Positive Association between Peri-Surgical Opioid Exposure and Post-Discharge Opioid-Related Outcomes.

Background: Multiple studies have investigated the epidemic of persistent opioid use as a common postsurgical complication. However, there exists a knowledge gap in the association between the level of opioid exposure in the peri-surgical setting and post-discharge adverse outcomes to patients and healthcare settings. We analyzed the association between peri-surgical opioid exposure use and post-discharge outcomes, including persistent postsurgical opioid prescription, opioid-related symptoms (ORS), and healthcare resource utilization (HCRU). Methods: A retrospective cohort study included patients undergoing cesarean delivery, hysterectomy, spine surgery, total hip arthroplasty, or total knee arthroplasty in an academic healthcare system between January 2015 and June 2018. Peri-surgical opioid exposure was converted into morphine milligram equivalents (MME), then grouped into two categories: high (>median MME of each surgery cohort) or low (≤median MME of each surgery cohort) MME groups. The rates of persistent opioid use 30 and 90 days after discharge were compared using logistic regression. Secondary outcomes, including ORS and HCRU during the 180-day follow-up, were descriptively compared between the high and low MME groups. Results: The odds ratios (95% CI) of high vs. low MME for persistent opioid use after 30 and 90 days of discharge were 1.38 (1.24−1.54) and 1.41 (1.24−1.61), respectively. The proportion of patients with one or more ORS diagnoses was greater among the high-MME group than the low-MME group (27.2% vs. 21.2%, p < 0.01). High vs. low MME was positively associated with the rate of inpatient admission, emergency department admissions, and outpatient visits. Conclusions: Greater peri-surgical opioid exposure correlates with a statistically and clinically significant increase in post-discharge adverse opioid-related outcomes. The study findings warrant intensive monitoring for patients receiving greater peri-surgical opioid exposure.

Assessing pharmacy student confidence to answer patient questions regarding herbal medicines and natural product drugs.

BACKGROUND AND PURPOSE: To assess the change in confidence answering questions about herbal medicines and natural product drugs (HMNPD) in third year professional pharmacy students in an HMNPD course. EDUCATIONAL ACTIVITY AND SETTING: A questionnaire was developed to query confidence in responding to patient questions, recommending specific products, and ability to retrieve resources regarding HMNPD. It was administered the first and last week of the semester; responses were evaluated using a Chi-squared test. FINDINGS: At baseline, 46 students (84%) were "very hesitant", "hesitant", or "neither hesitant nor confident" in responding to HMNPD questions; after the course, most students were "confident" or "very confident" (n=30, 54%) (p < .001). Confidence in finding reliable resources increased from the first week (29 students [40%] were "confident" or "very confident") to the last week (51 students [91%] were "confident" or "very confident" [p < .001]). At baseline, five students (9%) were "confident" or "very confident" in ability to recommend a specific product; after the course, 26 students (46%) were "confident" or "very confident" (p < .001). Nine students (16%) felt "very confident" or "confident" in HMNPD safety/effectiveness at baseline; the same proportion felt this way at conclusion (p = .93). Four students (7%) were confident in HMNPD efficacy at baseline and nine (16%) felt the same way at the end (p = .12). DISCUSSION: Significant increases in student confidence answering patient questions, responding to disease-specific queries, and using appropriate resources were found. There was no difference in confidence in HMNPD safety/efficacy. SUMMARY: This study supported continued HMNPD education in the pharmacy program.

Laboratory Monitoring of Low-Molecular-Weight Heparin and Fondaparinux.

Compared with older agents, low-molecular-weight heparins (LMWH) and fondaparinux offer improved bioavailability and more predictable, dose-independent clearance. While routine monitoring of coagulation parameters is not usually necessary with these agents, certain populations (including pregnant patients, children, obese patients, and patients with renal impairment) may benefit from the monitoring of anti-factor Xa activity, thromboelastography, or other coagulation assays to help guide therapy. The chromogenic anti-factor Xa assay is currently the gold standard for monitoring LMWH and fondaparinux therapy. Thromboelastography has been used to monitor LMWH therapy in special situations but is not needed for routine use.