Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs

Neurosurgery ◽  
2021 ◽  
Author(s):  
Karam Asmaro ◽  
Hassan A Fadel ◽  
Sameah A Haider ◽  
Jacob Pawloski ◽  
Edvin Telemi ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Tumor Resection ◽  
Educational Interventions ◽  
Prescribing Patterns ◽  
Prescribing Practices ◽  
Post Intervention ◽  
Intracranial Surgery ◽  
Opioid Prescribing ◽  
Before And After ◽  
Craniotomy For Tumor Resection

Abstract BACKGROUND Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P < .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105). CONCLUSION A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns.

scholarly journals Prescriber Aimed Intervention to Optimize Opioid Prescribing Patterns After Intracranial Surgery: Addressing the Nation's Opioid Epidemic and Decreasing the Neurosurgeon's Narcotic Footprint

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Karam P Asmaro ◽  
Sameah A Haider ◽  
Ankush Chandra ◽  
Edvin Telemi ◽  
Tarek R Mansour ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Pain Control ◽  
Prescribing Patterns ◽  
Intracranial Surgery ◽  
Opioid Prescribing ◽  
Patient Dissatisfaction ◽  
Pain Scores ◽  
Before And After ◽  
Optimal Quantity

Abstract INTRODUCTION Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity to dispense. While pain control is essential acutely, opioid need for subacute recovery remains controversial. Over-prescribing may adversely contribute to the epidemic of opioid abuse, chronic use, and diversion. The aim of this study is to evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia and patient satisfaction. METHODS Patients undergoing intracranial surgery for tumor with home disposition were identified from June 2017 to December 2018. Patients were stratified as those discharged before and after the intervention which consisted of developing departmental consensus guidelines, provider coaching, and ongoing reinforcement. We queried the amount of opioids prescribed at discharge measured in morphine milligram equivalents (MME), preoperative opioid intake, pain scores before and after discharge, and total opioid intake 24-hr before discharge in addition to procedure-specific variables. RESULTS A total of 238 consecutive home discharges were examined (mean age: 52.7 yr; 129 men [54%]). Following a 2-mo educational period, the quantity of opioids prescribed decreased by 48% in the craniotomy group (n = 203; median MME [IQR], 225 [109-450] vs 108 [0-240], P < .00002) in addition to refill requests (17% vs 7.6%, P = .047) despite both groups having similar baseline pain scores on discharge. Pain scores remained satisfactory at outpatient follow-up (1.23 vs 0.85, P = .17). Similar results were observed in the burr hole group (n = 35) where the quantity of opioids prescribed decreased by 67% (median MME [IQR], 225 [109-450] vs 10 [0-187.5], P = .06) with no consequent increase in refill requests, follow-up pain scores, or patient dissatisfaction. CONCLUSION Opioids may be overprescribed postoperatively, however, we were able to achieve a dramatic reduction in opioids prescribed without affecting refill requests, patient satisfaction, or perceived analgesia. More studies are needed to optimize postoperative pain control while reducing superfluous narcotic disbursement.

Impact of Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida

2021 ◽  
pp. 1-9
Author(s):  
Aakriti R. Carrubba ◽  
Amy E. Glasgow ◽  
Elizabeth B. Habermann ◽  
Amanda P. Stanton ◽  
Megan N. Wasson ◽  
...  
Keyword(s):  
Statistical Analysis ◽  
Cohort Analysis ◽  
Oral Morphine ◽  
Interrupted Time Series ◽  
Interrupted Time Series Analysis ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Before And After ◽  
Legislative Changes

<b><i>Objectives:</i></b> This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states. <b><i>Design:</i></b> This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018. <b><i>Methods:</i></b> Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum <i>t</i> tests for OMEs and χ<sup>2</sup> <i>t</i> tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). <b><i>Results:</i></b> In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (<i>p</i> &#x3c; 0.0001). The opioid refill rate remained unchanged at 7.4% (<i>p</i> = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (<i>p</i> &#x3c; 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; <i>p</i> = 0.739). <b><i>Limitations:</i></b> Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design. <b><i>Conclusions:</i></b> Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.

scholarly journals P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S105-S106
Author(s):  
P. Doran ◽  
G. Sheppard ◽  
B. Metcalfe
Keyword(s):  
Emergency Department ◽  
Acute Pain ◽  
Oral Morphine ◽  
Prescribing Patterns ◽  
Evidence Based ◽  
Emergency Physicians ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Ensure Patient Safety ◽  
Evidence Based Guidelines

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.

Acute Diarrhoea Management in Emergency; Influencing Antibiotic Prescribing Patterns

Med Phoenix ◽  
2017 ◽  
Vol 2 (1) ◽  
pp. 12-17
Author(s):  
Mohammed Mansuri Islam ◽  
Md. Parwez Ahmad ◽  
Akhtar Alam Ansari ◽  
Tarannum Khatun ◽  
Mohammad Ashfaque Ansari ◽  
...  
Keyword(s):  
Acute Diarrhoea ◽  
Educational Interventions ◽  
High Rate ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Intervention Period ◽  
Post Intervention ◽  
Emergency Case ◽  
Clinical Criteria ◽  
Prescribing Behaviour

Background: Medical students are taught the internationally accepted approach to acute diarrhoea, viz. adequate fluid and electrolyte replacement is the fundamental management of acute diarrhoea. Antibiotics should be restricted to specific indications, such as acute dysentery. Despite the well known rationale, there has been a high rate of prescription of antibiotics for acute diarrhoea presenting to Emergency.Methods: The pre and post intervention data was collected in the following way. All Emergency case records were routinely scrutinized in the Dept of Family Medicine after discharge with the exception of cases that were admitted to the wards. All cases with a discharge diagnosis fitting the clinical criteria of acute diarrhoeal syndrome: diarrhoea, gastroenteritis, dysentery and cholera were separated, analysed and recorded sequentially.Results: Initially doctors were prescribing  antibiotics for 52.8% of case of non-bloody diarrhoea. In the 2nd intervention period there were few cases, but it is remarkable how few were prescribed antibiotic (20%) while the survey of prescribing habits was underway. In the 3rd intervention period when an education event took place, it was the peak of the diarrhea season. Prescribing increased somewhat to 29%. In the 4th intervention a letter was sent out to the doctors describing the results so far, and pointing out the lower prescribing by “senior doctors”. The overall changes in prescribing behaviour after the educational interventions were statistically significant. The reduction in prescribing noted when comparing intervention 1 and intervention 4, is highly significant (antibiotic p < 0.0001, anti-protozoal p<0.0001). In the 5th intervention period when appropriate prescribing was no longer actively promoted, the rate of prescribing increased again to 41.4% of cases. A similar pattern is noted for antiprotozoal prescribing. The increase in prescribing noted in the 5th period was still less than in the 1st period (antibiotic p=0.041, anti-protozoal p=0.055). The increase in prescribing from periods 4 to 5 was significant. (Antibiotics p<0.0001, anti-protozoal p = 0.012).Med Phoenix Vol.2(1) July 2017, 12-17 

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

2020 ◽  
Author(s):  
Connor A. King ◽  
David C. Landy ◽  
Alexander T. Bradley ◽  
Bryan Scott ◽  
John Curran ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Educational Intervention ◽  
Knee Arthroplasty ◽  
Primary Total Knee Arthroplasty ◽  
Prescribing Patterns ◽  
Quality Improvement Initiative ◽  
Time Series Regression ◽  
Opioid Prescribing ◽  
Before And After ◽  
Total Knee

AbstractPatterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (p = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.

scholarly journals Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study

10.2196/24360 ◽  
2021 ◽  
Vol 23 (4) ◽  
pp. e24360
Author(s):  
Benjamin Heritier Slovis ◽  
Jeffrey M Riggio ◽  
Melanie Girondo ◽  
Cara Martino ◽  
Bracken Babula ◽  
...  
Keyword(s):  
The United States ◽  
Prescribing Patterns ◽  
Duration Of Treatment ◽  
Opioid Prescription ◽  
Hospital System ◽  
Opioid Prescribing ◽  
Before And After ◽  
Control And Prevention ◽  
Prescribing Practice ◽  
Quasi Experimental

Background The United States is in an opioid epidemic. Passive decision support in the electronic health record (EHR) through opioid prescription presets may aid in curbing opioid dependence. Objective The objective of this study is to determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system. Methods We performed a quasi-experimental retrospective pre–post analysis of a 24-month period before and after modifications to our EHR’s opioid prescription presets to match Centers for Disease Control and Prevention guidelines. We included all opioid prescriptions prescribed at our institution for nonchronic pain. Our modifications to the EHR include (1) making duration of treatment for an opioid prescription mandatory, (2) adding a quick button for 3 days’ duration while removing others, and (3) setting the default quantity of all oral opioid formulations to 10 tablets. We examined the quantity in tablets, duration in days, and proportion of prescriptions greater than 90 morphine milligram equivalents/day for our hospital system, and compared these values before and after our intervention for effect. Results There were 78,246 prescriptions included in our study written on 30,975 unique patients. There was a significant reduction for all opioid prescriptions pre versus post in (1) the overall median quantity of tablets dispensed (54 [IQR 40-120] vs 42 [IQR 18-90]; P<.001), (2) median duration of treatment (10.5 days [IQR 5.0-30] vs 7.5 days [IQR 3.0-30]; P<.001), and (3) proportion of prescriptions greater than 90 morphine milligram equivalents/day (27.46% [10,704/38,976; 95% CI 27.02%-27.91%] vs 22.86% [8979/39,270; 95% CI 22.45%-23.28%]; P<.001). Conclusions Modifications of opioid prescribing presets in the EHR can improve prescribing practice patterns. Reducing duration and quantity of opioid prescriptions could reduce the risk of dependence and overdose.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

2019 ◽  
Vol 129 (2) ◽  
pp. 142-148 ◽  
Author(s):  
Molly N. Huston ◽  
Rouya Kamizi ◽  
Tanya K. Meyer ◽  
Albert L. Merati ◽  
John Paul Giliberto
Keyword(s):  
The United States ◽  
Opioid Abuse ◽  
Prescribing Patterns ◽  
Opioid Analgesia ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Opioid Prescription ◽  
Opioid Prescribing

Background: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. Objective: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. Methods: A cross-sectional survey of otolaryngologists at a national laryngology meeting. Results: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. Conclusions: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

Telehealth acceptability and opioid prescribing patterns of providers of painful chronic diseases during the COVID-19 pandemic: A survey of sickle cell providers

2021 ◽  
Vol 17 (6) ◽  
pp. 489-497
Author(s):  
Martha O. Kenney, MD ◽  
Benjamin Becerra, DrPH; MBA, MPH, MS ◽  
Sean Alexander Beatty, BA ◽  
Wally R. Smith, MD
Keyword(s):  
Chronic Diseases ◽  
Sickle Cell ◽  
Online Survey ◽  
Management Practices ◽  
Risk Mitigation ◽  
The United States ◽  
Prescribing Patterns ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
The Impact

Objective: The coronavirus disease 2019 (COVID-19) has led to a rapid transition to telehealth services. It is unclear how subspecialists managing painful chronic diseases—such as sickle cell disease (SCD), an inherited hemoglobinopathy with significant disparities in access and outcomes—have viewed the transition to telehealth or altered their pain management practices. This study elicits the views of sickle cell providers regarding their transition to telehealth and their opioid prescribing patterns during the COVID-19 pandemic.Design: An anonymous online survey was sent to eligible sickle cell providers.Setting: Comprehensive sickle cell centers and/or clinics across the United States. Participants: Physicians and advanced practice providers providing care to SCD patients.Main outcome measures: Respondents answered questions regarding their (1) views of telehealth compared to in-person encounters and (2) opioid prescribing practices during the early months of the pandemic.Results: Of the 130 eligible participants, 53 respondents from 35 different sickle cell centers completed at least 90 percent of the survey. Respondents reported a significant increase in telehealth encounters for routine and acute appointments (mean difference and standard deviation: 57.6 ± 31.9 percent, p 0.001 and 24.4 ± 34.1 percent, p 0.001, respectively) since COVID-19. The overwhelming majority of respondents reported no changes in their opioid prescribing patterns since COVID-19, despite increased telehealth use. Only a minority coprescribed naloxone as a risk mitigation strategy.Conclusion: The rapid uptake of telehealth has not suppressed ambulatory providers’ prescribing of opioids for SCD. Studies assessing the impact of the COVID-19 pandemic and telehealth on opioid prescribing practices in other painful chronic diseases are needed to ensure health equity for vulnerable pain patients.

Cerebrospinal fluid disturbances after 381 consecutive craniotomies for intracranial tumors in pediatric patients

2014 ◽  
Vol 14 (6) ◽  
pp. 604-614 ◽  
Author(s):  
Sayied Abdol Mohieb Hosainey ◽  
Benjamin Lassen ◽  
Eirik Helseth ◽  
Torstein R. Meling
Keyword(s):  
Brain Tumors ◽  
Pediatric Patients ◽  
Tumor Resection ◽  
Pediatric Brain Tumors ◽  
University Hospital ◽  
Consecutive Series ◽  
Intracranial Tumors ◽  
Intracranial Surgery ◽  
Before And After ◽  
New Onset

Object The aim of this study was to investigate the incidence of CSF disturbances before and after intracranial surgery for pediatric brain tumors in a large, contemporary, single-institution consecutive series. Methods All pediatric patients (those < 18 years old), from a well-defined population of 3.0 million inhabitants, who underwent craniotomies for intracranial tumors at Oslo University Hospital in Rikshospitalet between 2000 and 2010 were included. The patients were identified from the authors' prospectively collected database. A thorough review of all medical charts was performed to validate all the database data. Results Included in the study were 381 consecutive craniotomies, performed on 302 patients (50.1% male, 49.9% female). The mean age of the patients in the study was 8.63 years (range 0–17.98 years). The follow-up rate was 100%. Primary craniotomies were performed in 282 cases (74%), while 99 cases (26%) were secondary craniotomies. Tumors were located supratentorially in 249 cases (65.3%), in the posterior fossa in 105 (27.6%), and in the brainstem/diencephalon in 27 (7.1%). The surgical approach was supratentorial in 260 cases (68.2%) and infratentorial in 121 (31.8%). Preoperative hydrocephalus was found in 124 cases (32.5%), and 71 (86.6%) of 82 achieved complete cure with tumor resection only. New-onset postoperative hydrocephalus was observed in 9 (3.5%) of 257 cases. The rate of postoperative CSF leaks was 6.3%. Conclusions Preoperative hydrocephalus was found in 32.5% of pediatric patients with brain tumors treated using craniotomies. Tumor resection alone cured preoperative hydrocephalus in 86.6% of cases and the incidence of new-onset hydrocephalus after craniotomy was only 3.5%.

scholarly journals Opioid Prescribing Practices Before and After Initiation of Palliative Care in Outpatients

2013 ◽  
Vol 45 (6) ◽  
pp. 1107-1111 ◽  
Author(s):  
J. Cameron Muir ◽  
Carl Scheffey ◽  
Heidi M. Young ◽  
Agustin O. Vilches ◽  
Malene S. Davis ◽  
...  
Keyword(s):  
Palliative Care ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Before And After
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