Faculty Bibliography

BACKGROUND:With evolving prescription policies, the clinical utility of patient-centered opioid prescribing remains unclear. We evaluated whether a patient-centered opioid prescribing approach improves outcomes compared to default strategies: "treat all" (emulating opioid over-prescribing practices in the late 1990s and 2000s) or "treat none" (reflecting prescribing restrictions in Centers for Disease Control and Prevention 2016 guideline). METHODS:We conducted a decision curve analysis using electronic medical data from 1136 adult patients undergoing laparoscopic cholecystectomy for benign indications (October 2015 - December 2018) at an urban tertiary care center. Perioperative opioid needs were categorized as "none/low" or "medium/high" based on pain scores and opioid prescriptions/administrations from 30 days pre-operative to two weeks postoperative. RESULTS:Of 803 patients in the training dataset, 63.9 % required medium/high opioid levels. Key predictors included sex, preoperative medication use (opioids, acetaminophen, other nonsteroidal anti-inflammatory drug, antidepressants), emergent surgery, anesthesia type, and surgical indications. The prediction model's c-statistic was 0.65 (95 %CI: 0.58-0.71) and Brier score was 0.20 (95 % CI: 0.009-0.71) in the testing dataset. At an optimal threshold probability of 0.60, the prediction model correctly identified 16 more true positive cases per 100 patients needing medium/high opioid prescriptions than the "treat all" strategy, accounting for false positives. Across a threshold range of 0.18-0.91, the model-based strategy constantly outperformed both default strategies. CONCLUSION/CONCLUSIONS:Prediction-based, patient-centered opioid prescribing provides greater clinical utility across most thresholds.

Although Alcoholics Anonymous and other Twelve-Step interventions are among the most widely utilized self-help options by persons with chemical dependency, little is known concerning whether this approach should be integrated with non-spirituality based self-help approaches. The purpose of this study was to assess the extent to which clients receiving inpatient treatment in a residential therapeutic community (TC) felt that spirituality based interventions should be featured in TC treatment. Three hundred twenty-two members of the Daytop TC completed a survey assessing personal orientation to spirituality and attitudes towards spirituality based treatments. The majority of clients believed that the TC program should feature spirituality more in treatment. Nearly half agreed that the Twelve-Step (AA) approach should be more a part of TC treatment. Preference for Twelve-Step meeting interventions was positively correlated with past attendance at Twelve-Step meetings. Personal spiritual orientation to life was positively correlated with endorsement of spirituality based interventions in TC treatment. These findings highlight the importance of integrating treatment approaches which address the spiritual needs of TC residents