Hospital opioid use predicts the need for discharge opioid prescriptions following laparoscopic bariatric surgery

Inpatient opioid use and pain control after robotic versus laparoscopic sleeve gastrectomy

BACKGROUND

During the past decade, the proportion of bariatric surgery performed robotically has been rising. However, the clinical benefits of the robotic approach over laparoscopy are uncertain. One area in need of further investigation is pain control after robotic versus laparoscopic bariatric surgery.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients undergoing laparoscopic or robotic sleeve gastrectomy at a single institution from October 2019 to August 2022. Inpatient opioid use was measured in morphine milliequivalents. Pain scores were collected by the nursing staff.

RESULTS

A total of 368 patients were included: 286 laparoscopic and 82 robotic surgery patients. The groups shared similar demographics. For the entire cohort, the mean age was 42 years, the body mass index was 50 kg/m2, and 79% were female. Mean operative time was significantly lower for laparoscopic surgeries (87.5 ± 47.3 minutes vs 109.3 ± 30.3 minutes; P < .01). The median total inpatient morphine milligram equivalents used was similar for both groups: 52.3 (31.5-77.0) for the laparoscopic group versus 40 (24-74.5) for robotic (P = .13). Mean postoperative pain scores (scale out of 10) were not significantly different between groups: 5.2 ± 1.7 (postoperative day 0) and 4.5 ± 1.7 (day 1) for laparoscopic patients versus 5.1 ± 2.0 (day 0) and 4.4 ± 1.8 (day 1) for robotic. The proportion of patients prescribed opioids at discharge was significantly higher for the laparoscopic group (75.2% vs 62.2%; P = .02). Other clinical outcomes, including duration of stay, 30-day readmissions, and visits to the emergency department, were not significantly different.

CONCLUSION

There is no difference in inpatient opioid use or pain scores between patients undergoing laparoscopic and robotic sleeve gastrectomy.

Effect of oxycodone combined with ultrasound-guided thoracic paravertebral nerve block on postoperative analgesia in patients with lung cancer undergoing thoracoscopic surgery: protocol for a randomised controlled study

INTRODUCTION

Postoperative pain is a main component influencing the recovery of patients with lung cancer. The combination of patient-controlled intravenous analgesia (PCIA) and paravertebral nerve block for postoperative analgesia in patients undergoing thoracoscopic lobectomy for lung cancer can achieve a satisfactory analgesic effect and promote early rehabilitation of patients. The objective is to investigate the optimal dose of oxycodone for PCIA combined with paravertebral nerve block, to achieve effective multimodal analgesia management in patients undergoing thoracoscopic lung cancer lobectomy.

METHODS AND ANALYSIS

This prospective, double-blind, single-centre, parallel-group, superiority study from 7 April 2023 to 31 December 2024 will include 160 participants scheduled for thoracoscopic lobectomy for lung cancer. Participants will be randomly assigned to four groups in a 1:1:1:1 ratio: OCA group (oxycodone: 0.5 mg/kg), OCB group (oxycodone: 1.0 mg/kg), OCC group (oxycodone: 1.5 mg/kg) and one sufentanil group (sufentanil: 2 µg/kg). Flurbiprofen 50 mg and ondansetron 16 mg are added to each group. All the drugs are diluted with 0.9% saline in a 100 mL volume, with a background infusion rate of 2 mL/hour, a bolus dose of 0.5 mL and a lockout interval of 15 min. The primary outcome is pain scores at rest and dynamic at 24 hours after surgery using a Numeric Rating Scale (NRS). Dynamic NRS scores are defined as NRS when coughing. NRS scores will be assessed at 2, 4, 12, 24 and 48 hours postoperatively. The secondary outcomes include the following variables: (1) NRS score at rest and dynamic at 2, 4, 12 and 48 hours postoperatively; (2) total dose of sufentanil or oxycodone consumption in PCIA; (3) the times of patient-controlled analgesia; (4) Ramsay Sedation Score (RSS) at 2, 4, 12, 24 and 48 hours after the surgery; (5) extubation time; (6) serum C-reactive protein and interleukin six levels; (7) incidence of postoperative nausea and vomiting; (8) incidence of itching; (9) incidence of respiratory depression and (10) gastrointestinal recovery (exhaust time).

ETHICS AND DISSEMINATION

The First Affiliated Hospital of Shandong First Medical University's Ethics Committee granted consent for this study (approval number: YXLL-KY-2022(116)). To enable widespread use of the data gathered, we plan to publish the trial's findings in an appropriate scientific journal after it is complete.

TRIAL REGISTRATION NUMBER

NCT05742256.

Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study

INTRODUCTION

In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients.

METHODS

This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption.

RESULTS

We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]).

CONCLUSION

This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Opioid Analgesics after Bariatric Surgery: A Scoping Review to Evaluate Physiological Risk Factors for Opioid-Related Harm

The persisting use of opioids following bariatric surgery has emerged as a prevalent complication, heightening the probability of opioid-related harm (ORM), such as opioid-related fatalities and prescription opioid use disorder (OUD). A comprehensive review of PubMed literature from 1990 to 2023 was conducted to pinpoint physiological influences on postoperative ORM. As a result, we found that patients undertaking bariatric operations often exhibit an inherently higher risk for substance use disorders, likely attributable to genetic predisposition and related neurobiological changes that engender obesity and addiction-like tendencies. Furthermore, chronic pain is a common post-bariatric surgery complaint, and the surgical type impacts opioid needs, with increased long-term opioid use after surgeries. Additionally, the subjective nature of pain perception in patients with obesity can distort pain reporting and the corresponding opioid prescription both before and after surgery. Furthermore, the postoperative alterations to the gastrointestinal structure can affect the microbiome and opioid absorption rates, resulting in fluctuating systemic exposure to orally ingested opioids. The prospect of ORM development post-bariatric surgery appears amplified due to a preexisting susceptibility to addictive habits, surgically induced pain, modified gut-brain interaction and pain management and the changed pharmacokinetics post-surgery. Further research is warranted to clarify these potential risk variables for ORM, specifically OUD, in the bariatric population.

Factors that influence discharge opioid prescribing among bariatric surgeons across Michigan

BACKGROUND

Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices.

METHODS

We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis.

RESULTS

At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery.

CONCLUSION

Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery

BACKGROUND

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME).

RESULTS

A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation.

CONCLUSION

Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.

Analgesic Efficacy of Gabapentin and Pregabalin in Patients Undergoing Laparoscopic Bariatric Surgeries: a Systematic Review and Meta-analysis

This meta-analysis investigated the effect of oral gabapentinoids (i.e., pregabalin and gabapentin) on analgesic consumption (i.e., primary outcome) and pain relief (i.e., secondary outcome) in patients following bariatric surgery. Analysis of five eligible trials published between 2010 and 2019 including 363 participants receiving gabapentinoids revealed a significantly lower morphine consumption [mean difference (MD) =  - 15.1 mg, p = 0.004; evidence certainty: low] and risk of nausea/vomiting [risk ratio (RR) = 0.49, p = 0.002; evidence certainty: high] at postoperative 6-24 h. There was also a lower pain score at postoperative 0-4 h (MD =  - 1.41, p < 0.00001; evidence certainty: low) and 6-12 h (MD =  - 0.9, p = 0.007; evidence certainty: low) compared with controls, while pain severity at postoperative 24 h was comparable between two groups. In summary, preoperative oral gabapentinoids optimized postoperative pain outcomes and reduced risk of nausea/vomiting following bariatric surgery.

Feasibility of an Opioid Sparing Discharge Protocol Following Laparoscopic Bariatric Surgery

BACKGROUND

Opioids are commonly prescribed after laparoscopic bariatric surgery but have untoward effects including dependence and diversion. Prior investigation revealed that over three-fourths of discharge opioids prescribed to our patients went unused.

OBJECTIVES

To determine the feasibility of an opioid sparing discharge protocol following laparoscopic bariatric surgery.

METHODS

A total of 212 opioid-naïve patients undergoing laparoscopic bariatric surgery were examined and divided into two groups; 106 prior to (Cohort A) and 106 after implementation of an opioid sparing discharge protocol (Cohort B). Opioids were converted to morphine milligram equivalents (MME) and post-operative consumption was examined. Data was described as mean ± standard deviation.

RESULTS

No patients in Cohort B and 54.7% (58) in Cohort A received an opioid discharge prescription (37.5 MME). Of the 154 patients that remained, only 1.3% (2) received one after discharge. Cohort A took greater amounts of opioids than Cohort B after discharge (4.74 ± 11 vs. 0.21 ± 2 MME; p < 0.001). During hospitalization, Cohort A took greater amounts of opioids (6.92 ± 11 vs. 2.74 ± 5 MME; p < 0.001) but lower amounts of methocarbamol (759 ± 590 vs. 966 ± 585 mg; p = 0.011). No patient requested an opioid prescription refill or presented to the emergency room secondary to pain.

CONCLUSION

Following laparoscopic bariatric surgery, an opioid sparing discharge protocol is feasible with < 2% of patients receiving opioids after discharge and no increase in emergency room visits. Education regarding these protocols may impact the amount of opioids taken during hospitalization.

Perioperative Pain Management in Bariatric Anesthesia

Weight loss (bariatric) surgery is the most commonly performed elective surgical procedure in patients with morbid obesity. In this review, we provide an evidence-based update on perioperative pain management in bariatric anesthesia. We mention some newer preoperative aspects—medical optimization, physical preparation, patient education, and psychosocial factors—that can all improve pain management. In the intraoperative period, with bariatric surgery being almost universally performed laparoscopically, we emphasize the use of non-opioid adjuvant infusions (ketamine, lidocaine, and dexmedetomidine) and suggest some novel regional anesthesia techniques to reduce pain, opioid requirements, and side effects. We discuss some postoperative strategies that additionally focus on patient safety and identify patients at risk of persistent pain and opioid use after bariatric surgery. This review suggests that the use of a structured, step-wise, severity-based, opioid-sparing multimodal analgesic protocol within an enhanced recovery after surgery (ERAS) framework can improve postoperative pain management. Overall, by incorporating all these aspects throughout the perioperative journey ensures improved patient safety and outcomes from pain management in bariatric anesthesia.