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Background Opioid overuse is a costly and significant problem in the United States. Medical specialties including surgery are a contributor to opioid prescriptions while having few clear prescribing guidelines. Machine learning predictive tools can assist surgeons with evaluating patients for opioid prescriptions and help prevent prescriptions for patients at-risk for prolonged post-operative opioid use. This project aims to develop accurate and transparent machine learning models to predict prolonged opioid use by individuals undergoing rotator cuff surgery. Methods Six machine learning models were trained on a dataset of 852 individuals undergoing rotator cuff surgery and evaluated for predictive accuracy. Machine learning explainability techniques were used to improve model transparency, including Shapley Additive explanations (SHAP) for global variable importance and local interpretable model-agnostic explanations (LIME) for local variable effects and importance. Results Four of six machine learning models developed had predictive accuracy greater than 0.71, with our top three models having an accuracy of 0.98 (XGBoost), 0.94 (Random Forest), and 0.74 (Decision Tree). SHAP and LIME explanations were created for models allowing insight and interpretation into model outputs. Conclusion We were able to develop predictive machine learning models that displayed predictive accuracy in predicting prolonged post-operative opioid use while improving model explainability and transparency.

Background The utilization patterns of opioid analgesics and the proportion of long-term opioid use after surgery in Norway is largely unknown. Methods This study aimed to estimate the proportion of one-year long-term prescription opioid use among all Norwegian postoperative opioid users. Complete data from central health registries (NPR, NorPD, Statistics Norway, CoDR) were linked via the personal identification number unique to all citizens. The study period was January 1st 2010 until December 31st 2019. Long-term opioid use was defined as at least two opioid dispensings within two subsequent 90-day periods, with a minimum average use of 10 MME/day for the first 90 days. Results The study population consisted of 693 495 post-operative opioid users (53.6% women), whereof 73.2% had not used opioids the year before surgery (new users). Among the postoperative opioid users, 3.8% were one-year long-term opioid users. The corresponding figures for new and previous opioid users were 0.4% and 13.1%, respectively. The highest proportions of long-term opioid use were found after transluminal endoscopy, eye surgery and assessments related to surgical procedures. In previous opioid users, the proportion of one-year long-term use was higher among women than men in all age groups, a difference that increased with age. Conclusions The proportion of postoperative long-term opioid use in Norway is generally low. We detected higher proportions of long-term opioid use after certain types of surgery, but our crude surgery definition warrants further examination. Previous opioid users pose a particular challenge in the management of postoperative pain. Trial registration The study used national health registry data from the period 2010–2019. A pre-registered analysis plan is available at Open Science Framework.

BACKGROUNDTreatment of ovarian cancer often requires extensive surgical resection. The transversus abdominis plane (TAP) block has been utilized in benign gynecologic surgery to decrease post-operative pain and opioid use. We hypothesized that TAP blocks would decrease total opioid use in the first 24 hours and decrease length of stay following staging and cytoreductive surgery for ovarian cancer compared with either no local anesthetic or local wound infiltration alone. METHODSAll patients undergoing surgery for ovarian cancer from November 2016 to June 2017 were included in this retrospective cohort study. Median opioid use at 24, 48, and 72 hours post-operatively, as well as length of stay, were assessed. Multivariate median regression analysis was performed to adjust for potential confounderspost-operative non-steroidal anti-inflammatory drug (NSAID) usage, pre-operative opioid consumption, and extent of cytoreductive surgery. Length of stay was compared using Cox regression analysis. RESULTSOne-hundred-and-twenty patients were included in the analysis. Eighty-two patients had a TAP block, while 38 did not. After adjusting for potential confounders there was no difference in median 24 hours opioid consumption (p=0.29) or length of stay (HR 0.95, p=0.78) between patients receiving TAP block compared with those without. After adjusting for potential confounders, patients receiving scheduled NSAIDs had a 2.6-fold greater likelihood of being discharged (p<0.0005) and a significant reduction in median opioid use at 24 hours (23.5 vs 14.5 mg) (p=0.017) compared with those patients without NSAIDs. DISCUSSIONPost-operative administration of NSAIDs, but not TAP block, was associated with a decrease in post-operative opioid use and length of stay following surgery for ovarian cancer. Further investigation into alternative regional anesthetics for Enhanced Recovery after Surgery (ERAS) protocols is warranted.

Sleep is important for our health and well-being and is especially pertinent to orthopedic surgery because it has been shown to play a role in pain tolerance. Knowing the benefits of sleep, one way to positively impact patients’ pain and recovery post-surgery is to encourage sleep. Zolpidem, a pharmacologic sleep aid, has been shown to decrease opioid consumption, reduce pain, and increase quality of life when briefly used after orthopedic procedures. Cognitive Behavioral Therapy for Insomnia (CBT-I), a nonpharmacologic sleep aid, has been shown to increase the quality of sleep and sleep time, decrease sleep onset latency, decrease pain, and help patients maintain those gains. Because of the dangers of opioids, it is important for physicians to search for alternative methods to manage their patients’ pain, like zolpidem and CBT-I. More research is needed to determine which method may be the most efficacious and how these can be integrated into patient care.

Background: Cebranopadol is a potent, first-in-class analgesic with a novel mechanistic approach combining nociceptin/orphanin FQ peptide (NOP) and opioid peptide receptor agonism. Objective: We aim to evaluate, for the first time, the analgesic efficacy, safety, and tolerability of cebranopadol in patients suffering from moderate to severe acute pain following bunionectomy. Study Design: We conducted a phase IIa, randomized, multi-center, double-blind, double-dummy, placebo- and active-controlled, parallel group clinical trial. Methods: A total of 258 patients who underwent a primary bunionectomy were randomly assigned to receive a single oral administration of cebranopadol 200 μg, 400 μg, or 600 μg, morphine controlledrelease (CR) 60 mg, or placebo. The primary efficacy end-point was the sum of pain intensity (SPI) 2 to 10 hours (SPI2–10) after the first investigational medicinal product (IMP) intake time-point. Results: Cebranopadol doses of 400 µg and 600 µg were more effective in reducing postoperative acute pain compared to placebo, from 2 hours until approximately 22 hours after the first IMP intake time-point. No difference was observed between cebranopadol 200 μg and placebo. Per the subject global impression of the IMP assessment, patients who received cebranopadol 400 μg and 600 μg were more satisfied with the ability of the medication to treat their pain compared to those who received morphine CR 60 mg. On the primary end-point, the effect of morphine CR 60 mg was smaller than that of cebranopadol 400 μg and 600 μg. However, the analgesic effect of morphine CR 60 mg emerged later relative to IMP intake, as shown by the fact that similar SPI results as seen for cebranopadol 400 μg and 600 μg were obtained for later time windows. Cebranopadol treatment was safe, and single-dose administrations of 400 µg were better tolerated than morphine CR 60 mg. The relative frequency of patients with at least one treatment-emergent adverse event (TEAE) increased with increasing cebranopadol doses and was highest in the morphine CR 60 mg group. Limitation: Although a double-dummy design was used to ensure blinding, a limitation of this trial was that cebranopadol and morphine CR were administered at 2 different time-points post-surgery, given the anticipated difference in the time to reach the maximum plasma concentration between the 2 treatments. Conclusion: Administration of single cebranopadol doses of 400 µg and 600 µg induced more effective analgesia following bunionectomy surgery compared to the traditional opioid morphine on the primary end-point (SPI2–10), while both cebranopadol doses and morphine ensured adequate 24- hour pain relief. Moreover, cebranopadol was better tolerated and received a better overall rating by the patients. Key words: Opioids, morphine, µ-opioid receptor, nociceptin/orphanin FQ peptide receptor, analgesic, bunionectomy, surgery, post-operative pain, single hallux valgus repair

Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002–1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291–0.8521) were independent predictors of opioid-free discharge. Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription. [Display omitted] •Opioid free-discharge is relatively infrequent after laparoscopic cholecystectomy.•Non-elective cholecystectomy and older age were associated with opioid-free discharge.•Surgical teams should pay particular attention to patient and procedural factors when prescribing opioids.

Over the past two decades, the United States has experienced a rise of opioid misuse, with a significant increase in drug overdose deaths– many of these deaths have been attributed to prescription opiate misuse. Given this epidemic, numerous specialties have created enhanced recovery after surgery protocols to decrease opiate usage post-operatively and some specialties have even created guidelines advising how many morphine milligram equivalents per day are recommended at discharge. The neurosurgical literature is lacking on best practices for discharge opiate prescribing. The goal of this review is to assess opiate prescribing practices at discharge for both cranial and spine neurosurgical patients, and to determine if neurosurgeons are over-prescribing opiates to their patients. A systematic literature review was performed according to PRISMA guidelines. After searching PubMed, Cochrane, and Embase, a total of 288 abstracts were identified, 71 studies underwent full text review and 23 were included in this study. Studies that quantified opiate usage (number of pills prescribed, morphine equivalents, prescription refills) were included. The range of opiate prescribing varied and there was a tendency to both over-prescribe and under-prescribe; therefore, no conclusions could be made. This review underscores the need to take individual patient pain needs into account and shows the need for higher quality literature that can help formulate guideline creation.

BACKGROUND: Opioid abuse has been an increasing problem since the 1990s. With over 47,000 opioid related deaths recorded in 2017 alone, concerns have been raised regarding the dangers of introducing opioids perioperatively to patients undergoing major surgeries. OBJECTIVES: The present study proposes to examine the frequency, amount, and trends in post-operative opioid consumption in patients undergoing orthopedic surgical procedures. STUDY DESIGN: This was a randomized, retrospective questionnaire-based study. SETTING: Patients who underwent any type of orthopedic surgery at the University of Pennsylvania Presbyterian Hospital from 1/1/2018 to 3/12/2019 were randomly selected and called during the summer of 2019. METHODS: In this retrospective questionnaire-based study, 828 patients were called by telephone in the summer of 2019. These patients were asked a variety of questions involving opioid consumption behavior post-surgery. The study ended after receiving responses from 200 patients. RESULTS: Nineteen (9.5%) patients reported positively for experiencing euphoria while taking opioids post-surgery. Of the 200 patients contacted, 6 patients (3%) reported switching to marijuana instead of opioids. Thirty-eight (19%) patients preferred to take no opioids at all post-surgery, and one patient was found to have given their prescription to a family member or friend. Twenty-one patients (10.5%) were found to have been taking opioids for non-severe pain. Blacks and whites were the most common racial demographics, making up 84 and 109 of the totals, respectively. The odds ratios for all of the predictors showed that the relative risk for opioid misuse was higher for black patients than white patients (OR = 3.034). There was no relationship between the intra- and post-operative opioid administration and long-term opioid misuse. LIMITATIONS: Patients are self-selected and had the option to opt out of the study when contacted. Some patients may not have been available to answer the phone when our study was being conducted. This study was only conducted for orthopedic patients and for patients who received surgery at the University of Pennsylvania Presbyterian Hospital, thus affecting the demographics for our research. CONCLUSIONS: Prescription opioid misuse is more common among the black population. The total opioid consumption is frequently lower than the quantity prescribed. Patients frequently use opioids even though they feel that pain is insufficient to deserve such an intervention. Euphoria is experienced by a significant number of patients taking prescription opioids Often patients do not take any opioids, although they had prescriptions. KEY WORDS: Opioids, post-operative pain, misuse, abuse

Background Prescription opioid abuse has become a major issue across the world and especially in North America. Canada has the second highest number of opioid prescriptions per capita in the world, second only to the United States, with numbers continuing to rise in recent years. Surgeons play a critical role in this discussion as they are responsible for the management of post-operative pain in their patients . The objective of this study is to evaluate the opioid prescribing practices of Otolaryngologists-Head and Neck Surgeons in Canada and determine factors that may influence these practices. Methods The online survey was distributed to members of the Canadian Society of Otolaryngology-Head and Neck Surgery. Questions surveyed the respondents’ demographics and opioid prescribing practices for common pediatric and adult elective surgeries. Results The survey was sent to 670 surgeons and trainees and 121 responses were received (18%). There was representation across all subspecialties with a mix of community and academic surgeons. The most commonly prescribed opioid was Codeine/Acetaminophen, 48.2% ( n  = 53), in the adult population, and Morphine, 47.1% ( n  = 41), in the pediatric population. The median total oral morphine equivalents prescribed across all adult surgeries was 123.75 mg (24.75 doses). The surgery with the highest oral morphine equivalents prescribed was tonsillectomy/adenoidectomy for both adult and pediatric patients, with a median of 150 mg (30 doses) for adults and 4.5 mg/kg (23 doses) for pediatrics. Gender, training years, year in residency, or reported level of conservatism did not predict the dose prescribed to either adult or pediatric patients. Due to the relatively low response rate, the generalizability of these results is unclear. Conclusions Our study demonstrates a wide variability in opioid prescriptions across procedures and within each individual procedure. This variability reflects the lack of guidelines available for post-operative opioid prescribing and suggests that some Otolaryngologists may be prescribing higher doses of opioids than required. Opportunities for improving patient safety and resource stewardship regarding optimal prescribing practices should be explored.

Opioids are often prescribed after outpatient inguinal hernia repair despite limited evidence of benefit and well-documented risks. We evaluated their impact on complications and patient-reported outcomes. This prospective observational study enrolled adults undergoing outpatient inguinal hernia repair (June 2022–October 2024) at a single institution. Pain, satisfaction, hernia-related quality of life (HerQLes), and early (≤1 week) and late (12 weeks) complications were assessed. Opioid use was quantified in morphine milligram equivalents. Logistic regression adjusted for age and comorbidity estimated complication risk. Among 110 patients, 16 (14.5 %) used opioids. Opioid use was associated with higher early (50 % vs 43.6 %) and late (43.8 % vs 40 %) complications (AOR 1.12, p = .018), with no improvement in pain, medication satisfaction, or quality of life over time. Even after low-risk surgery, opioids may add harm without benefit. Opioid-sparing regimens should be prioritized for outpatient inguinal hernia repair. [Display omitted] •Prospective cohort of 110 patients after outpatient inguinal hernia repair.•Opioid use increased early and late complication risk (AOR up to 1.28).•No benefit in pain control, satisfaction, or quality of life with opioids.•Safer pain control achieved with opioid-sparing multimodal regimens.•Findings reinforce national efforts to curb opioid overprescribing.