5

Identifying and Prioritizing Indications for Clinical Practice Guidelines

In addition to developing a framework to evaluate existing clinical practice guidelines (CPGs) for opioid prescribing for acute pain, the National Academies of Sciences, Engineering, and Medicine (the National Academies) committee was tasked with identifying and prioritizing up to 50 specific surgical procedures and medical conditions that are associated with acute pain and for which opioid analgesics are commonly prescribed. The committee was also tasked with recommending where evidence-based CPGs would help inform prescribing practices. To accomplish this task, the committee considered the 1995 Institute of Medicine (IOM) report Setting Priorities for Clinical Practice Guidelines, which recommended that:

The committee agreed that the criteria in the 1995 IOM report would help it identify surgical and medical indications for which evidence-based CPGs for opioid prescribing for acute pain should be developed. However, it also recognized that obtaining and reviewing such information on all possible surgical and medical indications associated with acute pain and for which opioids have been prescribed would not be feasible in the committee’s timeframe. Ideally, evidence-based CPGs could be developed for all indications, but such a task might be prohibitive, given the rapid rate of change in treatment practices and the volume of information being generated on opioid prescribing and other acute pain interventions. For many indications, opioid prescribing practices continue to evolve as they integrate new evidence, such as the effectiveness of nonopioid pharmacotherapies for acute pain indications (e.g.,

acetaminophen and nonsteroidal anti-inflammatory drugs), the introduction of opioid-sparing or highly restrictive acute pain protocols, and the implementation of state and federal policies restricting opioid prescribing in response to rising opioid-related morbidity and mortality.

The committee’s approach to identifying and reviewing the literature and other data sources to develop the priority list of indications is detailed in Chapter 1 in the section on the committee’s approach. The committee’s method for identifying guidelines for the surgical and medical indications is given below.

METHODS FOR IDENTIFYING PRIORITY SURGICAL AND MEDICAL INDICATIONS FOR CLINICAL PRACTICE GUIDELINE DEVELOPMENT

The committee used the key factors in Box 5-1 to prioritize the surgical procedures given in Table 5-2 and the medical conditions given in Table 5-3 to produce a list of candidates for the development of CPGs. The committee deemed these indications to have the greatest potential public health impact based on the frequency of the surgical procedure or prevalence of the medical condition, the variation in opioid prescribing practices, and the potential harms in light of various patient- or procedural-related factors, such as prescribing for vulnerable patients (e.g., children and patients with a history of or current opioid use disorder). The committee notes that it considered all of the indications in the two tables to be priorities and did not rank them (they are listed alphabetically); thus, one indication should not be considered of greater priority than another in either table.

After the list of priority indications had been developed on the basis of public health impact as described in Chapter 1, the committee determined whether some type of clinical guideline had been published for that indication. A literature search was conducted specifically to identify any guidelines published for the indications listed in Tables 5-2 and 5-3 (see Appendix B for the search strategy and the number of citations retrieved). The availability or lack of a guideline did not affect whether the indication was included in a table. Although the committee divided the list of indications into surgical conditions and medical conditions, it recognized the potential for overlap, as some medical conditions might ultimately require surgical or procedural interventions (e.g., nephrolithiasis), and some surgical indications may subsequently require medical management (e.g., cholecystectomy).

The committee also conducted a literature search to identify CPGs that were specific for (1) opioids, (2) acute pain, and (3) a specific indication (see Appendix B for the search strategy and the number of citations retrieved). Few guidelines met all three criteria, but numerous guidelines met at least two of the criteria. For example, several CPGs broadly address both acute and chronic pain, but are not specific for a particular surgical or medical indication. These include the American Society of Interventional Pain

Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain, which includes an extensive evidence assessment (Manchikanti et al., 2012. Note: Page S83 of the guidelines says the principles may be “applied for patients who are treated for acute pain management, but also have other risk factors and for whom pain may become chronic”). ASIPP’s development process for the guidelines was based on the recommendations in the 2011 IOM report Clinical Practice Guidelines We Can Trust. CPGs such as the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain (VA/DoD, 2017) and the CDC Guideline for Prescribing Opioids for Chronic Pain (Dowell et al., 2016) also briefly address acute pain as well as chronic pain (see Chapter 3 for other examples of guidelines). Several evidence-based CPGs address acute pain following surgery but are not procedure specific, such as the Society for Pediatric Anesthesia’s recommendations on the use of opioids in children during the perioperative period (Cravero et al., 2019). If an indication had an evidence-based CPG on opioid prescribing for acute pain that met the committee’s analytic framework, it would not have been included in either Table 5-2 or Table 5-3; however, none of the CPGs or other guidelines reviewed by the committee for any of its selected indications did so.

Challenges to Creating an Algorithm for Prioritization

Because of the heterogeneity of the potential indications for acute pain, the committee did not create a standardized algorithm for prioritizing the creation of CPGs. For example, for some indications, such as carpal tunnel release, there is strong evidence of overprescribing, but the occurrence of these procedures is relatively infrequent compared with other procedures such as hernia repair (Steiner et al., 2017). Similarly, the committee deemed other indications, such as neck pain, to be of lesser priority for CPG development because of the heterogeneity in its presentation, cause, severity, and time course. As another example, although traumatic injuries are common, there is wide variety in the severity, treatment, and presence of other injuries that may make the creation of broad, overarching CPGs regarding opioid prescribing difficult. Finally, the availability of evidence was mixed for each prioritization factor across indications (e.g., the prevalence of the condition, the prevalence of opioid prescribing, variation in prescribing, and associated harms) and often not uniformly available, limiting the committee’s ability to account for or compare each of the factors across conditions and precluding a weight-of-the-evidence approach to prioritization. Realizing that others might prioritize conditions differently, the committee has provided the evidence it used to reach its priorities in Tables 5-2 and 5-3.

The committee emphasizes that because of substantial variation in the presentation of acute pain, the list of priority indications developed by the committee in Tables 5-2 and 5-3 should not be considered to be as exclusive or exhaustive. There are other factors that may influence the inclusion of a condition for CPG development, including opioid prescribing practices, strong stakeholder advocacy, the probability of converting acute to chronic pain, and expert judgment.

SURGICAL INDICATIONS OVERVIEW

Surgical Care and Opioid Prescribing

In 2014 there were approximately 17 million hospital visits related to 22 million surgical procedures in the United States (Steiner et al., 2017), and in 2009 there were approximately 548 million dental surgical procedures (Manski and Brown, 2012). Acute pain following surgical care is one of the most common indications for opioid prescribing. Currently, the majority (76% for adult and 60% for children) of opioid-naïve patients undergoing major and minor elective surgery procedures fill an opioid

prescription following surgery, and approximately 9% of opioid-naïve adult patients and 5% of pediatric patients refill prescriptions at least once in the postoperative period (As-Sanie et al., 2017; Harbaugh et al., 2018; Ladha et al., 2019; Sekhri et al., 2018). The committee recognizes that these numbers are likely to decrease in the next several years as opioid prescribing practices change in response to the awareness of opioid-related harms and alternative pain management approaches, the emergence of effective opioid alternatives, and state and organizational limits on opioid prescribing.

Surgical care is often episodic, rather than longitudinal, which has several implications for guidelines for postoperative opioid prescribing. First, because the surgeon may not be involved in the long-term care after the surgery nor manage the entirety of a patient’s comorbid conditions and associated medications, care is often transitioned to other providers, such as primary care clinicians. As such, postoperative opioid prescribing requires appropriate coordination with the patient’s other health care providers, particularly those providing ongoing care for patients using opioids at the time of surgery or at high risk for chronic pain and chronic opioid use or misuse (Klueh et al., 2018). Moreover, ongoing opioid decisions may be transferred to other providers. For example, many patients undergoing total knee arthroplasty are taking opioids at the time of surgery, and thus primary care providers may bear the burden of postoperative opioids prescribing for ongoing joint pain (Bell et al., 2018). Therefore, when possible, it is important to communicate and plan for opioid prescribing prior to surgical care in order to ensure safe pain management, the avoidance of high-risk prescribing behaviors (e.g., multiple overlapping prescriptions and prescriptions from multiple providers), and the avoidance of ongoing opioid prescribing when other interventions may be preferable or equally effective.

In addition, surgical care presents an important opportunity for quality improvement initiatives. Recent initiatives, such as the use of perioperative antibiotics or venous-thromboembolism prophylaxis, are routinely incorporated into quality metrics by key stakeholders (e.g., health insurers, policy makers, health care organizations, and professional societies) in order to benchmark providers. Because procedures are performed by defined groups or specialties, health care organizations have the opportunity to track pain- and opioid-related outcomes as well as opioid prescribing in order to create best practices, identify outliers, and enhance the safety and quality of postoperative pain management. The committee notes that it found more evidence of variation in opioid prescribing and discrepancies in opioid prescribing, opioid consumption, and pain-related outcomes for surgical procedures than for medical conditions causing acute pain (see Tables 5-2 and 5-3).

Variation in Prescribing for Surgery

In the absence of CPGs, current prescribing often represents a provider’s judgment regarding the amount of opioid, if any, a patient will require following surgery. In contrast to chronic pain, opioid prescribing for acute pain following procedural care is typically provided on an as-needed basis. Acute postoperative pain is expected to subside with the resolution of inflammation and with the healing of the tissue, typically within 3 months after the index procedure, although the precise level of pain is dependent on both patient and procedural factors (Schug et al., 2019). As such, the extent of tissue injury may influence opioid prescribing, and patients undergoing larger or more “invasive” surgical procedures (e.g., greater dissection, tissue injury, and length of surgery) may require a greater amount of pain medication than is necessary for less extensive procedures.

In contrast with other types of care for which opioid prescribing has remained flat or declined, there is some evidence that prescribing for surgical, dental, and emergency care has been increasing—according to one study, by 15.8% between 2010 and 2016 (p<0.001) (Larach et al., 2018). During this period, outpatient postoperative opioid prescribing among primary care and other specialties decreased by about 9% (Larach et al., 2018). The authors found that the amount per person and the prescribing rate

for high-dosage prescriptions, short-term prescriptions, and extended release and long-acting formulations decreased over that period, whereas the duration and prescribing rate for long-term prescriptions of opioids increased.

Multiple studies have found a wide variation in opioid prescribing within procedures in adults and children (Anderson et al., 2018; As-Sanie et al., 2017; Cartmill et al., 2019; Horton et al., 2019a; Johnson and Makai, 2019; Madsen et al., 2018; Osmundson et al., 2017). Makary et al. (2017) found that following laparoscopic cholecystectomy, opioid prescriptions ranged from zero to more than 50 pills, with only about one-fifth of the surgeons prescribing within institutional prescribing guidelines of ≤10 pills. Variations in opioid prescribing were found for children after anterior cruciate ligament (ACL) repairs, appendectomy, cholecystectomy, and hernia repair (Anandarajan et al., 2019; Denning et al., 2019; Pruitt et al., 2019; Sonderman et al., 2018). Johnson and Makai (2019) described postoperative prescribing following minimally invasive gynecologic surgery as ranging from 125 to 300 oral morphine equivalents. In addition, Ziegelmann et al. (2019) described wide variation within procedure type for patients undergoing open nephrectomy, cystectomy, and retroperitoneal lymph node dissection.

Opioid prescribing may vary by provider type and hospital. In a statewide analysis of hospitals, prescribing was found to vary 4.7-fold across centers, and prescriptions provided by advanced practice providers were 18% higher than prescriptions provided by physicians (Cron et al., 2018, 2019; Lund et al., 2019). Similarly, for surgical care that occurs in teaching hospitals, prescribing may differ between surgeons in training and other prescriber types (Bhashyam et al., 2019; Bicket et al., 2017; Chiu et al., 2018; Cron et al., 2019; Lancaster et al., 2019).

Excessive Prescribing

In addition to demonstrating variation in prescribing, a number of studies have also found excessive opioid prescribing (Cartmill et al., 2019; Horton et al., 2019b; Paulozzi et al., 2014; Sonderman et al., 2018). These studies suggest that efforts to reduce opioid prescribing for postoperative pain so that they align more closely with patient-reported opioid use may yield comparable outcomes with respect to pain, satisfaction, and postoperative quality of life. For example, recent studies suggest that postoperative opioid use can be decreased as a result of provider- and health care–system interventions (Hill et al., 2018b), policy and legislative measures (Dave et al., 2019), and enhancing patient education and engagement in postoperative pain management (Alter and Ilvas, 2017). A recent study of pediatric patients undergoing outpatient surgery found that after the implementation of institutional guidelines, most patients were not prescribed opioids following surgery, did not report opioid use, did not require refills, and that a greater proportion of patients were directed to and used nonopioid alternatives for postoperative pain management (Harbaugh et al., 2018).

Risk of Prolonged Postoperative Opioid Use

Recent studies assessing the risk that opioid-naïve patients, including both adults and children, will transition to prolonged opioid use following surgery have produced probabilities ranging from 1% to 15% (Alam et al., 2012; Clarke et al., 2014; Sun et al., 2016). For example, Sun et al. (2016) found that male sex, age older than 50 years, and a preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among adult surgical patients. The risk factors for persistent opioid use among pediatric surgical patients include older age, female sex, previous substance use disorder, family opioid use, chronic pain, and preoperative opioid use (Harbaugh et al., 2018). Other studies have demonstrated that postoperative opioid use may

be correlated with a number of other patient factors beyond patient-reported pain or procedure type, such as anxiety, mental health conditions, medical comorbidities, and prolonged opioid use, which may not entirely reflect ongoing pain (Badreldin et al., 2018; Brummett et al., 2013; Committee on Practice Bulletins—Obstetrics, 2018; Hilliard et al., 2018; Kelly et al., 2018; Velanovich, 2000). Finally, there is growing evidence that a greater amount of opioid being prescribed prior to or at the time of surgery is correlated with greater opioid consumption and a higher risk of prolonged opioid use (Brummett et al., 2017; Gil et al., 2019; Howard et al., 2018a).

Classification of Surgical Indications

The classification of surgical procedures for creating CPGs for postoperative outpatient opioid prescribing may be framed in multiple ways. In order to facilitate the prioritization of surgical procedures for possible CPG development, the committee sought to categorize procedures into groups that might be most amenable for CPG development. Notably, the committee did not identify any classification frameworks for surgical procedures based on patient attributes, surgical intensity, or tissue injury. The committee believes that such groups would reflect the practicalities of clinical care, which could facilitate the creation and dissemination of a CPG. For example, surgeons often perform multiple types of procedures, and opioid prescribing may not be specific to an individual procedure type. In particular, one study showed that when opioid prescribing for laparoscopic cholecystectomies was reduced, there was a spillover effect of reduced opioid prescribing for other surgeries of similar scope and tissue injury (Howard et al., 2018a), suggesting that guidelines created for one procedure type may have applicability to other procedures. Moreover, observational studies often group procedures together when examining postoperative opioid use and prescribing. For example, recent studies that examined opioid prescribing and use after surgical procedures were often aligned within surgical specialty or by technical approach or grouped by anatomic location (Fleischman et al., 2019; Hill et al., 2017, 2018b; Horton et al., 2019b; Howard et al., 2018b) (see Table 5-1).

In this report the committee chose to align surgical conditions and procedures based on similarities in operative approach (e.g., laparoscopic, open), anatomic region (e.g., abdominal cavity, extremity, thoracic procedures), underlying cause of injury (e.g., sports-related injuries), or where the surgery is performed (e.g., inpatient or outpatient). Each of these attributes may influence the amount and duration of opioids prescribed following surgery, if they are prescribed at all. While discussed individually, in practice these categories are not mutually exclusive, and CPGs may be based on whatever single attribute or combination of attributes that is most clinically relevant. However, creating more granular CPGs for specific surgeries based on procedural nuances may be an opportunity in the future as the knowledge gaps regarding tissue injury, acute pain, and opioid requirements close with future research. For example, laparoscopic cholecystectomy procedures may be performed on an emergency basis or electively and in either inpatient or outpatient settings, and the majority of current evidence has focused only on these performed on an elective, outpatient basis. CPGs developed for elective, outpatient laparoscopic cholecystectomies could be applied to cases performed on an emergency basis or in an inpatient setting, or they could be refined in future work for the nuances of these aspects of clinical care. The section below provides a rationale for the classification of surgical procedures in order to provide clarity on the groups selected for prioritization in the committee’s Statement of Task and to inform efforts for future CPG development in which stakeholders may opt to classify procedures differently.

TABLE 5-1 Attributes for Classifying Surgical Procedures for Clinical Practice Guideline Development

Surgical Approach

CPGs for postoperative opioid prescribing also could be considered according to their procedural attributes, including the surgical approach, indications, and anatomic location. For example, CPGs could be created based on the technical approach for the procedure, such the use of open or minimally invasive techniques, including laparoscopic, robotic, endoscopic, and endovascular strategies and dental procedures. Classifying procedures by surgical approach is advantageous in that techniques may better capture the magnitude of tissue injury due to the extent of the incision and dissection. In addition, classification by approach may allow similar procedures to be grouped together. For example, the extent of tissue injury for a laparoscopic hysterectomy may be similar to the tissue injury of a laparoscopic colectomy, and the opioid consumption and pain trajectories identified for certain procedures may translate to other procedures based on operative approach (AJRR, 2017; Kremers et al., 2015). Although the extent to which incision size directly correlates with patient-reported postoperative pain and analgesic use is not well understood, numerous studies have demonstrated that minimally invasive approaches yield faster recovery and less patient-reported pain (Hota et al., 2018; Leach et al., 2018; Theisen et al., 2019). Thus, procedures could be grouped together by operative approach when considering CPGs, such as all laparoscopic abdominal or pelvic procedures being considered under common recommendations (Sloan et al., 2018). This approach may also be clinically intuitive for prescribers, since spillover effects into procedures of similar scope and approach have been observed after implementing opioid prescribing protocols or other enhanced recovery (Bedard et al., 2017; Bicket et al., 2019; Johnson and Makai, 2019; Kahlenberg et al., 2019).

Timing of Procedure

Surgical procedures may also be classified by the timing of intervention, such as elective, urgent, or emergency surgical procedures. Differences in timing may reflect important differences in the severity of

and underlying pathology for surgery. For example, a laparoscopic cholecystectomy performed electively may have far less inflammation and tissue injury related to additional surgical dissection than a procedure performed urgently or in an emergency situation for acute infection, perforation, or gangrenous changes (Mou et al., 2019; Roulin et al., 2016; To et al., 2013). Similarly, an elective hip arthroplasty performed for symptomatic osteoarthritis may differ substantially from a procedure performed for a hip fracture, in which underlying frailty, comorbid conditions, and physical function may create a much different pain trajectory and risk of opioid prescribing following surgery (Charette et al., 2019; Kester et al., 2016; Schairer et al., 2017). Most third molar extractions at an early age (mean age 19 years) are another example of an uncomplicated elective procedure. In contrast, emergency extractions performed for teeth with pulpal and periapical infections that result in a disseminating cellulitis and potential airway obstruction may require more extensive treatment and follow-up (Resnick et al., 2019). Given these nuances in care, the timing and acuity of surgical conditions will inform CPGs for acute pain following surgery.

Indication and Anatomic Location

Surgical procedures could also be classified by the indication for the procedure or anatomic location. For example, procedures could be grouped by anatomic region, such as extremity, torso, or head and neck. The advantages of this approach are that these categories may align with surgical disciplines, such as otolaryngology or gastrointestinal surgery, which are clustered in anatomic regions (Fujii et al., 2018; Johnson and Makai, 2019; Sabatino et al., 2018; Sloan et al., 2018). However, categorizing by anatomic site alone may not capture the extent of tissue injury for procedures, nor the differences in indication, such as malignancy, which may influence the extent of the operation and the expected course of pain and recovery after surgery. In addition, the postoperative pain trajectory may be associated with the type of tissue involved in the procedure. For example, patients undergoing upper extremity procedures involving only skin and soft tissue require fewer opioids than patients undergoing fracture repair or joint procedures (Fujii et al., 2018). Finally, tissue injury, inflammation, pain, and recovery may vary by indication, such as malignancy, inflammation, trauma, degenerative disease, or infectious conditions. For example, patients undergoing breast reconstruction had longer duration of opioid use than patients undergoing benign breast resections, who used more opioids initially but then quit their use more quickly.

Surgical Setting

Finally, from a health care delivery perspective, surgical procedures may be categorized by the setting in which the surgery occurs and the need for an inpatient stay. Postoperative pain requirements may be different for similar procedures performed in either an inpatient or an outpatient setting. For example, patients undergoing total knee arthroplasty may undergo the procedure with a planned inpatient stay, in which both intravenous and oral opioid regimens are available for postoperative pain control and monitored by health care staff. Alternatively, for patients undergoing total knee arthroplasty as an outpatient procedure, postoperative prescribing may need to anticipate the potential pain requirements the patient will experience at home. Therefore, prescribing guidelines may need to address whether the procedure is to be performed in an inpatient or outpatient setting. If the procedure is to be inpatient, the duration of an inpatient hospital stay may be a factor in determining the opioid prescribing regimen, as postoperative pain may decline to levels in which opioids are not necessary at discharge.

Priority Surgical Indications for Clinical Practice Guideline Development

The committee used specific criteria (see Box 5-1) and explored numerous attributes (see Table 5-1) for identifying the groups of common surgical procedures that it considered priorities for the development of evidence-based CPGs. Many of the surgical procedure groupings apply to pediatrics as well as adult populations, including sport-related injuries, spine procedures, laparoscopic abdominal procedures, and thoracic procedures. Despite this overlap between pediatric and adult patients for many of the surgical groupings, the committee did recognize surgical procedures that are generally unique to pediatrics, such as cleft and craniofacial procedures, correction of pectus excavatum, and correction of congenital limb and hip anomalies (e.g., femoral malformations, acetabular osteotomy, leg length discrepancy).

In response to the committee’s Statement of Task, the following surgical procedures and the reasons for their grouping are briefly summarized below; information supporting their prioritization is given in Table 5-2.

• Anorectal, pelvic floor, and urogynecologic procedures (vaginal/perineal approach)
• Breast procedures
• Dental surgeries
• Extremity trauma requiring surgery
• Joint replacement
• Laparoscopic abdominal procedures
• Laparoscopic or open abdominal wall procedures
• Obstetric procedures
• Open abdominal procedures
• Oropharyngeal procedures
• Spine procedures
• Sport-related injuries
• Thoracic procedures

In prioritizing the surgical procedures listed in Table 5-2, the committee focused on procedures for which there was evidence of opioid prescribing, noting the possibility of variation in prescribing across providers and in relation to patient-reported outcomes or patient-centered outcomes. The committee notes that several common surgical procedures identified by Steiner et al. (2017) are surgeries for which outpatient postoperative opioid prescribing is exceedingly rare (e.g., cataract surgery, myringotomy, and tympanostomy tube placement); these were thus also determined to be less of a priority for CPG development. For example, Steiner et al. (2017) determined that of the almost 10 million ambulatory or inpatient surgeries performed in 2014, lens and cataract procedures were the most prevalent, at about 1.4 million procedures; however, opioids are rarely prescribed for pain following cataract surgery (Shoss and Tsai, 2013). There are also many surgical procedures performed on infants and children in which opioids are aggressively used both intra- and postoperatively, such as posterior spinal fusion for scoliosis and hip reconstruction for dysplasia, but prospective data are not available to guide subsequent opioid dosing. For example, evidence suggests that opioid alternatives are superior for pain management following myringotomy and tympanostomy tube placement in children, and opioids are rarely prescribed (Pappas et al., 2003).

Table 5-2 details the existing evidence and current guidelines for opioid prescribing for specific indications. These guidelines range from those developed at the institutional level (e.g., Overton et al., 2018) to those at the national level (e.g., Hegmann et al., 2014). For example, Overton et al. (2018) developed consensus recommendations for opioid prescribing after 20 common surgical procedures; stakeholders in this consensus process included surgeons, pain specialists, outpatient nurses, pharmacists, and patients. Other groups, such as the Michigan Opioid Prescribing Engagement Network, have created guidelines on the basis of patient-reported outcomes, specifically patient-reported postoperative opioid use following various procedure types (Vu et al., 2019).

TABLE 5-2 Opioid Prescribing Patterns for Priority Surgical Indications

* For most inpatient or ambulatory surgeries, Steiner et al. (2017) do not indicate whether the surgery was open or laparoscopic; where the type of surgery was specified this is reported.

NOTE: ACL=anterior cruciate ligament; CI=confidence interval; CPG=clinical practice guideline; IQR=interquartile range;

MME=morphine milligram equivalent; NSAID=nonsteroidal anti-inflammatory drug; OME=oral morphine equivalent;

THA=total hip arthroplasty; TKA=total knee arthroplasty.

MEDICAL INDICATIONS OVERVIEW

Acute pain may be ascribed to a number of medical conditions, ranging from relatively common conditions such as back pain to less frequently occurring conditions such as sickle cell disease. However, in contrast to the burgeoning literature on the use of opioids to treat postoperative or procedural pain, there is less evidence about opioid prescribing for specific medical conditions, about the over- and under-prescribing of opioids for those conditions, and about the outcomes for different opioid prescribing strategies.

The time course of resolution for medical conditions that produce acute pain is variable, and it depends on the etiology of the pain; the natural history of acute pain in the condition; patient factors, such as comorbidities, tolerance, and expectations of pain; and whether definitive treatment is available and used. Furthermore, in some conditions for which opioids are not a first-line treatment, certain patients may not have the expected alleviation of pain by nonopioid treatments (David Jevsevar, Dartmouth Geisel School of Medicine, presentation to committee, July 9, 2019). For such patients, prescribing opioids as a second-line treatment approach may be indicated.

Opioid prescribing for acute pain for medical conditions may occur in primary care clinics, emergency departments (EDs), inpatient hospital settings, and specialty practices such as pain clinics and practices devoted to rheumatology, urology and nephrology, neurology, or orthopedics. Kea et al. (2016) found that the pain-related diagnoses for which opioids were most frequently prescribed in the ED were renal stones (62% of patients received an opioid prescription), neck pain (52%), dental/jaw pain (50%), fracture (49%), cholelithiasis (48%), and back pain (45%). Conversely, among patients prescribed an opioid in the ED, the six most common pain-related diagnoses were non-fracture injuries (29%), back pain (10.5%), fractures (9.5%), abdominal pain (8.3%), dental/jaw pain (6%), and headache (4%). Hudgins et al. (2019) examined trends in opioid prescribing for adolescents and young adults in ambulatory care settings from 2005 to 2015 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS). They found that 5.2% of visits were associated with an opioid prescription, of which nearly 56% were provided in EDs and another 43% were provided in outpatient clinics. The rates of opioid prescribing were the highest for ED visits by young adults. The most common diagnoses resulting in an opioid prescription in the ED were dental pain and acute injuries among adolescents and dental pain and low back pain among young adults.

In another study that examined opioid prescribing in 19 EDs during 1 week in 2012, there were 19,321 discharges, of which 17.0% received an opioid prescription. The 10 most common diagnoses associated with a discharge opioid prescription were musculoskeletal back pain (10.2%), abdominal pain (10.1%), extremity fracture (7.1%), extremity sprain (6.5%), dental/oral issue (6.2%), other extremity pain (5.8%), nephrolithiasis (4.5%), skin contusion (3.9%), chest pain (including non-cardiac; 3.3%), and closed head injury (3.0%) (Hoppe et al., 2015b).

Mundkur et al. (2019) characterized patterns of opioid analgesic use for acute pain in primary care settings using commercial insurance claims data from 2014. They found that in 2014, 9.1% of patients presenting at their first visit for pain began opioids at that visit. The rate of initiation varied substantially by the reason for the pain; in this study, patients with a history of prior opioid fills were excluded. Among patients with an acute pain complaint, nearly 8% filled an opioid prescription. The authors examined 10 common acute pain conditions selected on the basis of the frequency of their occurrence in the authors’ dataset. The conditions, in order of descending prevalence, were joint pain (4.9% filled an opioid prescription); back pain without radiculopathy (13.4% filled an opioid prescription); headache (3.5% filled an opioid prescription); neck pain (9.2% filled an opioid prescription); tendonitis/bursitis (3.4% filled an opioid prescription); muscle strain/sprain (9% filled an opioid prescription); back pain with radiculopathy (17.4% filled an opioid prescription); renal stones (14.2% filled an opioid prescription);

musculoskeletal injury (e.g., ligament tear) (5.8% filled an opioid prescription); and dental pain (27.6% filled an opioid prescription). The authors found that the initial opioid prescription duration was not consistently associated with refill rate, suggesting that for these common medical conditions opioids may be overprescribed. Thus, opioid prescribing for acute medical conditions, like postsurgical care, requires a health care provider’s judgment regarding the appropriate dose and duration of opioid.

Chung et al. (2018) analyzed outpatient opioid prescription data among children and adolescents enrolled in Tennessee Medicaid from 1999 to 2014. The annual mean prevalence of opioid prescriptions was 15%. The conditions most commonly associated with an opioid prescription were dental procedures (31.1% prescriptions), outpatient procedure or surgery (25.1%), trauma (18.1%), and infections (16.5%). One out of every 2,611 opioid prescriptions (437 of 1,362,503 total prescriptions) was related to an opioid-adverse event; 71.2% of the adverse events were related to the therapeutic use of the opioid versus abuse or intentional harm.

Methods for Identifying Priority Medical Conditions for Clinical Practice Guideline Development

The committee used several approaches to identify medical indications for priority CPG development. To prioritize medical conditions for CPG development, the committee selected and considered the same key factors (see Box 5-1) that it used to prioritize surgical procedures, for example, the prevalence of the condition, evidence of over-prescribing or under-prescribing of opioids for the condition, and the lack of a CPG or an evidence-based CPG.

The committee began by reviewing a Centers for Disease Control and Prevention (CDC) data analysis of the 2016 NHAMCS ED diagnoses that are associated with a discharge opioid prescription for acute pain (Schappert and Rui, 2019). The committee asked CDC to provide a list of the primary diagnoses for all ED visits at which opioids were prescribed at discharge.

The committee then reviewed the literature to identify data on opioid prescribing in the primary care setting. Although there were numerous studies that looked at opioid prescribing for individual medical indications, the committee found two published studies that examined the prevalence of medical conditions and associated opioid prescriptions for acute pain and thus were useful in prioritizing medical indications for the purposes of the committee. One study analyzed data from NAMCS on opioid prescribing in the primary care setting (Sherry et al., 2018). NAMCS is a national, annual survey of visits made to nonfederally employed, office-based physicians who are primarily engaged in direct patient care and of visits to community health centers; the survey collects information on patient, provider, and visit characteristics (CDC, 2019). Another useful study analyzed administrative data from Optum’s Clinformatics^TM DataMart on the prevalence of medical conditions and associated opioid prescriptions in the primary care setting (Mundkur et al., 2019). This database is derived from commercial insurance claims that contains a combination of inpatient and outpatient claims, pharmacy dispensing information, and patient demographics routinely collected during health insurance enrollment. In addition, the committee received input from a variety of experts at its public session on priority medical and surgical conditions to be considered for CPG development. Finally, the committee used the expertise of its members not only to review the medical indications that were relatively prevalent and strongly associated with opioids, but also to identify less common medical indications related to acute pain that might be worthy of CPG development based on such factors as evidence of under-prescribing, disproportionate impact on certain populations (e.g., children and adolescents, minorities, older adults), or a strong association with over-prescribing and opioid misuse.

The committee further refined the list of medical indications by removing indications that were overly broad, such as undifferentiated abdominal pain, neck pain, and chest pain. In the committee’s judgment it would be difficult to develop an evidence-based CPG at present for such poorly defined indications because their causes can be diverse or unknown and numerous medical specialties may be involved in treating the indication, making it difficult to direct the CPG to a specific medical practice area. For example, in the Mundkur et al. (2018) study, 27 International Classification of Diseases, Ninth Edition codes were used to identify neck pain. Preliminary literature searches for these broadly termed indications did not result in substantive articles on the prevalence of the indication and opioid prescribing patterns for the indication. The lack of specific evidence for these indications made them poor candidates for the committee’s task.

Of note, the issue of the prevalence of opioid prescribing and the relative distribution of medical conditions in which opioids are prescribed is not consistently studied, as different investigators do not always describe their selection of conditions to consider or define the painful conditions in exactly the same way. In addition, the terminology used to describe and categorize medical conditions is inconsistent across studies. Therefore, the committee grouped related terms together—for example, the committee considered low back pain (the term it uses) to include lumbago, back pain, backache, unspecified dorsalgia, and unspecified low back pain—all of them with or without radiculopathy. This variation in terminology and selection criteria added to the difficulty in determining both prevalence and opioid prescribing practices for an indication.

After the list of potential medical indications was developed, the committee sought evidence on prescribing opioids for each indication. This search was not exhaustive, but rather it focused on recent literature that demonstrated that opioids were prescribed for the indication in the ED, primary care setting, or other health care clinic outside of a surgical setting. For those conditions for which such evidence was available, the committee then sought some evidence of over- or under-prescribing, as such evidence would suggest that evidence-based CPGs might reduce inappropriate practice variation. In addition, the committee sought evidence of new chronic opioid use in opioid-naïve patients who received an opioid prescription for the acute indication. Again, this search was not extensive; a single, well-conducted study showing data on leftover pills or refills was deemed to be sufficient to show that over- or under-prescribing had occurred and that the area warranted further investigation.

Finally, the committee considered whether there was a guideline available on prescribing opioids for acute pain associated with the selected indications. A literature search was conducted to identify any such guidelines (see Appendix B). Although there is considerable guidance available for some indications, little is specific for acute pain or opioid prescribing. Thus, as with surgical procedures, the committee did not identify any CPGs that contain specific recommendations for prescribing opioids to treat acute pain for the specific priority medical indications identified by the committee, although several of them do provide guidances on opioid therapy in the ED or inpatient settings (e.g., NHBLI, 2014). The committee has indicated what guidelines exist and their specificity in Table 5-3. Based on the above information, the committee recommends that CPGs for opioid prescribing be considered for the following medical conditions (see Table 5-3).

• Dental pain (non-surgical)
• Fractures
• Low back pain (includes lumbago, dorsalgia, backache)
• Migraine headache
• Renal stones (also called kidney stones, nephrolithiasis, calculus of the kidney, renal colic)
• Sickle cell disease
• Sprains and strains, musculoskeletal
• Tendonitis/bursitis

TABLE 5-3 Opioid Prescribing Patterns for Selected Medical Indications

NOTE: CI=confidence interval; CPG=clinical practice guideline; ED=emergency department; MME=morphine milligram equivalent; NHANES=National Health and Nutrition Examination Survey; OME=oral morphine equivalent; SCD=sickle cell disease.

EMERGENCY DEPARTMENT CONSIDERATIONS

While there exists enough evidence for many acutely painful conditions, such as acute low back pain, to generate condition-specific guidelines on the use of opioids, the committee also recognizes the importance of having clinical setting–specific guidelines for pain management in patients after they are discharged from the ED (Chou et al., 2017; Qaseem et al., 2017). Pain is one of the most common reasons patients present to the ED, representing the primary symptom in 45% of visits (Chang et al., 2014). And the ED is the most appropriate care setting for the management of severe pain episodes, with primary care offices and outpatient clinics often triaging patients to the ED for acute management. Therefore, prompt, safe, and effective pain management is a core mission of clinical practice in the ED.

The NHAMCS for 2006–2010 indicated that opioids were prescribed for about 18.7% of all ED discharges (Kea et al., 2016). Kea et al. (2016) used NHAMCS data to assess ED discharge opioid prescribing practices for adults and children. During this period, there were 502.4 million ED discharges, in which opioids were prescribed for 94.0 million patients. Overall, opioid prescribing increased from 17.2 million discharges with opioids in 2006 to 20.2 million discharges with opioids in 2010. The rate of opioid prescriptions is 14.9% for ED visits and 2.8% for outpatient visits for adolescents and young adults (Hudgins et al., 2019).

The specialty of emergency medicine was among the first to promote specialty-specific pain management guidelines regarding opioid prescribing (ACEP, 2017; Cantrill et al., 2012; Motov et al., 2017). Today there are numerous national, state, and municipal CPGs and policy statements on acute pain management in the ED that include the use of opioids upon discharge from the ED (ACEP, 2017; Broida et al., 2017; Cantrill et al., 2012; Motov et al., 2017; NYCDOH, 2019).

When patients present to the ED with severe acute pain, ED clinicians carry out clinical assessments and diagnostic tests, seeking to identify the cause of the pain and to determine whether the patient should be admitted to the hospital or discharged. While in the ED, patients may receive treatment for acute pain and for the underlying cause of pain. Acute pain management in the ED is ideally patient-specific, pain syndrome–targeted, and based on appropriate pharmacologic and nonpharmacologic approaches (Motov et al., 2017). For example, some patients presenting with an acute shoulder dislocation may have their pain relieved with injection of lidocaine into the shoulder joint before relocating the shoulder, while others may require intravenous opioids to achieve adequate pain control prior to relocating the shoulder.

As in any clinical setting, the goals of managing patients with acute pain who are being discharged from the ED are to alleviate pain, restore function, and reduce the potential for adverse effects of medication. A common tenet in ED opioid prescribing guidelines is that given the known harms of opioid analgesia, ED clinicians should take every opportunity to use nonopioid and nonpharmacologic options to treat acute pain, especially on discharge, and to use opioid analgesics only when the benefits outweigh the risks (Strayer et al., 2017). For example, it has been found that among opioid-naïve patients with Medicaid insurance in Washington State who were prescribed opioids upon discharge from the ED, 13.7% went onto high-risk opioid use within 1 year, as compared with 3.2% among those who were not prescribed opioids (Meisel et al., 2019). Given that this finding is consistent across several studies in ED patients (Barnett et al., 2017; Hoppe et al., 2015a; Jeffery et al., 2018), in addition to the harms associated with diversion and misuse, a common recommendation for ED clinicians and others who treat acute pain is to keep opioid-naïve patients opioid-naïve when possible (Motov et al., 2017; Nelson et al., 2015).

The ability to assess a patient’s response to treatments administered for pain in the ED allows for more individualized pain treatment than is possible in other outpatient settings. Thus, the patient’s response to analgesic treatment in the ED can guide the choice of whether to prescribe opioids upon discharge as well as the dosage and duration. If opioids are determined to be necessary, the risks of opioids can be reduced by prescribing only immediate-release formulations at the lowest effective dose and for the shortest appropriate course (Strayer et al., 2017).

The time over which the acute pain is expected to resolve can guide the choice and duration of pain treatments. For example, a patient who presents with a dislocated shoulder that was relocated after intravenous analgesia is unlikely to have persistent severe pain, whereas a patient treated for long bone fracture is likely to require analgesia after discharge. For the majority of patients treated for acute pain in the ED, the pain improves or resolves within 6 days (Chapman et al., 2012); however, individual pain trajectories can vary widely (Daoust et al., 2019). Unlike the emerging literature documenting the average number of opioid pills used and left over after surgical procedures, there is a paucity of similar evidence for patients discharged from the ED. One study in a Canadian academic center ED found the median number of opioid pills consumed upon discharge was 7, but this varied from 3 pills for renal stones to 11 pills for fractures (Daoust et al., 2018). The authors concluded that opioid prescriptions from the ED for acute pain should be no more than a 3-day supply, with a maximum of 30 pills per prescription for patients with severe fracture pain (Daoust et al., 2018).

Finally, a key distinguishing aspect of emergency medicine practice is that ED clinicians do not have a longitudinal relationship with their patients. The standard of care in emergency medicine is to refer patients back to their primary care or outpatient longitudinal provider within 2–5 days for reassessment,

particularly if symptoms are not improving. Given that EDs serve as a safety net location of care for underserved patients without longitudinal care providers, discharge prescription dosing quantities need to account for the challenges that patients may face in obtaining adequate follow-up care. For patients who face barriers in obtaining timely outpatient follow-up, a recommendation of returning to the ED for reassessment if symptoms have not resolved or are worsening is prudent.

CONCLUSIONS

Thus, based on the information presented above, the committee finds that opioid prescribing for acute postoperative pain varies substantially by provider and hospital, including EDs. Furthermore, as shown in Tables 5-2 and 5-3, the committee finds that there is evidence that excessive opioids are prescribed for acute pain associated with both surgical procedures and some medical conditions. Consequently, the committee also finds that some opioid-naïve patients who receive opioids for acute postoperative pain and acute pain episode from medical conditions may develop new chronic opioid use.

Taken together, this body of evidence regarding variation in prescribing, excessive prescribing, and new prolonged use highlights the need to develop rigorous, evidence-based CPGs to direct opioid prescribing for the priority indications identified in Tables 5-2 and 5-3 that are aligned with actual patient use in order to minimize unwarranted variation and excess prescribing. Because different kinds of providers may be caring for patients during surgical and medical care and providing prescriptions, such as advanced practice providers, trainees, or surgeons, the opioid CPGs needs to meet the needs of these individual groups.

REFERENCES

Ahmed, Z.A., D.A. Nacopoulos, S. John, N. Papesh, D. Levine, and C.C. Bamford. 2017. An algorithm for opioid and barbiturate reduction in the acute management of headache in the emergency department. Headache 57(1):71–79.

AHS (American Headache Society). 2019. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache 59(1):1–18.

AJRR (American Joint Replacement Registry). 2017. AJRR 2017 annual report. http://www.ajrr.net/images/annual_reports/AJRR-2017-Annual-Report---Final.pdf?hsCtaTracking=61a2fedc-0f48-4241-a282-2bca6e4b68ad%7Ce4ed88d8-6b8e4d0c-9a47-d1c169759e83 (accessed June 17, 2019).

Alam, A., T. Gomes, H. Zheng, M.M. Mamdani, D.N. Juurlink, and C.M. Bell. 2012. Long-term analgesic use after low-risk surgery: A retrospective cohort study. Archives of Internal Medicine 172(5):425–430.

Alter, T.H., and A.M. Ilyas. 2017. A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery. Journal of Hand Surgery 42(10):810–815.

Amin, S., S.J. Achenbach, E.J. Atkinson, S. Khosla, and L.J. Melton, 3rd. 2014. Trends in fracture incidence: A population-based study over 20 years. Journal of Bone and Mineral Research 29(3):581–589.

Anandarajan, D., D. Talwar, and L. Wells. 2019. Significant nationwide variation exists in opioid prescription rates amongst pediatric patients with ACL injuries: A retrospective cohort study. Orthopaedic Journal of Sports Medicine 7(3 Suppl):2325967119S0008.

Anderson, K.T., M.A. Bartz-Kurycki, D.M. Ferguson, A.L. Kawaguchi, M.T. Austin, L.S. Kao, K.P. Lally, and K. Tsao. 2018. Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients. Journal of Pediatric Surgery 53(12):2374–2377.

Anthony, C.A., R.W. Westermann, N. Bedard, N. Glass, M. Bollier, C.M. Hettrich, and B.R. Wolf. 2017. Opioid demand before and after anterior cruciate ligament reconstruction. American Journal of Sports Medicine 45(13):3098–3103.

As-Sanie, S., S.R. Till, E.L. Mowers, C.S. Lim, B.D. Skinner, L. Fritsch, A. Tsodikov, V.K. Dalton, D.J. Clauw, and C.M. Brummett. 2017. Opioid prescribing patterns, patient use, and postoperative pain after hysterectomy for benign indications. Obstetrics & Gynecology 130(6):1261–1268.

ASMBS (American Society for Metabolic and Bariatric Surgery). 2018. Estimate of bariatric surgery numbers, 2011–2017. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers (accessed August 28, 2019).

Bachur, R.G., M.C. Monuteaux, and M.I. Neuman. 2015. A comparison of acute treatment regimens for migraine in the emergency department. Pediatrics 135(2):232–238.

Badreldin, N., W.A. Grobman, K.T. Chang, and L.M. Yee. 2018. Opioid prescribing patterns among postpartum women. American Journal of Obstetrics and Gynecology 219(1):e101–e103.

Barnett, M.L., A.R. Olenski, and A.B. Jena. 2017. Opioid-prescribing patterns of emergency physicians and risk of long-term use. New England Journal of Medicine 376(7):663–673.

Bartels, K., L.M. Mayes, C. Dingmann, K.J. Bullard, C.J. Hopfer, and I.A. Binswanger. 2016. Opioid use and storage patterns by patients after hospital discharge following surgery. PLOS ONE 11(1):e0147972.

Bedard, N.A., A.J. Pugely, S.B. Dowdle, K.R. Duchman, N.A. Glass, and J.J. Callaghan. 2017. Opioid use following total hip arthroplasty: Trends and risk factors for prolonged use. Journal of Arthroplasty 32(12):3675–3679.

Beithon J., M. Gallenberg, K. Johnson, P. Kildahl, J. Krenik, M. Liebow, L. Linbo, C. Myers, S. Peterson, J. Schmidt, and J. Swanson. 2013. Diagnosis and treatment of headache. Institute for Clinical Systems Improvement. https://www.icsi.org/wp-content/uploads/2019/01/Headache.pdf (accessed August 28, 2019).

Bell, K.L., N. Shohat, K. Goswami, T.L. Tan, I. Kalbian, and J. Parvizi. 2018. Preoperative opioids increase the risk of periprosthetic joint infection after total joint arthroplasty. The Journal of Arthroplasty 33:3246–3251.

Bhashyam, A.R., J. Young, R.A. Qudsi, R.L. Parisien, and G.S.M. Dyer. 2019. Opioid prescribing patterns of orthopedic surgery residents after open reduction internal fixation of distal radius fractures. Journal of Hand Surgergy 44(3):201–207.

Bicket, M.C., D. Kattail, M. Yaster, C.L. Wu, and P. Pronovost. 2017. An analysis of errors, discrepancies, and variation in opioid prescriptions for adult outpatients at a teaching hospital. Journal of Opioid Management 13(1):51–57.

Bicket, M.C., E. White, P.J. Pronovost, C.L. Wu, M. Yaster, and G.C. Alexander. 2019. Opioid oversupply after joint and spine surgery: A prospective cohort study. Anesthesia & Analgesia 128(2):358–364.

Bree Collaborative. 2017. Dental guideline on prescribing opioids for acute pain management. http://www.breecollaborative.org/wp-content/uploads/2017-10-26-FINAL-Dental-Opioid-Recommendations_Web.pdf (accessed November 4, 2019).

Broida, R.I., T. Gronowski, A.F. Kalnow, A.G. Little, and C.M. Lloyd. 2017. State emergency department opioid guidelines: Current status. Western Journal of Emergency Medicine 18(3):340–344.

Brummett, C.M., A.M. Janda, C.M. Schueller, A. Tsodikov, M. Morris, D.A. Williams, and D.J. Clauw. 2013. Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: A prospective, observational cohort study. Anesthesiology 119(6):1434–1443.

Brummett, C.M., J.F. Waljee, J. Goesling, S. Moser, P. Lin, M.J. Englesbe, A.S.B. Bohnert, S. Kheterpal, and B.K. Nallamothu. 2017. New persistent opioid use after minor and major surgical procedures in U.S. adults. JAMA Surgery 152(6):e170504.

Burge, R., B. Dawso-Hughes, D.H. Solomon, J.B. Wong, A. King, and A. Tosteson. 2007. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. Journal of Bone and Mineral Research 22(3):465–475.

Cantrill, S.V., M.D. Brown, R.J. Carlisle, K.A. Delaney, D.P. Hays, L.S. Nelson, R.E. O’Connor, A. Papa, K.A. Sporer, K.H. Todd, and R.R. Whitson. 2012. Clinical policy: Critical issues in the prescribing of opioids for adult patients in the emergency department. https://www.acep.org/globalassets/new-pdfs/clinical-policies/opioids-2012.pdf (accessed August 26, 2019).

Carmichael, J.C., D.S. Keller, G. Baldini, L. Bordeianou, E. Weiss, L. Lee, M. Boutros, J. McClane, L.S. Feldman, and S.R. Steele. 2017. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Diseases of the Colon & Rectum 60(8):761–784.

Carney, M.J., J.M. Weissler, J.P. Fox, M.G. Tecce, J.Y. Hsu, and J.P. Fischer. 2017. Trends in open abdominal surgery in the United States—Observations from 9,950,759 discharges using the 2009–2013 National Inpatient Sample (NIS) datasets. American Journal of Surgery 214(2):287–292.

Cartmill, R.S., D.Y. Yang, S. Fernandes-Taylor, and J.E. Kohler. 2019. National variation in opioid prescribing after pediatric umbilical hernia repair. Surgery 165(4):838–842.

CDC (Centers for Disease Control and Prevention). 2017. Data & statistics on sickle cell disease. https://www.cdc.gov/ncbddd/sicklecell/data.html (accessed September 20, 2019).

CDC. 2019. Ambulatory health care data: Welcome NAMCS participants. https://www.cdc.gov/nchs/ahcd/namcs_participant.htm (acessed November 12, 2019).

Chang, H.Y., M. Daubresse, S.P. Kruszewski, and G.C. Alexander. 2014. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. American Journal of Emergency Medicine 32(5):421–431.

Chapman, C.R., D. Fosnocht, and G.W. Donaldson. 2012. Resolution of acute pain following discharge from the emergency department: The acute pain trajectory. The Journal of Pain 13(3):235–241.

Charette, R.S., M. Sloan, and G.C. Lee. 2019. Not all hip arthroplasties are created equal: Increased complications and readmissions after total hip arthroplasty for femoral neck fractures compared with osteoarthritis. Bone Joint Journal 101B(6 Suppl B):84–90.

Chiu, A.S., J.M. Healy, M.P. DeWane, W.E. Longo, and P.S. Yoo. 2018. Trainees as agents of change in the opioid epidemic: Optimizing the opioid prescription practices of surgical residents. Journal of Surgical Education 75(1):65–71.

Choo, S., S. Nogan, and L. Matrka. 2019. Postoperative opioid prescribing and consumption patterns after tonsillectomy. Otolaryngology–Head and Neck Surgery 161(6):960–966.

Chou, R., R. Deyo, J. Friedly, A. Skelly, M. Weimer, R. Fu, T. Dana, P. Kraegel, J. Griffin, and S. Grusing. 2017. Systemic pharmacologic therapies for low back pain: A systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine 166(7):480–492.

Chung, C.P., S.T. Callahan, W.O. Cooper, W.D. Dupont, K.T. Murray, A.D. Franklin, K. Hall, J.A. Dudley, C.M. Stein, and W.A. Ray. 2018. Outpatient opioid prescriptions for children and opioid-related adverse events. Pediatrics 142(2):e20172156.

Clarke, H., N. Soneji, D.T. Ko, L. Yun, and D.N. Wijeysundera. 2014. Rates and risk factors for prolonged opioid use after major surgery: Population-based cohort study. British Medical Journal 348:g1251.

Committee on Practice Bulletins—Obstetrics. 2018. ACOG practice bulletin no. 198: Prevention and management of obstetric lacerations at vaginal delivery. Obstetrics & Gynecology 132(3):e87–e102.

Cook, D.J., S.W. Kaskovich, S.C. Pirkle, M.A.C. Mica, L.L. Shi, and M.J. Lee. 2019. Benchmarks of duration and magnitude of opioid consumption after total hip and knee arthroplasty: A database analysis of 69,368 patients. Journal of Arthroplasty 34(4):638–644.

CORE (Center for Opioid Research and Education). 2018. Dental opioid guidelines. https://www.solvethecrisis.org/dental-guidelines (accessed August 28, 2019).

Cravero, J.P., R. Agarwal, C. Berde, P. Birmingham, C.J. Cote, J. Galinkin, L. Isaac, S. Kost-Byerly, D. Krodel, L. Maxwell, T. Voepel-Lewis, N. Sethna, and R. Wilder. 2019. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatric Anaesthesiology 29(6):547–571.

Cron, D.C., J.S. Lee, J.M. Dupree, J.D. Syrjamaki, H.M. Hu, W.C. Palazzolo, M.J. Englesbe, C.M. Brummett, and J.F. Waljee. 2018. Provider characteristics associated with outpatient opioid prescribing after surgery. Annals of Surgery, September 20. [Epub ahead of print].

Cron, D.C., C. Hwang, H.M. Hu, J.S. Lee, J.M. Dupree, J.D. Syrjamaki, K.C. Chung, C.M. Brummett, M.J. Englesbe, and J.F. Waljee. 2019. A statewide comparison of opioid prescribing in teaching versus nonteaching hospitals. Surgery 165(4):825–831.

Csintalan, R.P., M.C.S. Inacio, and T.T. Funahashi. 2008. Incidence rate of anterior cruciate ligament reconstructions. The Permanente Journal 12(3):17–21.

Daoust, R., J. Paquet, A. Cournoyer, E. Piette, J. Morris, S. Gosselin, M. Emond, G. Lavigne, J. Lee, and J.M. Chauny. 2018. Quantity of opioids consumed following an emergency department visit for acute pain: A Canadian prospective cohort study. British Medical Journal Open 8(9):e022649.

Daoust, R., J. Paquet, A. Cournoyer, E. Piette, J. Morris, J. Lessard, V. Castonguay, G. Lavigne, and J.M. Chauny. 2019. Acute pain resolution after an emergency department visit: A 14-day trajectory analysis. Annals of Emergency Medicine 74(2):224–232.

Dave, C.V., E. Patorno, J.M. Franklin, K. Huybrechts, A. Sarpatwari, A.S. Kesselheim, and B.T. Bateman. 2019. Impact of state laws restricting opioid duration on characteristics of new opioid prescriptions. Journal of General Internal Medicine. doi: 10.1007/s11606-019-05150-z. [Epub ahead of print].

Davis, B.R., S.A. Lee-Kong, J. Migaly, D.L. Feingold, and S.R. Steele. 2018. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Diseases of the Colon & Rectum 61(3):284–292.

Delgado, M.K., Y. Huang, Z. Meisel, S. Hennessy, M. Yokell, D. Polsky, and J. Perrone. 2018. National variation in opioid prescribing and risk of prolonged use for opioid-naïve patients treated in the emergency department for ankle sprains. Annals of Emergency Medicine 72(4):389–400.

Denning, N.-L., C. Kvasnovsky, J.M. Golden, B.S. Rich, and A.M. Lipskar. 2019. Inconsistency in opioid prescribing practices after pediatric ambulatory hernia surgery. Journal of Surgical Research 241:57–62.

Dionne, R.A., S.M. Gordon, and P.A. Moore. 2016. Prescribing opioid analgesics for acute dental pain: Time to change clinical practices in response to evidence and misperceptions. Compendium of Continuing Education in Dentistry 37(6):372–378.

Doherty, C., E. Delahunt, B. Caulfield, J. Hertel, J. Ryan, and C. Bleakley. 2014. The incidence and prevalence of ankle sprain injury: A systematic review and meta-analysis of prospective epidemiological studies. Sports Medicine (Auckland, N.Z.) 44(1):123–140.

Donohoe, G.C., B. Zhang, J.L. Mensinger, and R.S. Litman. 2019. Trends in postoperative opioid prescribing in outpatient pediatric surgery. Pain Medicine 20(9):1789–1795.

Dowell, D., T.M. Haegerich, and R. Chou. 2016. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 315(15):1624–1645.

Duncan, C.B., and T.S. Riall. 2012. Evidence-based current surgical practice: Calculous gallbladder disease. Journal of Gastrointestinal Surgery 16(11):2011–2025.

Earle, D., J.S. Roth, A. Saber, S. Haggerty, J.F. Bradley, R. Fanelli, R. Price, W.S. Richardson, D. Stefanidis, and S.G. Committee. 2016. SAGES guidelines for laparoscopic ventral hernia repair. Surgical Endoscopy 30(8):3163–3183.

Finney, F.T., T.D. Gossett, H.M. Hu, J.F. Waljee, C.M. Brummett, D.M. Walton, P.G. Talusan, and J.R. Holmes. 2019. Rate of opioid prescriptions for patients with acute ankle sprain. Annals of Internal Medicine 171(6):441–443.

Fleischman, A.N., M. Tarabichi, C. Foltz, G. Makar, W.J. Hozack, M.S. Austin, A.F. Chen, and Opioid Prescription in Orthopedic Surgery After Discharge Research Group. 2019. Cluster-randomized trial of opiate-sparing analgesia after discharge from elective hip surgery. Journal of the American College of Surgeons 229(4):335–345.

Fox, T.R., J. Li, S. Stevens, and T. Tippie. 2013. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine 62(3):237–240.

Friedman, D.T., S. Ghiassi, M.O. Hubbard, and A.J. Duffy. 2019. Postoperative opioid prescribing practices and evidence-based guidelines in bariatric surgery. Obesity Surgery 29(7):2030–2036.

Friedman, J.W. 2007. The prophylactic extraction of third molars: A public health hazard. American Journal of Public Health 97(9):1554–1559.

Fujii, M.H., A.C. Hodges, R.L. Russell, K. Roensch, B. Beynnon, T.P. Ahern, P. Holoch, J.S. Moore, S.E. Ames, and C.D. MacLean. 2018. Post-discharge opioid prescribing and use after common surgical procedure. Journal of the American College of Surgeons 226(6):1004–1012.

Gil, J.A., V. Gunaseelan, S.F. DeFroda, C.M. Brummett, A. Bedi, and J.F. Waljee. 2019. Risk of prolonged opioid use among opioid-naïve patients after common shoulder arthroscopy procedures. American Journal of Sports Medicine 47(5):1043–1050.

Gossett, T.D., F.T. Finney, H.M. Hu, J.F. Waljee, C.M. Brummett, D.M. Walton, and J.R. Holmes. 2019. New persistent opioid use and associated risk factors following treatment of ankle fractures. Foot & Ankle International 40(9):1043–1051.

Gupta, N., M. Vujicic, and A. Blatz. 2018. Opioid prescribing practices from 2010 through 2015 among dentists in the United States: What do claims data tell us? Journal of the American Dental Association 149(4):237–245.

Han, J., J. Zhou, S.L. Saraf, V.R. Gordeuk, and G.S. Calip. 2018. Characterization of opioid use in sickle cell disease. Pharmacoepidemiology and Drug Safety 27(5):479–486.

Hannon, C.P., T.E. Calkins, J. Li, C. Culvern, B. Darrith, D. Nam, T.L. Gerlinger, A. Buvanendran, and C.J. Della Valle. 2019. The James A. Rand Young Investigator’s Award: Large opioid prescriptions are unnecessary after total joint arthroplasty: A randomized controlled trial. The Journal of Arthroplasty 34(7 Suppl):S4–S10.

Hanson, K.T., C.A. Thiels, S.F. Polites, H.M. Gazelka, M.D. Ray-Zack, M.D. Zielinski, and E.B. Habermann. 2018. The opioid epidemic in acute care surgery—Characteristics of overprescribing following laparoscopic cholecystectomy. Journal of Trauma and Acute Care Surgery 85(1):62–70.

Harbaugh, C.M., J.S. Lee, H.M. Hu, S.E. McCabe, T. Voepel-Lewis, M.J. Englesbe, C.M. Brummett, and J.F. Waljee. 2018. Persistent opioid use among pediatric patients after surgery. Pediatrics 141(1):e20172439.

Hegmann, K.T., M.S. Weiss, K. Bowden, F. Branco, K. DuBrueler, C. Els, S. Mandel, D.W. McKinney, R. Miguel, K.L. Mueller, R.J. Nadig, M.I. Schaffer, L. Studt, J.B. Talmage, R.L. Travis, T. Winters, M.S. Thiese, and J.S. Harris. 2014. ACOEM practice guidelines: Opioids for treatment of acute, subacute, chronic, and postoperative pain. Journal of Occupational and Environmental Medicine 56(12):e143–e159.

Herzog, M.M., S.W. Marshall, J.L. Lund, V. Pate, C.D. Mack, and J.T. Spang. 2018. Trends in incidence of ACL reconstruction and concomitant procedures among commercially insured individuals in the United States, 2002–2014. Sports Health 10(6):523–531.

Hill, M.V., M.L. McMahon, R.S. Stucke, and R.J. Barth, Jr. 2017. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Annals of Surgery 265(4):709–714.

Hill, M.V., R.S. Stucke, S.E. Billmeier, J.L. Kelly, and R.J. Barth. 2018a. Guideline for discharge opioid prescriptions after inpatient general surgical procedures. Journal of the American College of Surgeons 226(6):996–1003.

Hill, M.V., R.S. Stucke, M.L. McMahon, J.L. Beeman, and R.J. Barth, Jr. 2018b. An educational intervention decreases opioid prescribing after general surgical operations. Annals of Surgery 267(3):468–472.

Hilliard, P.E., J. Waljee, S. Moser, L. Metz, M. Mathis, J. Goesling, D. Cron, D.J. Clauw, M. Englesbe, G. Abecasis, and C.M. Brummett. 2018. Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery. JAMA Surgery 153(10):929–937.

Hoppe, J.A., H. Kim, and K. Heard. 2015a. Association of emergency department opioid initiation with recurrent opioid use. Annals of Emergency Medicine 65(5):493–499.

Hoppe, J.A., L.S. Nelson, J. Perrone, S.G. Weiner, and Prescribing Opioids Safely in the Emergency Department Study Investigators. 2015b. Opioid prescribing in a cross-section of U.S. emergency departments. Annals of Emergency Medicine 66(3):253–259.

Hoppe, J.A., C. McStay, B.C. Sun, and R. Capp. 2017. Emergency department attending physician variation in opioid prescribing in low acuity back pain. Western Journal of Emergency Medicine 18(6):1135–1142.

Horton, J.D., S. Munawar, C. Corrigan, D. White, and R.A. Cina. 2019a. Inconsistent and excessive opioid prescribing after common pediatric surgical operations. Journal of Pediatric Surgery 54(7):1427–1431.

Horton, J.D., S. Munawar, A. Feuvrier, C. Corrigan, M. Lockett, D. White, and R.A. Cina. 2019b. Specialty-specific reduction in opioid prescribing after common pediatric surgical operations. Journal of Pediatric Surgery 54(10):1984–1987.

Hota, L.S., H.A. Warda, M.J. Haviland, F.M. Searle, and M.R. Hacker. 2018. Opioid use following gynecologic and pelvic reconstructive surgery. International Urogynecolgy Journal 29(10):1441–1445.

Howard, R., M. Alameddine, M. Klueh, M. Englesbe, C. Brummett, J. Waljee, and J. Lee. 2018a. Spillover effect of evidence-based postoperative opioid prescribing. Journal of the American College of Surgeons 227(3):374–381.

Howard, R., B. Fry, V. Gunaseelan, J. Lee, J.Waljee, C. Brummett, D. Campbell Jr., E. Seese, M. Englesbe, and J. Vu. 2018b. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surgery 154(1):e184234.

Howard, R., J. Waljee, C. Brummett, M. Englesbe, and J. Lee. 2018c. Reduction in opioid prescribing through evidence-based prescribing guidelines. JAMA Surgery 153(3):285–287.

Hsu, J.R., H. Mir, M.K. Wally, R.B. Seymour, and Orthopaedic Trauma Association Musculoskeletal Pain Task Force. 2019. Clinical practice guidelines for pain management in acute musculoskeletal injury. Journal of Orthopaedic Trauma 33(5):e158–e182.

Huang, P.S., and S.N. Copp. 2019. Oral opioids are overprescribed in the opiate-naïve patient undergoing total joint arthroplasty. Journal of the American Academy of Orthopaedic Surgeons 27(15):e702–e708.

Hudgins, J.D., J.J. Porter, M.C. Monuteaux, and F.T. Bourgeois. 2019. Trends in opioid prescribing for adolescents and young adults in ambulatory care settings. Pediatrics 143(6):e20181578.

Huston, K. 2019. Tendinitis (bursitis). https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Tendinitis-Bursitis (accessed September 20, 2019).

ICSI (Institute for Clinical Systems Improvement). 2018. Health care guideline: Adult acute and subacute low back pain. https://www.icsi.org/wp-content/uploads/2019/08/March-2018-LBP-Interactive2.pdf (accessed August 28, 2019).

IHE (Institute of Health Economics). 2016. Primary care management of headache in adults. http://www.topalbertadoctors.org/download/597/Guideline%20for%20Primary%20Care%20Management%20of%20Headache%20in%20Adults.pdf?_20190920234617 (accessed August 28, 2019).

IOM (Institute of Medicine). 1995. Setting priorities for clinical practice guidelines. Washington, DC: National Academy Press.

Jaroszewski, D., D. Notrica, L. McMahon, D.E. Steidley, and C. Deschamps. 2010. Current management of pectus excavatum: A review and update of therapy and treatment recommendations. Journal of the American Board of Family Medicine 23(2):230–239.

Javed, M., S. Mustafa, S. Boyle, and F. Scott. 2015. Elbow pain: A guide to assessment and management in primary care. British Journal of General Practice 65(640):610–612.

Jeffery, M.M., W.M. Hooten, E.P. Hess, E.R. Meara, J.S. Ross, H.J. Henk, B. Borgundvaag, N.D. Shah, and M.F. Bellolio. 2018. Opioid prescribing for opioid-naïve patients in emergency departments and other settings: Characteristics of prescriptions and association with long-term use. Annals of Emergency Medicine 71(3):326–336.

Johnson, C.M., and G.E.H. Makai. 2019. A systematic review of perioperative opioid management for minimally invasive hysterectomy. Journal of Minimally Invasive Gynecology 26(2):233–243.

Jones, B.Q., C.J. Covey, and M.H. Sineath, Jr. 2015. Nonsurgical management of knee pain in adults. American Family Physician 92(10):875–883.

Kahl, L.K., M.W. Stevens, A.C. Gielen, E.M. McDonald, and L. Ryan. 2019. Characteristics of opioid prescriptions for discharged pediatric emergency department patients with acute injuries. Journal of Investigative Medicine 67(6):1024–1027.

Kahlenberg, C.A., J.G. Stepan, A. Premkumar, F.D. Lovecchio, and M.B. Cross. 2019. Institutional guidelines can decrease the amount of opioids prescribed after total joint replacement. HSS Journal 15(1):27–30.

Kaiser Permanente. 2017. Non-specific back pain guideline. Kaiser Foundation Health Plan of Washington. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/back-pain.pdf (accessed May 12, 2019).

Kea, B., R. Fu, R.A. Lowe, and B.C. Sun. 2016. Interpreting the National Hospital Ambulatory Medical Care Survey: United States emergency department opioid prescribing, 2006–2010. Academic Emergency Medicine 23(2):159–165.

Kelly, M.P., T.E. Calkins, C. Culvern, M. Kogan, and C.J. Della Valle. 2018. Inpatient versus outpatient hip and knee arthroplasty: Which has higher patient satisfaction? Journal of Arthroplasty 33(11):3402–3406.

Kester, B.S., J. Williams, J.A. Bosco, J.D. Slover, R. Iorio, and R. Schwarzkopf. 2016. The association between hospital length of stay and 90-day readmission risk for femoral neck fracture patients: Within a total joint arthroplasty bundled payment initiative. Journal of Arthroplasty 31(12):2741–2745.

King, W.C., J.-Y. Chen, S.H. Belle, A.P. Courcoulas, G.F. Dakin, D.R. Flum, M.W. Hinojosa, M.A. Kalarchian, J.E. Mitchell, W.J. Pories, K. Spaniolas, B.M. Wolfe, S.Z. Yanovski, S.G. Engel, and K.J. Steffen. 2017. Use of prescribed opioids before and after bariatric surgery: Prospective evidence from a U.S. multicenter cohort study. Surgery for Obesity and Related Disease 13(8):1337–1346.

Klueh, M.P., H.M. Hu, R.A. Howard, J.V. Vu, C.M. Harbaugh, P.A. Lagisetty, C.M. Brummett, M.J. Englesbe, J.F. Waljee, and J.S. Lee. 2018. Transitions of care for postoperative opioid prescribing in previously opioid-naïve patients in the USA: A retrospective review. Journal of General Internal Medicine 33(10):1685–1691.

Kou, Y.-F., R.B. Mitchell, and R.F. Johnson. 2019. A cross-sectional analysis of pediatric ambulatory tonsillectomy surgery in the United States. Otolaryngology–Head and Neck Surgery 161(4):699–704.

Kremers, H.M., D.R. Larson, C.S. Crowson, W.K. Kremers, R.E. Washington, C.A. Steiner, W.A. Jiranek, and D.J. Berry. 2015. Prevalence of total hip and knee replacement in the United States. Journal of Bone and Joint Surgery 97(17):1386–1397.

Kumar, K., L.V. Gulotta, J.S. Dines, A.A. Allen, J. Cheng, K.G. Fields, J.T. YaDeau, and C.L. Wu. 2017. Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits. American Journal of Sports Medicine 45(3):636–641.

Ladha, K.S., M.D. Neuman, G. Broms, J. Bethell, B.T. Bateman, D.N. Wijeysundera, M. Bell, L. Hallqvist, T. Svensson, C.W. Newcomb, C.M. Brensinger, L.J. Gaskins, and H. Wunsch. 2019. Opioid prescribing after surgery in the United States, Canada, and Sweden. JAMA Network Open 2(9):e1910734.

Lancaster, E., T. Bongiovanni, J. Lin, R. Croci, E. Wick, and K. Hirose. 2019. Residents as key effectors of change in improving opioid prescribing behavior. Journal of Surgical Education 76(6):e167–e172.

Larach, D.B., J.F. Waljee, H.M. Hu, J.S. Lee, R. Nalliah, M.J. Englesbe, and C.M. Brummett. 2018. Patterns of initial opioid prescribing to opioid-naïve patients. Annals of Surgery, July 24. [Epub ahead of print].

Leach, D.A., E.B. Habermann, A.E. Glasgow, and J.A. Occhino. 2018. Postoperative opioid prescribing following gynecologic surgery for pelvic organ prolapse. Female Pelvic Medicine Reconstruction Surgery, September 22. [Epub ahead of print].

Lillemoe, H.A., T.E. Newhook, T.J. Vreeland, E.M. Arvide, W.L. Dewhurst, E.G. Grubbs, T.A. Aloia, J.N. Vauthey, J.E. Lee, and C.-W.D. Tzeng. 2019. Educating surgical oncology providers on perioperative opioid use: Results of a departmental survey on perceptions of opioid needs and prescribing habits. Annals of Surgical Oncology 26(7):2011–2018.

Linder, B.J., S. Wiest, J.A. Occhino, C. Klingele, E. Trabuco, and J. Gebhart. 2019. Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery. American Journal of Obstetrics and Gynecology 220(3):S690–S691.

Lovecchio, F., J.G. Stepan, A. Premkumar, M.E. Steinhaus, M. Sava, P. Derman, H.J. Kim, and T. Albert. 2019. An institutional intervention to modify opioid prescribing practices after lumbar spine surgery. Journal of Neurosurgery 30(4):483–490.

Loveless, M.S., and A.L. Fry. 2016. Pharmacologic therapies in musculoskeletal conditions. Medical Clinics of North America 100(4):869–890.

Ma, C.B., and B.T. Feeley. 2012. Basic principles and operative management of the rotator cuff. Thorofare, NJ: Slack Incorporated.

Madsen, A.M., L.M. Stark, P. Has, J.B. Emerson, J. Schulkin, and K.A. Matteson. 2018. Opioid knowledge and prescribing practices among obstetrician-gynecologists. Obstetrics & Gynecology 131(1):150–157.

Makary, M.A., H.N. Overton, and P. Wang. 2017. Overprescribing is major contributor to opioid crisis. British Medical Journal 359:j4792.

Manchikanti, L., S. Abdi, S. Atluri, C.C. Balog, R.M. Benyamin, M.V. Boswell, K.R. Brown, B.M. Bruel, D.A. Bryce, P.A. Burks, A.W. Burton, A.K. Calodney, D.L. Caraway, K.A. Cash, P.J. Christo, K.S. Damron, S. Datta, T.R. Deer, S. Diwan, I. Eriator, F.J. Falco, B. Fellows, S. Geffert, C.G. Gharibo, S.E. Glaser, J.S. Grider, H. Hameed, M. Hameed, H. Hansen, M.E. Harned, S.M. Hayek, S. Helm, 2nd, J.A. Hirsch, J.W. Janata, A.D. Kaye, A.M. Kaye, D.S. Kloth, D. Koyyalagunta, M. Lee, Y. Malla, K.N. Manchikanti, C.D. McManus, V. Pampati, A.T. Parr, R. Pasupuleti, V.B. Patel, N. Sehgal, S.M. Silverman, V. Singh, H.S. Smith, L.T. Snook, D.R. Solanki, D.H. Tracy, R. Vallejo, B.W. Wargo, and American Society of Interventional Pain Physicians. 2012. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2—Guidance. Pain Physician 15(3 Suppl):67–116.

Manski, R.J., and E. Brown. 2012. Statistical brief #368: Dental procedures, United States, 1999 and 2009. https://meps.ahrq.gov/data_files/publications/st368/stat368.shtml (accessed August 26, 2019).

Marcusa, D.P., R.A. Mann, D.C. Cron, B.R. Fillinger, A.K. Rzepecki, J.H. Kozlow, A. Momoh, M. Englesbe, C. Brummett, and J.F. Waljee. 2017. Prescription opioid use among opioid-naïve women undergoing immediate breast reconstruction. Plastic Reconstruction Surgery 140(6):1081–1090.

Martin, R.L., T.E. Davenport, S. Paulseth, D.K. Wukich, and J.J. Godges. 2013. Ankle stability and movement coordination impairments: Ankle ligament sprains. Journal of Orthopaedic & Sports Physical Therapy 43(9):A1–A40.

Martin, J.A., B.E. Hamilton, M.J.K. Osterman, A.K. Driscoll, and P. Drake. 2018a. Births: Final data for 2017. National Vital Statistics Reports 67(8):1–50.

Martin, R.L., R. Chimenti, T. Cuddeford, J. Houck, J.W. Matheson, C.M. McDonough, S. Paulseth, D.K. Wukich, and C.R. Carcia. 2018b. Achilles pain, stiffness, and muscle power deficits: Midportion achilles tendinopathy revision, 2018. Journal of Orthopaedic & Sports Physical Therapy 48(5):A1–A38.

McDermott, K.W., W.J. Freeman, and A. Elixhauser. 2017. Overview of operating room procedures during inpatient stays in U.S. hospitals, 2014. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb233-Operating-Room-Procedures-United-States-2014.jsp (accessed August 28, 2019).

Meisel, Z.F., N. Lupulescu-Mann, C.J. Charlesworth, H. Kim, and B.C. Sun. 2019. Conversion to persistent or high-risk opioid use after a new prescription from the emergency department: Evidence from Washington Medicaid beneficiaries. Annals of Emergency Medicine S0196-0644(19):30310–30315.

Michigan. 2018. Acute care opioid treatment and prescribing recommendations: Dental. https://www.michigan.gov/documents/lara/Acute_Care_Opioid_Treatment_and_Prescibing_Recommendations_Dental-_FINAL_620735_7.PDF (accessed August 28, 2019).

Mills, J.R., M.M. Huizinga, S.B. Robinson, L. Lamprecht, A. Handler, M. Petros, T. Davis, and K. Chan. 2019. Draft opioid-prescribing guidelines for uncomplicated normal spontaneous vaginal birth. Obstetrics & Gynecology 133(1):81–90.

Minen, M.T., E. Ortega, R.B. Lipton, and R. Cowan. 2018. American Headache Society survey about urgent and emergency management of headache patients. Headache 58(9):1389–1396.

Mitchell, R.B., S.M. Archer, S.L. Ishman, R.M. Rosenfeld, S. Coles, S.A. Finestone, N.R. Friedman, T. Giordano, D.M. Hildrew, T.W. Kim, R.M. Lloyd, S.R. Parikh, S.T. Shulman, D.L. Walner, S.A. Walsh, and L.C. Nnacheta. 2019. Clinical practice guideline: Tonsillectomy in children (update). Otolaryngology–Head and Neck Surgery 160(1 Suppl):S1–S42.

Monitto, C.L., A. Hsu, S. Gao, P.T. Vozzo, P.S. Park, D. Roter, G. Yenokyan, E.D. White, D. Kattail, A.E. Edgeworth, K.J. Vasquenza, S.E. Atwater, J.E. Shay, J.A. George, B.A. Vickers, S. Kost-Byerly, B.H. Lee, and M. Yaster. 2017. Opioid prescribing for the treatment of acute pain in children on hospital discharge. Anesthesia & Analgesia 125(6):2113–2122.

Moore, P.A., H.S. Nahouraii, J.G. Zovko, and S.R. Wisniewski. 2006. Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics. General Dentistry 54(3):201–207.

Morris, M., H.C. Thode, and A.J. Singer. 2019. Use of opioids and analgesics among ED patients with dental and low back pain: A national perspective. American Journal of Emergency Medicine 37(6):1085–1090.

Mosher, H.J. 2019. Regional and rural–urban variaton in opioid prescribing in the Veterans Health Administration. Military Medicine 184(11–12):894–900.

Moskowitz, D., K. Amin, A. Lucioni, K. Kobashi, and U. Lee. 2019. Opioid prescription and use in sacral neuromodulation, mid-urethral sling, and pelvic organ prolapse surgery: An educational intervention to avoid over-prescribing. Journal of Urology 201(5):979–986.

Motov, S., R. Strayer, B. Hayes, M. Reiter, S. Rosenbaum, M. Richman, Z. Repanshek, S. Taylor, and B. Friedman. 2017. AAEM white paper on acute pain management in the emergency department. https://www.aaem.org/resources/statements/position/white-paper-on-acute-pain-management-in-the-emergency-department (accessed August 26, 2019).

Motov, S., J. Drapkin, M. Butt, A. Thorson, A. Likourezos, P. Flom, and J. Marshall. 2018. Analgesic administration for patients with renal colic in the emergency department before and after implementation of an opioid reduction initiative. Western Journal of Emergency Medicine 19(6):1028–1035.

Mou, D., T. Tesfasilassie, S. Hirji, and S.W. Ashley. 2019. Advances in the management of acute cholecystitis. Annals of Gastroenterology Surgery 3(3):247–253.

Mundkur, M.L., J.M. Franklin, Y. Abdia, K.F. Huybrechts, E. Patorno, J.J. Gagne, T.E. Meyer, J. Staffa, and B.T. Bateman. 2019. Days’ supply of initial opioid analgesic prescriptions and additional fills for acute pain conditions treated in the primary care setting—United States, 2014. Morbidity and Mortality Weekly Report 68(6):140–143.

Nelson, L.S., D.N. Juurlink, and J. Perrone. 2015. Addressing the opioid epidemic. JAMA 314(14):1453–1454.

Nelson, S.E., A.J. Adams, M.J. Buczek, C.A. Anthony, and A.S. Shah. 2019. Postoperative pain and opioid use in children with supracondylar humeral fractures: Balancing analgesia and opioid stewardship. Journal of Bone and Joint Surgery 101(2):119–126.

New England Pediatric Sickle Cell Consortium. 2009. Management of acute pain in pediatric patients with sickle cell disease (vaso-occlusive episodes). http://nepscc.org/2017/wp-content/uploads/2017/06/CPG-Pain-3-09.pdf (accessed August 28, 2019).

NHLBI (National Heart, Lung, and Blood Institute). 2014. Evidence-based management of sickle cell disease: Expert panel report, 2014. Evidence report. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health.

NICE (UK National Institute for Health and Care Excellence). 2017. Hip fracture: Management. https://www.nice.org.uk/guidance/cg124 (accessed August 28, 2019).

NYCDOH (New York City Department of Health). 2019. Opioid prescribing resources for emergency departments. https://www1.nyc.gov/site/doh/providers/health-topics/opioid-prescribing-resources-for-emergency-departments.page (accessed August 25, 2019).

Ochroch, E.A., A. Gottschalk, J. Augostides, K.A. Carson, L. Kent, N. Malayaman, L.R. Kaiser, and S.J. Aukburg. 2002. Long-term pain and activity during recovery from major thoracotomy using thoracic epidural analgesia. Anesthesiology 97(5):1234–1244.

Oskoui, M., T. Pringsheim, Y. Holler-Managan, S. Potrebic, L. Billinghurst, D. Gloss, A.D. Hershey, N. Licking, M. Sowell, M.C. Victorio, E.M. Gersz, E. Leininger, H. Zanitsch, M. Yonker, and K. Mack. 2019. Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 93(11):487–499.

Osmundson, S.S., L.A. Schornack, J.L. Grasch, L.C. Zuckerwise, J.L. Young, and M.G. Richardson. 2017. Postdischarge opioid use after cesarean delivery. Obstetrics & Gynecology 130(1):36–41.

Overton, H.N., M.N. Hanna, W.E. Bruhn, S. Hutfless, M.C. Bicket, M.A. Makary, and Opioids After Surgery. 2018. Opioid-prescribing guidelines for common surgical procedures: An expert panel consensus. Journal of the American College of Surgeons 227(4):411–418.

Pappas, A.L., E.M. Fluder, S. Creech, A. Hotaling, and A. Park. 2003. Postoperative analgesia in children undergoing myringotomy and placement equalization tubes in ambulatory surgery. Anesthesia & Analgesia 96(6):1621–1624.

Patel, H.D., A. Srivastava, N.D. Patel, F.A. Faisal, W. Ludwig, G.A. Joice, Z.R. Schwen, M.E. Allaf, M. Han, and A.S. Herati. 2019. A prospective cohort study of postdischarge opioid practices after radical prostatectomy: The ORIOLES initiative. European Urology 75(2):215–218.

Paulozzi, L.J., K.A. Mack, and J.M. Hockenberry. 2014. Variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. Morbidity and Mortality Weekly Report 63(26):563–568.

Peahl, A.F., V.K. Dalton, J.R. Montgomery, Y.-L. Lai, H.M. Hu, and J.F. Waljee. 2019. Rates of new persistent opioid use after vaginal or cesarean birth among U.S. women. JAMA Network Open 2(7):e197863.

Pearle, M.S., D.S. Goldfarb, D.G. Assimos, G. Curhan, C.J. Denu-Ciocca, B.R. Matlaga, M. Monga, K.L. Penniston, G.M. Preminger, T.M.T. Turk, and J.R. White. 2014. Medical management of kidney stones: AUA guideline. Journal of Urology 192(2):316–324.

Pennsylvania. 2017. The safe prescribing of opioids in orthopedics and sports medicine. https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Nursing/Documents/Board%20Documents/Guidelines%20Orthopedics%20and%20Sports%20Medicine.pdf (accessed August 28, 2019).

Pennsylvania. 2018. Pennsylvania guidelines on the use of opioids in dental practice. https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Documents/PA%20Guidelines%20Dentists.pdf (accessed August 28, 2019).

Prabhu, M., E.M. Garry, S. Hernandez-Diaz, S.C. MacDonald, K.F. Huybrechts, and B.T. Bateman. 2018. Frequency of opioid dispensing after vaginal delivery. Obstetrics & Gynecology 132(2):459–465.

Premkumar, A., F.C. Lovecchio, J.G. Stepan, P.K. Sculco, S.A. Jerabek, A. Gonzalez Della Valle, D.J. Mayman, A.D. Pearle, M.M. Alexiades, T.J. Albert, M.B. Cross, and S.B. Haas. 2019. Characterization of opioid consumption and disposal patterns after total knee arthroplasty. The Bone & Joint Journal 101-B(7 Suppl C):98–103.

Pruitt, L.C.C., D.S. Swords, K.W. Russell, M.D. Rollins, and D.E. Skarda. 2019. Prescription vs. consumption: Opioid overprescription to children after common surgical procedures. Journal of Pediatric Surgery 54(11):2195–2199.

Qaseem, A., P. Dallas, M.A. Forciea, M. Starkey, T.D. Denberg, and Clinical Guidelines Committee of the American College of Physicians. 2014. Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 161(9):659–667.

Qaseem, A., T.J. Wilt, R.M. McLean, M.A. Forciea, and Clinical Guidelines Committee of the American College of Physicians. 2017. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 166(7):514–530.

Resnick, C.M., C.E. Calabrese, S. Afshar, and B.L. Padwa. 2019. Do oral and maxillofacial surgeons over-prescribe opioids after extraction of asymptomatic third molars? Journal of Oral Maxillofacial Surgery 77(7):1332–1336.

Roulin, D., A. Saadi, L. Di Mare, N. Demartines, and N. Halkic. 2016. Early versus delayed cholecystectomy for acute cholecystitis, are the 72 hours still the rule?: A randomized trial. Annals of Surgery 264(5):717–722.

Rui, P., K. Kang, and J.J. Ashman. 2016. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2016_ed_web_tables.pdf (accessed April 19, 2019).

Sabatino, M.J., S.T. Kunkel, D.B. Ramkumar, B.J. Keeney, and D.S. Jevsevar. 2018. Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. Journal of Bone and Joint Surgery 100(3):180–188.

Sada, A., C.A. Thiels, M.K. Britain, A. Dudakovic, W.J. Bergquist, S.R. Nickel, M.J. Moran, J. Martinez-Jorge, and J.W. Jakub. 2019. Optimizing discharge opioid prescribing practices after mastectomy with immediate reconstruction. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 3(2):183–188.

SCAC/GENES (Sickle Cell Advisory Committee of the Genetic Network of New York, Puerto Rico, and the Virgin Islands). 2002. Guidelines for the treatment of people with sickle cell disease. https://www.downstate.edu/peds/pdf/SCACguide.pdf (accessed August 28, 2019).

Scales, C.D., Jr., A.C. Smith, J.M. Hanley, C.S. Saigal, and Urologic Diseases in America Project. 2012. Prevalence of kidney stones in the United States. European Urology 62(1):160–165.

Schairer, W.W., J.M. Lane, D.A. Halsey, R. Iorio, D.E. Padgett, and A.S. McLawhorn. 2017. The Frank Stinchfield award: Total hip arthroplasty for femoral neck fracture is not a typical DRG470: A propensity-matched cohort study. Clinical Orthopaedics and Related Research 475(2):353–360.

Schappert, S., and P. Rui. 2019. Estimated number and percent distribution of hospital emergency department visits at which opioids were prescribed at discharge, for selected diagnosis groups: United States, 2016. Special Topics. https://www.cdc.gov/nchs/ahcd/ahcd_products.htm (accessed September 10, 2019).

Schieber, L.Z., G.P. Guy, Jr., P. Seth, R. Young, C.L. Mattson, C.A. Mikosz, and R.A. Chieber. 2019. Trends and patterns of geographic variation in opioid prescribing practices by state, United States, 2006–2017. Journal of the American Medical Association Network Open 2(3):2–15.

Schug, S.A., P. Lavand’homme, A. Barke, B. Korwisi, W. Rief, R.D. Treede, and IASP Taskforce for the Classification of Chronic Pain. 2019. The IASP classification of chronic pain for ICD-11: Chronic postsurgical or posttraumatic pain. Pain 160(1):45–52.

Scully, R.E., A.J. Schoenfeld, W. Jiang, S. Lipsitz, M.A. Chaudhary, P.A. Learn, T. Koehlmoos, A.H. Haider, and L.L. Nguyen. 2018. Defining optimal length of opioid pain medication prescription after common surgical procedures. Journal of the American Medical Association Surgery 153(1):37–43.

Sekhri, S., N.S. Arora, H. Cottrell, T. Baerg, A. Duncan, H.M. Hu, M.J. Englesbe, C. Brummett, and J.F. Waljee. 2018. Probability of opioid prescription refilling after surgery: Does initial prescription dose matter? Annals of Surgery 268(2):271–276.

Sherry, T.B., A. Sabety, and N. Maestas. 2018. Documented pain diagnoses in adults prescribed opioids: Results from the National Ambulatory Medical Care Survey, 2006–2015. Annals of Internal Medicine 169(12):892–894.

Shoss, B.L., and L.M. Tsai. 2013. Postoperative care in cataract surgery. Current Opinion in Ophthalmology 24(1):66–73.

Silberstein, S.D. 2000. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology 55(6):754–762.

Silberstein, S.D., S. Holland, F. Freitag, D.W. Dodick, C. Argoff, E. Ashman, N., and Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. 2012. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the quality standards subcommittee of the American Aacademy of Neurology and the American Headache Society. Neurology 78(17):1337–1345.

Simons, M.P., M. Smietanski, H.J. Bonjer, R. Bittner, M. Miserez, T.J. Aufenacker, R.J. Fitzgibbons, P.K. Chowbey, H.M. Tran, R. Sani, F. Berrevoet, J. Bingener, T. Bisgaard, K. Bury, G. Campanelli, D.C. Chen, J. Conze, D. Cuccurullo, A.C. de Beaux, H.H. Eker, R.H. Fortelny, J.F. Gillion, B.J. van den Heuvel, W.W. Hope, L.N. Jorgensen, U. Klinge, F. Köckerling, J.F. Kukleta, I. Konate, A.L. Liem, D. Lomanto, M.J.A. Loos, M. Lopez-Cano, M.C. Misra, A. Montgomery, S. Morales-Conde, F.E. Muysoms, H. Niebuhr, P. Nordin, M. Pawlak, G.H. van Ramshorst, W.M.J. Reinpold, D.L. Sanders, N. Schouten, S. Smedberg, R.K.J. Simmermacher, S. Tumtavitikul, N. van Veenendaal, D. Weyhe, A.R. Wijsmuller, and The HerniaSurge Group. 2018. International guidelines for groin hernia management. Hernia 22(1):1–165.

Sloan, M., A. Premkumar, and N.P. Sheth. 2018. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. Journal of Bone and Joint Surgery 100(17):1455–1460.

Sonderman, K.A., L.L. Wolf, A.L. Madenci, N.K. Kwon, L.B. Armstrong, K.N. Wanis, K. Taylor, T. Uribe-Leitz, T.P. Koehlmoos, R.L. Ricca, Jr., B.R. Weil, C.B. Weldon, A.H. Haider, and S.E. Rice-Townsend. 2018. Opioid prescription patterns for children following laparoscopic appendectomy. Annals of Surgery. doi: 10.1097/SLA.0000000000003171.

Steinberg, A.C., M.O. Schimpf, A.B. White, C. Mathews, D.R. Ellington, P. Jeppson, C. Crisp, S.O. Aschkenazi, M.M. Mamik, E.M. Balk, and M. Murphy. 2017. Preemptive analgesia for postoperative hysterectomy pain control: Systematic review and clinical practice guidelines. American Journal of Obstetrics and Gynecology 217(3):303–313.

Steiner, C.A., Z. Karaca, B.J. Moore, M.C. Imshaug, and G. Pickens. 2017. Surgeries in hospital-based ambulatory surgery and hospital inpatient settings, 2014: Statistical brief #223. In Healthcare Cost and Utilization Project (HCUP) statistical briefs. Rockville, MD: Agency for Healthcare Research and Quality.

Strayer, R.J., S.M. Motov, and L.S. Nelson. 2017. Something for pain: Responsible opioid use in emergency medicine. American Journal of Emergency Medicine 35(2):337–341.

Sun, E.C., B.D. Darnall, L.C. Baker, and S. Mackey. 2016. Incidence of and risk factors for chronic opioid use among opioid-naïve patients in the postoperative period. JAMA Internal Medicine 176(9):1286–1293.

Syed, U.A.M., A.W. Aleem, C. Wowkanech, D. Weekes, M. Freedman, F. Tjoumakaris, J.A. Abboud, and L.S. Austin. 2018. Neer award 2018: The effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: A prospective, randomized clinical trial. Journal of Shoulder and Elbow Surgery 27(6):962–967.

Theisen, K.M., J.M. Myrga, N. Hale, G. Cochran, C. Sewall, L.C. Macleod, B.L. Jacobs, and B.J. Davies. 2019. Excessive opioid prescribing after major urologic procedures. Urology 123:101–107.

To, K.B., J.R. Cherry-Bukowiec, M.J. Englesbe, M.N. Terjimanian, C. Shijie, D.A. Campbell, Jr., and L.M. Napolitano. 2013. Emergent versus elective cholecystectomy: Conversion rates and outcomes. Surgical Infection 14(6):512–519.

Tompach, P.C., C.L. Wagner, A.B. Sunstrum, R.A. Nadeau, and H.K. Tu. 2019. Investigation of an opioid prescribing protocol after third molar extraction procedures. Journal of Oral and Maxillofacial Surgery 77(4):705–714.

Türk, C., A. Petřík, K. Sarica, C. Seitz, A. Skolarikos, M. Straub, and T. Knoll. 2016. EAU guidelines on diagnosis and conservative management of urolithiasis. European Urology 69(3):468–474.

VA/DoD (U.S. Department of Veterans Affairs/U.S. Department of Defense). 2017. VA/DoD clinical practice guideline for opioid therapy for chronic pain. https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf (accessed August 26, 2019).

Vail, D., T.D. Azad, C. O’Connell, S.S. Han, A. Veeravagu, and J.K. Ratliff. 2018. Postoperative opioid use, complications, and costs in surgical management of lumbar spondylolisthesis. Spine 43(15):1080–1088.

Velanovich, V. 2000. Laparoscopic vs. open surgery. Surgical Endoscopy 14(1):16–21.

Vu, J.V., R.A. Howard, V. Gunaseelan, C.M. Brummett, J.F. Waljee, and M.J. Englesbe. 2019. Statewide implementation of postoperative opioid prescribing guidelines. New England Journal of Medicine 381:7.

Washington. 2018. 2019 Washington State opioid prescribing requirements. https://www.doh.wa.gov/Portals/1/Documents/Pubs/630140-PrescriberHandout-Dental.pdf (accessed August 28, 2019).

Waterman, B.R., B.D. Owens, S. Davey, M.A. Zacchilli, and P.J.J. Belmont. 2010. The epidemiology of ankle sprains in the United States. Journal of Bone and Joint Surgery 92(13):2279–2284.

Wisconsin. 2017. Best practices for prescribing controlled substances guidelines. Wisconsin Dentistry Examining Board. https://dsps.wi.gov/Documents/BoardCouncils/DEN/DENGuidelinesApril2017.pdf (accessed August 28, 2019).

Yawn, B.P., G.R. Buchanan, A.N. Afenyi-Annan, S.K. Ballas, K.L. Hassell, A.H. James, L. Jordan, S.M. Lanzkron, R. Lottenberg, W.J. Savage, P.J. Tanabe, R.E. Ware, M.H. Murad, J.C. Goldsmith, E. Ortiz, R. Fulwood, A. Horton, and J. John-Sowah. 2014. Management of sickle cell disease: Summary of the 2014 evidence-based report by expert panel members. JAMA 312(10):1033–1048.

Ziegelmann, M.J., J.P. Joseph, A.E. Glasgow, M.D. Tyson, R.W. Pak, H.M. Gazelka, A.L. Schatz, B.C. Leibovich, E.B. Habermann, and M.T. Gettman. 2019. Wide variation in opioid prescribing after urological surgery in tertiary care centers. Mayo Clinic Proceedings 94(2):262–274.

Ziegler-Graham, K., E.J. MacKenzie, P.L. Ephraim, T.G. Travison, and R. Brookmeyer. 2008. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation 89(3):422–429.

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