IMPORTANCE There is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption. OBJECTIVE To describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery. DESIGN, SETTING, AND PARTICIPANTS A retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients. EXPOSURES Opioid prescription size in the initial postoperative prescription. MAIN OUTCOMES AND MEASURES Patient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors. RESULTS In this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills; P < .001). The quantity of opioid prescribed had the strongest association with patient-reported opioid consumption, with patients using 0.53 more pills (95% CI, 0.40-0.65; P < .001) for every additional pill prescribed. Patient-reported pain in the week after surgery was also significantly associated with consumption but not as strongly as prescription size. Compared with patients reporting no pain, patients used a mean (SD) 9 (1) more pills if they reported moderate pain and 16 (2) more pills if they reported severe pain (P < .001). Other significant risk factors included history of tobacco use, American Society of Anesthesiologists class, age, procedure type, and inpatient surgery status. After adjusting for these risk factors, patients in the lowest quintile of opioid prescribing had significantly lower mean (SD) opioid consumption compared with those in the highest quintile (5 [2] pills vs 37 [3] pills; P < .001). CONCLUSIONS AND RELEVANCE The quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.

ing dual antiplatelet therapy) had had AT medication temporarily stopped in preparation for surgery and were therefore excluded from the study. The remaining 93 patients continued their normal AT regimen through surgery. There were 69 patients taking aspirin, 7 taking warfarin, 9 taking clopidogrel, 1 taking dabigatran, 3 taking warfarin plus aspirin, and 4 taking dual antiplatelet therapy. Patients treated with AT agents were older than the control group (mean, 66.1 years vs 56.9 years; P < .001). They were also more likely to be male (96.8% vs 84.4%; P = .002), diabetic (55.9% vs 22.9%; P < .001), and nonsmokers (82.8% vs 71.7%; P = .04). Average preoperative median nerve motor latencies at the wrist did not differ significantly between the AT user and non-AT user groups (6.9 milliseconds vs 6.7 milliseconds; P = .44), nor did the rate of intraoperative tourniquet use (32% vs 56% for AT user and nonuser groups, respectively; P = .22). Estimated blood loss was higher in the no-tourniquet group for both AT users (4.33 mL vs 3.22 mL; P = .02) and non-AT users (4.21 mL vs 3.13 mL; P = .006). Mean operating time was shorter in the no-tourniquet group for both those treated with AT agents (20.1 minutes vs 25.7 minutes; P = .001) and those not treated with AT agents (22.40 minutes vs 24.52 minutes; P = .13). There was no statistical difference in EBL (3.94 mL vs 3.89 mL; P = .87) or operative time (22.0 minutes vs 23.0 minutes; P = .38) in AT and non-AT patient groups overall. Rates of postoperative complications were similar between the AT group and the non-AT group (5.4% vs 4.9%; P > .99). No hematomas or neurological complications were reported, and no patients required reoperation during the study period. Overall, 91.8% of patients reported improvement of symptoms postoperatively, with a mean follow-up time of 3.3 months (Table).

Opioids are widely overprescribed after surgery. 1 Leftover medication is often diverted into the community, contributing to the opioid epidemic. 2 The lack of evidence regarding ideal prescribing practice after surgery may hinder efforts to reduce overprescribing. 3 In this study, we developed and disseminated postoperative prescribing guidelines and measured the impact on prescribing in a statewide hospital collaborative.

Background: Surgery is a major physiologic stress comparable to intense exercise. Diminished cardiopulmonary reserve is a major predictor of poor outcomes. Current preoperative workup focuses mainly on identifying risk factors, however little attention is devoted to improving cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a “surgical marathon” similar to the preparation of an athlete. Study Design: The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in four activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. We prospectively collected demographic, intraoperative (first hour), and postoperative data for patients enrolled in MSHOP undergoing major abdominal surgery. Statistical analysis was performed using 2:1 propensity score matching to compare the MSHOP group (N=40) to emergency (N=40) and elective, non-MSHOP (N=76) patients. Results: Overall, 70% of MSHOP patients complied with the program. Age, gender, ASA classification, and BMI did not differ significantly between groups. One hour intraoperatively, MSHOP patients showed improved systolic and diastolic blood pressures and lower heart rate (Figure). There was a significant reduction in Clavien-Dindo class 3–4 complications in the MSHOP group (30%) compared to the non-prehabilitation (38%) and emergency (48%) groups (p=0.05). This translated to total hospital charges averaging $75,494 for the MSHOP group, $97,440 for the non-prehabilitation group, and $166,085 for the emergency group (p < 0.001). Conclusion: Patients undergoing prehabilitation prior to colectomy showed positive physiologic effects and experienced fewer complications. The average savings of $21,946 per patient represents a significant cost offset for a prehabilitation program, and should be considered for all patients undergoing surgery.

BACKGROUND: Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures. STUDY DESIGN: Patients undergoing 6 procedures were offered the opportunity to participate in an opioidsparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small "rescue" opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed. RESULTS:A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 AE 14 vs 59 AE 13 years; p ¼ 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p ¼ 0.014), received larger rescue prescriptions (6 AE 3 vs 4 AE 4 pills; p ¼ 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p ¼ 0.001). There were no other significant differences between opioid users and non-users. CONCLUSIONS: Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures. (J Am Coll Surg 2019;229:316e322. Ó

BACKGROUND: Excessive opioid prescribing is common in surgical oncology with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines. We then evaluated the impact of this intervention. METHODS: In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills. RESULTS: During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (P=0.03), equivalent to 13 tablets of 5mg oxycodone. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42% or 12 tablets of 5mg oxycodone (P=0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, P=0.8), or lumpectomy/breast biopsy (4% vs. 5%, P=0.7). CONCLUSIONS: Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.

Our results demonstrate specific deficits in neurophysiological activity in the attentional domain among the shift-work disorder group relative to night workers.

This cross-sectional study examines the attributable association of modifiable risk factors for adverse outcomes after hernia repair and increased health care spending associated with these adverse outcomes.