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      Opioid utilization after orthopaedic trauma hospitalization among Medicaid-insured adults

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          Abstract

          Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010–2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07–1.18) and those between 31–50 years of age (OR = 1.15, 95% CI: 1.08–1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71–0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83–0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66–0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51–65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.

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          Most cited references37

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          CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016.

          Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose.
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            Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.

            Black Americans are systematically undertreated for pain relative to white Americans. We examine whether this racial bias is related to false beliefs about biological differences between blacks and whites (e.g., "black people's skin is thicker than white people's skin"). Study 1 documented these beliefs among white laypersons and revealed that participants who more strongly endorsed false beliefs about biological differences reported lower pain ratings for a black (vs. white) target. Study 2 extended these findings to the medical context and found that half of a sample of white medical students and residents endorsed these beliefs. Moreover, participants who endorsed these beliefs rated the black (vs. white) patient's pain as lower and made less accurate treatment recommendations. Participants who did not endorse these beliefs rated the black (vs. white) patient's pain as higher, but showed no bias in treatment recommendations. These findings suggest that individuals with at least some medical training hold and may use false beliefs about biological differences between blacks and whites to inform medical judgments, which may contribute to racial disparities in pain assessment and treatment.
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              Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

              Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.
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                Author and article information

                Contributors
                URI : https://loop.frontiersin.org/people/2557845/overviewRole: Role: Role:
                URI : https://loop.frontiersin.org/people/2557907/overviewRole: Role: Role: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/2557895/overviewRole: Role: Role: Role: Role: Role:
                Role: Role: Role:
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                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                26 March 2024
                2024
                : 12
                : 1327934
                Affiliations
                [1] 1Nell Hodgson Woodruff School of Nursing, Emory University , Atlanta, GA, United States
                [2] 2H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology , Atlanta, GA, United States
                [3] 3Department of Orthopaedics, School of Medicine, Emory University , Atlanta, GA, United States
                [4] 4Grady Memorial Hospital , Atlanta, GA, United States
                [5] 5The Christopher Wolf Crusade , Atlanta, GA, United States
                Author notes

                Edited by: Dabney Evans, Emory University, United States

                Reviewed by: Isain Zapata, Rocky Vista University, United States

                Shweta Pathak, University of North Carolina at Chapel Hill, United States

                *Correspondence: Nicholas A. Giordano, ngiorda@ 123456emory.edu
                Article
                10.3389/fpubh.2024.1327934
                11003548
                38596512
                0125f368-c2f9-4a3b-a981-9b458884e659
                Copyright © 2024 Giordano, Zhao, Kalicheti, Schenker, Wimberly, Rice and Serban.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 25 October 2023
                : 15 February 2024
                Page count
                Figures: 0, Tables: 3, Equations: 0, References: 43, Pages: 8, Words: 6221
                Funding
                The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported, in part by, the Injury Prevention Research Center at Emory (NCIPC R49 CE003072) and the Christopher Wolf Crusade, a 501(c) (3) nonprofit organization. NG received funding from the National Institute of Drug Abuse (K23DA057415).
                Categories
                Public Health
                Original Research
                Custom metadata
                Injury prevention and control

                opioid,trauma,injury,pain,emergency medicine,orthopaedic trauma & surgery

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