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Purpose: The diagnosis of carpal tunnel syndrome (CTS) can be made clinically using the Carpal Tunnel Syndrome-6 (CTS-6) criteria. The role of electrodiagnostic studies (EDS) is controversial. We examined differences in the utilization of CTS-6 and EDS based on surgeon experience and practice setting., Methods: Members of the American Society for Surgery of the Hand were emailed an anonymous web-based link to participate. The survey included an assessment of hypothetical CTS scenarios with varying clinical severity. We collected surgeon demographic attributes, years in practice, practice setting, and frequency of CTS-6 and EDS utilization. A comparison was made of years of experience with surgeon-reported utilization of CTS-6 and EDS as well as treatment recommendation., Results: We received 771 responses (25% response rate). Surgeons recommended carpal tunnel release (CTR) for patients without EDS (16%), normal EDS (33%), and abnormal EDS (90%). Fifty-three percent of surgeons with <15 years in practice reported often/always using CTS-6 criteria in their practice compared to 30% and 29% of surgeons with 16-30 years and > 30 years in practice, respectively. Surgeons with 16-30 and >30 years in practice had significantly lower odds of reporting often/almost always using CTS-6 relative to surgeons with 1-15 years in practice (OR 0.35 and 0.31, respectively). A greater proportion of surgeons with 16-30 years (68%) and >30 years (65.5%) in practice responded often/almost always applying EDS compared to surgeons with <15 years (56%) in practice. In addition, surgeons with 16-30 years and >30 years in practice had a higher odds of often/always using EDS (ORs 1.74 and 1.98, respectively) compared to surgeons with 1-15 years in practice (P < .05)., Conclusions: Utilization of CTS-6 and EDS varied based on years in practice. This difference may reflect changing guidelines, the growing evidence regarding clinical assessment tools, and the emergence of other diagnostic modalities., Clinical Relevance: Given the expense and invasiveness of EDS, opportunities to integrate clinical assessment tools readily into the diagnostic algorithm may shift the role of EDS toward selective utilization for complex clinical scenarios rather than for routine use., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflict of interest statement(s), disclosure(s), and/or financial support information: Mark Bicket receives grant support from Blue Cross Blue Shield of Michigan. Mark R. Hemmila receives grant support from Blue Cross Blue Shield of Michigan/Blue Care Network and the Michigan Department of Health and Human Services for the Michigan Trauma Quality Improvement Program. Mark R. Hemmila receives grant support from the Henry M. Jackson Foundation and the Department of Defense for investigation of combat wound infections. Mark R. Hemmila receives grant support from General Motors Corp., Toyota North America, Subaru Corp., and the Insurance Institute for Highway Safety for the International Center for Automotive Medicine and the Vulnerable Road Users Injury Prevention program.

Despite a decline in opioid prescriptions over the past decade, patients commonly receive opioid analgesics as a treatment for postoperative pain in the USA. One complication that patients may experience after surgery is persistent postoperative opioid use (PPOU), or opioid use beyond the typical recovery period. Often defined as beyond 3 months postsurgery, PPOU is frequently conflated with chronic postsurgical pain (CPSP), where pain persists well after the expected healing time following surgery. This narrative review explores the distinct risk factors for each condition, their interrelation, and potential future research directions.For PPOU, major risk factors include the risky use of substances including misuse and use disorders; depression and other mental health disorders; a history of chronic pain before surgery including back pain; and certain surgical types (ie, total knee arthropathy, open cholecystectomy, total hip arthropathy). Conversely, CPSP risk factors include the type of surgery (ie, thoracic and breast surgeries), mental health conditions (particularly catastrophizing), and pain in both the preoperative and postoperative phases. Despite the overlap of some factors, studies typically employ different frameworks when examining PPOU and CPSP, with a biopsychosocial model applied for CPSP and little emphasis on an individual's social environment employed for PPOU. Additionally, existing studies predominantly rely on retrospective insurance claims data, which may not capture the full scope of risk factors.To fill gaps in understanding, investigations may prospectively assess and analyze patient-reported outcomes, implement similar frameworks, and concurrently measure both conditions to advance the scientific understanding of PPOU and CPSP., Competing Interests: Competing interests: SR receives support from the Foundation for Anesthesia Education and Research through the Medical Student Anesthesia Research Fellowships (MSARF) program. Other authors have no sources of funding to declare for this manuscript., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/importance: Considerable attention has been paid to identifying and mitigating perioperative opioid-related harms. However, rates of postsurgical opioid use disorder (OUD) and overdose, along with associated risk factors, have not been clearly defined., Objective: Evaluate the evidence connecting perioperative opioid prescribing with postoperative OUD and overdose, compare these data with evidence from the addiction literature, discuss the clinical impact of these conditions, and make recommendations for further study., Evidence Review: State-of-the-art narrative review., Findings: Nearly all evidence is from large retrospective studies of insurance claims and Veterans Health Administration (VHA) data. Incidence rates of new OUD within the first year after surgery ranged from 0.1% to 0.8%, while rates of overdose events ranged from 0.01% to 0.8%. Higher rates were seen among VHA patients, which may reflect differences in data completeness and/or risk factors. Identified risk factors included those related to substance use (preoperative opioid use; non-opioid substance use disorders; preoperative sedative, anxiolytic, antidepressant, and gabapentinoid use; and postoperative new persistent opioid use (NPOU)); demographic attributes (chiefly male sex, younger age, white race, and Medicaid or no insurance coverage); psychiatric comorbidities such as depression, bipolar disorder, and PTSD; and certain medical and surgical factors. Several challenges related to the use of administrative claims data were identified; there is a need for more granular retrospective studies and, ideally, prospective cohorts to assess postoperative OUD and overdose incidence with greater accuracy., Conclusions: Retrospective data suggest an incidence of new postoperative OUD and overdose of up to 0.8% during the first year after surgery, but prospective studies are lacking., Competing Interests: Competing interests: CMB serves as a consultant for Vertex Pharmaceuticals and Merck Pharmaceuticals, and provides expert medicolegal testimony. For the remaining authors, no conflicts of interest were declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To define recent trends in opioid prescribing after surgery and new persistent opioid use in the United States., Summary Background Data: New persistent opioid use after surgery among opioid-naïve individuals has emerged as an important postoperative complication. In response, initiatives to promote more appropriate post-operative opioid prescribing have been adopted in recent years. However, current estimates of opioid prescribing and new persistent opioid use following surgery remain unknown., Methods: A retrospective cohort study of opioid-naïve privately insured adult patients undergoing 17 common surgical procedures between 2013 and 2021 was conducted utilizing multi-payer claims data from the Health Care Cost Institute (HCCI). Initial opioid prescription size in oral morphine equivalents and new persistent opioid use were the outcomes of interest. Trends in opioid prescribing and rates of new persistent opioid use were evaluated across the study period. Mixed effects logistic regression was performed to evaluate independent predictors of new persistent opioid use while adjusting for patient-level factors and year., Results: Among 989,354 opioid-naïve individuals, the adjusted initial opioid prescription size decreased from 282 mg OME to 164 mg OME, a reduction of 118 mg OME (95% CI: 116-120). The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%-2.8%) to 1.1% in 2021 (95% CI: 1.0%-1.2%). For every 30 OME increase in initial opioid prescription size, new persistent opioid use increased by 3.1%. Other predictors of new persistent opioid use included preoperative non-opioid controlled substances fills (31-365 days: aOR=1.78, 95% CI: 1.70-1.86; 0-30 days: aOR=2.71, 95% CI: 2.59-2.84) and undergoing orthopedic procedures (total knee arthroplasty (aOR=3.43, 95% CI: 3.15-3.72); shoulder arthroscopy (aOR=2.39, 95% CI: 2.24-2.56))., Conclusions: Both opioid prescription size after surgery and new persistent opioid use decreased over the last decade, suggesting that opioid stewardship practices had favorable effects on the risk of long-term opioid use., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives: Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing., Methods: We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years., Results: Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%)., Conclusions: Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: Dr Chua reports receiving consulting fees from the US Department of Justice and the Benter Foundation for unrelated work. Dr Brummett is a consultant for Vertex Pharmaceuticals and Merck Pharmaceuticals, and he previously consulted for Heron Therapeutics. He also provides expert medical testimony. Dr Bicket reports past unrelated grants from the Arnold Foundation. The other authors have indicated they have no relevant conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

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: We sought to compare identification of unhealthy substance use before surgery using The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS), a standardized 4-item instrument, versus routine clinical documentation in the electronic medical record (EHR)., Summary Background Data: Over 20% of individuals exhibit unhealthy substance use before elective surgery. Routine EHR documentation is often based on non-standard questions that may not fully capture the extent of substance use and is subject to bias. In contrast, brief standardized screening could provide a more efficient and systematic approach., Methods: We conducted a cross-sectional study among adults (≥18 y) at a preoperative clinic from August to September, 2021. Positive screens for unhealthy substances by TAPS were compared to data from the EHR. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were reported. Receiver operating characteristic curves (ROCs) were used to assess diagnostic ability. Multivariable logistic regression was used to estimate the predictors of positive screens by TAPS., Results: The cohort included 240 surgical patients. TAPS screening identified significantly more positive screens than EHR documentation (43.3% vs. 14.2%). Patients with unhealthy substance use were younger (50.8 vs. 56.7 y; P=0.003), and TAPS revealed alcohol misuse in 30.8% of cases, contrasting with 0% in clinician documentation (P<0.001). Of the 104 TAPS-positive patients, 69.2% were missed by EHR documentation. Sensitivity (31%) and accuracy (AUC=0.65) of clinician documentation for any unhealthy substance use were lower compared to TAPS., Conclusion: Standardized TAPS screening detected preoperative unhealthy substance use more frequently than routine clinician documentation, emphasizing the need for integrating standardized measures into surgical practice to ensure safer perioperative care and outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To evaluate changes in opioid prescribing and patient-reported outcomes after surgery following implementation of Michigan's prescription drug monitoring program (PDMP) use mandate in June 2018., Background: Most states mandate clinicians to query prescription drug monitoring program (PDMP) databases before prescribing controlled substances. Whether these PDMP use mandates affect opioid prescribing and patient-reported outcomes after surgery is unclear, especially among patients with elevated "Narx" scores, a risk score for overdose death used in most PDMPs., Methods: We conducted an interrupted time series analysis of a statewide surgical registry linked to Michigan's PDMP database. Analyses included adults undergoing general surgical procedures during January 2017-October 2019. Outcomes included monthly mean days supplied in dispensed opioid prescriptions (those filled within 3 days of discharge) and monthly mean scores for 3 patient-reported outcomes (pain in the week after surgery, care satisfaction, regret undergoing surgery). Segmented regression models were used to assess for level and slope changes in outcomes in June 2018. Analyses were repeated among patients with Narx scores ≥200, a threshold that defines the top quartile., Results: Analyses included 21,897 patients. The mandate was associated with a -0.5 (95% CI: -0.8, -0.2) level decrease in mean days supplied in dispensed opioid prescriptions, but not with worsened patient-reported outcomes. Findings were similar among patients with Narx scores ≥200., Conclusions: Following implementation of Michigan's PDMP use mandate, the duration of opioid prescriptions decreased, but patient-reported outcomes did not worsen. Findings suggest PDMP use mandates may not be associated with worsened experience among general surgical patients., Competing Interests: Conflict of Interest Disclosures: Dr. Chua reports receiving consulting fees from the U.S. Department of Justice. Dr. Brummett reports consulting for Heron Therapeutics, Merck Pharmaceutical and Vertex Pharmaceuticals for work outside the current study. Dr. Brummett also provides expert medical testimony outside the current study. Dr. Bohnert reports serving as an expert witness for the State of Michigan in a suit related to opioid distribution. No other conflicts of interest were reported., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Objective: This study aimed to describe opioid prescribing patterns for pregnant patients with a history of or active opioid use to inform postpartum pain management strategies., Study Design: We conducted a retrospective cohort analysis of all patients with a history of opioid use disorder (OUD) or chronic pain seen at a single outpatient clinic specializing in opioid use and OUD in pregnancy from January 2019 to August 2021. Patient characteristics, delivery outcomes, and opioid prescribing information were collected through electronic health record fields. We used descriptive statistics to characterize differences in receipt of an opioid prescription, prescription size, and receipt of a prescription refill across three patient groups: patients with OUD on medication, patients with OUD maintaining abstinence, and patients with chronic pain using opioids. In the study period, the institutional average rate of opioid prescribing after cesarean and vaginal birth were 80.0 and 2.8%, respectively., Results: Of the 69 patients included in this study, 46 (66.7%) had a history of OUD on medication, 14 (20.3%) had a history of OUD maintaining abstinence, and 9 (13.0%) had a history of chronic pain. Receipt of an opioid prescription after childbirth was more common after cesarean birth (12/23, 52.2%) than vaginal birth (3/46, 6.5%). Refills were common in patients who received an opioid proscription (cesarean: 5/12, 41.7%; vaginal: 1/3, 33.3%)., Conclusion: Compared with institutional averages, postpartum opioid prescribing rates for people with a history of OUD or chronic pain were 50 to 60% lower for cesarean birth and three times higher for vaginal birth. Future work is needed to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations., Key Points: · Opioid prescribing rates for patients with OUD/chronic pain were 60% lower for cesarean birth than institutional averages.. · Opioid prescribing rates for patients with OUD/chronic pain were three times higher for vaginal birth than institutional averages.. · Refill rates following birth were high overall for cesarean (40%) and vaginal (33%) birth.. · More work is needed to balance opioid prescribing with adequate pain control in high-risk patients.., Competing Interests: A.F.P. is a consultant for Maven. The remaining authors report no conflicts of interest., (Thieme. All rights reserved.)

Objective: To compare outcomes of patients using versus not using cannabis as a treatment for pain after discharge from surgery., Background: Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes., Methods: Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing 16 procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included postdischarge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life, and regret to undergo surgery (secondary)., Results: Of 11,314 included patients (58% females, mean age: 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI: 0.4-1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (adjusted odds ratio: 1.7, 95% CIL 1.4-2.1) and 1 month (adjusted odds ratio: 2.1, 95% CI: 1.7-2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs 82.6%), best quality of life (46.7% vs 63.0%), and no regret (87.6% vs 92.7%) (all P < 0.001)., Conclusions: Patient-reported cannabis use, to treat postoperative pain, was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes., Competing Interests: C.M.B serves as a consultant for Heron Therapeutics, a biotech company that produces a nonopioid analgesic for acute pain, and he served as a consultant for Vertex Pharmaceuticals, Alosa Health, and the Benter Foundation. In addition, he provides expert medicolegal testimony unrelated to this analysis. K.F.B. has received protocol development funding from Tryp Therapeutics and currently sits on a Data Safety and Monitoring Committee for Vireo Health (unpaid). K.S.L. is a co-principal investigator on an observational study on medical cannabis funded by Shoppers Drug Mart. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Although substantial attention has been given to opioid prescribing in the United States, opioid-related mortality continues to climb due to the rising incidence and prevalence of opioid use disorder. Perioperative care has an important role in the consideration of opioid prescribing and the care of individuals at risk for poor postoperative pain- and opioid-related outcomes. Opioids are effective for acute pain management and commonly prescribed for postoperative pain. However, failure to align prescribing with patient need can result in overprescribing and exacerbate the flow of unused opioids into communities. Conversely, underprescribing can result in the undertreatment of pain, complicating recovery and impairing well-being after surgery. Optimizing pain management can be particularly challenging for individuals who are previously exposed to opioids or have critical risk factors, including opioid use disorder. In this review, we will explore the role of perioperative care in the broader context of the opioid epidemic in the United States, and provide considerations for a multidisciplinary, comprehensive approach to perioperative pain management and optimal opioid stewardship., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Introduction: Gabapentin is commonly prescribed as an off-label adjunct to opioids because of its safer risk profile. Recent evidence has shown an increased risk of mortality when coprescribed with opioids. Therefore, we aimed to evaluate whether the addition of off-label gabapentin in patients with chronic opioid use is associated with a reduction in opioid dosage., Methods: We performed a retrospective cohort study of patients with chronic opioid use with a new off-label gabapentin prescription (2010-2019). Our primary outcome of interest was a reduction in opioid dosage measured via oral morphine equivalents (OME) per day after the addition of a new off-label gabapentin prescription., Results: In our cohort of 172,607 patients, a new off-label gabapentin prescription was associated with a decrease in opioid dosage in 67,016 patients (38.8%) (median OME/day reduction:13.8), with no change in opioid dosage in 24,468 patients (14.2%), and an increase in opioid dosage in 81,123 patients (47.0%) (median OME/day increase: 14.3). A history of substance/alcohol use disorders was associated with a decrease in opioid dosage after the addition of a new off-label gabapentin (aOR 1.20, 95% CI 1.16 to 1.23). A history of pain disorders was associated with a decrease in opioid dosage after the initiation of a new gabapentin prescription including arthritis (aOR 1.12, 95% CI 1.09 to 1.15), back pain (aOR 1.10, 95% CI 1.07 to 1.12), and other pain conditions (aOR 1.08, 95% CI 1.06 to 1.10)., Conclusions: In this study of patients with chronic opioid use, an off-label gabapentin prescription did not reduce opioid dosage in the majority of patients. The coprescribing of these medications should be critically evaluated to ensure optimal patient safety., Competing Interests: Competing interests: CMB is a consultant for Heron Therapeutics (San Diego, California, USA)., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: While identifying opioid prescriptions in claims data has been instrumental in informing best practises, studies have not evaluated whether certain methods of identifying opioid prescriptions yield better results. We compared three common approaches to identify opioid prescriptions in large, nationally representative databases., Methods: We performed a retrospective cohort study, analyzing MarketScan, Optum, and Medicare claims to compare three methods of opioid classification: claims database-specific classifications, National Drug Codes (NDC) from the Centers for Disease Control and Prevention (CDC), or NDC from Overdose Prevention Engagement Network (OPEN). The primary outcome was discrimination by area under the curve (AUC), with secondary outcomes including the number of opioid prescriptions identified by experts but not identified by each method., Results: All methods had high discrimination (AUC>0.99). For MarketScan (n=70,162,157), prescriptions that were not identified totalled 42,068 (0.06%) for the CDC list, 2,067,613 (2.9%) for database-specific categories, and 0 (0%) for the OPEN list. For Optum (n=61,554,852), opioid prescriptions not identified totalled 9,774 (0.02%) for the CDC list, 83,700 (0.14%) for database-specific categories, and 0 (0%) for the OPEN list. In Medicare claims (n=92,781,299), the number of opioid prescriptions not identified totalled 8,694 (0.01%) for the CDC file and 0 (0%) for the OPEN list., Discussion: This analysis found that identifying opioid prescriptions using methods from CDC and OPEN were similar and superior to prespecified database-specific categories. Overall, this study shows the importance of carefully selecting the approach to identify opioid prescriptions when investigating claims data., Competing Interests: Competing interests: CMB serves as a consultant for Vertex Pharmaceuticals and Merck Pharmaceuticals. In addition, CMB provides expert medicolegal testimony unrelated to this analysis., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: To balance adequate pain management while minimizing opioid-related harms after surgery, opioid prescribing guidelines rely on patient-reported use after surgery. However, it is unclear how many patients are required to develop precise guidelines. We aimed to compare patterns of use, required sample size, and the precision for patient-reported opioid consumption after common surgical procedures., Methods: We analyzed procedure-specific 30-day opioid consumption data reported after discharge from 15 common surgical procedures between January 2018 and May 2019 across 65 hospitals in the Michigan Surgical Quality Collaborative. We calculated proportions of patients using no pills and the estimated number of pills meeting most patients' needs, defined as the 75th percentile of consumption. We compared several methods to model consumption patterns. Using the best method (Tweedie), we calculated sample sizes required to identify opioid consumption within a 5-pill interval and estimates of pills to meet most patients' needs by calculating the width of 95% CIs., Results: In a cohort of 10,688 patients, many patients did not consume any opioids after all types of procedures (range 20%-40%). Most patients' needs were met with 4 pills (thyroidectomy) to 13 pills (abdominal hysterectomy). Sample sizes required to estimate opioid consumption within a 5-pill wide 95% CI ranged from 48 for laparoscopic appendectomy to 188 for open colectomy. The 95% CI width for estimates ranged from 0.7 pills for laparoscopic cholecystectomy to 7.0 pills for ileostomy/colostomy., Conclusions: This study demonstrates that profiles of opioid consumption share more similarities than differences for certain surgical procedures. Future investigations on patient-reported consumption are required for procedures not currently included in prescribing guidelines to ensure surgeons and perioperative providers can appropriately tailor recommendations to the postoperative needs of patients., Competing Interests: Competing interests: JS, YL, and VG have no disclosures. CMB, MJE, JFW, and MCB receive funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse (R01DA042859). CMB is a consultant for Heron Therapeutics, Vertex Pharmaceuticals, Alosa Health and the Benter Foundation, not related to this work. JS had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons., Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender., Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience., Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons., Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals., Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Purpose: Differences in the utilization of carpal tunnel release (CTR) by Blacks and women are well documented, but less is known regarding the impact of patient-provider concordance on treatment recommendations. To investigate this, we surveyed hand surgeons using hypothetical scenarios to evaluate variations in treatment recommendations for carpal tunnel syndrome based on patient-related factors and patient-provider concordance., Methods: Three pairs (six total) of hypothetical scenarios with clinical symptoms of carpal tunnel syndrome were created varying sex, race, and occupation. We used names as a proxy for sex and race. Occupation included manual laborers, secretaries, athletes, and retirees. American Society for Surgery of the Hand members were emailed an anonymous web-based link to participate. We used descriptive statistics to analyze the scenario-based treatment recommendations., Results: We identified 3,067 eligible members for participation; 770 surgeons responded (25%) and provided recommendations for 3,742 scenarios. For scenarios involving symptomatic patients without electrodiagnostic studies (EDS), with normal EDS, and with abnormal EDS, no difference was noted in surgeon treatment recommendations based on patients' race, sex, and occupation. Surgeons recommended EDS for 31% and 32.8% of the scenarios with Black female and White male patients, respectively, who did not have EDS at presentation and CTR for 32.3% and 33% of White females and Black males with normal EDS, respectively. Among retired Black female and White male patients older than 80 years of age with abnormal EDS, surgeons recommended CTR in 89.9% and 89.3% of them, respectively. For patient-provider racially concordant pairs, White surgeons recommended CTR to a similar proportion of Black and White hypothetical patients; however, Black surgeons recommended CTR to a greater proportion of patients with Black-sounding names., Conclusions: We found that surgeon treatment recommendation was not associated with patient race, sex, or occupation; however, differences did emerge based on patient-provider racial concordance, suggesting that alignment of patient and provider identities may influence treatment recommendations., Type of Study/level of Evidence: Prognostic III., (© 2023 The Authors.)

Background: U.S. data on opioid prescribing by dentists are limited to 2019. More recent data are needed to understand the effect of the COVID-19 outbreak on dental opioid prescribing, characterize current practices, and determine if dental opioid stewardship initiatives are still warranted., Objective: To evaluate the association between the COVID-19 outbreak and the rate of opioid prescribing by U.S. dentists., Methods: During February-April 2023, the authors conducted a cross-sectional analysis of the IQVIA Longitudinal Prescription Database, which reports 92% of prescriptions dispensed in U.S. retail pharmacies. The authors calculated the monthly dental opioid dispensing rate, defined as the monthly number of dispensed opioid prescriptions from dentists per 100,000 U.S. individuals, during January 2016-February 2020 and June 2020-December 2022. To prevent distortions in trends, data from March-May 2020, when dental opioid dispensing declined sharply, were excluded. Using linear segmented regression models, the authors assessed for level and slope changes in the dental opioid dispensing rate during June 2020., Results: Analyses included 81,189,605 dental opioid prescriptions. The annual number of prescriptions declined from 16,105,634 in 2016 to 8,910,437 in 2022 (-44.7%). During January 2016-February 2020, the dental opioid dispensing rate declined -3.9 (95% CI: -4.3, -3.6) per month. In June 2020, this rate abruptly increased by 31.4 (95% CI: 19.3, 43.5) and the monthly decline in the dental opioid dispensing rate slowed to -2.1 (95% CI: -2.6, -1.6) per month. As a result, 6.1 million more dental opioid prescriptions were dispensed during June 2020-December 2022 than would be predicted had trends during January 2016-February 2020 continued., Discussion: U.S. dental opioid prescribing is declining, but the rate of this decline slowed after the COVID-19 outbreak. Findings highlight the continued importance of dental opioid stewardship initiatives., Competing Interests: Drs. Chua, Brummett, and Nalliah report receiving honoraria from the Benter Foundation to design an initiative to improve opioid prescribing by U.S. dentists. Dr. Chua also reports receiving consulting fees from the U.S. Department of Justice. Dr. Brummett also reports providing expert testimony and serving as a consultant for Heron Therapeutics, Vertex Pharmaceuticals, and Alosa Health. No other conflicts of interest were reported. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Zhang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Excessive opioid prescribing has resulted in opioid diversion and misuse. In July 2018, Michigan's Public Act 251 established a state-wide policy limiting opioid prescriptions for acute pain to a 7-day supply. Traumatic injury increases the risk for new persistent opioid use, yet the impact of prescribing policy in trauma patients remains unknown. To determine the relationship between policy enactment and prescribing in trauma patients, we compared oral morphine equivalents prescribed at discharge before and after implementation of Public Act 251., Methods: In this cross-sectional study, adult patients who received any oral opioids at discharge from a Level 1 trauma center between January 1, 2016, and June 30, 2021, were identified. The exposure was patients admitted starting July 1, 2018. Inpatient oral morphine equivalents per day 48 hours before discharge and discharge prescription oral morphine equivalents per day were calculated. Student's t test and an interrupted time series analysis were performed to compare mean oral morphine equivalents per day pre- and post-policy. Multivariable risk adjustment accounted for patient/injury factors and inpatient oral morphine equivalent use., Results: A total of 3,748 patients were included in the study (pre-policy n = 1,685; post-policy n = 2,063). Implementation of the prescribing policy was associated with a significant decrease in mean discharge oral morphine equivalents per day (34.8 ± 49.5 vs 16.7 ± 32.3, P < .001). After risk adjustment, post-policy discharge prescriptions differed by -19.2 oral morphine equivalents per day (95% CI -21.7 to -16.8, P < .001). The proportion of patients obtaining a refill prescription 30 days post-discharge did not increase after implementation (0.38 ± 0.48 vs 0.37 ± 0.48, P = .7)., Conclusion: Discharge prescription amounts for opioids in trauma patients decreased by approximately one-half after the implementation of opioid prescribing policies, and there was no compensatory increase in subsequent refill prescriptions. Future work is needed to evaluate the effect of these policies on the adequacy of pain management and functional recovery after injury., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain., Objective: To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan., Design, Setting, and Participants: This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019., Exposure: Policy limiting opioid prescriptions to a 5-day supply in February 2018., Main Outcomes and Measures: Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume., Results: Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone., Conclusions: This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.

Objective: To assess the prevalence of and identify characteristics associated with unhealthy use before surgery., Background: Although the escalation in US drug overdose deaths is apparent, the unhealthy use of substances among patients presenting for surgery is unclear., Methods: We conducted a retrospective study of patients presenting for elective surgical procedures between December 2018 and July 2021 and prospectively recruited to 1 of 2 clinical research studies (Michigan Genomics Initiative, Prevention of Iatrogenic Opioid Dependence after Surgery Study). The primary outcome was unhealthy substance use in the past 12 months as determined using the Tobacco, Alcohol, Prescription medication, and other Substance use tool., Results: Among 1912 patients, unhealthy substance use was reported in 768 (40.2%). The most common substances with unhealthy use were illicit drugs [385 (20.1%)], followed by alcohol 358 (18.7%)], tobacco [262 (13.7%)], and prescription medications [86 (4.5%)]. Patients reporting unhealthy substance use were significantly more likely to be younger, male [aOR: 1.95 (95% CI, 1.58-2.42)], and have higher scores for pain [aOR: 1.07 (95% CI, 1.02-1.13)], and anxiety [aOR: 1.03 (95% CI, 1.01-1.04)]. Unhealthy substance use was more common among surgical procedures of the forearm, wrist, and hand [aOR: 2.58 (95% CI, 1.01-6.55)]., Conclusions: As many as 2 in 5 patients in the preoperative period may present with unhealthy substance use before elective surgery. Given the potential impact of substance use on surgical outcomes, increased recognition of the problem by screening patients is a critical next step for surgeons and perioperative care teams., Competing Interests: Dr M.C.B reports past personal fees and other from Axial Healthcare and past personal fees from Alosa Health outside the submitted work. Dr C.M.B. serves as a consultant for Heron Therapeutics, a biotech company that produces a nonopioid analgesic for acute pain, and he served as a one-time consultant for Vertex Pharmaceuticals, Alosa Health, and the Benter Foundation. In addition, Dr C.M.B. provides expert medicolegal testimony unrelated to this viewpoint. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare the rates of operative recurrence between male and female patients undergoing groin hernia repair., Background Data: Groin hernia repair is common but understudied in females. Limited prior work demonstrates worse outcomes among females., Methods: Using Medicare claims, we performed a retrospective cohort study of adult patients who underwent elective groin hernia repair between January 1, 2010 and December 31, 2017. We used a Cox proportional hazards model to evaluate the risk of operative recurrence up to 5 years following the index operation. Secondary outcomes included 30-day complications following surgery., Results: Among 118,119 patients, females comprised the minority of patients (n=16,056, 13.6%). Compared with males, female patients were older (74.8 vs. 71.9 y, P <0.01), more often white (89.5% vs. 86.7%, P <0.01), and had a higher prevalence of nearly all measured comorbidities. In the multivariable Cox proportional hazards model, we found that female patients had a significantly lower risk of operative recurrence at 5-year follow-up compared with males (aHR 0.70, 95% CI 0.60-0.82). The estimated cumulative incidence of recurrence was lower among females at all time points: 1 year [0.68% (0.67-0.68) vs. 0.88% (0.88-0.89)], 3 years [1.91% (1.89-1.92) vs. 2.49% (2.47-2.5)], and 5 years [2.85% (2.82-2.88) vs. 3.7% (3.68-3.75)]. We found no significant difference in the 30-day risk of complications., Conclusions: We found that female patients experienced a lower risk of operative hernia recurrence following elective groin hernia repair, which is contrary to what is often reported in the literature. However, the risk of operative recurrence was low overall, indicating excellent surgical outcomes among older adults for this common surgical condition., Competing Interests: A.P.E. receives related funding from SAGES, and unrelated funding from the Blue Cross Blue Shield of Michigan Foundation and the Association for Academic Surgery. R.H. receives unrelated funding from the Blue Cross Blue Shield of Michigan Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases (5T32DK108740-05). D.A.T. receives unrelated funding from the National Institute of Diabetes and Digestive and Kidney Diseases and receives consulting fees from Medtronic. J.B.D. receives unrelated grant funding from the National Institutes of Health, the Agency for Healthcare Research and Quality, Blue Cross Blue Shield of Michigan Foundation, and is a cofounder of ArborMetrix, Inc. The remaining authors do not have any disclosures. No funder had any part in the design or execution of this study. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Summary: Understanding causal association and inference is critical to study health risks, treatment effectiveness, and the impact of health care interventions. Although defining causality has traditionally been limited to rigorous, experimental contexts, techniques to estimate causality from observational data are highly valuable for clinical questions in which randomization may not be feasible or appropriate. In this review, the authors highlight several methodologic options to deduce causality from observational data, including regression discontinuity, interrupted time series, and difference-in-differences approaches. Understanding the potential applications, assumptions, and limitations of quasi-experimental methods for observational data can expand our interpretation of causal relationships for surgical conditions., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Hand surgeons are constantly faced with evaluation of new evidence to identify best practices in clinical care. However, even the most rigorous study designs have limitations due to biases, generalizability, and other flaws. Here, we highlight seven common aspects of study design and analysis that should be considered by hand surgeons when interpreting findings. The evaluation of these practices can optimize the peer-review process and assess the value of evidence to be incorporated into clinical practice., (Copyright © 2023. Published by Elsevier Inc.)

Objective: We examined long-term health outcomes associated with new persistent opioid use after surgery and hypothesized that patients with new persistent opioid use would have poorer overall health outcomes compared with those who did not develop new persistent opioid use after surgery., Background: New persistent opioid use is a common surgical complication. Long-term opioid use increases risk of mortality, fractures, and falls; however, less is known about health care utilization among older adults with new persistent opioid use after surgical care., Methods: We analyzed claims from a 20% national sample of Medicare beneficiaries ≥65 years undergoing surgery between January 1, 2009, and June 30, 2019. We estimated associations between new persistent use and subsequent health events between 6 and 12 months after surgery, including mortality, serious fall/fall-related injury, and respiratory or opioid/pain-related readmission/emergency department (ED) visits using a Cox proportional hazards model to estimate mortality and multivariable logistic regression for the remaining outcomes, adjusting for demographic/clinical characteristics. Our primary outcome was mortality within 6 to 12 months after surgery. Secondary outcomes included falls and readmissions or ED visits (respiratory, pain related/opioid related) within 6 to 12 months after surgery., Results: Of 229,898 patients, 6874 (3.0%) developed new persistent opioid use. Compared with patients who did not develop new persistent opioid use, patients with new persistent opioid use had a higher risk of mortality (hazard ratio 3.44, CI, 2.99-3.96), falls [adjusted odds ratio (aOR): 1.21, 95% CI, 1.05-1.39], and respiratory-related (aOR: 1.67, 95% CI, 1.49-1.86) or pain-related/opioid-related (aOR: 1.68, 95% CI, 1.55-1.82) readmissions/ED visits., Conclusions: New persistent opioid use after surgery is associated with increased mortality and poorer health outcomes after surgery. Although the mechanisms that underlie this risk are not clear, persistent opioid use may also be a marker for greater morbidity requiring more care in the late postoperative period. Increased awareness of individuals at risk for new persistent use after surgery and close follow-up in the late postoperative period is critical to mitigate the harms associated with new persistent use., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Collaborative quality improvement (CQI) models, often supported by private payers, create hospital networks to improve health care delivery. Recently, these systems have focused on opioid stewardship; however, it is unclear whether reduction in postoperative opioid prescribing occurs uniformly across health insurance payer types., Objective: To evaluate the association between insurance payer type, postoperative opioid prescription size, and patient-reported outcomes in a large statewide CQI model., Design, Setting, and Participants: This retrospective cohort study used data from 70 hospitals within the Michigan Surgical Quality Collaborative clinical registry for adult patients (age ≥18 years) undergoing general, colorectal, vascular, or gynecologic surgical procedures between January 1, 2018, and December 31, 2020., Exposure: Insurance type, classified as private, Medicare, or Medicaid., Main Outcomes and Measures: The primary outcome was postoperative opioid prescription size in milligrams of oral morphine equivalents (OME). Secondary outcomes were patient-reported opioid consumption, refill rate, satisfaction, pain, quality of life, and regret about undergoing surgery., Results: A total of 40 149 patients (22 921 [57.1%] female; mean [SD] age, 53 [17] years) underwent surgery during the study period. Within this cohort, 23 097 patients (57.5%) had private insurance, 10 667 (26.6%) had Medicare, and 6385 (15.9%) had Medicaid. Unadjusted opioid prescription size decreased for all 3 groups during the study period from 115 to 61 OME for private insurance patients, from 96 to 53 OME for Medicare patients, and from 132 to 65 OME for Medicaid patients. A total of 22 665 patients received a postoperative opioid prescription and had follow-up data for opioid consumption and refill. The rate of opioid consumption was highest among Medicaid patients throughout the study period (16.82 OME [95% CI, 12.57-21.07 OME] greater than among patients with private insurance) but increased the least over time. The odds of refill significantly decreased over time for patients with Medicaid compared with patients with private insurance (odds ratio, 0.93; 95% CI, 0.89-0.98). Adjusted refill rates for private insurance remained between 3.0% and 3.1% over the study period; adjusted refill rates among Medicare and Medicaid patients decreased from 4.7% to 3.1% and 6.5% to 3.4%, respectively, by the end of the study period., Conclusions and Relevance: In this retrospective cohort study of surgical patients in Michigan from 2018 to 2020, postoperative opioid prescription size decreased across all payer types, and differences between groups narrowed over time. Although funded by private payers, the CQI model appeared to have benefitted patients with Medicare and Medicaid as well.

Background: The present study was designed to test the hypothesis that there was no association between initial opioid prescription size and the likelihood of refill after elective primary total knee (TKA) and hip arthroplasty (THA)., Methods: We retrospectively analyzed large national datasets of commercial and Medicare insurance claims to identify a weighted cohort of 120,889 primary total joint arthroplasties (76,900 TKA and 43,989 THA) comprised of opioid-naive patients aged 18 to 75 years who had surgery between January 2015 and November 2019. The primary outcome was refill of any prescription opioid medication within 30 days after discharge, and the primary predictor variable was the total amount of opioid filled in the initial discharge prescription measured in oral morphine equivalents (OMEs). Logistic regressions were used to estimate the likelihood of refill, given a particular prescription size while adjusting for multiple patient factors, including age, sex, comorbidities, and year of surgery., Results: The 30-day refill rate was 59.6% following TKA and 26.1% for THA. Adjusted odds of refill decreased by 2% for every 75 OME (10 tablets of 5 mg oxycodone) increase to the initial prescription size among the THA cohort (adjusted odds ratio [OR] = 0.98; 95% CI 0.97-0.99), and decreased by 3% for the TKA cohort (aOR = 0.97; 95% CI 0.97-0.98)., Conclusion: These nationally representative data demonstrated that larger initial opioid prescription size was associated with small but clinically insignificant decreases in 30-day refill after total joint arthroplasty. This finding should allay concerns about efforts to decrease postsurgical opioid prescribing., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The present study assessed concordance in perioperative opioid fulfillment data between Michigan's prescription drug monitoring program (PDMP) and a national pharmacy prescription database., Background: PDMPs and pharmacy dispensation databases are widely utilized, yet no research has compared their opioid fulfilment data postoperatively., Methods: This retrospective study included participants (N=19,823) from 2 registry studies at Michigan Medicine between July 1, 2016, and February 7, 2019. We assessed the concordance of opioid prescription fulfilment between the Michigan PDMP and a national pharmacy prescription database (Surescripts). The primary outcome was concordance of opioid fill data in the 91 to 180 days after surgical discharge, a time period frequently used to define persistent opioid use. Secondary outcomes included concordance of opioid dose and number of prescriptions fulfilled. Multinomial logistic regression analysis examined concordance across key subgroups., Results: In total, 3076 participants had ≥1 opioid fulfillments 91 to 180 days after discharge, with 1489 (49%) documented in PDMP only, 243 (8%) in Surescripts only, and 1332 (43%) in both databases. Among participants with fulfillments in both databases, there were differences in the number (n=239; 18%) and dose (n=227; 17%). The PDMP database was more likely to capture fulfillment among younger and publicly insured participants, while Surescripts was more likely to capture fulfillment from counties bordering neighboring states. The prevalence of persistent opioid use was 10.7% using PDMP data, 5.5% using Surescripts data only, and 11.7% using both data resources., Conclusions: The state PDMP appears reliable for detecting opioid fulfillment after surgery, detecting 2 times more patients with persistent opioid use compared with Surescripts., Competing Interests: C.M.B. is a consultant for Heron Therapeutics and Vertex Pharmaceuticals. He has performed 1-time advisory roles for Alosa Health and the Benter Foundation. In addition, he provides expert testimony for medical malpractice. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually., Methods: This was a retrospective cohort study of adult patients undergoing elective groin hernia repair in a 20% representative Medicare sample from 2010-17. Surgical approach [minimally invasive (MIS) vs open] was defined using appropriate CPT codes. The primary outcome was operative recurrence at up to 5 years following surgery. We estimated the overall risk of operative recurrence using a multivariable Cox proportional hazards model., Results: Among 118119 patients, the majority (76.4%) underwent an open repair. Compared to patients who underwent MIS repair, patients in the open surgery cohort were older (mean age 72.7 vs 71.0, p < 0.001), more often female (14.4 vs 10.9%, p < 0.001), less often white (86.9 vs 87.7%, p < 0.001), and had a higher prevalence of nearly all measured comorbidities Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79-0.93)., Conclusions: In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To estimate high-risk prescribing patterns among opioid prescriptions from U.S. surgeons; to characterize the distribution of high-risk prescribing among surgeons., Background: National data on the prevalence of opioid prescribing and high-risk opioid prescribing by U.S. surgeons are lacking., Methods: Using the IQVIA Prescription Database, which reports dispensing from 92% of U.S. pharmacies, we identified opioid prescriptions from surgeons dispensed in 2019 to patients ages ≥12 years. "High-risk" prescriptions were characterized by: days supplied >7, daily dosage ≥50 oral morphine equivalents (OMEs), opioid-benzodiazepine overlap, and extended-release/long-acting opioid. We determined the proportion of opioid prescriptions, total OMEs, and high-risk prescriptions accounted for by "high-volume surgeons" (those in the ≥95th percentile for prescription counts). We used linear regression to identify characteristics associated with being a high-volume surgeon., Results: Among 15,493,018 opioid prescriptions included, 7,036,481 (45.4%) were high-risk. Among 114,610 surgeons, 5753 were in the 95th percentile or above for prescription count, with ≥520 prescriptions dispensed in 2019. High-volume surgeons accounted for 33.5% of opioid prescriptions, 52.8% of total OMEs, and 44.2% of high-risk prescriptions. Among high-volume surgeons, 73.9% were orthopedic surgeons and 60.6% practiced in the South. Older age, male sex, specialty, region, and lack of affiliation with academic institutions or health systems were correlated with high-risk prescribing., Conclusions: The top 5% of surgeons account for 33.5% of opioid prescriptions and 45.4% of high-risk prescriptions. Quality improvement initiatives targeting these surgeons may have the greatest yield given their outsized role in high-risk prescribing., Competing Interests: K.P.C. and C.M.B. report receiving honoraria from the Benter Foundation for work outside the current manuscript. C.M.B. also reports providing expert testimony and serving as a consultant for Heron Therapeutics, Vertex Pharmaceuticals, and Alosa Health. M.C.B. reports past consultations with Axial Health Care and Alosa Health not related to this work. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Autologous fat grafting (AFG) has traditionally been used for facial rejuvenation and soft tissue augmentation, but in recent years, its use has expanded to treat diseases of the hand. Autologous fat grafting is ideal for use in the hand because it is minimally invasive, can restore volume, and has regenerative capabilities. This review summarizes the emerging evidence regarding the safety and efficacy of AFG to the hand in several conditions, including systemic sclerosis, Dupuytren disease, osteoarthritis, burns, and traumatic fingertip injuries. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search on the use of AFG in hand pathologies was performed on October 8, 2020, in Ovid MEDLINE, Elsevier Embase, Clarivate Web of Science, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by 2 independent reviewers and a third reviewer adjudicated when required. Reviewers identified 919 unique hits. Screening of the abstracts identified 22 manuscripts which described the use of AFG to treat an identified hand condition. Studies suggest AFG in the hands is a safe, noninvasive option for the management of systemic sclerosis, Dupuytren contracture, osteoarthritis, burns, and traumatic fingertip injuries. While AFG is a promising therapeutic option for autoimmune, inflammatory, and fibrotic disease manifestations in the hand, further studies are warranted to understand its efficacy and to establish more robust clinical guidelines. Studies to date show the regenerative, immunomodulatory, and volume-filling properties of AFG that facilitate wound healing and restoration of hand function with limited complications.

Objective: In this study, we explored which postoperative opioid prescribing practices were associated with persistent opioid use among adolescents and young adults., Background: Approximately 5% of adolescents and young adults develop postoperative new persistent opioid use. The impact of physician prescribing practices on persistent use among young patients is unknown., Methods: We identified opioid-naïve patients aged 13 to 21 who underwent 1 of 13 procedures (2008-2016) and filled a perioperative opioid prescription using commercial insurance claims (Optum Deidentified Clinformatics Data Mart Database). Persistent use was defined as ≥ 1 opioid prescription fill 91 to 180 days after surgery. High-risk opioid prescribing included overlapping opioid prescriptions, co-prescribed benzodiazepines, high daily prescribed dosage, long-acting formulations, and multiple prescribers. Logistic regression modeled persistent use as a function of exposure to high-risk prescribing, adjusted for patient demographics, procedure, and comorbidities., Results: High-risk opioid prescribing practices increased from 34.9% to 43.5% over the study period; the largest increase was in co-prescribed benzodiazepines (24.1%-33.4%). High-risk opioid prescribing was associated with persistent use (aOR 1.235 [1.12,1.36]). Receipt of prescriptions from multiple opioid prescribers was individually associated with persistent use (aOR 1.288 [1.16,1.44]). The majority of opioid prescriptions to patients with persistent use beyond the postoperative period were from nonsurgical prescribers (79.6%)., Conclusions: High-risk opioid prescribing practices, particularly receiving prescriptions from multiple prescribers across specialties, were associated with a significant increase in adolescent and young adult patients' risk of persistent opioid use. Prescription drug monitoring programs may help identify young patients at risk of persistent opioid use., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine whether laws limiting opioid prescribing have been associated with reductions in the incidence of persistent postoperative opioid use., Summary of Background Data: In an effort to address the opioid epidemic, 26 states (as of 2018) have passed laws limiting opioid prescribing for acute pain. However, it is unknown whether these laws have achieved their reduced the risk of persistent postoperative opioid use., Methods: We identified 957,639 privately insured patients undergoing one of 10 procedures between January 1, 2004 and September 30, 2018. We then estimated the association between persistent postoperative opioid use, defined as having filled ≥10 prescriptions or ≥120 days supply of opioids during postoperative days 91-365, and whether opioid prescribing limits were in effect on the day of surgery. States were classified as having: no limits, a limit of ≤7 days supply, or a limit of >7 days supply. The regression models adjusted for observable confounders such as patient comorbidities and also utilized a difference-in-differences approach, which relied on variation in state laws over time, to further minimize confounding., Results: The adjusted incidence of persistent postoperative opioid use was 3.5% (95%CI 3.3%-3.7%) for patients facing a limit of ≤7 days supply, compared with 3.3% (95%CI 3.3%-3.3%) for patients facing no prescribing limits ( P = 0.13 for difference compared to no prescribing limits) and 3.4%, (95%CI 3.2%-3.6%) for patients facing a limit of >7 days supply ( P = 0.43 for difference compared to no prescribing limits)., Conclusions: Laws limiting opioid prescriptions were not associated with subsequent reductions in persistent postoperative opioid use., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment., Background: Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large., Methods: Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment., Results: There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (β = 0.504, 95% CI: 0.341-0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (β = 0.178, 95% CI: 0.153-0.203)., Conclusions: Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To describe PAC utilization and associated payments for patients undergoing common elective procedures., Summary of Background Data: Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures., Methods: Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012 to 2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization., Results: Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7830, P < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9439, P < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8062, P < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.29-2.02, P < 0.001]. Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, P < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, P = 0.039)., Conclusions: We found both modifiable (eg, obesity) and nonmodifiable (eg, female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors and systems and processes to address these factors., Competing Interests: The authors declare no conflict of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Advanced practice clinicians (APCs), defined as nurse practitioners and physician assistants, are increasingly being incorporated into surgical teams. Despite this inclusion, there are no recent national data on the role of these clinicians in surgical opioid prescribing or the dosing of such prescriptions., Objective: To calculate the proportion of surgical opioid prescriptions written by APCs and to compare the total and daily dosages of these prescriptions with those written by surgeons., Design, Setting, and Participants: This cross-sectional study used the Optum's De-Identified Clinformatics Data Mart, which contains deidentified claims from patients with private insurance and Medicare Advantage plans across the US. Adults and children who underwent 1 of 31 inpatient and outpatient surgical procedures from January 1, 2017, through November 30, 2019, were identified. The analysis was limited to procedures with 1 or more perioperative opioid prescriptions, defined as an opioid prescription dispensed within 3 days of the index date of surgery. Data were analyzed from April 1, 2021, to July 31, 2022., Exposures: Prescriber specialty., Main Outcomes and Measures: The outcome was the proportion of perioperative opioid prescriptions and refill prescriptions written by APCs. Linear regression was used to compare the total dosage of perioperative opioid prescriptions written by APCs vs surgeons measured in morphine milligram equivalents (MMEs). Models were adjusted for demographic characteristics, comorbidities, opioid-naive status, year of index date, hospitalization or observation status, surgical complications, and surgeon specialty. Analyses were conducted at the procedure level, and patients with multiple procedures were included., Results: Analyses included 628 197 procedures for 581 387 patients (358 541 females [57.1%]; mean [SD] age, 56 [18] years). Overall, APCs wrote 119 266 (19.0%) of the 628 197 perioperative opioid prescriptions and 59 679 (25.1%) of the 237 740 refill prescriptions. Perioperative opioid prescriptions written by APCs had higher total dosages compared with those written by surgeons (adjusted difference, 40.0 MMEs; 95% CI, 31.3-48.7 MMEs). This difference persisted in a subgroup analysis limited to opioid-naïve patients (adjusted difference, 15.7 MMEs; 95% CI, 13.9-17.5 MMEs)., Conclusions and Relevance: In this cross-sectional analysis, one-fifth of perioperative opioid prescriptions and one-quarter of refill prescriptions were written by APCs. While surgeons wrote most perioperative opioid prescriptions that were intended for perioperative analgesia, higher total dosages from APCs suggest that opioid stewardship initiatives that support the role of APCs may be warranted.

Importance: In part to prevent the harms associated with dental opioid prescriptions, most states have enacted policies limiting the duration of opioid prescriptions for acute pain. Whether these limits are associated with changes in the duration of opioid prescriptions written by dentists is unclear., Objective: To evaluate the association between state opioid prescribing limits and the duration of opioid prescriptions from dentists., Design, Setting, and Participants: This difference-in-differences cross-sectional study used data from the IQVIA Longitudinal Prescription Database, an all-payer database reporting prescription dispensing from 92% of retail pharmacies in the US. The sample included opioid prescriptions from dentists dispensed to children aged 0 to 17 years and adults 18 years or older from January 2014 through February 2020. Treatment states were those that implemented limits between January 2016 and December 2018. Control states were those that did not implement limits during the study period. Data on opioid prescribing limits were derived from the Prescription Drug Abuse Policy System. Data were analyzed from January 1 to September 30, 2022., Exposures: State opioid prescribing limits., Main Outcomes and Measures: The outcome was opioid prescription duration, as measured by days' supply. The association between limits and duration was evaluated using a linear model with a 2-way fixed-effects specification. Covariates included patient characteristics, prescription characteristics, and indicators of implementation of prescription drug monitoring program use mandates. Separate analyses of data from adults and children were conducted owing to differences in the number of treatment states and restrictiveness of limits by age., Results: The adult analysis included 56 607 314 opioid prescriptions for 34 364 775 patients (18 448 788 females [53.7%]; mean [SD] age at the earliest fill, 44.0 [17.4] years) in 22 treatment states and 12 control states. The child analysis included 3 720 837 opioid prescriptions for 3 165 880 patients (1 740 449 females [55.0%]; mean [SD] age at the earliest fill, 14.4 [3.5] years) in 23 treatment states and 12 control states. In both analyses, the median (25th-75th percentile) duration of opioid prescriptions was 3.0 (2-5) days. Implementation of limits, most of which allowed up to a 7-day supply of opioids, was not associated with changes in the duration of opioid prescriptions for adults (mean days' supply: -0.06 days; 95% CI, -0.11 to <0.001 days) or children (mean days' supply: -0.07 days; 95% CI, -0.15 to 0.02 days)., Conclusions and Relevance: In this study of national pharmacy dispensing data, opioid prescribing limits were not associated with changes in the duration of opioid prescriptions from dentists. Future research should investigate the potential role of alternative interventions in reducing opioid prescribing by dentists.