Gazelka, Halena M.

Objective: To compare patient-reported outcomes before and after implementation of evidence-based, procedure-specific opioid prescribing guidelines. Background: The opioid epidemic remains a significant public health issue. Many institutions have responded by reducing opioid prescribing after surgery. However, the impact of this on patient-reported outcomes remains poorly understood. Methods: Opioid-naïve adults undergoing 12 elective general surgery procedures at a single institution prospectively completed telephone surveys at median 26 days from discharge. Patients were compared before (March 2017–January 2018) and after (May 2019–November 2019) implementation of evidence-based, procedure-specific opioid prescribing guidelines. Results: A total of 603 preguideline and 138 postguideline patients met inclusion criteria and completed surveys. Overall, 60.5% of preguideline and 92.5% of postguideline prescriptions fell within recommendations (P<0.001), while refill rates were similar (4.5% vs 5.8%, P=0.50). A statistically significant drop in median morphine milligram equivalent prescribed was observed for 9 of 12 procedures (75%). No opioids were prescribed for 16.7% of patients in both cohorts (P=0.98). While 93.3% of preguideline and 87.7% of postguideline patients were very/somewhat satisfied with their pain control, the proportion of patients who were very/somewhat dissatisfied increased from 4.2% to 9.4% (P=0.039). Conclusions: Prescribing guidelines successfully reduced opioid prescribing without increased refill rates. Despite decreased prescribing overall, there was a continued reluctance to prescribe no opioids after surgery. Although most patients experienced good pain control, there remains a subset of patients whose pain is not optimally managed in the era of reduced opioid prescribing.

OBJECTIVE Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid). METHODS The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90–180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days’ supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use. RESULTS A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05). CONCLUSIONS In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

Abstract BACKGROUND With a dramatic rise in prescription opioid use, it is imperative to review postsurgical prescribing patterns given their contributions to the opioid epidemic. OBJECTIVE To evaluate the impact of departmental postoperative prescribing guidelines on opioid prescriptions following elective spine surgery. METHODS Patients undergoing elective cervical or lumbar spine surgery between 2017 and 2018 were identified. Procedure-specific opioid prescribing guidelines to limit postoperative prescribing following neurosurgical procedures were developed in 2017 and implemented in January 2018. Preguideline data were available from July to December 2017, and postguideline data from July to December 2018. Discharge prescriptions in morphine milliequivalents (MMEs), the proportion of patients (i) discharged with an opioid prescription, (ii) needing refills within 30 d, (iii) with guideline compliant prescriptions were compared in the 2 groups. Multivariable (MV) analyses were performed to assess the impact of guideline implementation on refill prescriptions within 30 d. RESULTS A total of 1193 patients were identified (cervical: 308; lumbar: 885) with 569 (47.7%) patients from the preguideline period. Following guideline implementation, fewer patients were discharged with a postoperative opioid prescription (92.5% vs 81.7%, P < .001) and median postoperative opioid prescription decreased significantly (300 MMEs vs 225 MMEs, P < .001). The 30-d refill prescription rate was not significantly different between preguideline and postguideline cohorts (pre: 24.4% vs post: 20.2%, P = .079). MV analyses did not demonstrate any impact of guideline implementation on need for 30-d refill prescriptions for both cervical (odds ratio [OR] = 0.68, confidence interval [CI] = 0.37-1.26, P = .22) and lumbar cohorts (OR = 0.95, CI = 0.66-1.36, P = .78). CONCLUSION Provider-aimed interventions such as implementation of procedure-specific prescribing guidelines can significantly reduce postoperative opioid prescriptions following spine surgery without increasing the need for refill prescriptions for pain control.

Background: Epidural injection of corticosteroids is a commonly used treatment for radicular pain. However, the benefits are often short lived, and repeated injections are often limited secondary to concerns of side effects from cumulative steroid doses. In addition, rare, catastrophic complications, including brain and spinal cord embolic infarcts have been attributed to particulate steroid injections. A previous study has shown that dexamethasone has less particulate than other corticosteroids, possibly reducing embolic risk. Furthermore, a recent study indicated that clonidine may be useful in the treatment of radicular pain when administered via epidural steroid injection. The combination of corticosteroid and clonidine is an intriguing, yet unstudied, alternative to traditional treatment. Objective: Our study examines whether mixing clonidine and various corticosteroids results in increased particle size or aggregation. Methods: Evaluations under light microscopy for particle size were made of samples of clonidine alone and clonidine mixed with equal parts of 3 corticosteroids solutions: dexamethasone sodium phosphate injection, triamcinolone acetonide injectable suspension, and betamethasone sodium phosphate and betamethasone acetate injectable suspension. Four mL each of clonidine (100 μcg/ mL), clonidine (100 μcg/mL) + dexamethasone sodium phosphate injection (4 mg/mL), clonidine (100 μcg/mL) + triamcinolone acetonide injectable suspension (40 mg/mL), and clonidine (100 μcg/mL) + betamethasone sodium phosphate and betamethasone acetate injectable suspension (6 mg/mL) were examined Their particle sizes were compared to measurements taken when each steroid solution was examined alone. Results: Clonidine was determined to be nonparticulate when examined by light microscopy. Clonidine mixed with equal parts of each of the 3 corticosteroids mentioned above did not result in increased clumping or increased particle size over each of the corticosteroids measured alone. Conclusion: Mixing clonidine with corticosteroids did not increase particulation compared to corticosteroids alone. Combining clonidine and corticosteroids for epidural injection may prove to be a useful treatment for radicular pain. The combination of these is unlikely to result in a solution that is more likely to cause embolic infarcts than the use of corticosteroids alone. Key words: steroid, epidural, clonidine, injection, particulate, aggregation

Pain is a common symptom for patients with advanced illness. Palliative care (PC) clinicians are experts in pharmacologic and nonpharmacologic treatment of pain and other symptoms for these patients. True multimodal pain control should include consideration of interventional procedures and pumps to improve difficult-to-manage pain. This article, written by clinicians with expertise in interventional pain and PC, outlines and explains many of the adjunctive and interventional therapies that can be considered for patients with pain in the setting of serious illness. Only by understanding and considering all available options can we ensure that our patients are receiving optimal care.

AbstractThe field of malignant hematology has experienced extraordinary advancements with survival rates doubling for many disorders. As a result, many life-threatening conditions have since evolved into chronic medical ailments. Paralleling these advancements have been increasing rates of complex hematologic pain syndromes, present in up to 60% of patients with malignancy who are receiving active treatment and up to 33% of patients during survivorship. Opioids remain the practice cornerstone to managing malignancy-associated pain. Prevention and management of opioid-related complications have received significant national attention over the past decade, and emerging data suggest that patients with cancer are at equal if not higher risk of opioid-related complications when compared with patients without malignancy. Numerous tools and procedural practice guides are available to help facilitate safe prescribing. The recent development of cancer-specific resources directing algorithmic use of validated pain screening tools, prescription drug monitoring programs, urine drug screens, opioid use disorder risk screening instruments, and controlled substance agreements have further strengthened the framework for safe prescribing. This article, which integrates federal and organizational guidelines with known risk factors for cancer patients, offers a case-based discussion for reviewing safe opioid prescribing practices in the hematology setting.

Background. Critical limb ischemia (CLI) is limb pain occurring at rest or impending limb loss as a result of lack of blood flow to the affected extremity. CLI pain is challenging to control despite multimodal pharmacologic analgesia and surgical intervention. We described the successful use of a continuous local anesthetic infusion via a popliteal nerve catheter to control severe refractory ischemic lower limb pain in a patient who failed surgical intervention and performed a brief narrative literature review on regional anesthesia for ischemic pain.Case Presentation. A 74-year-old female with acute myelogenous leukemia presented with CLI after experiencing left popliteal artery occlusion. Palliative medicine service was consulted for pain management in the setting of escalating narcotic dose requirements. She experienced a complicated hospital course with several failed attempts at surgical revascularization due to arterial rethrombosis. In accordance with the patient’s goals of care, a continuous popliteal nerve catheter was placed, despite the high risk nature of an intervention in an immunocompromised patient with thrombocytopenia (platelet count of 30,000 platelets/microliter) and ongoing therapeutic anticoagulation. The patient experienced immediate relief while transitioning to comfort care.Conclusion. This is the first report of successful analgesia for CLI via a continuous popliteal catheter in a patient with rethrombosis and failed surgical revascularization. Based on our collaborative experience, we recommend the development of partnerships between the acute pain service and palliative care service to facilitate the early evaluation and decision to utilize regional anesthesia for treatment of CLI.

Background: Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines. Methods: This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME. Results: In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums. Conclusions: Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Objective Spinal cord stimulation (SCS) is an evidence-based therapy for the treatment of refractory pain. Current American College of Graduate Medical Education requirements for pain medicine fellowship graduation include observation of five neuromodulation cases. Matriculating fellows have varying degrees of technical skill, training, and experience. The purpose of this study was to use an innovative skill-based assessment tool using the validated Zwisch scale to evaluate fellow surgical performance during SCS cases. Design Cross-sectional survey Setting Mayo Clinic, Rochester, Minnesota. Subjects Consultant faculty (10) in the Division of Pain Medicine and pain medicine fellows (5). Methods A list of faculty-driven neuromodulation surgical objectives was formed and a rubric was created that focused on technical approach, imaging, epidural access and wound closure. Consultants who perform surgical cases were instructed to use the Zwisch scale as a guide to evaluate fellow surgical performance during a neuromodulation case. Faculty and fellows were surveyed before and after implementation of the tool to determine their satisfaction with use of the skill assessment tool. Results The consultants reported they were more satisfied, consistent, and efficient with feedback provided to the trainee on every aspect of neuromodulation surgical cases. The improvement was most significant during the fellows’ intraoperative skill assessment. The fellows indicated increased satisfaction, improved communication, and increased efficiency of feedback when the tool was utilized. The fellows reported greater intraoperative skill assessment and consistency of feedback provided. Conclusions The diverse nature of primary specialty backgrounds observed in pain medicine fellowship training offers a unique opportunity to assess and improve fellow skill and surgical competence in the field of neuromodulation. Both faculty and fellows reported improved satisfaction, consistency and efficiency with feedback provided. Importantly, this pilot project observed that implementation of a skill assessment tool was beneficial for both the faculty and fellow as the feedback received was viewed as strongly beneficial to the educational experience.