Analgesic potential of transdermal nicotine patch in surgery: a systematic review and meta-analysis of randomised placebo-controlled trials

Ecological momentary assessment of cigarette smoking behavior and pain intensity among individuals with chronic back pain who smoke

Chronic pain affects ∼20% of the adult population and is associated with smoking. Smoking and pain worsen each other in the long term, but short-term temporal associations between smoking and pain throughout the day are unclear. Understanding these relationships may inform strategies for managing comorbid smoking and pain. Participants with chronic back pain who smoke responded to 81.5% of ecological momentary assessment (EMA) prompts delivered 5 times daily. Independent variables were: 1) urge to smoke (from 1-9), 2) intention to smoke (about to smoke, not about to smoke), and 3) smoking recency (smoked <30 min ago, smoked >30 min ago); smoking now was included as a separate category in models 2 and 3. Associations with pain intensity (from 1-9) were estimated using multi-level models, including an interaction term between the independent variable and Pain and Smoking Inventory score (PSI). Urge to smoke was associated with increased pain intensity (β=0.10 [SE=0.02], p<0.001), and this difference was greater for individuals with higher PSI scores (β=0.03 [0.01], p=0.003). Not being about to smoke was associated with lower pain intensity than smoking now (β=-0.29 [0.09], p=0.001). Compared to smoking now, both smoking <30 min ago (β=-0.30 [0.09], p=0.001) and smoking >30 min ago (β=-0.23 [0.11], p=0.029) were associated with lower pain intensity. Smoking urges may increase pain intensity (or vice versa), especially when people perceive strong relationships between smoking and pain. Smoking may also attenuate perceived pain. Further research is needed on interventions that combine tailored smoking cessation treatments and behavioral pain management strategies. PERSPECTIVE: This analysis of momentary data reported throughout the day by people with back pain who smoke revealed novel insights into short-term relationships between pain and smoking. Study results can inform future treatment development for individuals with chronic pain who smoke.

Effect of Nicotine Replacement Therapy on Perioperative Pain Management and Opioid Requirement in Abstinent Tobacco Smokers Undergoing Spinal Fusion: A Double-blind Randomized Controlled Trial

BACKGROUND

Smoking negatively impacts postoperative outcomes but acute abstinence from smoking during hospitalization can increase postoperative pain, lower pain thresholds, disrupt pain management, and trigger hyperalgesia due to abrupt nicotine withdrawal in tobacco users. Nicotine replacement therapy has been recommended to minimize these complications. We hypothesized that a high dose (21 mg/24 h) transdermal nicotine (TDN) patch would reduce postoperative pain and opioid requirements.

METHODS

One hundred abstinent tobacco smokers undergoing single-level spinal fusion were randomized into placebo (n=50) and nicotine treatment (n=50) groups. Placebo and TDN patches were applied 24 hours before surgery until 48 hours after surgery. Primary outcomes were postoperative pain scores and opioid (morphine) consumption, and serum nicotine levels. The relationship between daily tobacco use and pain and opioid requirements, and between serum nicotine levels and morphine consumption, were assessed.

RESULTS

Postoperative pain scores at rest and on movement were lower in the nicotine group than in the placebo group at 6 hours, 12 hours, and 24 hours after surgery (P<0.05). Postoperative morphine consumption was lower in the nicotine group than in the placebo group (9.92 ± 4.0 vs. 15.9 ± 5.0 mg, respectively; P=0.0002). There was a positive correlation between the number of cigarettes smoked per day and postoperative pain scores at rest (r = 0.4553; P = 0.0001) and during movement and a negative correlation between serum nicotine concentration and postoperative morphine consumption (r =-0.3664; P = 0.0089).

CONCLUSIONS

TDN patches (21 mg/24 h) reduced postoperative pain and opioid requirements in abstinent tobacco smokes undergoing spinal fusion.

The Anti-Nociceptive Effects of Nicotine in Humans: A Systematic Review and Meta-Analysis

BACKGROUND

Pain can have a serious impact on a patient's physical, mental, and social health, often causing their quality of life to decline. Various nicotine dosage forms, such as nicotine patches and nasal spray, have been developed and used as analgesics in clinical settings. However, there is controversy over the anti-nociceptive effects of nicotine among different clinical trials. The purpose of this meta-analysis is to quantify the analgesic effect of nicotine patches, nicotine nasal spray, and tobacco smoking on pain in humans.

METHODS

Relevant articles published in English prior to July 2023 were identified using the PubMed, Cochrane Library, and Embase online databases in accordance with PRISMA (2020) guidelines. Two reviewers independently screened and selected studies, extracted data, and assessed the quality of the included studies using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). RStudio was used for data synthesis, heterogeneity assessment, sensitivity analysis, publication bias assessment, trim-and-fill analyses, and generating forest plots.

RESULTS

Sixteen eligible articles, including k = 5 studies of pain tolerance (n = 210), k = 5 studies of pain threshold (n = 210), and k = 12 studies of pain scores (N = 1249), were included for meta-analysis. Meta-analytic integration for pain threshold (Hedges' g = 0.28, 95% CI = 0-0.55, Z = 1.99, p = 0.05) and pain tolerance (Hedges' g = 0.32, 95% CI = 0.05-0.59, Z = 2.30, p = 0.02) revealed that nicotine administered via tobacco smoke generated acute analgesic effects to thermal stimuli. Meta-analytic integration for pain scores revealed that nicotine had a weak anti-nociceptive effect on postoperative pain of -0.37 (95% CI = -0.77 to 0.03, Z = -1.80) but with no statistical significance (p = 0.07). In addition, a limited number of included studies revealed that long-term smoking produced hyperalgesia that may be characterized as small to medium in magnitude (Hedges' g = 0.37, 95% CI = 0.29-0.64, Z = 5.33, p < 0.01).

CONCLUSION

These results help to clarify the mixed outcomes of trials and may ultimately inform the treatment of pain. We observed that acute nicotine administration prolonged the laboratory-induced pain threshold and tolerance time and may mildly relieve postoperative pain. In addition, long-term tobacco smoking may have a nociceptive effect on different types of chronic pain. More research is needed to determine the anti-nociceptive effects of nicotine in humans, and to understand the optimal timing, dose, and method of delivery of nicotine.