Abstract Background Personalized medicine promises to tailor treatments to the individual, but it carries a hidden risk: mistaking statistical noise for actionable clinical insight. Current machine learning approaches often provide predictions, but fail to inform clinicians when those predictions are unreliable. Objective Develop a deployment-readiness framework that integrates causal inference, interpretable effect-trees, and calibration assessment to distinguish actionable signal from unreliable variation, and to support treatment selection only when the estimated benefit is both reliable and clinically meaningful. Methods Using retrospective observational cohort EHR data from the INSPIRE perioperative dataset (N>130,000 surgical operations, 2011–2020), we estimated treatment effects using causal forests with double machine learning, benchmarked against other causal methods to assess convergence. We used the estimated causal effects to create effect-trees and translated estimates into interpretable rules. We validated the treatment recommendations by assessing subgroup calibration to identify which groups were reliable for treatment selection. Results In a prostate procedures case study (neuraxial versus general anesthesia; total N=2,822), neuraxial anesthesia was associated with substantially lower post-operative opioid use (ATE = −1.38 opioid medications, 95% CI [−1.62, −1.15]). The effect-tree produced five clinically interpretable subgroups using BMI, ASA status, and age, with effects ranging from −1.10 to −1.59 opioid medications. Calibration analysis identified four of five subgroups as reliable for deployment (calibration error < 0.08), while one small subgroup (N=250) showed higher calibration error (0.44), illustrating how the framework rates unreliable heterogeneity. Conclusions Individual prediction heterogeneity does not automatically justify clinical personalization. By combining effect-trees with calibration, this framework distinguishes actionable heterogeneity from noisy heterogeneity (detectable but unreliable). This approach transforms causal machine learning from a black box into a validated decision support system that enables selective deployment of treatment decision rules.
2Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion
Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion
Read moreRegarding “Risk Factors for Postoperative Opioid Use in Arthroscopic Meniscal Surgery”
Regarding “Risk Factors for Postoperative Opioid Use in Arthroscopic Meniscal Surgery”
25Risk Factors for Chronic Opioid Use Following Hip and Knee Arthroplasty: Evidence from New Zealand Population Data
Risk Factors for Chronic Opioid Use Following Hip and Knee Arthroplasty: Evidence from New Zealand Population Data
146Opioid Pain Medication Use After Dermatologic Surgery
To better understand postoperative opioid use after dermatologic surgery. Prospective observational study. Academic dermatology department. The study included 212 adults (1) who were undergoing a single skin excision (including Mohs micrographic surgery), (2) who consented to participate,and (3) who were able to be reached by telephone on postoperative day 3 or 4. Patients who did not meet these criteria and those referred to another physician for further surgical treatment or repair were excluded. The study examined(1) the incidence of opioid prescription after dermatologic surgery, (2) the percentage of prescribed opioid pain medications used in the postoperative period, and (3) patient and surgical characteristics associated with opioid pain medication prescription and use. Opioids were prescribed to 72 of the 212 patients(34%). Twenty-five of the 72 patients (35%) who were prescribed opioids did not use them. Forty-nine of 57 patients (86%) who filled an opioid prescription had leftover pills, and 26 of the 49 patients (53%) planned to keep them. Only maximum pain score was significantly associated with opioid use. Opioids were over prescribed after dermatologic surgery. Patients who had left over opioids did not dispose of them properly, which could lead to potential misuse and abuse.
Read more19The good, the bad, and the ugly: the many faces of opioids
The good, the bad, and the ugly: the many faces of opioids
50Multimodal pain control in adolescent posterior spinal fusion patients: a double-blind, randomized controlled trial to validate the effect of gabapentin on postoperative pain control, opioid use, and patient satisfaction.
Multimodal pain control in adolescent posterior spinal fusion patients: a double-blind, randomized controlled trial to validate the effect of gabapentin on postoperative pain control, opioid use, and patient satisfaction.
Read morePre-pperative low intensity vestibular shockwave therapy (LiSWT) decreases opioid use post-vestibulectomy: A pilot study
Pre-pperative low intensity vestibular shockwave therapy (LiSWT) decreases opioid use post-vestibulectomy: A pilot study
7Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF?
Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF?
2Postoperative Pain Following Coblation of Sinonasal Hereditary Hemorrhagic Telangiectasias.
Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease and epistaxis is the most common symptom. This can be treated conservatively but severe cases may require operative interventions. Endoscopic endonasal coblation of HHT lesions has been used successfully but postoperative pain management has not been well described. This study aimed to assess levels of postoperative pain and opioid use among patients with HHT who underwent coblation of sinonasal lesions. This is a longitudinal, prospective cohort study of adult patients undergoing endoscopic endonasal coblation for treatment of HHT lesions with or without bevacizumab injection between November 2019 and March 2020 at a single academic university hospital. Patients were given preoperative questionnaires and contacted via telephone 48 hours after surgery. If they reported using opioids for pain control, they were called every 2 days until they no longer used these medications. Fourteen cases, including 13 unique patients, were included in this study. Opioids were ordered on discharge in 4 cases and the average morphine milligram equivalent prescribed on discharge was 41. The median pain score on postoperative day (POD) 2 was 4 of 10. Twelve patients reported using acetaminophen and 4 were using opioid pain medications. Of those using opioid pain medications, only 1 patient was using opioid pain medication by POD 4 and denied any use after POD 10. This study is the first to analyze postoperative pain management and opioid prescribing patterns in HHT patients undergoing endonasal coblation of telangiectasias. Postoperative pain was mild to moderate and most patients stopped using opioid medications by POD 4, although the majority of patients solely used acetaminophen. Future studies with increased sample size will be useful to further identify predictors of need for analgesics postoperatively and other non-opioid adjuncts for pain control.
Read moreP121. Chronic opioid use following anterior cervical discectomy and fusion surgery for degenerative cervical pathology
P121. Chronic opioid use following anterior cervical discectomy and fusion surgery for degenerative cervical pathology
51Bilateral Breast Reduction Without Opioid Analgesics: A Comparative Study.
Breast reduction has traditionally been performed under general anesthesia with adjunct opioid use. However, opioids are associated with a wide variety of adverse effects, including nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction. This study compares bilateral breast reduction using a multimodal opioid-free pain management regimen vs traditional general anesthesia with adjunct opioids. A total of 83 female patients were enrolled in this study. Group 1 includes a retrospective series of 39 patients that underwent breast reduction via general anesthesia with adjunct opioid use. This series was compared to 2 prospective groups of patients who did not receive opioids either preoperatively or intraoperatively. In group 2, twenty-six patients underwent surgery under intravenous sedation and local anesthesia. In group 3, eighteen patients underwent surgery with general anesthesia. All patients in groups 2 and 3 received preoperative gabapentin and celecoxib along with infiltration of local anesthetics during the operation and prior to discharge to the Post-Anesthesia Care Unit (PACU). Primary outcome measures included the duration of surgery, time from end of operation to discharge home, postoperative opioid and antiemetic use, and unplanned postoperative hospitalizations. When compared to group 1, groups 2 and 3 experienced a shorter time from end of operation to discharge home (P < 0.05), fewer unplanned hospital admissions (P < 0.05), and highly significant decrease in postoperative opioid use (P < 0.001). This multimodal approach allows patients to safely undergo opioid-free bilateral breast reduction either under local or general anesthesia as an outpatient. This method resulted in significantly less morbidity, use of opioids postoperatively, as well as unplanned hospital admissions compared to "traditional" breast reduction under general anesthesia with the use of opioids. 3.
Read more1Enhanced Recovery After Surgery Pathway for Cesarean Delivery: Effect on Opioid Use and Pain Scores [5K
INTRODUCTION: One in 300 opioid-naïve women develop opioid addiction following cesarean delivery (CD). Enhanced recovery after surgery (ERAS) pathways provide a multidisciplinary, evidence-based approach to postoperative care and have been shown to decrease postoperative opioid consumption. We implemented an ERAS CD pathway and evaluated the impact on postoperative opioid use and pain scores. METHODS: We conducted an IRB approved, retrospective cohort study comparing postoperative opioid use and pain scores among women on the ERAS CD pathway in the first year of implementation (4/2017-3/2018, n=531) compared to historical controls (3/2016-2/2017, n=661). Women with pregestational diabetes on insulin preconception, preeclampsia with severe features, and/or complex pain needs were excluded. Analysis was stratified for women undergoing planned (no labor, n=530) and unplanned (labor, n=662) CD. Postoperative opioid use and pain scores were compared using chi-squared and t-tests. RESULTS: During implementation, 531 (83%) of 640 eligible women were included in the ERAS CD pathway. Compared to baseline, the ERAS CD pathway resulted in an overall decrease of 13.7% (p=0.001) in postoperative opioid use with a 23.2% reduction in patients with unplanned CD (p<0.001). There was no difference in postoperative opioid use in patients with planned CD (p=0.456). ERAS patients with planned CD had a 9.5% reduction in pain scores on postoperative day 0 (p<0.05). There were no other significant differences in pain scores. CONCLUSION: The ERAS CD pathway was associated with decreased postoperative opioid use overall. Interestingly, the decrease in opioid use was driven by the unplanned CD subset. Further research should explore these differences.
Read more5Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis
Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis
40Evaluating Postoperative Narcotic Use in Prepectoral Versus Dual-plane Breast Reconstruction Following Mastectomy
Background:The majority of postmastectomy breast reconstruction performed in the United States is device-based. Typically, a tissue expander or implant is placed in the dual-plane (ie, subpectoral). Prepectoral breast reconstruction with acellular dermal matrices following mastectomy is a relatively new technique that has favorable outcomes with minimal complications and satisfactory aesthetic results. Few studies have compared opioid use between the 2 approaches. This study compares duration of postoperative opioid use among patients undergoing prepectoral device-based breast reconstruction with those in whom dual-plane devices were placed.Methods:We reviewed the records of adult female patients aged 18 years or older who underwent prepectoral or dual-plane device-based breast reconstructions following mastectomy by one of the 2 plastic surgeons (A.M. or M.V.) from 2015 to 2017 at a large tertiary care hospital. Patients with a history of substance abuse, chronic pain, or who were already receiving opioid medication were excluded. Electronic medical records were reviewed and patient surveys were conducted during postoperative visits to determine postoperative opioid requirements.Results:During the study period, 58 patients underwent dual-plane breast reconstruction and 94 underwent prepectoral reconstruction. Demographics and comorbidities of the groups were similar. By multivariate regression analysis, the prepectoral reconstruction group required 33% fewer days on opioid analgesic medication (P = 0.016) and were 66% less likely to require opioid prescription refills (P = 0.027). There were no statistically significant differences in other outcomes or complications.Conclusion:Patients undergoing prepectoral tissue expander or implant-based reconstruction required fewer days of opioid pain medication than those managed with the dual-plane technique.
Read more2Perioperative Analgesics and Anesthesia as Risk Factors for Postoperative Chronic Opioid Use in Patients Undergoing Total Knee Arthroplasty: A Retrospective Cohort Study Using Japanese Hospital Claims Data
BackgroundPatients with chronic postsurgical pain are commonly prescribed opioids chronically because of refractory pain although chronic opioid use can cause various severe problems.ObjectiveWe aimed to investigate postoperative chronic opioid use and its association with perioperative pain management in patients who underwent a total knee arthroplasty in a Japanese real-world clinical setting.MethodsWe conducted a retrospective cohort study using an administrative claims database. We used a multivariate logistic regression analysis to examine the association between perioperative analgesic and anesthesia prescriptions and postoperative chronic opioid use. We calculated all-cause medication and medical costs for each patient.ResultsOf the 23,537,431 patient records, 14,325 patients met the criteria and were included in the analyses. There were 5.4% of patients with postoperative chronic opioid use. Perioperative prescriptions of weak opioids, strong and weak opioids, and the α2δ ligand were significantly associated with postoperative chronic opioid use (adjusted odds ratio [95% confidence interval], 7.22 [3.89, 13.41], 7.97 [5.07, 12.50], and 1.45 [1.13, 1.88], respectively). Perioperative combined prescriptions of general and local anesthesia were also significantly associated with postoperative chronic opioid use (3.37 [2.23, 5.08]). These medications and local anesthesia were more commonly prescribed on the day following surgery, after routinely used medications and general anesthesia were prescribed. The median total direct costs were approximately 1.3-fold higher among patients with postoperative chronic opioid use than those without postoperative chronic opioid use.ConclusionsPatients who require supplementary prescription of analgesics for acute postsurgical pain are at high risk of postoperative chronic opioid use and these prescriptions should be given careful consideration to mitigate the patient burden.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40801-023-00363-5.
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