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Butkus JM, Sagalow ES, Alfonsi S, Riordan J, Zhan T, McGettigan B, Fisher K, Rosen D, Boon M, Huntley C. Prednisone Decreases Opioid Use in Adults Undergoing Benign Oropharyngeal Surgery. Otolaryngol Head Neck Surg 2024; 170:405-413. [PMID: 37702155 DOI: 10.1002/ohn.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/09/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE This study sought to analyze the efficacy and safety of postoperative prednisone to reduce reliance on opioids in adult benign oropharyngeal surgery. STUDY DESIGN Prospective cohort study. SETTING Single tertiary-care facility. METHODS Patients undergoing tonsillectomy (T), tonsillectomy and adenoidectomy (T&A), and/or modified uvulopalatopharyngoplasty (UPPP) from December 2020 to January 2023 received the standard of care postoperative management. A prednisone taper was dependent on surgeon preference. Cohorts were based on the prescription of postoperative steroids. Patients completed a survey to assess opioid usage, pain scores, and steroid compliance. RESULTS Seventy-two patients were included. The nonsteroid cohort (N = 29) received an average of 467 ± 94.1 morphine milligram equivalents (MME), and the steroid cohort (N = 43) received an average of 285 ± 128 MME (P < 0.001). The nonsteroid cohort consumed 1.62 times more opioids than the steroid cohort (P < 0.002). There were no significant differences in complication or refill rates between treatment groups. There were no significant differences in pain scores on the day of surgery or postoperative days 1, 5, or 10 (P = 0.34, P = 0.66, P = 0.62, and P = 0.22, respectively). Patients undergoing T&A (p = 0.019) or who had current psychiatric medication use (P < 0.006) consumed significantly more opioids. Patients who received a total opioid prescription of >300 MME (40 5-mL doses of 5 mg/5 mL liquid oxycodone) consumed 2.27 times more postoperative opioids than patients with opioid prescriptions ≤300 MME (P < 0.001). CONCLUSION Patients who did not receive steroids consumed 1.62 times more postoperative opioids compared to those who completed a steroid taper. Corticosteroid use was not associated with changes in pain scores, refill rates, or complication rates and may be considered in a multimodal approach to pain management in adults undergoing benign oropharyngeal surgery, although further study is warranted.
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Affiliation(s)
- Joann M Butkus
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Emily S Sagalow
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Samuel Alfonsi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jacob Riordan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tingting Zhan
- Department of Biostatistics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian McGettigan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kyle Fisher
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Rosen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Butkus JM, Awosanya S, Scott ER, Perlov N, Hannikainen P, Tekumalla S, Armache M, Stewart M, Willcox T, Chiffer R. Multimodal Analgesia and Patient Education Reduce Postoperative Opioid Consumption in Otology. Otolaryngol Head Neck Surg 2023. [PMID: 36939618 DOI: 10.1002/ohn.229] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/08/2022] [Accepted: 11/23/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study sought to validate alternative pain management strategies that can reduce reliance on opioids for postoperative pain management in otology. STUDY DESIGN Prospective cohort study. SETTING Single tertiary-care facility. METHODS Adult patients who underwent outpatient otologic surgery from September 2021 to July 2022 were randomized into treatment cohorts. The opioid monotherapy cohort received a standard opioid prescription. The multimodal analgesia cohort received the same opioid prescription, prescriptions for acetaminophen and naproxen, and additional pain management education with a flyer on discharge. All patients completed a questionnaire 1 week after surgery to evaluate opioid usage and pain scores. RESULTS Eighty-six patients completed the study. The opioid monotherapy cohort (n = 42) and multimodal analgesia cohort (n = 44) were prescribed an average of 42.1 ± 20.4 morphine milligram equivalents (MME) and 38.4 ± 5.7 MME, respectively (p = 0.373). Four patients (9.52%) in the opioid monotherapy cohort required opioid refills compared to 1 patient (2.27%) in the multimodal analgesia cohort (p = 0.156). Multivariate analysis demonstrated that the multimodal analgesia cohort consumed significantly fewer opioids on average than the opioid monotherapy cohort (11.9 ± 15.9 MME vs 22.8 ± 28.0 MME, respectively). There were no significant differences in postoperative rehospitalizations (p = 0.317) or Emergency Department visits (p = 0.150). Pain scores on the day of surgery, postoperative day (POD) 1, POD3, and POD7 were not significantly different between cohorts (p = 0.395, 0.896, 0.844, 0.765, respectively). CONCLUSION The addition of patient education, acetaminophen, and naproxen to postoperative opioid prescriptions significantly reduced opioid consumption without affecting pain scores, refill rates, or complication rates after otologic surgery.
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Affiliation(s)
- Joann M Butkus
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samiat Awosanya
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth Reilly Scott
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Natalie Perlov
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paavali Hannikainen
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sruti Tekumalla
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maria Armache
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew Stewart
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas Willcox
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rebecca Chiffer
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Thal AG, Ahmed S, Kim S, Yang CJ, Gao Q, Gangar M, Mehta V. Assessing Impact: Implementing an Opioid Prescription Protocol in Otolaryngology. J Patient Saf 2022; 18:e992-e998. [PMID: 35093975 DOI: 10.1097/pts.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A lack of guidance for pain control after otolaryngology surgery can lead to overprescription of opioids. We implemented a postoperative site-specific opioid prescription protocol and analyzed the impact on opioid prescriptions. METHODS This is a retrospective cohort study. A postoperative opioid prescription protocol was implemented within our otolaryngology department at a tertiary academic medical center on January 1, 2020. Retrospective chart review was completed for all patients undergoing otolaryngology surgery from November 1, 2019, to February 29, 2020 (2 months before and after initiation of intervention; n = 1070). The primary outcome was change in the amount of opioid prescribed for the preintervention and postintervention cohorts. Unplanned contact related to pain and opioid refills were tracked to assess pain control. RESULTS A total of 940 cases were included; adult and pediatric data were analyzed separately. There were 489 pediatric cases, 250 preintervention and 239 postintervention. There was a significant decrease in the amount of opioid prescribed per pediatric patient in the postintervention cohort (2.7 versus 0.32 morphine milligram equivalents, P = 0.02), and 99% of patients were not prescribed opioids at all. There was no significant change in unplanned contact, and no refills were required. There were 451 adult cases, 200 preintervention and 251 postintervention. There was no statistically significant decrease in the amount of opioid prescribed per adult patient (56.8 versus 51.7 morphine milligram equivalents, P = 0.23). There was no significant increase in unplanned contact or refills. CONCLUSIONS A postoperative opioid prescribing protocol can reduce the amount of opioid prescribed without increasing unplanned contact or opioid refills.
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Affiliation(s)
- Arielle G Thal
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| | - Sadia Ahmed
- Albert Einstein College of Medicine, The Bronx, New York
| | - Stanley Kim
- Albert Einstein College of Medicine, The Bronx, New York
| | - Christina J Yang
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| | - Qi Gao
- Albert Einstein College of Medicine, The Bronx, New York
| | - Mona Gangar
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| | - Vikas Mehta
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
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Go BC, Go CC, Chorath K, Moreira A, Rajasekaran K. Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review. World J Otorhinolaryngol Head Neck Surg 2022; 8:107-117. [PMID: 35782401 PMCID: PMC9242426 DOI: 10.1002/wjo2.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/30/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients. Methods Pubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti‐inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30‐day outcomes. Results A total of five studies representing 592 patients (MMA, n = 275; non‐MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30‐day mortality and readmission rates. Conclusion MMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient. Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesia and undesired side effects. Five studies (n = 592 patients) reported on the use of nonsteroidal anti‐inflammatory drugs, acetaminophen, anticonvulsants, local anesthetics, and corticosteroids. Four studies described a significant decrease in overall postoperative narcotic usage though subjective pain scores widely varied. Multimodal analgesia is a popular and effective strategy that may reduce dependence on opioids for the treatment of postoperative pain.
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Affiliation(s)
- Beatrice C. Go
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
| | - Cammille C. Go
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Kevin Chorath
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
| | - Alvaro Moreira
- Department of Pediatrics, Division of Neonatology University of Texas Health‐San Antonio San Antonio Texas USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
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Dahm V, Lui JT, Chen JM, Kiss A, Hamour AF, Le TN, Lin VY. Pain Management Following Otological Surgery: A Prospective Study of Different Strategies. Laryngoscope 2021; 132:204-211. [PMID: 34495556 DOI: 10.1002/lary.29845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/27/2021] [Accepted: 08/20/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The aim of this study was to prospectively assess pain and associated analgesic consumption after otological surgery comparing two prescription patterns. STUDY DESIGN A prospective nonrandomized consecutive cohort study. METHODS 125 adult patients undergoing ambulatory otologic surgery-cochlear implantation and endaural middle ear surgery, were assigned (according to surgeon's preference) and prospectively studied in two arms: 1) acetaminophen 500 mg + ibuprofen 400 mg; 2) acetaminophen 500 mg + codeine 30 mg. Pain levels, medication dose, disposal patterns of opioids, and suspected side effects were evaluated. RESULTS All patients reported mild to moderate pain. There was a statistically significant reduction of pain from day to day, which was on average 0.26 lower than the day before. Sufficient pain control could be achieved with both drug regimens with no significant difference in pain levels. Only 50% of patients who were prescribed opioids used them. Additionally, the median tablet intake was 3 tablets while 10 to 20 tablets were prescribed. The majority of patients (97%) did not dispose of these drugs safely. CONCLUSION Adequate analgesia was achieved in both arms of this study. Pain control following otologic surgery with a combination of acetaminophen and nonsteroidal anti-inflammatory drugs is recommended unless contraindications or chronic opioid use are present. If opioids such as codeine (30 mg) are prescribed, the amount should be reduced as low as possible, such as five tablets, based on our studied population. LEVEL OF EVIDENCE Level 3-a prospective nonrandomized consecutive cohort study Laryngoscope, 2021.
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Affiliation(s)
- Valerie Dahm
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Justin T Lui
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joseph M Chen
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Amr F Hamour
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Trung N Le
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Dahm V, Lui JT, Liepins R, Chen JM, Le TN, Arnoldner C, Lin VYW. Is otologic surgery contributing to the opioid epidemic? J Otolaryngol Head Neck Surg 2021; 50:38. [PMID: 34158125 PMCID: PMC8220669 DOI: 10.1186/s40463-021-00521-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background The opioid epidemic is a significant public health crisis challenging the lives of North Americans. Interestingly, this problem does not exist to the same extent in Europe. Surgeons play a significant role in prescribing opioids, especially in the context of post-operative pain management. The aim of this study was to compare the post-surgical prescribing patterns of otologists comparing Canada and Austria. Methods An online questionnaire was sent to 33 Canadian and 32 Austrian surgeons, who perform otologic surgery on a regular basis. Surgeons were asked to answer some questions about their background as well as typical prescribing patterns for postoperative pain medication for different ear surgeries (cochlear implant, stapedotomy, tympanoplasty). In addition, surgeons were asked about the typical use of local anesthetics for pain control at the end of a procedure. Otologists gave an estimate how confident they were that their therapy and prescriptions provide sufficient pain control to their patients. Results Analysis of the returned questionnaires showed that opioids are more commonly prescribed in Canada than in Austria. Nonsteroidal anti-inflammatory drugs are used for postoperative pain more regularly after ear surgery in Austria, as opposed to Canada. Some of the prescribed drugs by European otologists are not available in North America. The use of local anesthetics at the end of surgery is not common in Austria. Surgeons´ confidence that the prescribed pain medication was sufficient to control postoperative symptoms was higher in the group not prescribing opioids than in the group that did routinely prescribe opioids. Conclusion Prescribing patterns differ substantially between the two evaluated countries. This data suggests an opportunity to reduce opioid prescriptions after otologic surgeries. Studies to evaluate pain after these operations as well as efficacy of analgesics following ear surgery are an important next step. Graphical abstract ![]()
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Affiliation(s)
- Valerie Dahm
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Justin T Lui
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Rudolfs Liepins
- Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Joseph M Chen
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Trung N Le
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head & Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Vincent Y W Lin
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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Abstract
OBJECTIVE Evaluate opioid prescribing patterns following tympanoplasty/mastoidectomy and assess factors associated to recurrent opioid use. STUDY DESIGN Retrospective cohort study. SETTING National pharmaceutical database recording opioid fulfillment (Truven Health Marketscan Commercial Claims/Encounters and Medicare Claims/Encounters database). PARTICIPANTS Patients who 1) underwent tympanoplasty and/or mastoidectomy, 2) filled postoperative opioid prescriptions between 2011 and 2016, and 3) had no opioid prescriptions filled 60 days before surgery. Cohort 1 filled only one prescription and cohort 2 filled more than one prescription in the 12 months following surgery. Univariate/multivariate analysis was performed to assess for associations with recurrent opioid use. MAIN OUTCOME MEASURE(S) Opioid prescription details and recurrent opioid use. RESULTS The study included 398 patients (cohort 1 = 233, cohort 2 [recurrent opioid user] = 165). Hydrocodone 5 mg was most frequently used. The average duration opioids were prescribed was 5.8 days with an average quantity of tablets of 36.51. Recurrent opioid use in cohort 2 was associated with total morphine milligram equivalents prescribed/d in the first postoperative week (odds ratio [OR] = 1.02, p < 0.001), post-op chronic pain disorder (OR = 2.00, p = 0.04), post-op substance abuse (OR = 2.12, p = 0.05), and post-op anxiety (OR = 1.96, p = 0.02). CONCLUSION Recurrent opioid use following tympanoplasty/mastoidectomy is associated with the amount prescribed per day but not opioid type or duration of treatment. Postoperative diagnoses such as chronic pain disorder, substance abuse, or anxiety could be predictive of or coexistent with recurrent opioid use. Limiting opioids prescribed per day and use of anti-inflammatory medications could decrease the risk of recurrent opioid use.
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Abdel Shaheed C, Ferreira GE, Dmitritchenko A, McLachlan AJ, Day RO, Saragiotto B, Lin C, Langendyk V, Stanaway F, Latimer J, Kamper S, McLachlan H, Ahedi H, Maher CG. The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews. Med J Aust 2021; 214:324-331. [PMID: 33786837 DOI: 10.5694/mja2.50992] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions. STUDY DESIGN Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo-controlled trials. Conduct of systematic reviews was assessed with AMSTAR-2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. DATA SOURCES MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 - 30 April 2020. DATA SYNTHESIS We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0-10-point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, -0.3 points; 95% CI, -0.6 to -0.1 points) and after craniotomy (MD, -0.8 points; 95% CI, -1.4 to -0.2 points); there is moderate quality evidence for its efficacy in tension-type headache (pain-free at 2 hours: RR, 1.3; 95% CI, 1.1-1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5-3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, -0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9-7.4). CONCLUSIONS For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required. PROSPERO REGISTRATION CRD42015029282 (prospective).
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Affiliation(s)
| | | | | | - Andrew J McLachlan
- Centre for Education and Research on Ageing, University of Sydney, Sydney, NSW
| | - Richard O Day
- St Vincent's Hospital, Sydney, NSW.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW
| | | | - Christine Lin
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | | | | | - Jane Latimer
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Steven Kamper
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Hanan McLachlan
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Harbeer Ahedi
- Institute for Musculoskeletal Health, University of Sydney, Sydney
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Husain Q, Banks C, Gray ST. Nonopioid Adjuncts and Alternatives. Otolaryngol Clin North Am 2020; 53:831-842. [PMID: 32682534 DOI: 10.1016/j.otc.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.
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Affiliation(s)
- Qasim Husain
- Hackensack Meridian School of Medicine at Seton Hall University, Coastal Ear, Nose, and Throat, 100 Commons Way, Suite 210, Holmdel, NJ 07733, USA.
| | - Catherine Banks
- Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, University of New South Wales, Sydney, Australia
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
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Fotio Y, Palese F, Guaman Tipan P, Ahmed F, Piomelli D. Inhibition of fatty acid amide hydrolase in the CNS prevents and reverses morphine tolerance in male and female mice. Br J Pharmacol 2020; 177:3024-3035. [PMID: 32077093 DOI: 10.1111/bph.15031] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Fatty acid amide hydrolase (FAAH) is an intracellular serine amidase that terminates the signalling of various lipid messengers involved in pain regulation, including anandamide and palmitoylethanolamide. Here, we investigated the effects of pharmacological or genetic FAAH removal on tolerance to the anti-nociceptive effects of morphine. EXPERIMENTAL APPROACH We induced tolerance in male and female mice by administering twice-daily morphine for 7 days while monitoring nociceptive thresholds by the tail immersion test. The globally active FAAH inhibitor URB597 (1 and 3 mg·kg-1 , i.p.) or the peripherally restricted FAAH inhibitor URB937 (3 mg·kg-1 , i.p.) were administered daily 30 min prior to morphine, alone or in combination with the cannabinoid CB1 receptor antagonist AM251 (3 mg·kg-1 , i.p.), the CB2 receptor antagonist AM630 (3 mg·kg-1 , i.p.), or the PPAR-α antagonist GW6471 (4 mg·kg-1 , i.p.). Spinal levels of FAAH-regulated lipids were quantified by LC/MS-MS. Gene transcription was assessed by RT-qPCR. KEY RESULTS URB597 prevented and reversed morphine tolerance in both male and female mice. This effect was mimicked by genetic FAAH deletion, but not by URB937. Treatment with AM630 suppressed, whereas treatment with AM251 or GW6471, attenuated the effects of URB597. Anandamide mobilization was enhanced in the spinal cord of morphine-tolerant mice. mRNA levels of the anandamide-producing enzyme N-acyl-phosphatidylethanolamine PLD (NAPE-PLD) and the palmitoylethanolamide receptor PPAR-α, but not those for CB2 , CB1 receptors or FAAH, were elevated in spinal cord CONCLUSION AND IMPLICATIONS: FAAH-regulated lipid signalling in the CNS modulated opiate tolerance, suggesting FAAH as a potential target for opiate-sparing medications.
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Affiliation(s)
- Yannick Fotio
- Department of Anatomy and Neurobiology, School of Medicine, University of California, Irvine, Irvine, California
| | - Francesca Palese
- Department of Anatomy and Neurobiology, School of Medicine, University of California, Irvine, Irvine, California
| | - Pablo Guaman Tipan
- Department of Anatomy and Neurobiology, School of Medicine, University of California, Irvine, Irvine, California
| | - Faizy Ahmed
- Department of Anatomy and Neurobiology, School of Medicine, University of California, Irvine, Irvine, California.,Center for the Study of Cannabis, University of California, Irvine, Irvine, California
| | - Daniele Piomelli
- Department of Anatomy and Neurobiology, School of Medicine, University of California, Irvine, Irvine, California.,Department of Biological Chemistry, School of Medicine, University of California, Irvine, Irvine, California.,Center for the Study of Cannabis, University of California, Irvine, Irvine, California
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