Development and Validation of a Bedside Risk Assessment for Sustained Prescription Opioid Use After Surgery

Chaudhary, Muhammad Ali; Bhulani, Nizar; Jager, Elzerie de; Lipsitz, Stuart R.; Kwon, Nicollette K.; Sturgeon, Daniel; Trinh, Quoc‐Dien; Koehlmoos, Tracey Pérez; Haider, Adil H.; Schoenfeld, Andrew J.

doi:10.1001/jamanetworkopen.2019.6673

Cited by 43 publications

(85 citation statements)

References 26 publications

(201 reference statements)

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“…We derived the risk score's points by comparing the β coefficient of the variable to the overall sum of coefficients in the model, multiplying by 100, and rounding to the nearest integer. 26 The risk score calculated for each patient represented the summed point totals from all variables present, where a higher score indicates more suitability for discharge.…”

Section: Discussionmentioning

confidence: 99%

Derivation of a Clinical Risk Score to Predict 14-Day Occurrence of Hypoxia, ICU Admission, and Death Among Patients with Coronavirus Disease 2019

Levine

Lipsitz

et al. 2020

J GEN INTERN MED

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Background Uncertainty surrounding COVID-19 regarding rapid progression to acute respiratory distress syndrome and unusual clinical characteristics make discharge from a monitored setting challenging. A clinical risk score to predict 14-day occurrence of hypoxia, ICU admission, and death is unavailable. Objective Derive and validate a risk score to predict suitability for discharge from a monitored setting among an early cohort of patients with COVID-19. Design Model derivation and validation in a retrospective cohort. We built a manual forward stepwise logistic regression model to identify variables associated with suitability for discharge and assigned points to each variable. Event-free patients were included after at least 14 days of follow-up. Participants All adult patients with a COVID-19 diagnosis between March 1, 2020, and April 12, 2020, in 10 hospitals in Massachusetts, USA. Main Measures Fourteen-day composite predicting hypoxia, ICU admission, and death. We calculated a risk score for each patient as a predictor of suitability for discharge evaluated by area under the curve. Key Results Of 2059 patients with COVID-19, 1326 met inclusion. The 1014-patient training cohort had a mean age of 58 years, was 56% female, and 65% had at least one comorbidity. A total of 255 (25%) patients were suitable for discharge. Variables associated with suitability for discharge were age, oxygen saturation, and albumin level, yielding a risk score between 0 and 55. At a cut point of 30, the score had a sensitivity of 83% and specificity of 82%. The respective c-statistic for the derivation and validation cohorts were 0.8939 (95% CI, 0.8687 to 0.9192) and 0.8685 (95% CI, 0.8095 to 0.9275). The score performed similarly for inpatients and emergency department patients. Conclusions A 3-item risk score for patients with COVID-19 consisting of age, oxygen saturation, and an acute phase reactant (albumin) using point of care data predicts suitability for discharge and may optimize scarce resources.

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Section: Discussionmentioning

confidence: 99%

Derivation of a Clinical Risk Score to Predict 14-Day Occurrence of Hypoxia, ICU Admission, and Death Among Patients with Coronavirus Disease 2019

Levine

Lipsitz

et al. 2020

J GEN INTERN MED

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“… Abbreviation: SOS, Stopping Opioids After Surgery. a Adapted from Chaudhary et al 81 b Defined as officer sponsor rank, proxy for high economic status. c Defined as enlisted sponsor rank, proxy for low socioeconomic status. d Appendectomy, inguinal herniorrhaphy, transurethral resection of prostate. e Requires access to major organ spaces or osseous resection, including colectomy, coronary artery bypass graft, nephrectomy, radical cystectomy, total knee arthroplasty, total hip arthroplasty, and hip fracture repair. f ≥6 months of continuous prescription without interruption exceeding 7 days. …”

Section: Key Action Statementsmentioning

confidence: 99%

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Anne¹,

Mims

Tunkel

et al. 2021

Otolaryngol.--head neck surg.

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Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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“…Several studies focused on identifying risk factors that predispose patients to this opioid dependency. Some studies found that performing instrumented spinal fusion was one of the leading risk factors that predicted prolonged opioid prescriptions in opioid-naive patients [ 26 , 27 , 28 ]. Moreover, Schoenfeld et al showed that low-intensity surgical procedures were associated with a higher likelihood of discontinuing opioid use [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Long-Term Pain Characteristics and Management Following Minimally Invasive Spinal Decompression and Open Laminectomy and Fusion for Spinal Stenosis

et al. 2021

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Background and Objectives: To compare the long-term pain characteristics and its chronic management following minimally invasive spinal (MIS) decompression and open laminectomy with fusion for lumbar stenosis. Materials and Methods: The study cohort included patients with a minimum 5-year postoperative follow-up after undergoing either MIS decompression or laminectomy with fusion for spinal claudication. The primary outcome of interest was chronic back and leg pain intensity. Secondary outcome measures included pain frequency during the day, chronic use of non-opioid analgesics, narcotic medications, medical cannabinoids, and continuous interventional pain treatments. Results: A total of 95 patients with lumbar spinal stenosis underwent one- or two-level surgery for lumbar spinal stenosis between April 2009 and July 2013. Of these, 50 patients underwent MIS decompression and 45 patients underwent open laminectomy with instrumented fusion. In the fusion group, a higher percentage of patients experienced moderate-to-severe back pain with 48% compared to 21.8% of patients in the MIS decompression group (p < 0.01). In contrast, we found no significant difference in the reported leg pain in both groups. In the fusion group, 20% of the patients described their back and leg pain as persistent throughout the day compared to only 2.2% in the MIS decompression group (p < 0.05). A trend toward higher chronic dependence on analgesic medication and repetitive pain clinic treatments was found in the fusion group. Conclusions: MIS decompression for the treatment of degenerative spinal stenosis resulted in decreased long-term back pain and similar leg pain outcomes compared to open laminectomy and instrumented fusion surgery.

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Development and Validation of a Bedside Risk Assessment for Sustained Prescription Opioid Use After Surgery

Cited by 43 publications

References 26 publications

Derivation of a Clinical Risk Score to Predict 14-Day Occurrence of Hypoxia, ICU Admission, and Death Among Patients with Coronavirus Disease 2019

Derivation of a Clinical Risk Score to Predict 14-Day Occurrence of Hypoxia, ICU Admission, and Death Among Patients with Coronavirus Disease 2019

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Long-Term Pain Characteristics and Management Following Minimally Invasive Spinal Decompression and Open Laminectomy and Fusion for Spinal Stenosis

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