optimized and pain scores improved shortly after the PCT involvement. Patients with cancer-related pain requiring opioids should be referred to a PCT as early as possible. [ABSTRACT FROM AUTHOR]

Objective To determine the feasibility, acceptability, and potential impact of using audit and feedback (A&F) with or without peer norm comparison on opioid prescribing by emergency medicine providers. Methods A convenience sample of 37 emergency medicine providers were recruited from 16 emergency departments in Western Pennsylvania for a pilot randomized controlled trial. Participants completed a baseline survey, were randomly allocated to A&F (N = 17) or A&F with peer norm comparison (N = 20), and were asked to complete a postintervention survey. We matched each participant 1:1 to a control who was not exposed to either intervention. Results At baseline, 57% of participants perceived that they prescribed opioids at the same frequency as their peers, whereas 32% perceived prescribing less than and 11% perceived prescribing more than their peers. Most participants rated the interventions as helpful, with no differences between conditions. For the A&F with peer norm comparison condition, from pre- to postintervention, there was a relative increase of 20% in the percentage of participants who perceived that they prescribed more opioids than their peers but no change in the A&F condition (P  = 0.02). 56.8% of controls, 52.9% of A&F participants, and 75.5% of A&F with peer norm comparison participants reduced their opioid prescribing (P  = 0.33). The mean reduction in opioid prescriptions (SD) was 3.3. (9.6) for controls, 3.9 (10.5) for A&F, and 7.3 (7.8) for A&F with peer norm comparison (P  = 0.31). Conclusions Audit and feedback interventions with peer norm comparisons are helpful to providers, can alter perceptions about prescribing norms, and are a potentially effective way to alter ED providers' opioid prescribing behavior. [ABSTRACT FROM AUTHOR]

Background: Opioid overdose is a national health priority and curbing inappropriate prescribing is critical. In 2016, the Centers for Disease Control and Prevention (CDC) issued appropriate prescribing guidelines. Objectives: Examine associations between care networks defined by shared patients and problematic opioid prescribing. Methods: Analysis was at the provider-year level. Social network analysis (SNA) applied to the Medicaid MarketScan® Research Database for the years 2010–2015 identified care communities, each community's level of integration (centralization), and each provider's integration (centrality). Nested multivariable logistic regressions controlling for patient mix and provider specialty simultaneously examined the risk of any (incident) and repeated (prevalent) inappropriate prescribing. Outcomes: Four behaviors defined by the CDC guidelines were examined: (1) more than 90 days continuous supply of high-dose opioid analgesics for chronic pain, (2) overlapping opioid supplies, (3) overlapping opioid and benzodiazepine prescriptions, and (4) prescribing an extended release opioid for an acute pain diagnosis. Results: Provider centrality was associated with reduced incidence of outcome (2) (OR: 0.95) and decreased prevalence of outcomes (1), (2), and (3). However, higher incidence (OR: 1.32) and prevalence (OR: 1.027) of outcome (4) were observed. Conversely, centralization associated with decreased incidence of (1) and (2) and lower prevalence of (1), (2), and (3). Conclusions: Greater provider integration is associated with a lower risk of a provider's patients repeatedly having potentially inappropriate prescription fills; however, the association with a provider having any potentially problematic prescription is more ambiguous. [ABSTRACT FROM AUTHOR]

National guidelines created by the Agency for Healthcare Research and Quality (AHRQ), the American College of Emergency Physicians (ACEP), and the American College of Physicians (ACP) support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) over opioids when treating acute low back pain (AHRQ, 2016; Harrison, 2017; Qaseem, Wilt, McLean, Forciea, & Clinical Guidelines Committee of the American College of Physicians, 2017). Opioids not only have many more side effects than NSAIDs but also carry the risk of opioid abuse and overdose (Qaseem et al., 2017). The purpose of this study was to determine whether emergency department (ED) providers, including physicians, nurse practitioners, and physician assistants, are following evidence-based low back pain management guidelines by assessing the measurement of opioid versus NSAID prescribing. A retrospective chart review including data from January through June 2017 was conducted at a rural ED. Subject inclusion criteria were as follows: older than 18 years, had experienced new-onset low back pain within the last 1 month, and had been given an ICD-10 (International Classification of Diseases, Tenth Revision) code of M54.5. Data regarding the type of provider seen, the treatment the provider prescribed, and demographics were collected. Inclusion criteria were met by 162 subjects. While 52.5% of subjects were prescribed an NSAID at discharge, 53.7% were prescribed an opioid at discharge. Subjects whose injury was work related were less likely to receive an opioid prescription (p = 0.027, 95% CL). Subjects whose pain started within 3 days were more likely to receive an opioid prescription than those whose pain had started more than 3 days before being seen (p = 0.018, 95% CL). Despite the current evidence-based guidelines by the AHRQ, ACEP, and ACP against opioid prescribing for acute low back pain, more subjects received an opioid prescription at discharge than a prescription for an NSAID. This retrospective chart review determined the need for increased ED provider education regarding treatment modalities for acute low back pain. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.Methods/design: The study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study's primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study's primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics.Discussion: Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices.Trial Registration: NCT04044521 (ClinicalTrials.gov). Registered 05 August 2019. [ABSTRACT FROM AUTHOR]

Purpose: This study compared rural to nonrural dentists with respect to opioid prescribing practices, perceptions about prescription drug abuse among patients, and training relevant to pain management and addictions. Methods: A web‐based, cross‐sectional questionnaire was administered to practicing dentist members of the National Dental Practice‐Based Research Network (PBRN; N = 822) and linked with network enrollment questionnaire data regarding practitioner demographics and practice characteristics. Pain management prescribing practices and perceptions regarding relevance and scope of addiction and drug diversion among patients were assessed. Rural practice was defined as a practice whose ZIP Code has more than 50% of its population in either a nonmetropolitan county and/or a rural Census tract. Findings: Rural dentists were significantly more likely than their nonrural counterparts to recommend nonsteroidal anti‐inflammatory agents/acetaminophen in combination with prescribing an opioid [F (1,820) = 4.59, P =.03]. Compared to nonrural dentists, rural dentists were more likely to report that opioid abuse/diversion was a problem in their practices [χ2 [1, n = 807] = 6.85, P <.001], were more likely to have suspected a patient of abuse or diversion [χ2 [1, n = 807] = 10.12, P =.001], and were more likely to have refrained from prescribing due to suspicions of abuse or diversion [χ2 [1, n = 807] = 12.49, P <.001]. Conclusion: Rural dentists may be disproportionately impacted by patients' opioid abuse and represent a viable target for educational outreach that encourages screening, identification, and referral of patients in need of drug abuse treatment. [ABSTRACT FROM AUTHOR]

Abstract Background This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named “systems consultation” aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels. Methods We tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques. Results Seven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: “I am more familiar with guidelines for safe opioid prescribing” and “My clinic’s workflow for opioid prescribing is easier.” At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were required to make the strategy more acceptable for primary care. Qualitatively, intervention clinics reported that chronic pain was now treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes. Conclusions The systems consultation implementation strategy demonstrated feasibility, acceptability, and effectiveness in a study involving eight primary care clinics. This multi-disciplinary strategy holds potential to mitigate the prevalence of opioid addiction and ultimately may help to improve implementation of clinical guidelines across healthcare. Trial registration ClinicalTrials.gov (NCT02433496). https://clinicaltrials.gov/ct2/show/NCT02433496 Registered May 5, 2015

Abstract Background Opioid addiction prevention has become an urgent public health priority, with several countries declaring a state of emergency due to rising death tolls from opioid abuse. Reducing the risk of developing addiction among opioid-naïve patients exposed to prescribed opioids during the process of medical care may be an important primary prevention strategy. Our objective is to synthesize the available evidence about factors associated with the development of addiction among patients first exposed to prescribed opioids, with a focus on opioid-naïve patients. Methods We will perform a systematic search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases in collaboration with a health information specialist using a comprehensive search strategy. We will also supplement our search with a scan of the grey literature to identify relevant ongoing and unpublished studies. We will include studies reporting on risk factors for opioid addiction in patients prescribed opioid analgesic therapy through a prescription from a licensed medical professional, with a focus on opioid-naïve patients. We will exclude studies focusing on patients who are first exposed to illicit opioids, those who use prescription opioids for cancer pain, and/or who are palliative. Two reviewers will independently review titles, abstracts, and full texts for inclusion and exclusion criteria. They will then extract data from included full texts using standardized piloted data extraction forms and assess study quality through risk of bias assessment. We will synthesize the effect sizes of risk factors derived from clinically homogenous studies with similar designs and the remaining ones qualitatively. Discussion Understanding risk factors for opioid addiction among patients who require analgesia has the potential to inform clinical care and opioid prescribing guidelines aiming to reduce opioid addiction. We will also use this information as a starting point for developing interventions for primary prevention.

Abstract Background Pain is among the most commonly treated symptoms in the emergency department, and opioids are commonly prescribed from the emergency department to treat moderate to severe pain. Prescription drug monitoring programs (PDMP) can be used to assist physicians identify individuals at increased risk to misuse or abuse opioids. While the use of the PDMP has been shown useful among clinicians, in the past, utilization of the PDMP has been less than optimal. The objective of this study was to assess the current utilization and perceptions of the prescription drug monitoring program among emergency medicine providers in Florida. Methods A survey assessing the utilization and perception of Florida’s prescription drug monitoring program was distributed to emergency medicine providers in Florida over a 5 week period. Attending physicians, physicians in training, and extenders from a variety of practice types were assessed. Results A total of 88 surveys were completed. Over two thirds (67%) of the respondents were male. The majority of respondents were attending physicians (62%), 13 (14%) were residents, and 21 (23%) were extenders. Nearly all (99%) were aware of Electronic-Florida Online Reporting of Controlled Substance Evaluation Program (EFORCSE) and 84% had registered accounts. More than 2/3 (73%) reported feeling pressured to prescribe opioids, and 70% reported receiving no formal education on identifying individuals at increased risk of opioid misuse. Approximately half (51%) reported that they used EFORCSE only when they suspect the patient may misuse the medication, 21% reported that they rarely used EFORCSE, and only 3% reported using PDMP every time that they prescribed opioids. Residents used PDMP less frequently than extenders and attending physicians. The most common barriers associated with PDMP use were related to access. Conclusions Although most providers reported that they were aware of their states’ PDMP, utilization of the PDMP among emergency medicine providers in Florida remains low. Low utilization was associated with barriers to access. If further enhancements to PDMPs can be made to improve accessibility, then rates of PDMP utilization may increase.

Objectives: 1. List components of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, 2. Describe the prescribing habits of medical residents and attending physicians within a family medicine residency program, 3. Discuss the direction of future research Methods: A report was generated for all patients with opioids listed as a medication at Christ Health Center family medicine clinic from July 2016 to June 2017. A total of 153 patients were identified with prescriptions written for chronic non-cancer pain indications. Clinical management via a retrospective chart review was completed utilizing a standardized data collection form centered around four of twelve recommendations within the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain: (1) Avoid concurrent opioid and benzodiazepine prescribing; (2) evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy; (3) perform urine drug testing before starting opioids and consider at least annually; and (4) offer/prescribe medication for opioid use disorder for all patients taking chronic opioids. Results: A total of 153 prescriptions were written for chronic indications. The most common indications were chronic back pain (32.0%), unspecified chronic pain (31.4%), and osteoarthritis (9.8%). Average duration of therapy was 26.6 months. Forty-two (27.5%) patients were concurrently receiving benzodiazepine therapy. Eighteen (11.8%) patients performed a drug test before or during therapy. Twenty-two (14.4%) patients had documented discussion with their prescriber evaluating the benefits and harms of their opioid regimens. No patients were prescribed medication for opioid overdose. Conclusion: Prescribing habits did not align with the four-guideline recommendations evaluated. The need for provider-focused education on current pain management practice guidelines was identified. Article Type: Student Project

Objective: To determine the proportion of initial opioid prescriptions for opioid-naive patients prescribed by surgeons, dentists, and emergency physicians. We hypothesized that the percentage of such prescriptions grew as scrutiny of primary care and pain medicine opioid prescribing increased and guidelines were developed. Summary of Background Data: Data regarding the types of care for which opioid-naive patients are provided initial opioid prescriptions are limited. Methods: A retrospective cross-sectional study using a nationwide insurance claims dataset to study US adults aged 18 to 64 years. Our primary outcome was a change in opioid prescription share for opioid-naive patients undergoing surgical, emergency, and dental care from 2010 to 2016; we also examined the type and amounts of opioid filled. Results: From 87,941,718 analyzed lives, we identified 16,292,018 opioid prescriptions filled by opioid-naive patients. The proportion of prescriptions for patients receiving surgery, emergency, and dental care increased by 15.8% from 2010 to 2016 (P < 0.001), with the greatest increases related to surgical (18.1%) and dental (67.8%) prescribing. In 2016, surgery patients filled 22.0% of initial prescriptions, emergency medicine patients 13.0%, and dental patients 4.2%. Surgical patients' mean total oral morphine equivalents per prescription increased from 240 mg (SD 509) in 2010 to 403 mg (SD 1369) in 2016 (P < 0.001). Over the study period, surgical patients received the highest proportion of potent opioids (90.2% received hydrocodone or oxycodone). Conclusions: Initial opioid prescribing attributable to surgical and dental care is increasing relative to primary and chronic pain care. Evidence-based guideline development for surgical and dental prescribing is warranted in order to curb iatrogenic opioid morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objective The University of Washington instituted a policy requiring all credentialed clinicians who prescribe opioids to complete a one-time education activity about safe and responsible opioid prescribing. A scenario-based, interactive online learning module was developed for opioid management of acute pain in hospitalized adults. This study examined the impact of the education module on learners' knowledge, perceived competence, and use of guideline-adherent practices. Methods Clinicians who completed the education module participated in a voluntary de-identified online survey approximately six months after the learning activity. Survey questions were related to 1) the perception of improved knowledge; 2) impact on learner's use of three guideline-adherent practices; and 3) perceived competence in managing opioids for acute pain. Descriptive statistics were generated, and multiple linear regression models were used for analysis. Results Clinicians (N = 167) reported improvement in knowledge and perceived competence. Controlling for other aspects of knowledge evaluated, learning to construct a safe opioid taper plan for acute pain, distinguishing between short- and long-acting opioids, and safely initiating opioids for acute pain were significantly associated with increased self-reported likelihood of incorporating the Washington state Prescription Monitoring Program (P  = 0.003), using multimodal analgesia (P  = 0.022), and reducing the duration of opioids prescribed (P  = 0.016). Only improvement in knowledge of how to construct a safe opioid taper plan was significantly associated with increased perceived competence (P  = 0.002). Conclusions Our findings suggest that this online education module about safe opioid prescribing for acute pain management was effective at improving knowledge, increasing the likelihood of using guideline-adherent clinical practices, and increasing perceived competence. [ABSTRACT FROM AUTHOR]

Objective To determine if there are differences in opioid prescribing among generalist physicians, nurse practitioners (NPs), and physician assistants (PAs) to Medicare Part D beneficiaries. Design Serial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services. Subjects All generalist physicians, NPs, and PAs who provided more than 10 total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting. Methods The main outcomes were total opioid claims and opioid claims as a proportion of all claims in patients treated by these prescribers in each of the three settings of interest. Binomial regression was used to generate marginal estimates to allow comparison of the volume of claims by these prescribers with adjustment for practice setting, gender, years of practice, median income of the ZIP code, state fixed effects, and relevant interaction terms. Results There were 36,999 generalist clinicians (physicians, NPs, and PAs) with at least one year of Part D prescription drug claims data between 2013 and 2016. The number of adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval [CI] = 660–661), for NPs was 755 (95% CI = 753–757), and for PAs was 812 (95% CI = 811–814). Conclusions We find relatively high rates of opioid prescribing among NPs and PAs, especially at the upper margins. This suggests that well-designed interventions to improve the safety of NP and PA opioid prescribing, along with that of their physician colleagues, could be especially beneficial. [ABSTRACT FROM AUTHOR]

Objective: Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. Summary Background Data: During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. Methods: We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. Results: Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. Conclusion: A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes. [ABSTRACT FROM AUTHOR]

Background: From 1999 to 2010, the annual number of US deaths due to opioid overdose increased about 400% as the number of opioids prescribed yearly also increased by approximately 400%. Over this period, hydrocodone combination products drove the opioid epidemic, as they became the most frequently prescribed medication in the United States. Our objective was to determine if the Drug Enforcement Administration's (DEA) 2014 policy change – which made it more difficult to prescribe hydrocodone combination products by moving them from Schedule III to Schedule II – reduced the total amount of opioid prescriptions as intended. Methods: We conducted a longitudinal analysis of the 10 most populous US states, beginning at the time each state began collecting data on opioid prescribing, and concluding at the end of 2016. The exposure was the DEA-mandated October 6, 2014 hydrocodone combination product schedule change. Results: After the DEA's schedule change for hydrocodone combination products, the total number of opioids prescribed each year per 100 people did not substantially change in California, Florida, Michigan, or New York. Although prescription rates dropped for hydrocodone combination products (CA: 43.2, 35.0; MI: 66.8, 55.6; NY: 20.8, 15.1), the reduction was commensurately counteracted by increased rates for tramadol (CA: 0.2, 9.9; MI: 0.1, 17.3; NY: 0.0, 7.6) and oxycodone (CA: 8.7, 9.7; MI: 10.3, 11.9; NY: 18.1, 18.8). Surprisingly, the other 6 states assessed had no viable mechanism in place for assessing state-wide opioid prescription totals, routinely expunged collected data, or only instituted a reporting mechanism toward the end of our study. Conclusion: Total opioid prescriptions were relatively unchanged following the 2014 DEA-mandated schedule change, however, physicians did change their prescribing habits by substituting tramadol for hydrocodone combination products. This substitution of similar medications for hydrocodone suggests alternative approaches are needed to reduce total US opioid prescription rates. Additionally, the current lack of standardized prescription reporting by states makes detailed opioid prescription analysis alarmingly difficult and insufficient to guide policy or monitor the impact of policy changes. [ABSTRACT FROM AUTHOR]

As the nation works to improve the opioid epidemic, safer opioid prescribing is needed. Prescriber education is one method to assist with this aim. To gauge current surgical residents' opioid prescribing practices at a safety-net hospital, an evaluation was completed before a general surgery–specific opioid prescribing education (OPE) session. The effectiveness of this OPE was measured through a postparticipation evaluation. A voluntary, anonymous evaluation immediately before and after a one-hour OPE session was performed at an urban safety-net hospital. Descriptive statistics and Student's t-test comparisons of means were performed to analyze the results. Twenty-three residents completed the surveys. Eleven (47.8%) completed prior OPE with the most common modality being online (7, 63.6%). No participant performed an opioid risk assessment before prescribing opioids. More than half of the residents (14, 60.9%) never used the prescription drug monitoring program. Less than 1/3 (7, 30.4%) used preoperative gabinoids (gabapentin or pregabalin) for elective surgeries. Only two residents provided information on unused opioid disposal. After the OPE, the participants were more likely to prescribe preoperative gabinoids (7 versus 21, P < 0.001). The mean opioid pills prescribed for laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic ventral hernia repair, and laparoscopic appendectomy were reduced by 2.6 (14.2%, P = 0.23), 3.7 (18.9%, P = 0.07), 2.6 (13.1%, P = 0.23), and 1.1 (7.3%, P = 0.60) pills, respectively. A short OPE delivered to surgical residents at a safety-net hospital significantly improved the use of preoperative gabinoids. Although the pill count reductions after the OPE were not statistically significant, there was a consistent reduction in amount of opiates prescribed after the OPE. However, clinical significance is important, as a reduction in any amount of opioid medication can help deter misuse and diversion. This suggests resident surgeons could participate in a specialty-specific OPE to improve opioid prescribing. [ABSTRACT FROM AUTHOR]

Background: In 2016, our provider group adopted an initial prescription opioid maximum guideline to reduce overprescription of opioids. The purpose of this study was to prospectively assess opioid consumption patterns following implementation of this guideline in patients undergoing outpatient foot and ankle surgery. Methods: Over a 1-year period, we prospectively analyzed opioid prescription and use patterns of 303 consecutive patients. Opioid consumption was verified by pill counts completed at the 2- and 6-week postoperative visits. The morphine equivalent dose was calculated for each prescription and converted to the equivalent 5-mg oxycodone "pill." We used the regression coefficients from a regression model of opioid consumption to create a revised guideline for maximum initial opioid prescriptions based on patient age, bony vs nonbony procedure, and anatomic location (forefoot/midfoot/hindfoot/ankle). Results: On average, 37.4 pills were prescribed and 18.9 pills used (47.6% utilization). Only 17.2% of patients used their full prescription quantity. By 2 weeks, 88% of patients no longer used opioids. Only 1.3% of patients used prescription opioids beyond 6 weeks. Independent risk factors for increased opioid consumption were younger age (P =.003), male sex (P =.007), recent preoperative opioid use (P =.019), bony procedures (P <.001), and ankle/hindfoot procedures (P =.016 and P <.001). Conclusion: This study showed the amount of opioid consumption for patients undergoing foot and ankle procedures. We present a modified guideline for the maximum initial prescription of opioids following outpatient foot and ankle procedures that can be used as a benchmark for further study in decreasing overprescribing. Level of Evidence: Level II, prospective observational cohort study. [ABSTRACT FROM AUTHOR]

To quantify, and identify predictors of, post-discharge opioid use in gynecologic oncology patients undergoing minimally invasive hysterectomy (MIH). For this prospective cohort study, gynecologic oncology patients planning to undergo MIH were recruited at a single institution. Post-operative opioid usage was evaluated via chart review and surveys at 1–2-week and 4–6-week post-operative visits. Opioids are converted to oral morphine milligram equivalents (MME) for standardization. Descriptive statistics and modified Poisson regression were used to quantify opioid requirements and evaluate predictors of post-discharge opioid use respectively. One hundred eighteen eligible women underwent MIH. Of these, 108 had complete data at both follow-up timepoints. Malignancy was present in 79% of cases, 71% of which were endometrial cancer. Most surgeries were laparoscopic (73%). Median hospital stay was 1 night (IQR 1–1). Inpatients received a median of 30.75 MME (IQR 7.5–52.5 MME). Twenty-three women (21.3%) used no opioids while inpatient. At the 1–2-week follow-up median usage was 6 pills of 5 mg oxycodone, or 45 MME (IQR 0–15.5 pills). After complete follow-up, median post-discharge usage was 10 pills, or 75 MME (IQR 0–22.5 pills) and 36 participants (33.33%) used no opioids after hospital discharge. The median prescription was for 30 pills (range 10–60). Above median inpatient opioid use was associated with an increased risk of above median opioid usage after hospital discharge (RR 2.31, 95% CI 1.38–3.87) on multivariable analysis. In this cohort, opioids were overprescribed relative to use. Inpatient use was the strongest predictor of post-discharge opioid use. More restrictive, and personalized, opioid prescribing practices may be a pathway to reduce opioid misuse and diversion. Opioids were overprescribed by a factor of three to gynecologic oncology patients, whose inpatient opioid requirement predicted post-discharge opioid needs after minimally invasive hysterectomy. • Opioids were over prescribed to gynecologic oncology patients after minimally invasive hysterectomy. • Inpatient opioid use was the strongest predictor of post-discharge opioid use after minimally invasive hysterectomy. • Applying these findings, by prescribing opioids based on patient need, may help curb opioid overprescribing after surgery. [ABSTRACT FROM AUTHOR]

Purpose: To describe opioid prescribing practice patterns and trends in emergency department visits (EDs) by provider type: physicians and advanced practice providers (APPs), which include nurse practitioners (NPs) and physician assistants (PAs).Methods: The data source was the ED visit files of the 2005-2015 National Hospital Ambulatory Care Survey. The study sample was opioid prescription-related ED visits. Descriptive and multinomial logistic regression analyses were conducted to assess the proportion of opioid prescription-related visits by provider type over time in total and by patient age group. We then characterized opioid prescribing practices of NPs, PAs, and physicians according to type of opioid and pain-related diagnosis.Results: From 2005 to 2015, there was a 116.7% increase in the proportion of the opioid prescription-related visits seen by NPs and a 61.2% increase seen by both APPs and physicians. In contrast, the proportion of the physician-only visits decreased (-8.3%). When stratified by age group, the growth was particularly notable among the visits with patients aged 65 and older seen by both APPs and physicians (AOR = 2.35, 95% CI = 1.69, 3.25). Proportionally less hydromorphone and morphine was prescribed by APPs than by physicians. Opioids were prescribed more often by APPs in visits involving dental and injury-related pain, whereas physicians prescribed opioids more in abdominal and chest pain-related visits.Conclusions: From 2005 to 2015, APPs, particularly NPs played an increasing role in opioid prescribing in EDs. Opioid prescribing practices of APPs and physicians varied by patient condition as well as by opioid type. [ABSTRACT FROM AUTHOR]

Background: Evidence has continued to accumulate regarding the potential risks of treating chronic pain with long-term opioid therapy (LTOT). Clinical practice guidelines now encourage clinicians to implement practices designed to reduce opioid-related risks. Yet how clinicians implement these guidelines within the context of the patient encounter has received little attention.Objective: This secondary analysis aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed LTOT for chronic pain.Design: Individual interviews guided by a semi-structured interview protocol probed: (1) methods clinicians utilize to reduce prescription opioid misuse and address aberrant opioid-related behaviors; (2) how clinicians respond to misuse; and (3) resources and constraints faced in managing and treating misuse among their patients.Participants: Interviews were conducted with 24 physicians and nurse practitioners, representing 22 Veterans Health Administration (VA) facilities across the USA, who had one or more patients in their clinical panels who were prescribed LTOT for the treatment of chronic non-cancer pain.Approach: Qualitative content analysis was the analytic approach utilized. A codebook was developed iteratively following group coding and discussion. All transcripts were coded with the finalized codebook. Quotes pertaining to key themes were retrieved and, following careful review, sorted into themes, which were then further categorized into sub-themes. Quotes that exemplified key sub-themes were selected for inclusion.Key Results: We detail the challenges clinicians describe in navigating conversations with patients around prescription opioid misuse, which include patient objection as well as clinician ambivalence. We identify verbal heuristics as one strategy clinicians utilize to structure these difficult conversations, and describe four heuristics: setting expectations, following orders, safety, and standardization.Conclusion: Clinicians frequently use verbal heuristics to routinize and increase the efficiency of care management discussions related to opioid prescribing, redirect responsibility, and defuse the potential emotional charge of the encounter. [ABSTRACT FROM AUTHOR]

The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation. We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research. We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers' concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention. We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative. [ABSTRACT FROM AUTHOR]

Background: There is currently a lack of evidence‐based guidelines regarding postoperative opioids after thyroid and parathyroid surgery. This study aimed to objectively characterize contemporary postoperative pain management practices via a national survey of head and neck endocrine surgeons. Methods: A standardized electronic survey was distributed to the membership of the American Head and Neck Society's Endocrine section. Results: A total of 102 surgeons completed the survey representing a 34% response rate. In all, 65.7% of respondents utilize opioids with wide variations in the total morphine equivalents prescribed. Practice environment (χ2 = 10.0; P = 0.04) and performing preoperative pain counseling (χ2 = 9.7; P = 0.002) were significantly associated with a decreased likelihood of prescribing postoperative opioids. Utilization of non‐opioid pain management strategies was common and significantly associated with performing outpatient surgery (χ2 = 6.2; P = 0.013) and preoperative pain counseling (χ2 = 4.5; P = 0.034). Conclusions: Pain management practice patterns vary significantly among head and neck endocrine surgeons which further emphasize the need for evidence‐based guidelines. [ABSTRACT FROM AUTHOR]

Objectives This research looked at whether notifying prescribers and pharmacies about patients who use multiple providers to obtain opioids reduces their prescribing activity (including use of multiple providers, numbers of opioid prescriptions, or amounts of opioids obtained). Design Nevada's prescription drug monitoring program (PDMP) identified patients using multiple providers to obtain opioids and assigned them alternately to an intervention or control group. Controlled substance prescription histories were sent only to intervention patients' providers. Subsequent opioid purchases by patients in both groups were compared. Setting All pharmacies and dispensers in the state are required to report every prescription for Schedule II–IV opioids dispensed to the PDMP. Subjects All patients receiving opioids from more than four different Nevada prescribers and more than four pharmacies during the previous six months assigned to the intervention (N = 436) or control group (N = 441). Methods We used ordinary least squares regression to estimate notification effects on each outcome, accounting for preexisting differences among groups. Results Providers receiving unsolicited notices were 13% less likely to continue prescribing to patients than providers not notified. Eighty-four percent of the intervention patients' prescribers discontinued prescribing to them after assignment, compared with 80.5% of the control group's prescribers—who were not notified. Because patients in both groups found other prescribers to replace discontinued prescribers, notification had at most a small effect on patients' use of multiple providers, numbers of opioid prescriptions, or amounts of opioids purchased. Conclusions Requiring prescribers to solicit patients' prescription histories is likely to be a more effective use of PDMP resources than proactive notification. [ABSTRACT FROM AUTHOR]

Aims: To characterize the impacts of policies intended to improve opioid prescribing and prevent opioid-related overdose and death on individuals who take opioids.Methods: We conducted a qualitative study using focus groups with 48 adults aged 18 years and over who had experience taking opioids. Participants were recruited from across Ontario, Canada, and separate focus groups were held for individuals taking opioids for chronic pain and individuals taking opioids for other reasons. We drew upon stigma theory to interpret participants' accounts.Results: Following analysis and interpretation, we generated three themes describing the impacts of recently implemented opioid-related policies and harm reduction interventions on people who take opioids: 'propagating stigma: addict as dominant status', 'loss of autonomy' and 'producing/reproducing structural vulnerabilities'. Specifically, participants characterize an environment in which 'addict' has become the dominant social identity ascribed to people who take opioids, and where relationships with providers have become strained as participants perceive themselves to be powerless when decisions regarding opioid use and pain management are made. These shifts in identity and relationships had negative repercussions when help-seeking and exposed larger vulnerabilities related to poverty and criminalization.Conclusions: The introduction of opioid-related policies had unintended consequences for people who take opioids. Potential measures for mitigating these consequences include ensuring that people who take opioids are involved in all facets of policy development and implementation, integrating peer workers into the care of these individuals, and respecting patient agency when decisions about pain management and opioid use are made. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated the risk of opioid dose escalation as it relates to sex differences among patients receiving opioids for long-term therapy. Patients and methods: This retrospective cohort study was conducted in tertiary hospital settings in Malaysia using electronic prescription records. Opioid naïve patients, aged =18 years, who were undergoing long-term opioid therapy of =90 days, with at least one opioid prescription (buprenorphine, morphine, oxycodone, fentanyl, dihydrocodeine or tramadol) between 1st January 2011 and 31st December 2016, were included in the study. They were followed until (i) the end of the study period, (ii) death from any cause or (iii) discontinuation of therapy from their first opioid prescription without any intervals of =120 days between successive prescriptions. The risk of high opioid dose escalation to =100 mg/day and =200 mg/day relative to men and women was measured. Results: A total of 4688 patients (58.8% women, 41.3% men) on long-term opioid therapy were identified. Among these patients, 248 (5.29%) were escalated to high opioid doses of =100 mg/day and 69 (1.47%) were escalated to =200 mg/day. The escalation to high-dose opioid therapy was more likely to occur in men than in women, even after adjustment for age (dose =100 mg/day [adjusted hazard ratio 2.32; 95% confidence interval (CI), 1.79 to 3.00; p<0.0001] and =200 mg/day [adjusted hazard ratio 6.10; 95% CI, 3.39 to 10.98; p<0.0001]). Conclusion: The risk of opioid dose escalation differed between men and women, as men were at higher risk than women for high opioid dose escalation. [ABSTRACT FROM AUTHOR]

The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription. We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription. Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3–4 days' supply). Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined. • Most patients initially prescribed opioids for acute pain did not receive a refill. • Continued prescription opioid use generally increased with initial opioid duration. • Association of initial opioid days' supply and a refill varied by pain diagnosis. • Flexible prescription opioid duration limits should be considered. [ABSTRACT FROM AUTHOR]

Introduction: Patients prescribed higher opioid dosages have a higher risk of persistent opioid use, overdose, and death. There is a lack of standardization for opioid prescribing for acute surgical pain in emergency general surgery (EGS) patients. We hypothesized that implementing a guideline to standardize opioid prescribing would be associated with a decrease in prescribing at hospital discharge for EGS patients without increasing additional postdischarge refills., Methods: This was a quasi-experimental study evaluating opioid prescribing by EGS providers before and after the implementation of a prescribing guideline. Patients were assigned to preguideline and postguideline groups based on admission date surrounding the implementation of the guideline. The primary outcome was the proportion of patients receiving an opioid prescription for ≥50 Morphine Milligram Equivalents (MME) per day on hospital discharge., Results: There were 227 patients in the preguideline group and 226 patients in the postguideline group. After guideline implementation, median total MME prescribed decreased from 113 (interquartile range = 75) to 75 (interquartile range = 75, P = 0.03). The proportion of patients receiving a prescription for daily MME ≥50 also decreased from 75% to 25% (P ≤0.01). There were no increases in requested refills (17% versus 16%, P = 0.72) or received refills (14% versus 14%, P = 0.98). Guideline compliance ranged from 75% in ventral hernia repair patients to 94% in laparoscopic cholecystectomy patients., Conclusions: A departmental guideline to standardize postoperative opioid prescriptions was associated with a decrease in the amount of MMEs prescribed to EGS patients without an increase in requested or received refills., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Physician prescribing practices contributed to the US opioid epidemic, leading to increased regulation of opioid prescribing. In some instances, prescribers are unscrupulous or corrupt. They are criminally investigated and subject to prosecution. Less egregious opioid prescribing infractions are addressed through state medical licensing boards. At stake are physicians' licenses to practice medicine.