IMPORTANCE: Despite increased focus on reducing opioid prescribing for long-term pain, little is known regarding the incidence and risk factors for persistent opioid use after surgery. OBJECTIVE: To ...determine the incidence of new persistent opioid use after minor and major surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: Using a nationwide insurance claims data set from 2013 to 2014, we identified US adults aged 18 to 64 years without opioid use in the year prior to surgery (ie, no opioid prescription fulfillments from 12 months to 1 month prior to the procedure). For patients filling a perioperative opioid prescription, we calculated the incidence of persistent opioid use for more than 90 days among opioid-naive patients after both minor surgical procedures (ie, varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel) and major surgical procedures (ie, ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy). We then assessed data for patient-level predictors of persistent opioid use. MAIN OUTCOMES AND MEASURES: The primary outcome was defined a priori prior to data extraction. The primary outcome was new persistent opioid use, which was defined as an opioid prescription fulfillment between 90 and 180 days after the surgical procedure. RESULTS: A total of 36 177 patients met the inclusion criteria, with 29 068 (80.3%) receiving minor surgical procedures and 7109 (19.7%) receiving major procedures. The cohort had a mean (SD) age of 44.6 (11.9) years and was predominately female (23 913 66.1%) and white (26 091 72.1%). The rates of new persistent opioid use were similar between the 2 groups, ranging from 5.9% to 6.5%. By comparison, the incidence in the nonoperative control cohort was only 0.4%. Risk factors independently associated with new persistent opioid use included preoperative tobacco use (adjusted odds ratio aOR, 1.35; 95% CI, 1.22-1.50), alcohol and substance abuse disorders (aOR, 1.36; 95% CI, 1.02-1.80), mood disorders (aOR, 1.25; 95% CI, 1.10-1.43), anxiety (aOR, 1.24; 95% CI, 1.09-1.42), and preoperative pain disorders (back pain: aOR, 1.21; 95% CI, 1.08-1.36; arthritis: aOR, 1.24; 95% CI, 1.12-1.37; and centralized pain: aOR, 1.28; 95% CI, 1.16-1.41). CONCLUSIONS AND RELEVANCE: New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors. New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness.
Mentoring Millennials Waljee, Jennifer F; Chopra, Vineet; Saint, Sanjay
JAMA : the journal of the American Medical Association,
04/2018, Letnik:
319, Številka:
15
Journal Article
Recenzirano
The article discusses the personal experiences of the authors, physicians, on the mentoring of millennials or people born between 1980 and 2000 who have entered medicine. Some of the challenges ...involved in mentoring this age group as well as advantages and things to be learnt from them are highlighted.
Mentoring Millennials Waljee, Jennifer F; Chopra, Vineet; Saint, Sanjay
JAMA : the journal of the American Medical Association,
05/2020, Letnik:
323, Številka:
17
Journal Article
Recenzirano
In this narrative medical essay, the authors present 3 scenarios exemplifying the collision between mentoring expectations among millennials and older generation faculty and proposes strategies to ...bridge generational divides and engage the next generation of physicians.
OBJECTIVE:We sought to determine the correlation between the probability of postoperative opioid prescription refills and the amount of opioid prescribed, hypothesizing that a greater initial ...prescription yields a lower probability of refill.
BACKGROUND:Although current guidelines regarding opioid prescribing largely address chronic opioid use, little is known regarding best practices and postoperative care.
METHODS:We analyzed Optum Insight claims data from 2013 to 2014 for opioid-naïve patients aged 18 to 64 years who underwent major or minor surgical procedures (N = 26,520). Our primary outcome was the occurrence of an opioid refill within 30 postoperative days. Our primary explanatory variable was the total oral morphine equivalents provided in the initial postoperative prescription. We used logistic regression to examine the probability of an additional refill by initial prescription strength, adjusting for patient factors.
RESULTS:We observed that 8.67% of opioid-naïve patients refilled their prescriptions. Across procedures, the probability of a single postoperative refill did not change with an increase with initial oral morphine equivalents prescribed. Instead, patient factors were correlated with the probability of refill, including tobacco use odds ratio (OR) 1.42, 95% confidence interval (CI) 1.23–1.57, anxiety (OR 1.30, 95% CI 1.15–1.47), mood disorders (OR 1.28. 95% CI 1.13–1.44), alcohol or substance abuse disorders (OR 1.43, 95% CI 1.12–1.84), and arthritis (OR 1.21, 95% CI 1.10–1.34).
CONCLUSIONS:The probability of refilling prescription opioids after surgery was not correlated with initial prescription strength, suggesting surgeons could prescribe smaller prescriptions without influencing refill requests. Future research that examines the interplay between pain, substance abuse, and mental health could inform strategies to tailor opioid prescribing for patients.
Purpose To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States. Methods We studied insurance claims from the Truven MarketScan databases ...to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression. Results In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use. Conclusions Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States. Clinical relevance The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.
Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an ...increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients.
We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure.
Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%-15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01-5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill.
Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.
Although visibility of nonbinary gender identities continues to improve in the United States, there is still a paucity of medical literature on the unique needs and experiences of nonbinary ...individuals. Using the TransPop survey, we compared gender-affirming treatment preferences and societal affirmation among nonbinary individuals, transmen, and transwomen using bivariate analysis and multivariable linear regression. Nonbinary individuals had or desired surgery and hormones at lower rates compared with binary transgender individuals. Nonbinary respondents had lower rates of adjusted and nonadjusted societal affirmation. This study showed variation in both treatment preferences and societal affirmation, which should be considered in clinical care and research studies clustering transgender and nonbinary individuals in analysis.
BACKGROUND:The misuse of opioid analgesics is a major public health concern, and guidelines regarding postoperative opioid use are sparse. The authors examined the use of opioids following outpatient ...upper extremity procedures to discern the variation by procedure type and patient factors.
METHODS:The authors studied opioid prescriptions among 296,452 adults older than 18 years who underwent carpal tunnel release, trigger finger release, cubital tunnel release, or thumb carpometacarpal arthroplasty from 2009 to 2013 using insurance claims drawn from the Truven Health MarketScan Commercial Claims and Encounters, which encompasses over 100 health plans in the United States. Using multivariable regression, the authors compared the receipt of opioids, number of days supplied, indicators of inappropriate prescriptions, and number of refills by patient factors.
RESULTS:In this cohort, 59 percent filled a postoperative prescription for opioid medication, and 8.8 percent of patients had an indicator of inappropriate prescribing. The probability of filling an opioid prescription declined linearly with advancing age. On multivariate analysis, patients who had previously received opioids were more likely to fill a postoperative opioid prescription (66 percent versus 59 percent), receive longer prescriptions (24 versus 5 days), receive refills following surgery (24 percent versus 5 percent), and have at least one indicator of potentially inappropriate prescribing (19 percent versus 6 percent).
CONCLUSIONS:Current opioid users are more likely to require postoperative opioid analgesics for routine procedures and more likely to receive inappropriate prescriptions. More evidence is needed to identify patients who derive the greatest benefit from opioids to curb opioid prescriptions when alternative analgesics may be equally effective and available.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, III.
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