Opioid use and over-prescription in post-operative patients. Opioid Epidemic. Opioid Epidemic 6/5/2017. epidemic?

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1 Opioid use and over-prescription in post-operative patients Eric Chen, MD/PhD Department of Orthopaedic Surgery Boston University / Boston Medical Center Lahey Hospital Medical Center Opioid Epidemic Nationwide crisis Massachusetts 2015: 1,531 deaths from opioid overdose Kolodny et al. Annu. Rev. Public Health out of 5 current heroin users report use began with prescription opioids (Muhuri et al. CBHSQ Data Review. 2013) 70.3% of opioids used for nonmedical purposes are obtained from a friend or relative (Jones et al. JAMA internal medicine. 2014) Opioid Epidemic Nationwide crisis Massachusetts 2015: 1,531 deaths from opioid overdose Kolodny et al. Annu. Rev. Public Health out of 5 current heroin users report use began with prescription Are physicians opioids contributing (Muhuri et al. CBHSQ to this Data Review. 2013) epidemic? 70.3% of opioids used for nonmedical purposes are obtained from a friend or relative (Jones et al. JAMA internal medicine. 2014) 1

2 Opioid Epidemic Nationwide crisis Massachusetts 2015: 1,531 deaths from opioid overdose Kolodny et al. Annu. Rev. Public Health out of 5 current heroin users report use began with prescription opioids (Muhuri et al. CBHSQ Data Review. 2013) 70.3% of opioids used for nonmedical purposes are obtained from a friend or relative (Jones et al. JAMA internal medicine. 2014) Nationwide crisis Massachusetts 2015: 1,531 deaths from opioid overdose Opioid Epidemic 4 out of 5 current heroin users report use began with prescription opioids (Muhuri et al. CBHSQ Data Review. 2013) Are surgeons prescribing excessive amounts of opioids? 70.3% of opioids used for nonmedical purposes are obtained from a friend or relative (Jones et al. JAMA internal medicine. 2014) Over-prescription after surgery Reference Surgery Over-prescription Bartels et al. Plos One Cesarean section 83% reported taking half or less Bartels et al. Plos One Thoracic surgery 71% reported taking half or less Hill et al. Annals Surgery General surgery procedures 71.3% of pills not consumed 2

3 Over-prescription after surgery Reference Surgery Over-prescription Bartels et al. Plos One Cesarean section 83% reported taking half or less Bartels et al. Plos One Thoracic surgery 71% reported taking half or less Hill et al. Annals Surgery General surgery procedures 71.3% of pills not consumed Bates et al. J. Urology Urologic procedures 42% of meds not consumed Harris et al. JAMA Derm Dermatologic procedures 86% had leftover pills Kim et al. JSBS Upper extremity orthopedic procedures 84% did not complete meds Rodgers et al. J. Hand Surg Upper extremity orthopedic procedures 77% reported taking half or less Chapman et al. Hand Carpal tunnel release 4.3 pills consumed on average Is surgery a risk factor for chronic use? Alam et al. Arch Intern Med. 2012: Ontario patients, > 65 years Minor Surgery: Cataracts, laparoscopic cholecystectomy, TURP, varicose veins 0.7% long-term opioid users (> 1 year) Clarke et al. BMJ Ontario patients, > 65 years Major Surgery: Open CABG, Open/MIS hysterectomies, lung, colon, prostate resections 3.1% used opioids > 90 days Sun et al. JAMA Internal Medicine American privately insured patients (18 to 64 years) Major and Minor Surgery: TKA, THA, cholecystectomy, appendectomy, cesarean delivery, FESS, cataracts, TURP, mastectomy % used opioids > 90 days Patient-specific opioid prescribing Correlation between pre-discharge opioid requirement and quantity prescribed at discharge? Of patients off opioids, are they being overprescribed opioids? 3

4 Methods Retrospective Chart Review Post-operative length of stay of at least 24 hours Discharged home Excluded long-acting opioids, fentanyl, and PCA dosing 24-hour pre-discharge opioid requirement Quantity of opioids prescribed at discharge BMC vs. Lahey Boston Medical Center (BMC) Urban safety-net Level 1 trauma center 44.7 years (pediatrics) 62% females (obstetrics) $41,000 annual neighborhood income 58% Medicaid/uninsured Lahey Burlington (LHMC-B) Suburban, community-based Level 2 trauma center 61.1 years 46% females $57,000 annual neighborhood income 7% Medicaid/uninsured Demographics and Opioid Use BMC LHMC-B Combined Patients 9,795 8,550 18,345 Surgeries 11,292 10,162 21,454 Admissions 10,574 9,463 20,037 Procedure Length 111 mins 179 mins 143 mins Length of stay (LOS) 5.3 days 4.6 days 5 days Post-op LOS days 4

5 Opioids on Discharge (MME) Opioids on Discharge (MME) 6/5/2017 Demographics and Opioid Use BMC LHMC-B Combined Patients 9,795 8,550 18,345 Surgeries 11,292 10,162 21,454 Admissions 10,574 9,463 20,037 Procedure Length 111 mins 179 mins 143 mins Length of stay (LOS) 5.3 days 4.6 days 5 days Post-op LOS days Pre-discharge opioid requirement Opioid Quantity on discharge 44 MME 27 MME 36 MME 444 MME 301 MME 377 MME Cropped out 0 admissions Discharge Quantity vs. Kendall's tau = 0.27 (p = 0) Mean ± SD = 377 +/ 612 OverP = 3051, No Opioids = 5383, Total: Pre-Discharge Opioids Pre discharge Requirement vs. On Discharge Model: log(y>0) ~ m*log(x>0) + b R2 = m=0.33 b= hr Pre discharge Opioid Requirement (MME) Cropped out 0 admissions Discharge Quantity vs. Kendall's tau = 0.27 (p = 0) Mean ± SD = 377 +/ 612 OverP = 3051, No Opioids = 5383, Total: Pre-Discharge Opioids Pre discharge Requirement vs. On Discharge Required opioids on discharge (58%) 100 Model: log(y>0) ~ m*log(x>0) + b R2 = m=0.33 b= hr Pre discharge Opioid Requirement (MME) 5

6 Opioids on Discharge (MME) Opioids on Discharge (MME) Opioids on Discharge (MME) 6/5/2017 Cropped out 0 admissions Discharge Quantity vs. Kendall's tau = 0.27 (p = 0) Mean ± SD = 377 +/ 612 OverP = 3051, No Opioids = 5383, Total: Pre-Discharge Opioids Pre discharge Requirement vs. On Discharge Required opioids on discharge (58%) 100 Model: log(y>0) ~ m*log(x>0) + b R2 = m=0.33 b= hr Pre discharge Opioid Requirement (MME) Cropped out 0 admissions Discharge Quantity vs. Kendall's tau = 0.27 (p = 0) Mean ± SD = 377 +/ 612 OverP = 3051, No Opioids = 5383, Total: Pre-Discharge Opioids Pre discharge Requirement vs. On Discharge Required opioids on discharge (58%) Model: log(y>0) ~ m*log(x>0) + b R2 = m=0.33 b=4.65 Discharged without opioids (27%) hr Pre discharge Opioid Requirement (MME) Over-Prescribed (15%) Cropped out 0 admissions Discharge Quantity vs. Kendall's tau = 0.27 (p = 0) Mean ± SD = 377 +/ 612 OverP = 3051, No Opioids = 5383, Total: Pre-Discharge Opioids Pre discharge Requirement vs. On Discharge Required opioids on discharge (58%) Model: log(y>0) ~ m*log(x>0) + b R2 = m=0.33 b=4.65 Discharged without opioids (27%) hr Pre discharge Opioid Requirement (MME) 6

7 Risk Factors for Over-prescription Over-prescription defined as prescribed opioids despite not requiring any in the 24-hours predischarge No particularly large effects on the odds of over-prescription by hospital location or any other patient demographic factors Worker s compensation and auto insurance possibly associated with increased odds Surgical service most significant predictor of over-prescription Ophthalmology and pediatric surgery lower risk Obstetrics/gynecology highest risk of over-prescription OverP Odds Ratio Demographics BMC (ref.) LHMC B (1.65) Male (ref.) Female (0.812) Age (1) BMI (1.01) Median Income (1) Procedure Length (1) Overall LOS (1) Post Op LOS (0.997) Last Opioid from Surgery (1) Insurance Medicare (ref.) Military (0.667) Self pay Cash (0.916) Government assisted (1.05) Medicaid (1.09) Commercial/Private (1.37) Uninsured (1.53) Auto Insurance (2.1) Workers Compensation (3.88) Surgical Service General (ref.) Ophthalmology (1.78e 07) Pediatrics (2.16e 07) Anesthesiology (0.0166) Pulmonary (0.0246) Electrophysiology (0.0292) Cardiac Cath (0.0364) Non Invasive Cardiology (0.0631) Gastroenterology (0.0716) Vascular (0.288) Podiatry (0.292) Cardiac (0.413) Thoracic (0.56) Plastics (0.749) Neurosurgery (0.826) Otolaryngology (0.897) Transplant (0.99) Orthopedics (1.01) Urology (1.34) Maxillofacial Oral (1.78) Gynecology (2.38) Obstetrics (3.81) 1e 07 1e 05 1e 03 1e 01 Risk Factors for Over-prescription Over-prescription defined as prescribed opioids despite not requiring any in the 24-hours predischarge No particularly large effects on the odds of over-prescription by hospital location or any other patient demographic factors Worker s compensation and auto insurance possibly associated with increased odds Surgical service most significant predictor of over-prescription Ophthalmology and pediatric surgery lower risk Obstetrics/gynecology highest risk of over-prescription OverP Odds Ratio Demographics BMC (ref.) LHMC B (1.65) Male (ref.) Female (0.812) Age (1) BMI (1.01) Median Income (1) Procedure Length (1) Overall LOS (1) Post Op LOS (0.997) Last Opioid from Surgery (1) Insurance Medicare (ref.) Military (0.667) Self pay Cash (0.916) Government assisted (1.05) Medicaid (1.09) Commercial/Private (1.37) Uninsured (1.53) Auto Insurance (2.1) Workers Compensation (3.88) Surgical Service General (ref.) Ophthalmology (1.78e 07) Pediatrics (2.16e 07) Anesthesiology (0.0166) Pulmonary (0.0246) Electrophysiology (0.0292) Cardiac Cath (0.0364) Non Invasive Cardiology (0.0631) Gastroenterology (0.0716) Vascular (0.288) Podiatry (0.292) Cardiac (0.413) Thoracic (0.56) Plastics (0.749) Neurosurgery (0.826) Otolaryngology (0.897) Transplant (0.99) Orthopedics (1.01) Urology (1.34) Maxillofacial Oral (1.78) Gynecology (2.38) Obstetrics (3.81) 1e 07 1e 05 1e 03 1e 01 Risk Factors for Over-prescription Over-prescription defined as prescribed opioids despite not requiring any in the 24-hours predischarge No particularly large effects on the odds of over-prescription by hospital location or any other patient demographic factors Worker s compensation and auto insurance possibly associated with increased odds Surgical service most significant predictor of over-prescription Ophthalmology and pediatric surgery lower risk Obstetrics/gynecology highest risk of over-prescription OverP Odds Ratio Demographics BMC (ref.) LHMC B (1.65) Male (ref.) Female (0.812) Age (1) BMI (1.01) Median Income (1) Procedure Length (1) Overall LOS (1) Post Op LOS (0.997) Last Opioid from Surgery (1) Insurance Medicare (ref.) Military (0.667) Self pay Cash (0.916) Government assisted (1.05) Medicaid (1.09) Commercial/Private (1.37) Uninsured (1.53) Auto Insurance (2.1) Workers Compensation (3.88) Surgical Service General (ref.) Ophthalmology (1.78e 07) Pediatrics (2.16e 07) Anesthesiology (0.0166) Pulmonary (0.0246) Electrophysiology (0.0292) Cardiac Cath (0.0364) Non Invasive Cardiology (0.0631) Gastroenterology (0.0716) Vascular (0.288) Podiatry (0.292) Cardiac (0.413) Thoracic (0.56) Plastics (0.749) Neurosurgery (0.826) Otolaryngology (0.897) Transplant (0.99) Orthopedics (1.01) Urology (1.34) Maxillofacial Oral (1.78) Gynecology (2.38) Obstetrics (3.81) 1e 07 1e 05 1e 03 1e 01 7

8 Opiate over prescription (%) /5/2017 Risk Factors for Over-prescription Over-prescription defined as prescribed opioids despite not requiring any in the 24-hours predischarge No particularly large effects on the odds of over-prescription by hospital location or any other patient demographic factors Worker s compensation and auto insurance possibly associated with increased odds Surgical service most significant predictor of over-prescription Ophthalmology and pediatric surgery lower risk Obstetrics/gynecology highest risk of over-prescription OverP Odds Ratio Demographics BMC (ref.) LHMC B (1.65) Male (ref.) Female (0.812) Age (1) BMI (1.01) Median Income (1) Procedure Length (1) Overall LOS (1) Post Op LOS (0.997) Last Opioid from Surgery (1) Insurance Medicare (ref.) Military (0.667) Self pay Cash (0.916) Government assisted (1.05) Medicaid (1.09) Commercial/Private (1.37) Uninsured (1.53) Auto Insurance (2.1) Workers Compensation (3.88) Surgical Service General (ref.) Ophthalmology (1.78e 07) Pediatrics (2.16e 07) Anesthesiology (0.0166) Pulmonary (0.0246) Electrophysiology (0.0292) Cardiac Cath (0.0364) Non Invasive Cardiology (0.0631) Gastroenterology (0.0716) Vascular (0.288) Podiatry (0.292) Cardiac (0.413) Thoracic (0.56) Plastics (0.749) Neurosurgery (0.826) Otolaryngology (0.897) Transplant (0.99) Orthopedics (1.01) Urology (1.34) Maxillofacial Oral (1.78) Gynecology (2.38) Obstetrics (3.81) 1e 07 1e 05 1e 03 1e 01 Opioid overprescription by service BMC LHMC B Pearson = 0.79 (p = 5.7e 08) Gynecology Urology Transplant Otolaryngology Obstetrics General Gynecology Plastics Neurosurgery Maxillofacial Oral Orthopedics Cardiac Plastics Orthopedics General Cardiac Urology Neurosurgery Vascular Transplant Thoracic Otolaryngology Vascular Podiatry Non Invasive Cardiology Gastroenterology Gastroenterology Electrophysiology Ophthalmology Pulmonary Cardiac Cath Anesthesiology Pediatrics Requiring opioids within 24 hours pre discharge (%) Patient-specific opioid taper Prescribe opioids based on patient s 24-hour pre-discharge requirement Taper dose exponentially Reduces overall opioid prescription by 44% 8

9 Opioids administered (MME) Opioids administered (MME) /5/2017 Patient-specific opioid taper Model Simulation: 14 day taper in patients with Post op LOS between 4 and 5 days Prescribe opioids based on patient s 24-hour pre-discharge requirement Taper dose exponentially 24 hr Pre discharge Opioid Requirement 51 to 75 MME 26 to 50 MME 1 to 25 MME 0 MME Reduces overall opioid prescription by 44% Time from discharge (days) Patient-specific opioid taper Model Simulation: 14 day taper in patients with Post op LOS between 4 and 5 days Prescribe opioids based on patient s 24-hour pre-discharge requirement Taper dose exponentially 24 hr Pre discharge Opioid Requirement 51 to 75 MME 26 to 50 MME 1 to 25 MME 0 MME Reduces overall opioid prescription by 44% Time from discharge (days) Patient-specific opioid taper 9

10 Conclusions Opioids are not regularly prescribed in a patientspecific manner to post-operative patients. Opioid over-prescription occurs after nearly all surgical specialties. Services with higher rates of patients requiring opioids at discharge have higher rates of over-prescription A standardized opioid prescription protocol may help reduce opioid prescription. Acknowledgements BMC Paul Tornetta III, MD Linda Rosen LHMC-B Andrew Marcantonio, MD/MBA Fred Shorten BMC Committee of Interns and Residents Patient Safety Grant 10

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