Decreased pain tolerance before surgery and increased postoperative narcotic requirements in abstinent tobacco smokers

Establishment and Validation of Risk Prediction Models for Postoperative Pain After Endoscopic Submucosal Dissection: A Retrospective Clinical Study

Objective

Postoperative pain is a common complication in endoscopic submucosal dissection (ESD) patients. This study aimed to develop and validate predictive models for postoperative pain associated ESD.

Methods

We retrospectively constructed a development cohort comprising 2162 patients who underwent ESD at our hospital between January 2015 and April 2022. The dataset was randomly divided into a training set (n = 1541) and a validation set (n = 621) in a 7:3 ratio. The bidirectional stepwise regression with Akaike's information criterion (AIC) and multivariate logistic regression analysis were used to screen the predictors of post-ESD pain and construct three nomograms. We evaluated the model's discrimination, precision and clinical benefit through receiver operating characteristic (ROC) curves, calibration plots, Hosmer-Lemeshow (HL) goodness-of-fit test and decision curve analysis (DCA) in internal validation.

Results

The proportion of patients developing postoperative pain in the training and testing data set was 25.6% and 28.5%, respectively. Three nomograms were constructed according to the final logistic regression models. The clinical prediction models for preoperative risks, preoperative and intraoperative risks, and perioperative risks consisted of seven, nine and six independent predictors, respectively, after bidirectional stepwise elimination. The models demonstrated the AUC of 0.794 (95% CI 0.768-0.820), 0.823 (95% CI 0.799-0.847) and 0.817 (95% CI 0.792-0.842) in the training cohort and 0.702 (95% CI 0.655-0.748), 0.705 (95% CI 0.659-0.752) and 0.747 (95% CI 0.703-0.790) in the validation cohort. The calibration plot, HL and DCA demonstrated the model's favorable clinical applicability.

Conclusion

We developed and validated three robust nomogram models, which might identify patients at risk of post-ESD pain and promising for clinical applications.

Predictors of postoperative opioid use in ventral and incisional hernia repair

BACKGROUND

One in two ventral and incisional hernia repair (VIHR) patients have preoperative opioid prescription within a year before procedure. The study's aim was to investigate risk factors of increased postoperative prescription filling in patients with or without preoperative opioid prescription.

METHODS

VIHR cases from 2013 to 2017 were reviewed. State prescription drug monitoring program data were linked to patient records. The primary endpoint was cumulative opioid dose dispensed through post-discharge day 45. Morphine milligram equivalent (MME) was used for uniform comparison.

RESULTS

205 patients were included in the study (average age 53.5 years; 50.7% female). Over 35% met criteria for preoperative opioid use. Preoperative opioid tolerance, superficial wound infection, current smoking status, and any dispensed opioids within 45 days of admission were independent predictors for increased postoperative opioid utilization (p < 0.001).

CONCLUSION

Preoperative opioid use during 45-day pre-admission correlated strongly with postoperative prescription filling in VIHR patients, and several independent risk factors were identified.

A nomogram for predicting residual low back pain after percutaneous kyphoplasty in osteoporotic vertebral compression fractures

To establish a risk prediction model for residual low back pain after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures. We used retrospective data for model construction and evaluated the model using internal validation and temporal external validation and finally concluded that the model had good predictive performance.

INTRODUCTION

The cause of residual low back pain in patients with osteoporotic vertebral compression fractures (OVCFs) after PKP remains highly controversial, and our goal was to investigate the most likely cause and to develop a novel nomogram for the prediction of residual low back pain and to evaluate the predictive performance of the model.

METHODS

The clinical data of 281 patients with OVCFs who underwent PKP at our hospital from July 2019 to July 2020 were reviewed. The optimal logistic regression model was determined by lasso regression for multivariate analysis, thus constructing a nomogram. Bootstrap was used to perfomance the internal validation; receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to assess the predictive performance and clinical utility of the model, respectively. Temporal external validation of the model was also performed using retrospective data from 126 patients who underwent PKP at our hospital from January 2021 to October 2021.

RESULTS

Lasso regression cross-validation showed that the variables with non-zero coefficients were the number of surgical vertebrae, preoperative bone mineral density (pre-BMD), smoking history, thoracolumbar fascia injury (TLFI), intraoperative facet joint injury (FJI), and postoperative incomplete cementing of the fracture line (ICFL). The above factors were included in the multivariate analysis and showed that the pre-BMD, smoking history, TLFI, FJI, and ICFL were independent risk factors for residual low back pain (P < 0.05). The ROC and calibration curve of the original model and temporal external validation indicated a good predictive power of the model. The DCA curve suggested that the model has good clinical practicability.

CONCLUSION

The risk prediction model has good predictive performance and clinical practicability, which can provide a certain basis for clinical decision-making in patients with OVCFs.

The Effect of Smoking Cessation on Acute Pain: A Systematic Review

Smoking is a known risk factor for developing various pain-related disorders. However, acute pain often triggers the craving for cigarette consumption, resulting in a positive feedback mechanism. In addition, there is evidence of decreased pain tolerance during the early stages of abstinence. Therefore, in this study, we aimed to investigate whether a period of decreased pain tolerance and increased pain intensity occurs during smoking cessation. A systematic literature search was conducted through PubMed and Web of Science databases for controlled studies investigating the influence of smoking cessation on acute (defined as pain presentation of < 3 months) and postoperative pain. The outcomes of interest included pain perception threshold, pain tolerance, pain intensity, and postoperative opioid requirements. The search strategy yielded 1478 studies, of which 13 clinical studies met our inclusion criteria. The included studies collectively represented data from 1721 participants from four countries. Of these, 43.3% of the included individuals were females. The mean age of the included subjects was 44.2 ± 8.2 years. The duration of smoking cessation varied considerably. The shortest duration was 2 h; others investigated the effect after more than 1 month of smoking cessation. Smokers had a history of 14.6 ± 9.9 years of nicotine abuse. The mean number of daily smoked cigarettes was 17.5 ± 10.3. Most studies examined in this systematic review show a negative influence of smoking cessation on acute pain. However, the affected pain modalities, the duration of the altered pain perception, and whether male and female smokers are equally affected could not be ascertained due to high heterogeneity and few available studies.

Subcostal transversus abdominis plane block for postoperative analgesia in liver transplant recipients: a before-and-after study

INTRODUCTION

Postoperative pain management after orthotopic liver transplantation is complex due to impaired liver function and frequent acute kidney dysfunction. Subcostal transversus abdominis plane (TAP) block may be of interest in this population. The aim of this study was to evaluate the impact of subcostal TAP block on opioid consumption after liver transplantation.

METHODS

We conducted a before-and-after single center study. During the first period, we included patients whom did not receive an analgesic TAP block. During the second period, we included those with bilateral ultrasound-guided subcostal TAP block (20 mL ropivacaïne 0.2% each side). Patients requiring sedation within 48 hours of surgery as well as patients with combined liver and kidney transplants or skin-only closures were excluded. The primary outcome was cumulative oral morphine consumption within 48 hours after surgery. Secondary outcomes included pain scores and TAP block-related complications.

RESULTS

A total of 132 patients were included in the non-TAP block group and 78 patients in the TAP block group. The median oral morphine equivalent consumption (IQR) within 48 hours following surgery was 74 mg (39; 112) for the non-TAP block group and 50 mg (20; 80) for the TAP block group (p<0.001). There was no difference in pain scores between the two groups. No complications related to the TAP block were reported.

CONCLUSION

Subcostal TAP block appears to have a small opioid reducing effect after orthotopic liver transplantation surgery.

Consensus statement on smoking cessation in patients with pain

Smoking is closely associated with the development of various cancers and tobacco-related illnesses such as cardiovascular and respiratory disorders. However, data are scarce on the relationship between smoking and both acute and chronic pain. In addition to nicotine, tobacco smoke contains more than 4000 different compounds. Although nicotine is not the sole cause of smoking-induced diseases, it plays a critical role in pain-related pathophysiology. Despite the acute analgesic effects of nicotine, long-term exposure leads to tolerance and increased pain sensitivity due to nicotinic acetylcholine receptor desensitization and neuronal plastic changes. The purpose of smoking cessation interventions in smoking patients with pain is primarily not only to reduce their pain and associated limitations in activities of daily living, but also to improve the outcomes of underlying pain-causing conditions and reduce the risks of tobacco-related disorders. This statement aims to summarize the available evidence on the impact of smoking on pain and to inform medical professionals of the significance of smoking cessation in patients with pain.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

Mechanism of Electroacupuncture Analgesia on Nicotine Withdrawal-Induced Hyperalgesia in a Rat Model

Purpose

This study aimed to investigate the analgesic effect and mechanism of electroacupuncture (EA) in nicotine withdrawal-induced hyperalgesia rats.

Methods

Behavioral testing was conducted twice a week for 7 weeks during nicotine administration using von Frey filaments. Electroacupuncture at the bilateral “Zusanli” and “Taichong” points was applied daily for 3 days during nicotine withdrawal. Western blot analysis and immunohistology were used to determine expression levels of pain-related factors in the spinal cord and midbrain periaqueductal gray (PAG).

Results

Behavioral tests showed that electroacupuncture had a significant analgesic effect on nicotine withdrawal-induced hyperalgesic rats. Western blot results demonstrated that, in hyperalgesic rats, the expressions of nicotinic acetylcholine receptors (subunits: nAChR α7, α4, or β2) decreased in the spinal cord, nAChR α7, and β2 decreased in PAG. The proinflammatory factor cyclooxygenase 2 (COX2) and the activated microglia (ionized calcium-binding adaptor molecule 1, Iba1 positive cells) increased in the spinal cord and PAG compared to controls. After electroacupuncture treatment, nAChR α7 and nAChR β2 expressions increased significantly, and COX2 and Iba1 expressions decreased in the spinal cord. Compared with the nonelectroacupuncture nicotine withdrawal group, electroacupuncture stimulation increased the expression of nAChR α7 and nAChR α4 in the PAG of rats with electroacupuncture. Immunohistochemical results confirmed that electroacupuncture reversed nicotine withdrawal-induced changes in nAChR α7 positive neurons and Iba1-positive microglia in the dorsal horn of the spinal cord.

Conclusion

Electroacupuncture treatment has an analgesic effect on nicotine withdrawal-induced pain in nicotine-dependent rats. The mechanism of analgesia of the electroacupuncture treatment relates to the increased expression of nAChR α7 and nAChR β2 proteins in the spinal cord, nAChR α7 in the PAG, and decreased expression of Iba1 and COX2 protein in the spinal cord.

A practical guide for perioperative smoking cessation

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

A nomogram for short-term recurrent pain after percutaneous vertebroplasty for osteoporotic vertebral compression fractures

In clinical practice, it was found that some patients experienced short-term recurrent pain (SRP) in the original site after PVP treatment. This study was designed to develop and validate a nomogram for predicting the potential risks of SRP after PVP, which may help to provide a painless postoperative experience and personalized health management for patients with OVCF.

INTRODUCTION

With the aging of China's population, the incidence of osteoporotic vertebral compression fractures (OVCF) has increased significantly. Percutaneous vertebroplasty (PVP) has been widely accepted due to its minimally invasive, rapid, and effective characteristics. However, it has been found that some patients have short-term recurrent pain (SRP) in the original site after surgery in practical clinical work.

METHODS

We retrospectively reviewed the clinical data of OVCF patients who were treated with PVP in our center from January 1st, 2019, to December 30th, 2020. A total of 296 patients were enrolled in the study cohort, and patients were randomly divided into the training set (70%) and validation set (30%). Univariate and multivariate logistic regression analyses were used to determine the risk factors of SRP, and a nomogram predictive model was established accordingly. The model was evaluated by calibration curve, receiver operation characteristic (ROC) curve, and decision curve analysis (DCA).

RESULTS

Among the 296 patients, 83 (27.85%) patients experienced SRP after surgery. The independent risk factors included fracture segments (OR: 14.148, 95%CI: 1.532-130.661; p < 0.019), number of surgical vertebrae (OR: 7.896, 95%CI: 3.007-20.729; p < 0.001; (OR: 12.563, 95%CI: 2.223-70.993; p = 0.004), and smoking (OR: 3.833, 95%CI: 1.219-12.052; p = 0.022). The AUC of the prediction model was 0.819 in the training set and 0.794 in the validation set. The calibration curve and DCA indicated the good performance of this nomogram.

CONCLUSION

The nomogram prediction model had satisfactory accuracy and clinical utility, which may benefit clinical decision-making for the treatment of OVCF and strengthen patient education.

Magnetic resonance imaging for smoking abstinence: symptoms, mechanisms, and interventions

Tobacco smoking is the leading preventable cause of morbidity and mortality worldwide. Although a number of smokers are aware of the adverse outcomes of smoking and express a strong desire to stop smoking, most smoking quit attempts end in relapse within the first few days of abstinence, primarily resulting from the aversive aspects of the nicotine withdrawal syndrome. Therefore, studying the neural mechanisms of smoking abstinence, identifying smokers with heightened relapse vulnerability prior to quit attempts, and developing effective smoking cessation treatments appear to be promising strategies for improving the success of quit attempts. In recent years, with the development of magnetic resonance imaging, the neural substrates of smoking abstinence have become extensively studied. In this review, we first introduce the psychophysiological changes induced by smoking abstinence, including affective, cognitive, and somatic signs. We then provide an overview of the magnetic resonance imaging-based evidence regarding abstinence-related functional changes accompanied by these psychophysiological changes. We conclude with a discussion of the neural markers that could predict relapse during quit attempts and a summary of the psychophysiological interventions that are currently often used to help with smoking cessation. This review extends our understanding of the role of the central nervous system in smoking abstinence.

I smoke to cope with pain: patients' perspectives on the link between cigarette smoking and pain

BACKGROUND

For people with chronic pain, cigarette smoking is associated with greater pain intensity and impairment. Researchers have hypothesized a reciprocal relationship in which pain and smoking exacerbate each other, resulting in greater pain and increased smoking. This study aimed to qualitatively examine patient perspectives on this association.

METHODS

A retrospective thematic analysis of smoking cessation counseling notes for 136 veterans in the Pain and Smoking Study, a tailored smoking cessation trial, was conducted. A validated codebook was applied to each counseling note by four independent coders using Atlas.ti (Atlas.ti, Berlin, Germany). Coders participated in a consensus-forming exercise with salient themes validated among the wider research team.

KEY RESULTS

Participants averaged 60 years of age (range 28-77 years) and were 9% female. The median number of cigarettes smoked per day was 15, with a mean pain intensity score in the last week (from 0-10) of 5.1. While not all patients acknowledged a connection between pain and smoking, we found that (1) pain motivates smoking and helps manage pain-related distress, as a coping strategy and through cognitive distraction, and (2) pain motivates smoking but smoking does not offer pain relief. Concerns about managing pain without smoking was identified as a notable barrier to cessation.

CONCLUSION

Many patients with chronic pain who smoke readily identified pain as a motivator of their smoking behavior and are reluctant to quit for this reason. Integrated interventions for smokers with pain should address these perceptions and expectancies and promote uptake of more adaptive self-management strategies for pain.

Predictors of severe postoperative pain after orthopedic surgery in the immediate postoperative period

AIM

Severe pain in the immediate postoperative period can negatively affect patients' quality of recovery, prolong hospital stay, and increase the risk of developing persistent pain. This study aimed to examine the predictors of severe postoperative pain in the immediate postoperative period among orthopedic trauma patients.

METHODS

A prospective observational study design was used. Data were collected from 153 patients that underwent orthopedic surgery procedures. Pain scores were assessed by a numeric pain scale at 45 min in the Post Anesthesia Care Unit. Physical health status was measured by the American Society of Anesthesiologists Status Classification System, and total dose of opioids (converted to morphine equivalents) and other demographic and clinical characteristics were recorded from medical records.

RESULTS

Preoperative smoking and physical health status were statistically significant predictors of severe postoperative pain in the immediate postoperative period. The odds of severe postoperative pain for smokers were 2.42 times the odds of nonsmokers. Patients with severe systemic disease showed 4.27 times lower odds of severe pain than more healthy patients.

CONCLUSION

Preoperative predictors of severe postoperative pain should be considered when assessing and treating orthopedic patients postoperatively to assure adequate pain relief.

Nicotine withdrawal induces hyperalgesia via downregulation of descending serotonergic pathway in the nucleus raphe magnus

Patients deprived of cigarettes exhibit increased pain sensitivity during perioperative periods, yet the underlying neuroanatomical and molecular bases of this hypersensitivity are unclear. The present study showed that both the mechanical withdrawal threshold (MWT) and thermal withdrawal latency (TWL) were significantly decreased in a rat model of nicotine withdrawal. These rats showed less tryptophan hydroxylase 2 (TPH2) positive neurons and reduced TPH2 expression in the nucleus raphe magnus (NRM), and thus resulted in decreased 5-hydroxytryptamine (5-HT) levels in cerebrospinal fluid. Intrathecal injection of 5-HT or NRM microinjection of TPH-overexpression adeno-associated virus alleviated nicotine withdrawal-induced hyperalgesia, whereas 5-HT receptor pharmacological blockade by methysergide (a 5-HT receptor antagonist) exacerbated hypersensitivity and diminished the difference between the two groups. Together, these data indicate that hyperalgesia after nicotine withdrawal is mediated by declined descending serotonergic pathways in the NRM. This provides a new perspective to improve the postoperative pain management of patients, especially the smokers.

[Relation between tobacco smoking and pain: A narrative review of the scientific literature]

INTRODUCTION

Tobacco smoking and pain have an intimate, complex, two-way interaction. The purpose of this narrative review of the literature is to present what is currently understood about the relationship.

STATE OF KNOWLEDGE

Tobacco smoking (and the associated chronic exposure to nicotine) has been defined as a risk factor for chronic pain, involving nociceptive sensitisation. For people who smoke, pain will be both a motivational factor for tobacco consumption and a barrier to tobacco use cessation. Conversely, nicotine (acute exposure) has clearly demonstrated analgesic properties, mediated in particular by activation of nicotinic acetylcholine receptors.

PERSPECTIVES

The management of pain in people who smoke is still largely unaddressed, and further studies will be needed to develop effective strategies for tobacco use cessation in this context. Nicotine and modulators of nicotinic acetylcholine receptors represent innovative strategies for the discovery of new analgesics.

CONCLUSIONS

The effects of smoking on pain, chronic nociceptive sensitisation and acute analgesia, serve to maintain tobacco consumption via negative reinforcement. A holistic therapeutic strategy is necessary to maximise the likelihood of successful smoking cessation.

IRF8 is crucial for the nicotine withdrawal-induced hyperalgesia in mice

Background

Interferon regulatory factor 8 (IRF8) is involved in the pathogenesis of neuropathic pain. However, whether and how IRF8 can regulate the nicotine withdrawal (NTW)-induced hyperalgesia has not been clarified.

Methods

C57BL/6 mice were randomized and injected subcutaneously with saline (Control) or nicotine (3 mg/kg) three times per day for 7 consecutive days, followed by injection with mecamylamine to induce NTW. Their paw withdrawal latencies (PWLs) were measured, and the relative levels of IRF8 expression in the spinal cord tissues were determined longitudinally by western blot. The numbers of IRF8+ cells in the spinal cord tissues were examined. In addition, the NTW mice were randomized and infused intrathecally with vehicle saline (NS), control lentivirus or lentivirus for the expression of IRF8-specific shRNA for three days. Their PWLs, microglia activation, IRF8 and P2X4R and BDNF expression in the spinal cord tissues were determined.

Results

In comparison with the Control mice, the NTW significantly decreased the PWLs but increased the relative levels of IRF8 expression and the numbers of IRF8+ cells in the spinal cord tissues of mice. IRF8-silencing significantly mitigated the NTW-decreased PWLs and attenuated the NTW-enhanced microglia activation and P2X4R and BDNF expression in the spinal cord tissues of mice.

Conclusions

Spinal IRF8 is crucial for the NTW-induced hyperalgesia by enhancing microglia activation and spinal P2X4R and BDNF expression in mice. The IRF8/P2X4R/BDNF axis may be potential therapeutic targets for postoperative pain of smokers.

Independent association of tobacco use with opioid use disorder in patients of European ancestry with chronic non-cancer pain

BACKGROUND

The harms associated with prescription opioid abuse have become a public health crisis. There is a need for evidence-based objective markers of the risk of opioid use disorder (OUD) in patients with pain receiving opioid treatment. The objective of this study was to evaluate the independent association of tobacco use and OUD in patients with chronic non-cancer pain.

METHODS

This cross-sectional naturalistic study evaluated 798 adults ≥ 18 years with chronic non-cancer pain treated with long-term opioid therapy (≥ 6 months) who either developed an OUD (cases, n = 216) or displayed no evidence of an OUD (controls, n = 582). The primary outcome was presence of OUD. In addition to current self-reported tobacco use (primary predictor), covariates included demographics, pain severity, and psychiatric history. Data were collected between November 2012 and September 2018.

RESULTS

Current tobacco use independently was strongly associated with OUD [odds ratio (OR) 14.0, 95 % confidence interval (CI) 9.5-20.6, p < 0.001], and this association remained significant after adjusting for other risk factors [adjusted odds ratio (aOR) 7.6, 95 % CI 4.8-12.2, p < 0.001]. Other factors associated independently with development of OUD included age, marital status, financial status, education and pain severity.

CONCLUSIONS AND RELEVANCE

Current tobacco use is significantly associated with OUD in patients with chronic pain receiving long-term opioid therapy.

Menthol cigarette use and pain reporting among African American adults seeking treatment for smoking cessation

Nicotine has acute pain-relieving properties, and tobacco smokers often report using cigarettes to cope with pain. The proportion of smokers using menthol cigarettes has increased in recent years, and there is reason to suspect that menthol may enhance the analgesic effects of nicotine. Up to 90% of African American smokers report using menthol cigarettes, and African Americans tend to report more severe pain and greater difficulty quitting. Yet no known research has examined the relationship between menthol cigarette use and pain reporting. Thus, the goal of the current study was to test associations between menthol (vs. nonmenthol) cigarette use and pain among a sample of African American smokers. Current daily cigarette smokers (N = 115; 70% male; Mage = 47.05; MCPD = 15.2) were recruited to participate in a smoking cessation study. These data were collected at the baseline session. Daily menthol (vs. nonmenthol) cigarette use was associated with lower current pain intensity, lower average and worst pain over the past 3 months, and less pain-related physical impairment over the past 3 months. This study demonstrates that menthol (vs. nonmenthol) cigarette use is associated with less pain and pain-related functional interference among African American smokers seeking tobacco cessation treatment. Future research is needed to examine the potential acute analgesic effects of menthol versus nonmenthol cigarette use, examine temporal covariation between menthol cigarette use and pain reporting, and test whether pain-relevant processes contribute to the maintenance of menthol cigarette smoking among those with and without chronic pain. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effect of preoperative smoking cessation on postoperative pain outcomes in elderly patients with high nicotine dependence

OBJECTIVE

To investigate the effect of smoking cessation before surgery on postoperative pain and analgesic consumption after thoracoscopic radical resection of lung cancer in elderly patients with high nicotine dependence.

METHODS

A total of 107 male patients, ages 60 to 70 years, undergoing elective thoracoscopic radical lung cancer surgery from July 2017 to July 2018 were enrolled into 3 groups: group A (highly nicotine-dependent and discontinued smoking <3 weeks before surgery, n = 36), group B (highly nicotine-dependent and discontinued smoking >3 weeks before surgery, n = 38), and group C (nonsmokers, n = 33). Postoperative sufentanil consumption, visual analog scale (VAS) pain scores at rest and during cough, rescue analgesia, opioid-related adverse events, and patient satisfaction were assessed from 0 to 48 h postoperatively.

RESULTS

Patient characteristics were comparable among the 3 groups. Sufentanil consumption and VAS pain scores from postoperative 0 to 48 h were significantly higher in groups A and B than in group C. In addition, group B had lower sufentanil consumption and pain scores than group A. No differences in the need for rescue analgesia, patient satisfaction, or occurrence of postoperative adverse events, including nausea, vomiting, respiratory depression, and oversedation, were observed among the 3 groups.

CONCLUSION

Compared with nonsmokers, highly nicotine-dependent male patients who were deprived of cigarettes experienced more severe pain and required treatment with more sufentanil after thoracoscopic radical lung cancer surgery. Moreover, preoperative smoking cessation at least 3 weeks before surgery led to better postoperative pain outcomes than smoking cessation within 3 weeks of surgery.

[Peri-operative management of smoking]

Smoking is a public health issue, especially during the perioperative period. Tobacco increases the risk of hospital mortality by 20% and major postoperative complications by 40%. Active smoking is associated with respiratory complications particularly bronchospasm and pneumonia, but also all surgical complications as scar infections, local thrombosis, suture release and delayed bone healing. The perioperative period is an opportunity to stop smoking. Smoking cessation should always be recommended, regardless of the surgery and the date of intervention. All health professionals, doctors, surgeons, anesthetists, but also nurses and physiotherapists, must inform smokers of the benefits of stopping smoking, offer them a dedicated support and a personalized follow-up. Tobacco consultation and the prescription of nicotine replacement increase the rate of smoking cessation. Stopping smoking reduces perioperative complications and is associated with health benefits that increase with time.