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Admiraal M, Smulders PSH, Rutten MVH, de Groot EK, Heine Y, Baumann HM, van der Vegt VHC, Halm JA, Hermanns H, Schepers T, Hollmann MW, Hermanides J, Ten Hoope W. The effectiveness of ambulatory continuous popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia in patients undergoing foot or ankle surgery (CAREFREE trial); a randomized, open label, non-inferiority trial. J Clin Anesth 2024; 95:111451. [PMID: 38574504 DOI: 10.1016/j.jclinane.2024.111451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/22/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
STUDY OBJECTIVE Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care. DESIGN Single center, randomized, non-inferiority trial. SETTING Tertiary hospital in the Netherlands. PATIENTS Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery. INTERVENTION Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care. MEASUREMENTS The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption. MAIN RESULTS Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (-1.9 points, 90% CI -3.1 to -0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (-8.7 oral morphine milligram equivalents; 95% CI -16.1 to -1.4). CONCLUSIONS Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia.
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Affiliation(s)
- Manouk Admiraal
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Pascal S H Smulders
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Martin V H Rutten
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Eelko K de Groot
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Yvonne Heine
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Holger M Baumann
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Vincent H C van der Vegt
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jens A Halm
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Henning Hermanns
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Tim Schepers
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Anesthesiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands
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Mei F, Garfinkel V, Petroll M, Mancini R. Opioid Usage Following Oculoplastic Procedures. Aesthet Surg J 2024; 44:699-705. [PMID: 38299440 DOI: 10.1093/asj/sjae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND With the rising toll of the opioid crisis, oculoplastic surgeons have been looking at methods to decrease opioid prescription. OBJECTIVES The aim of this study was to identify factors that correlate with opioid usage after oculoplastic surgery. METHODS This was a prospective study conducted at University of Texas Southwestern. All patients who underwent an oculoplastic procedure were eligible for inclusion. Patients enrolled were provided 20 tablets of tramadol 50 mg, to take 1 tablet every 6 hours as needed for pain. At their postoperative week 1 appointment, participants had the remaining number of unused opioid tablets counted. The number of tablets taken were calculated by subtracting the remaining number of tablets from the original prescribed amount. RESULTS A total of 310 patients were enrolled in our study. Of these, 129 patients met the inclusion criteria. There was a statistically significant difference in the number of tramadol tablets taken between procedures for upper eyelids, lower eyelids, and both eyelids (P < .01). There were no statistically significant differences in tramadol usage when comparing procedures on eyelids with orbit procedures(P = .30), cosmetic with noncosmetic procedures (P = .52), males with females (P = .87), or patients naive to oculoplastic procedures with those undergoing reoperation (P = .58). Longer procedures were correlated with greater tramadol usage (R = 0.28, P < .01). CONCLUSIONS This is the first study in the literature that has objectively quantified opioid usage after oculoplastic surgery in a prospective manner. Procedures that involve both upper and lower eyelids simultaneously and longer procedures resulted in higher opioid use. Orbital procedures, cosmetic procedures, sex, and procedural naivety were not found to be associated with higher opioid usage. LEVEL OF EVIDENCE: 4
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Nawan A, Wang G, Zhao C, Zhang W, Jiang B, Feng Y. A Novel Preoperative Electroencephalogram-Derived Index to Predict Early Postoperative Delirium in Elderly Patients After Hip Fracture Surgeries: Development of a Prediction Model. Geriatr Orthop Surg Rehabil 2024; 15:21514593241258654. [PMID: 38835410 PMCID: PMC11149441 DOI: 10.1177/21514593241258654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/16/2024] [Accepted: 04/28/2024] [Indexed: 06/06/2024] Open
Abstract
Introduction It is appealing to accurately predict postoperative delirium (POD) before surgeries. In this study, it was hypothesized that a novel electroencephalogram-derived index, the delirium index (DELi), could extract latent information regarding the predisposing factors of POD preoperatively. This study was aimed at developing a concise model that incorporated this DELi score to predict the early POD of elderly patients after hip surgeries. Materials and Methods Elderly patients scheduled for elective hip fracture surgeries were prospectively enrolled in a tertiary care hospital from November 2020 to June 2022. DELi scores and patient characteristics (age, sex, types of fracture and surgery, the time interval between fracture and surgery, cognitive function assessed using the Montreal Cognitive Assessment (MoCA), and frailty status assessed using the FRAIL scale) were collected preoperatively as candidate predictors. POD diagnosed using the confusion assessment method (CAM) was the outcome. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to select predictors. Then, these predictors were entered into a backward logistical regression analysis to develop a prediction model. Discrimination, calibration and clinical utility were validated using the bootstrapping method. Results All data (144 qualified patients of 170) were used for development. POD was observed in 71 patients (49.3%). Preoperative DELi scores predicted early POD (the area under the curve (AUC) = .786, 95% confidence interval (CI): .712, .860, in internal validation). A nomogram with MoCA, FRAIL scale and DELi score was constructed with excellent discrimination (AUC = .920, 95% CI: .876, .963, in internal validation), accredited calibration (P = .733, Hosmer‒Lemeshow test), and a wide range of threshold probabilities (5% to 95%). Conclusions Preoperative DELi scores predicted the early POD of elderly patients after hip surgeries. A concise prediction model was developed and demonstrated excellent discrimination.
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Affiliation(s)
- Ayixia Nawan
- Department of Anaesthesiology, Peking University People's Hospital, Beijing, China
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Geng Wang
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Congcong Zhao
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Wenchao Zhang
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Bailin Jiang
- Department of Anaesthesiology, Peking University People's Hospital, Beijing, China
| | - Yi Feng
- Department of Anaesthesiology, Peking University People's Hospital, Beijing, China
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Stephenson KJ, Krinock DJ, Vasquez IL, Shewmake CN, Spray BJ, Ketha B, Wolf LL, Dassinger MS. Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital. J Patient Saf 2024; 20:299-305. [PMID: 38240645 DOI: 10.1097/pts.0000000000001209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.
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Affiliation(s)
| | - Derek J Krinock
- From the Department of Surgery, University of Arkansas for Medical Sciences
| | - Isabel L Vasquez
- Department of Surgery, Arkansas Children's Hospital Research Institute
| | | | | | - Bavana Ketha
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Lindsey L Wolf
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Melvin S Dassinger
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
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Dai M, Dou X, Chen M, Yang J, Long J, Lin Y. Strong opioids-induced cardiac, neurologic, and respiratory disorders: a real-world study from 2004 to 2023 based on FAERS. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4105-4121. [PMID: 38032491 DOI: 10.1007/s00210-023-02844-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023]
Abstract
Opioids are mainly used as adjuncts to the induction and maintenance of general anesthesia, postoperative analgesia, and treating moderate to severe cancer pain and chronic pain. However, the hazards of these drugs to various organ organs still need to be further explored. This study used the US FDA Adverse Event Reporting System (FAERS) database to determine whether commonly receiving opioids was higher than the baseline risk for all other medications. FAERS was asked about adverse events (AEs) for the opioids "morphine," "fentanyl," "oxycodone," "hydromorphone," "sufentanil," and "remifentanil" from the first quarter of 2004 (2004Q1) through the second quarter of 2023 (2023Q2). Disproportionality signaling analysis was performed by calculating reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM). AEs with system organ classes (SOCs) of "cardiac disease," "neurologic disease," and "respiratory, thoracic, and mediastinal disease" were then screened. The statistical analysis included 12,819,518 reports in the FAERS database from 2004Q1 to 2023Q2, of which 236,619 AEs were reported as "primary suspect" for the six drugs mentioned above, which were selected as "cardiac disorders," "nervous system disorders," and "respiratory, thoracic and mediastinal disorders." Some AEs identified in this study are consistent with the drug labeling, such as bradycardia, respiratory depression, and somnolence. In addition, some unexpected and significant acute adverse drug reactions (ADRs), such as toxic leukoencephalopathy and coma, may occur. This study identified potential new and unexpected ADRs for opioids, providing valuable evidence for safety studies of opioids.
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Affiliation(s)
- Maosha Dai
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Ministry of Education, Huazhong University of Science and Technology), Wuhan, China
| | - Xiaoke Dou
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Ministry of Education, Huazhong University of Science and Technology), Wuhan, China
| | - Min Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Ministry of Education, Huazhong University of Science and Technology), Wuhan, China
| | - Juexi Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Ministry of Education, Huazhong University of Science and Technology), Wuhan, China
| | - Junhao Long
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Ministry of Education, Huazhong University of Science and Technology), Wuhan, China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Key Laboratory of Anesthesiology and Resuscitation, Ministry of Education, Huazhong University of Science and Technology), Wuhan, China.
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Salehinejad H, Muaddi H, Ubl DS, Sharma V, Thiels CA. Deep learning predicts postoperative opioids refills in a multi-institutional cohort of surgical patients. Surgery 2024:S0039-6060(24)00219-8. [PMID: 38796387 DOI: 10.1016/j.surg.2024.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 05/28/2024]
Abstract
BACKGROUND To combat the opioid epidemic, several strategies were implemented to limit the unnecessary prescription of opioids in the postoperative period. However, this leaves a subset of patients who genuinely require additional opioids with inadequate pain control. Deep learning models are powerful tools with great potential of optimizing health care delivery through a patient-centered focus. We sought to investigate whether deep learning models can be used to predict patients who would require additional opioid prescription refills in the postoperative period after elective surgery. METHODS This is a retrospective study of patients who received elective surgical intervention at the Mayo Clinic. Adult English-speaking patients ≥18 years old, who underwent an elective surgical procedure between 2013 and 2019, were eligible for inclusion. Machine learning models, including deep learning, random forest, and eXtreme Gradient Boosting, were designed to predict patients who require opioid refills after discharge from hospital. RESULTS A total of 9,731 patients with mean age of 62.1 years (51.4% female) were included in the study. Deep learning and random forest models predicted patients who required opioid refills with high accuracy, 0.79 ± 0.07 and 0.78 ± 0.08, respectively. Procedure performed, highest pain score recorded during hospitalization, and total oral morphine milligram equivalents prescribed at discharge were the top 3 predictors for requiring opioid refills after discharge. CONCLUSION Deep learning models can be used to predict patients who require postoperative opioid prescription refills with high accuracy. Other machine learning models, such as random forest, can perform equal to deep learning, increasing the applicability of machine learning for combating the opioid epidemic.
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Affiliation(s)
- Hojjat Salehinejad
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN. https://twitter.com/SalehinejadH
| | - Hala Muaddi
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN. https://twitter.com/HalaMuaddi
| | - Dan S Ubl
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
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Fowler KG, O'Flynn O'Brien KL, Reimche P, Miller RJ. Standard Opiate Prescribing in Pediatric and Adolescent Gynecologic Surgery to Reduce Opiate Use: Brief Report. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00227-4. [PMID: 38768705 DOI: 10.1016/j.jpag.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
STUDY OBJECTIVE The aim of this quality improvement (QI) project was to assess postoperative narcotic use after pediatric gynecologic surgeries and establish standard postoperative opioid dosing. Through standard dosing, we hoped to decrease variability in postoperative opioid prescriptions and decrease excess opioid doses in the community. METHODS This quality improvement project was approved by the Children's Minnesota institutional review board. Counseling on postoperative pain management was provided pre- and postoperatively. At the 2-week postoperative visit, patients were asked about the number of opioid doses used and pain control satisfaction. Baseline data were collected for 6 months, with surgeons prescribing the number of opioid doses on the basis of their personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established, and data collection was repeated. RESULTS Complete data were recorded for 30 cases before implementation of standard doses and for 29 cases after implementation. Standardized opioid dosing resulted in a 30% decrease in total opioid doses in circulation (252 to 176 doses; P = .014) and a 15% reduction in excess doses in circulation (162 to 137 doses). Forty-three percent of patients did not use any opioid doses. There was no significant difference (P = .8818) in patient pain control satisfaction rating. CONCLUSION Standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient pain control satisfaction. Opioid dose standardization may decrease opioid circulation within the community. Approximately 2 of every 5 patients used 0 opioid doses, which suggests that a further reduction in the standard dose prescriptions is possible.
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Affiliation(s)
- Kylie G Fowler
- Department of Gynecology, Children's Minnesota, Minneapolis, Minnesota.
| | | | - Paige Reimche
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - Rachel J Miller
- Department of Gynecology, Children's Minnesota, Minneapolis, Minnesota
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Adams TJ, Levy N, Macintyre PE, Forget P. Limit packaging size for opioids prescribed at post-surgical discharge. Lancet 2024; 403:1745. [PMID: 38704159 DOI: 10.1016/s0140-6736(23)02021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/18/2023] [Indexed: 05/06/2024]
Affiliation(s)
- Tobias J Adams
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen AB25 2ZN, UK; Pain and Opioids after Surgery (PANDOS), European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital, Bury St Edmunds, UK
| | - Pamela E Macintyre
- Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Patrice Forget
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen AB25 2ZN, UK; Pain and Opioids after Surgery (PANDOS), European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; University Hospital Nîmes, Nîmes, France
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9
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Karlsen APH, Laigaard J, Pedersen C, Thybo KH, Gasbjerg KS, Geisler A, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors. Acta Anaesthesiol Scand 2024; 68:610-618. [PMID: 38380438 DOI: 10.1111/aas.14388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/05/2024] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods. METHODS This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression. RESULTS The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events. CONCLUSIONS In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.
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Affiliation(s)
- Anders Peder Højer Karlsen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Jens Laigaard
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Casper Pedersen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Smidt Gasbjerg
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
| | - Anja Geisler
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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10
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Birkebæk S, Lundsgaard LM, Juul N, Seyer-Hansen M, Rasmussen MM, Uhrbrand PG, Nikolajsen L. Intraoperative clonidine in endometriosis and spine surgery: A protocol for two randomised, blinded, placebo-controlled trials. Acta Anaesthesiol Scand 2024; 68:708-713. [PMID: 38462487 DOI: 10.1111/aas.14398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/10/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND A high proportion of patients who undergo surgery continue to suffer from moderate to severe pain in the early postoperative period despite advances in pain management strategies. Previous studies suggest that clonidine, an alpha2 adrenergic agonist, administered during the perioperative period could reduce acute postoperative pain intensity and opioid consumption. However, these studies have several limitations related to study design and sample size and hence, further studies are needed. AIM To investigate the effect of a single intravenous (IV) dose of intraoperative clonidine on postoperative opioid consumption, pain intensity, nausea, vomiting and sedation after endometriosis and spine surgery. METHODS Two separate randomised, blinded, placebo-controlled trials are planned. Patients scheduled for endometriosis (CLONIPAIN) will be randomised to receive either 150 μg intraoperative IV clonidine or placebo (isotonic saline). Patients undergoing spine surgery (CLONISPINE) will receive 3 μg/kg intraoperative IV clonidine or placebo. We aim to include 120 patients in each trial to achieve power of 90% at an alpha level of 0.05. OUTCOMES The primary outcome is opioid consumption within the first three postoperative hours. Secondary outcomes include pain intensity at rest and during coughing, nausea, vomiting and sedation within the first two postoperative hours and opioid consumption within the first six postoperative hours. Time to discharge from the PACU will be registered. CONCLUSION This study is expected to provide valuable information on the efficacy of intraoperative clonidine in acute postoperative pain management in patients undergoing endometriosis and spine surgery.
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Affiliation(s)
- Stine Birkebæk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Niels Juul
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Seyer-Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Mylius Rasmussen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Gaarsdal Uhrbrand
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Nikolajsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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11
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Silver J, Ford BT, Pavano CJ, Bellas N, Hewitt C, Solomito M, McCarthy C. Cannabis Use Is Associated With Fewer Filled Opioid Prescriptions After Treatment of Proximal Humerus Fractures. Orthopedics 2024; 47:147-151. [PMID: 37921529 DOI: 10.3928/01477447-20231027-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
The purpose of this study was to use a large claims database to determine if there is a difference in opioid use after operative intervention for proximal humerus fractures in patients with known cannabis use compared with those who do not report cannabis use. The PearlDiver database was queried to find all patients who underwent proximal humerus open reduction and internal fixation. A group of patients with reported cannabis use or dependence was matched to a cohort without known cannabis use. Between the two groups, differences in the number of opioid prescriptions filled in the postoperative period (within 3 days), the morphine milligram equivalents (MMEs) prescribed in total and per day, and the number of opioid prescription refills were explored. There were 66,445 potential control patients compared with 1260 potential study patients. After conducting the propensity score match, a total of 1245 patients were included in each group. The patients in the cannabis group filled fewer opioid prescriptions (P=.045) and were prescribed fewer total MMEs (P=.044) in the first 3 days postoperatively. Results of this study indicate that patients who use cannabis products may use fewer opioids after proximal humerus open reduction and internal fixation. [Orthopedics. 2024;47(3):147-151.].
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12
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Pence ST, Findlay BL, Bearrick EN, Pinkhasov AM, Fadel A, Anderson KT, Viers BR. Evaluation of an Opioid-free Pathway for Perineal Reconstructive Surgery: A 1-year Pilot Study. Urology 2024:S0090-4295(24)00304-2. [PMID: 38677369 DOI: 10.1016/j.urology.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE To evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution. METHODS Patients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record (EHR) in order to assess the efficacy of an opioid-free pathway. RESULTS Sixty-seven patients met the criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription. CONCLUSION An opioid-free pathway is appropriate for opioid naive men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain.
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Affiliation(s)
| | | | | | | | | | | | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN.
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13
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Kuo YF, Kim E, Westra J, Wilkes D, Raji MA. Pain Control Associated With Gabapentinoid Prescription After Elective Total Knee Arthroplasty. J Arthroplasty 2024; 39:941-947.e1. [PMID: 37871858 DOI: 10.1016/j.arth.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/09/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Gabapentinoid (GABA) prescribing has substantially increased as a nonopioid analgesics for surgical conditions. We examined the effectiveness of GABA use for postoperative pain control among patients receiving total knee arthroplasty (TKA). METHODS This retrospective cohort study using 2016 to 2019 data from a 20% national sample of Medicare enrollees included patients aged 66 and over years who received an elective TKA, were discharged to home, received home health care, and had both admission and discharge assessments of pain (n = 35,186). Study outcomes were pain score difference between admission and discharge and less-than-daily pain interfering with activity at discharge. Opioid and GABA prescriptions after surgery and receipt of nerve block within 3 days of surgery were also assessed. RESULTS There were 30% of patients who had a pain score decrease of 3 to 4 levels and 55.8% had pain score decreases of 1 to 2 levels. In multivariable analyses, receiving a nerve block was significantly associated with pain score reduction. A GABA prescription increased the magnitude of pain score reduction among those receiving a nerve block. Results from inverse probability weighted analysis with propensity score showed that coprescribing of GABA and low-dose opioid was associated with significantly lower pain scores. CONCLUSIONS Post-TKA opioid use was not associated with pain score reduction. Receiving a nerve block was associated with a modest pain score reduction. Co-prescribing GABA with low-dose opioid or receiving a nerve block was associated with increasing magnitudes of pain reduction. Further research should identify alternatives to opioid use for managing postoperative TKA pain.
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Affiliation(s)
- Yong-Fang Kuo
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Biostatistics & Data Science, University of Texas Medical Branch, Galveston, Texas; Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas
| | - Emily Kim
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Jordan Westra
- Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas
| | - Denise Wilkes
- Department and Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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14
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Xiang A, Braun AE, Chang C, Swerdloff D, Gross MS, Simhan J. Penoscrotal inflatable penile prosthesis recipients often fully recover from pain at two weeks following placement. Int J Impot Res 2024:10.1038/s41443-024-00871-0. [PMID: 38561424 DOI: 10.1038/s41443-024-00871-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
The symptoms and duration of pain following inflatable penile prosthesis (IPP) surgery remains poorly understood. We characterize postoperative pain following penoscrotal 3-piece inflatable penile prosthesis placement in patients managed with a standardized pain management protocol. This is a single-center prospective analysis of 96 virginal penoscrotal 3-piece IPP recipients (9/2019 to 9/2021) excluding patients with chronic pain, IPPs performed with alternative approaches or concomitantly with other surgeries and those with infections. Standardized pain questionnaire was performed by phone on post-operative day (POD) 2, 7, 14, and 30. The primary outcome was self-reported pain scores, measured by pain score 0-10 (0 = no pain, 10 = unbearable, "worst pain you have ever felt") at various locations (incision, penile, scrotal, abdominal) over the first 30 days postoperatively. A majority of pain reported was outside the scrotal area with 67.6% of complaints in the shaft, glans, abdomen and incision. From POD2 to POD30, there was a significant decrease in severe pain from 46.2 to 11.1% (p = 0.05) with an increase in mild pain from 23.1 to 62.4% (p = 0.05). Roughly half of the participants (47.9%, n = 46) reported no pain by POD14. Penoscrotal IPP recipients often fully recover from pain at the two-week period following surgery and those with lingering discomfort predominantly complain of penile shaft and glans pain.
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Affiliation(s)
- Alice Xiang
- Department of Urology, Jefferson Einstein Healthcare Network, Philadelphia, PA, USA
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Avery E Braun
- Department of Urology, Jefferson Einstein Healthcare Network, Philadelphia, PA, USA
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
- Department of Urology, University California of San Francisco, San Francisco, CA, USA
| | - Chrystal Chang
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Daniel Swerdloff
- Department of Urology, Jefferson Einstein Healthcare Network, Philadelphia, PA, USA
| | - Martin S Gross
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jay Simhan
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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15
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Galao-Malo R, Davidson A, D'Aoust R, Baker D, Scott M, Swain J. Implementing an evidence-based guideline to decrease opioids after cardiac surgery. J Am Assoc Nurse Pract 2024; 36:241-248. [PMID: 38236128 DOI: 10.1097/jxx.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/21/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Deaths related to overdoses continue growing in the United States. The overprescription of opioids after surgical procedures may contribute to this problem. LOCAL PROBLEM There is inconsistency in the prescription of opioids in cardiovascular surgery patients. Recommendations regarding the reduction of opioids at discharge are not fully implemented. METHODS This is a single-center, pre-post quality improvement project in adult patients after elective cardiac surgery through sternotomy. INTERVENTIONS Changes in guidelines, modification of order sets, creation of dashboards, and education to the providers to increase the prescription of acetaminophen around the clock on the step-down unit and at discharge, decrease the number of opioid tablets to 25 or less at discharge and decrease the prescription of opioids to 25 or less morphine milligram equivalents (MME) at discharge. RESULTS The preintervention group included 67 consecutive patients who underwent cardiac surgery from November to December 2021. The postintervention group had 67 patients during the same period in 2022. Acetaminophen prescription on the step-down unit increased from 9% to 96% ( p < .001). The proportion of patients discharged with 25 or less opioid tablets increased from 18% to 90% ( p < .001) and with 25 or less MME from 30% to 55% ( p < .01). Acetaminophen prescription at discharge increased from 10% to 48% ( p < .001). CONCLUSIONS Our intervention increased the use of acetaminophen and decreased the overprescription of opioids in cardiac surgery patients at discharge. Further research is necessary to continue improving pain management to reduce the number of opioids prescribed at discharge.
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Affiliation(s)
- Roberto Galao-Malo
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, New York
| | - Alison Davidson
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, New York
| | - Rita D'Aoust
- Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Deborah Baker
- Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Mackenzy Scott
- Cardiac Services, Mount Sinai Hospital, New York, New York
| | - Julie Swain
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, New York
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16
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Brian R, Lancaster E, Hiramoto J. A "just in time" educational intervention for opioid overprescribing in dialysis access surgery. Am J Surg 2024:S0002-9610(24)00193-4. [PMID: 38575443 DOI: 10.1016/j.amjsurg.2024.03.024] [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: 12/02/2023] [Revised: 03/04/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Despite widespread efforts to combat the opioid epidemic, an ongoing contributor to opioid misuse remains post-operative opioid overprescribing by residents. The goal of this study was to evaluate the impact of a low-cost, reproducible "just in time" intervention on opioid prescribing in dialysis access operations. METHODS Standardized opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. Wilcoxon rank-sum test and tests of proportions were used to compare groups. RESULTS Overall, 299 patients underwent dialysis access procedures. There was a decrease in patients discharged with opioids following the intervention from 58% to 36% (p = 0.003). For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents (p = 0.03). CONCLUSIONS This low-cost and timely learning intervention may be a useful adjunct to reduce post-operative opioid prescriptions.
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Affiliation(s)
- Riley Brian
- Department of Surgery, University of California, San Francisco, USA.
| | | | - Jade Hiramoto
- Department of Surgery, University of California, San Francisco, USA
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17
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Li L, Chang Y, Smith NA, Losina E, Costenbader KH, Laidlaw TM. Nonsteroidal anti-inflammatory drug "allergy" labeling is associated with increased postpartum opioid utilization. J Allergy Clin Immunol 2024; 153:772-779.e4. [PMID: 38040042 PMCID: PMC10939859 DOI: 10.1016/j.jaci.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Current guidelines recommend a stepwise approach to postpartum pain management, beginning with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with opioids added only if needed. Report of a prior NSAID-induced adverse drug reaction (ADR) may preclude use of first-line analgesics, despite evidence that many patients with this allergy label may safely tolerate NSAIDs. OBJECTIVE We assessed the association between reported NSAID ADRs and postpartum opioid utilization. METHODS We performed a retrospective cohort study of birthing people who delivered within an integrated health system (January 1, 2017, to December 31, 2020). Study outcomes were postpartum inpatient opioid administrations and opioid prescriptions at discharge. Statistical analysis was performed on a propensity score-matched sample, which was generated with the goal of matching to the covariate distributions from individuals with NSAID ADRs. RESULTS Of 38,927 eligible participants, there were 883 (2.3%) with an NSAID ADR. Among individuals with reported NSAID ADRs, 49.5% received inpatient opioids in the postpartum period, compared to 34.5% of those with no NSAID ADRs (difference = 15.0%, 95% confidence interval 11.4-18.6%). For patients who received postpartum inpatient opioids, those with NSAID ADRs received a higher total cumulative dose between delivery and hospital discharge (median 30.0 vs 22.5 morphine milligram equivalents [MME] for vaginal deliveries; median 104.4 vs 75.0 MME for cesarean deliveries). The overall proportion of patients receiving an opioid prescription at the time of hospital discharge was higher for patients with NSAID ADRs compared to patients with no NSAID ADRs (39.3% vs 27.2%; difference = 12.1%, 95% confidence interval 8.6-15.6%). CONCLUSION Patients with reported NSAID ADRs had higher postpartum inpatient opioid utilization and more frequently received opioid prescriptions at hospital discharge compared to those without NSAID ADRs, regardless of mode of delivery.
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Affiliation(s)
- Lily Li
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Yuchiao Chang
- Harvard Medical School, Boston, Mass; Division of General Internal Medicine, Massachusetts General Hospital, Boston, Mass
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Elena Losina
- Harvard Medical School, Boston, Mass; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Karen H Costenbader
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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18
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Kaur J, Pham NS, Cahan E, Halvorsen KC, Langner JL, Bryson XM, Chan CM, Vorhies JS. Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents. Orthopedics 2024; 47:83-88. [PMID: 37341565 DOI: 10.3928/01477447-20230616-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].
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19
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Gerlach EB, Plantz MA, Swiatek PR, Wu SA, Arpey N, Fei-Zhang D, Divi SN, Hsu WK, Patel AA. The Drivers of Persistent Opioid Use and Its Impact on Healthcare Utilization After Elective Spine Surgery. Global Spine J 2024; 14:370-379. [PMID: 35603925 PMCID: PMC10802539 DOI: 10.1177/21925682221104731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine the incidence of and risk factors for persistent opioid use after elective cervical and lumbar spine procedures and to quantify postoperative healthcare utilization in this patient population. METHODS Patients were retrospectively identified who underwent elective spine surgery for either cervical or lumbar degenerative pathology between November 1, 2013, and September 30, 2018, at a single academic center. Patients were split into 2 cohorts, including patients with and without opioid use at 180-days postoperatively. Baseline patient demographics, underlying comorbidities, surgical variables, and preoperative/postoperative opioid use were assessed. Health resource utilization metrics within 1 year postoperatively (ie, imaging studies, emergency and urgent care visits, hospital readmissions, opioid prescriptions, etc.) were compared between these 2 groups. RESULTS 583 patients met inclusion criteria, of which 16.6% had opioid persistence after surgery. Opioid persistence was associated with ASA score ≥3 (P = .004), diabetes (P = .019), class I obesity (P = .012), and an opioid prescription in the 60 days prior to surgery (P = .006). Independent risk factors for opioid persistence assessed via multivariate regression included multi-level lumbar fusion (RR = 2.957), cervical central stenosis (RR = 2.761), and pre-operative opioid use (RR = 2.668). Opioid persistence was associated with higher rates of health care utilization, including more radiographs (P < .001), computed tomography (CT) scans (.007), magnetic resonance imaging (MRI) studies (P = .014), emergency department (ED) visits (.009), pain medicine referrals (P < .001), and spinal injections (P = .003). CONCLUSIONS Opioid persistence is associated with higher rates of health care utilization within 1 year after elective spine surgery.
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Affiliation(s)
- Erik B. Gerlach
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Mark A. Plantz
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Peter R. Swiatek
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Scott A. Wu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Nicholas Arpey
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - David Fei-Zhang
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Srikanth N. Divi
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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20
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Wagner Z, Kirkegaard A, Mariano LT, Doctor JN, Yan X, Persell SD, Goldstein NJ, Fox CR, Brummett CM, Romanelli RJ, Bouskill K, Martinez M, Zanocco K, Meeker D, Mudiganti S, Waljee J, Watkins KE. Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions: A Randomized Clinical Trial. JAMA HEALTH FORUM 2024; 5:e240077. [PMID: 38488780 PMCID: PMC10943416 DOI: 10.1001/jamahealthforum.2024.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 03/18/2024] Open
Abstract
Importance Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration ClinicalTrials.gov NCT05070338.
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Affiliation(s)
| | | | | | - Jason N. Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Xiaowei Yan
- Palo Alto Medical Foundation, Palo Alto, California
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noah J. Goldstein
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | - Craig R. Fox
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | | | - Robert J. Romanelli
- Palo Alto Medical Foundation, Palo Alto, California
- RAND Europe, Westbrook Centre, Cambridge, United Kingdom
| | | | | | - Kyle Zanocco
- Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Daniella Meeker
- Keck School of Medicine, USC Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California
- Yale School of Medicine, New Haven, Connecticut
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21
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Hofer DM, Harnik M, Lehmann T, Stüber F, Baumbach P, Dreiling J, Meissner W, Stamer UM. Trajectories of pain and opioid use up to one year after surgery: analysis of a European registry. Br J Anaesth 2024; 132:588-598. [PMID: 38212183 DOI: 10.1016/j.bja.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Long-term opioid use after surgery is a crucial healthcare problem in North America. Data from European hospitals are scarce and differentiation of chronic pain has rarely been considered. METHODS In a mixed surgical cohort of the PAIN OUT registry, opioid use and chronic pain were evaluated before surgery, and 6 and 12 months after surgery (M6/M12). Subgroups with or without opioid medication and pre-existing chronic pain were analysed. M12-chronic pain was categorised as chronic postsurgical pain (CPSP) meeting the ICD-11 definition, chronic pain related to surgery not meeting the ICD-11 definition, and chronic pain unrelated to surgery. Primary endpoint was the rate of M12 opioid users. Variables associated with M12 opioid use and patient-reported outcomes were evaluated. RESULTS Of 2326 patients, 5.5% were preoperative opioid users; 4.4% and 3.5% took opioids at M6 and M12 (P<0.001). Chronic pain before operation and at M6/M12 was reported by 41.2%, 41.8%, and 34.7% of patients, respectively (P<0.001). The rate of M12 opioid users was highest in group unrelated (22.3%; related 8.3%, CPSP 1.5%; P<0.001). New opioid users were 1.1% (unrelated 7.1%, related 2.3%, CPSP 0.7%; P<0.001). M12 opioid users reported more pain, pain-related physical and affective interference, and needed more opioids than non-users. The predominant variable associated with M12 opioids was preoperative opioid use (estimated odds ratio [95% confidence interval]: 28.3 [14.1-56.7], P<0.001). CONCLUSIONS Opioid use was low in patients with CPSP, and more problematic in patients with chronic pain unrelated to surgery. A detailed assessment of chronic pain unrelated or related to surgery or CPSP is necessary. CLINICAL TRIAL REGISTRATION NCT02083835.
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Affiliation(s)
- Debora M Hofer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Harnik
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, University Hospital Jena, Jena, Germany
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Philipp Baumbach
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Johannes Dreiling
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Winfried Meissner
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Ulrike M Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of BioMedical Research, University of Bern, Bern, Switzerland; Pain and Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Brussels, Belgium.
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Dawson Z, Stanton SS, Roy S, Farjo R, Aslesen HA, Hallstrom BR, Bicket MC. Opioid Consumption After Discharge From Total Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2024:S0883-5403(24)00089-5. [PMID: 38336301 DOI: 10.1016/j.arth.2024.01.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Pain is challenging after recovery from total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures, and patients often receive prescription opioids. However, opioid consumption by patients remains unclear, and unused opioids may lead to risks including misuse and diversion. The objective of this systematic review and meta-analysis was to compare prescription size versus patient-reported consumption of opioids after discharge following TKA and THA. METHODS PubMed and Embase were systematically searched for publications published between 2015 and 2022 on patient-reported consumption of opioids after TKA and THA. The primary outcome was opioid use in oxycodone 5-mg equivalents. Team members independently reviewed studies for screening, inclusion, data extraction, and risk of bias. RESULTS Among the 17 included studies (15 TKA and 11 THA), discharge opioid prescribing exceeded consumption for both TKA (88.4 versus 65.0 pills at 6 weeks) and THA (64.0 versus 29.8 pills at 12 weeks). For both TKA and THA, the range of opioids prescribed varied significantly, by 1.6-fold for TKA and 2.8-fold for THA. Most studies reported pain outcomes (89%) and the use of nonopioid medications (72%). Of the 4 studies offering prescribing recommendations, the amounts ranged from 50 to 104 pills for TKA and 30 to 45 pills for THA. CONCLUSIONS Opioid prescribing exceeds the amount consumed following TKA and THA. These findings serve as a call to action to tailor prescribing guidelines to how much patients actually consume while emphasizing the use of nonopioid medications to better optimize recovery from surgery.
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Affiliation(s)
- Zahra Dawson
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Sofea S Stanton
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Samantha Roy
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Reem Farjo
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Heidi A Aslesen
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan; Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Brian R Hallstrom
- Department of Orthopaedic Surgery, Michigan Medicine, Ann Arbor, Michigan; Office of Clinical Affairs, Michigan Medicine, Ann Arbor, Michigan; Michigan Arthroplasty Registry Collaborative Quality Initiative, Ann Arbor, Michigan
| | - Mark C Bicket
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
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Chen VJ, Guan LS, Bokoch MP, Langnas E, Kothari R, Croci R, Campbell LJ, Quan D, Freise C, Guan Z. Mismatched Postsurgical Opioid Prescription to Liver Transplant Patients: A Retrospective Cohort Study From a Single High-volume Transplant Center. Transplantation 2024; 108:483-490. [PMID: 38259180 DOI: 10.1097/tp.0000000000004728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Improper opioid prescription after surgery is a well-documented iatrogenic contributor to the current opioid epidemic in North America. In fact, opioids are known to be overprescribed to liver transplant patients, and liver transplant patients with high doses or prolonged postsurgical opioid use have higher risks of graft failure and death. METHODS This is a retrospective cohort study of 552 opioid-naive patients undergoing liver transplant at an academic center between 2012 and 2019. The primary outcome was the discrepancy between the prescribed discharge opioid daily dose and each patient's own inpatient opioid consumption 24 h before discharge. Variables were analyzed with Wilcoxon and chi-square tests and logistic regression. RESULTS Opioids were overprescribed in 65.9% of patients, and 54.3% of patients who required no opioids the day before discharge were discharged with opioid prescriptions. In contrast, opioids were underprescribed in 13.4% of patients, among whom 27.0% consumed inpatient opioids but received no discharge opioid prescription. The median prescribed opioid daily dose was 333.3% and 56.3% of the median inpatient opioid daily dose in opioid overprescribed and underprescribed patients, respectively. Importantly, opioid underprescribed patients had higher rates of opioid refill 1 to 30 and 31 to 90 d after discharge, and the rate of opioid underprescription more than doubled from 2016 to 2019. CONCLUSIONS Opioids are both over- and underprescribed to liver transplant patients, and opioid underprescribed patients had higher rates of opioid refill. Therefore, we proposed to prescribe discharge opioid prescriptions based on liver transplant patients' inpatient opioid consumption to provide patient-centered opioid prescriptions.
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Affiliation(s)
- Victoria J Chen
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- Brown University, Providence, RI
| | - Lucy S Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Rhiannon Croci
- UCSF Health Informatics, University of California, San Francisco, San Francisco, CA
| | - Liam J Campbell
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
- University of the Incarnate Word School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX
| | - David Quan
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Chris Freise
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
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24
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Kurteva S, Pook M, Fiore JF, Tamblyn R. Rates and risk factors for persistent opioid use after cardiothoracic surgery: A cohort study. Surgery 2024; 175:271-279. [PMID: 38008605 DOI: 10.1016/j.surg.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/25/2023] [Accepted: 10/25/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND This study's aim was to estimate potential risk factors for persistent opioid use after cardiothoracic surgery. METHODS This study included participants in the McGill University Health Centre clinical trial (2014 to 2016). Provincial medical services, prescription claims, and medical charts data were linked. Persistent opioid use was defined as an initial peri-operative opioid dispensation followed by an opioid dispensation between 91 and 180 days postdischarge. Multivariable Cox Proportional Hazards models were used to assess factors associated with persistent opioid use. RESULTS A cohort of 815 patients (mean age: 68.9 [standard deviation = 8.9]) was assembled, of which 8.2% became persistent opioid users. Factors such as higher Charlson Comorbidity Index (adjusted hazard ratio: 3.4, 95% confidence interval: 1.1-10.6), history of diabetes (adjusted hazard ratio: 2.1, 95% confidence interval: 1.3-3.4), substance and alcohol abuse (adjusted hazard ratio: 16.3, 95% confidence interval: 5.3-49.5), and radiotherapy (adjusted hazard ratio: 2.4, 95% confidence interval: 1.5-4.1) were associated with a higher hazard of persistent opioid use. Previous opioid use (adjusted hazard ratio: 1.7, 95% CI: 1.0-2.8), daily peri-operative opioid dose (adjusted hazard ratio: 2.3, 95% confidence interval: 1.5-3.7), having an opioid dispensation 30 days pre-admission (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), and pre-admission analgesic use (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), were also associated with an increased hazard of persistent use. Being prescribed multimodal analgesia at discharge (adjusted hazard ratio: 0.54, 95% confidence interval: 0.32-0.92) was associated with a 46% decreased hazard of developing persistent opioid use. CONCLUSION Multiple patient- and medication-related characteristics were associated with an increased hazard of persistent opioid use.
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Affiliation(s)
- Siyana Kurteva
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.
| | - Makena Pook
- Division of Experimental Surgery, McGill University, Montreal, Canada
| | - Julio Flavio Fiore
- Division of Experimental Surgery, McGill University, Montreal, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada; Clinical and Health Informatics Research Group, McGill University, Montreal, Canada; Department of Surgery, McGill University, Montreal, Canada; Department of Medicine, McGill University Health Center, Montreal, Canada
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25
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Quaye A, McAllister B, Garcia JR, Nohr O, Laduzenski SJ, Mack L, Kerr CR, Kerr DA, Razafindralay CN, Richard JM, Craig WY, Rodrigue S. A prospective, randomized trial of liposomal bupivacaine compared to conventional bupivacaine on pain control and postoperative opioid use in adults receiving adductor canal blocks for total knee arthroplasty. ARTHROPLASTY 2024; 6:6. [PMID: 38297390 PMCID: PMC10832097 DOI: 10.1186/s42836-023-00226-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a commonly performed procedure to alleviate pain and improve functional limitations caused by end-stage joint damage. Effective management of postoperative pain following TKA is crucial to the prevention of complications and enhancement of recovery. Adductor canal blocks (ACB) with conventional bupivacaine (CB) provide adequate analgesia after TKA, but carry a risk of rebound pain following block resolution. Liposomal bupivacaine (LB) is an extended-release local anesthetic that can provide up to 72 h of pain relief. The objective of this study was to compare postoperative outcomes between ACBs using LB and CB after TKA. METHODS This single institution, prospective, randomized, clinical trial enrolled patients scheduled for TKA. Participants were randomized to receive ACB with either LB or CB. Pain scores up to 72 h postoperatively were assessed as the primary outcome. Opioid consumption and length of stay were evaluated as secondary outcomes. RESULTS A total of 80 patients were enrolled. Demographic and clinical characteristics were similar between the two groups. LB group showed significantly lower cumulative opioid use during the 72 h evaluated (P = 0.016). There were no differences in pain scores or length of stay between the groups. CONCLUSION The study demonstrated that LB ACBs led to significantly lower opioid consumption in the days following TKA without affecting pain scores or length of stay. This finding has important implications for improving postoperative outcomes and reducing opioid use in TKA patients. Previous studies have reported inconsistent results regarding the benefits of LB, highlighting the need for further research. TRIAL REGISTRATION This project was retrospectively registered with clinicaltrials.gov ( NCT05635916 ) on 2 December 2022.
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Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology, Northern Light Mercy Hospital, 175 Fore River Parkway, Portland, ME, 04102, USA.
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
- Division of Anesthesiology, Spectrum Healthcare Partners, 324 Gannett Drive, Suite 200, South Portland, ME, 04106, USA.
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA.
| | - Brian McAllister
- Department of Anesthesiology, Northern Light Mercy Hospital, 175 Fore River Parkway, Portland, ME, 04102, USA
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- Division of Anesthesiology, Spectrum Healthcare Partners, 324 Gannett Drive, Suite 200, South Portland, ME, 04106, USA
| | - Joseph R Garcia
- Department of Anesthesiology, Northern Light Mercy Hospital, 175 Fore River Parkway, Portland, ME, 04102, USA
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- Division of Anesthesiology, Spectrum Healthcare Partners, 324 Gannett Drive, Suite 200, South Portland, ME, 04106, USA
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Orion Nohr
- Department of Anesthesiology, Northern Light Mercy Hospital, 175 Fore River Parkway, Portland, ME, 04102, USA
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- Division of Anesthesiology, Spectrum Healthcare Partners, 324 Gannett Drive, Suite 200, South Portland, ME, 04106, USA
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Sarah J Laduzenski
- Department of Anesthesiology, Northern Light Mercy Hospital, 175 Fore River Parkway, Portland, ME, 04102, USA
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- Division of Anesthesiology, Spectrum Healthcare Partners, 324 Gannett Drive, Suite 200, South Portland, ME, 04106, USA
| | - Lucy Mack
- Department of Anesthesiology, Northern Light Mercy Hospital, 175 Fore River Parkway, Portland, ME, 04102, USA
- Division of Anesthesiology, Spectrum Healthcare Partners, 324 Gannett Drive, Suite 200, South Portland, ME, 04106, USA
| | - Christine R Kerr
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Danielle A Kerr
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Charonne N Razafindralay
- University of New England College of Osteopathic Medicine, 11 Hills Beach Rd, Biddeford, ME, 04005, USA
| | - Janelle M Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Wendy Y Craig
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
- Maine Health Institute for Research, 81 Research Dr, Scarborough, ME, 04074, USA
| | - Stephen Rodrigue
- Northern Light Mercy Orthopedics, 20 Northbrook Dr, Falmouth, ME, 04105, USA
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Burns ML, Hilliard P, Vandervest J, Mentz G, Josifoski A, Varghese J, Fisher C, Kheterpal S, Shah N, Bicket MC. Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution. JAMA Netw Open 2024; 7:e2351689. [PMID: 38227311 DOI: 10.1001/jamanetworkopen.2023.51689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Importance The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear. Objective To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories. Design, Setting, and Participants This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023. Main Outcomes and Measures The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs). Results Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques). Conclusions and Relevance In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.
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Affiliation(s)
- Michael L Burns
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Paul Hilliard
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - John Vandervest
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Ace Josifoski
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Jomy Varghese
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Clark Fisher
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor
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27
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Speed TJ, Hanna MN, Xie A. The Personalized Pain Program: A New Transitional Perioperative Pain Care Delivery Model to Improve Surgical Recovery and Address the Opioid Crisis. Qual Manag Health Care 2024; 33:61-63. [PMID: 38157257 PMCID: PMC10764066 DOI: 10.1097/qmh.0000000000000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Traci J Speed
- Department of Psychiatry and Behavioral Sciences (Dr Speed), Department of Anesthesiology and Critical Care Medicine (Drs Hanna and Xie), and Armstrong Institute for Patient Safety and Quality (Dr Xie), Johns Hopkins University School of Medicine, Baltimore, Maryland
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28
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Baltes A, Horton D, Trevino C, Quanbeck A, Deyo B, Nicholas C, Brown R. Feasibility of implementing a screening tool for risk of opioid misuse in a trauma surgical population. IMPLEMENTATION RESEARCH AND PRACTICE 2024; 5:26334895231226193. [PMID: 38322804 PMCID: PMC10838038 DOI: 10.1177/26334895231226193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background As the opioid crisis continues to affect communities across the United States, new interventions for screening and prevention are needed to mitigate its impact. Mental health diagnoses have been identified as a risk factor for opioid misuse, and surgical populations and injury survivors are at high risk for prolonged opioid use and misuse. This study investigated the implementation of a novel opioid risk screening tool that incorporated putative risk factors from a recent study in four trauma units across Wisconsin. Method The screening tool was implemented across a 6-month period at four sites. Data was collected via monthly meeting notes and "Plan, Do, Study, Act" (PDSA) forms. Following implementation, focus groups reflected on the facilitators and barriers to implementation. Meeting notes, PDSA forms, and focus group data were analyzed using the consolidated framework for implementation research, followed by thematic analyses, to generate themes surrounding the facilitators and barriers to implementing an opioid misuse screener. Results Implementation facilitators included ensuring patient understanding of the screener, minimizing staff burden from screening, and educating staff to encourage engagement. Barriers included infrastructure limitations that prevented seamless administration of the screener within current workflows, overlap of the screener with existing measures, and lack of guidance surrounding treatment options corresponding to risk. Recommended solutions to address barriers include careful timing of screener administration, accommodating workflows, integration of the screening tool within the electronic health record, and evidence-based interventions guided by screener results. Conclusion Four trauma centers across Wisconsin successfully implemented a pilot opioid misuse screening tool. Trauma providers and unit staff members believe that this tool would be a beneficial addition to their repertoire if their recommendations were adopted. Future research should refine opioid misuse risk factors and ensure screening items are well-validated with psychometric research supporting treatment responses to screener-indicated risk categories.
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Affiliation(s)
- Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Horton
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Colleen Trevino
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew Quanbeck
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Brienna Deyo
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher Nicholas
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Randall Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Kraimer K, Scott B, Farrell N, Geltzeiler M, Smith T, Detwiller K. Postoperative Pain Following Coblation of Sinonasal Hereditary Hemorrhagic Telangiectasias. Ann Otol Rhinol Laryngol 2024; 133:58-62. [PMID: 37377016 DOI: 10.1177/00034894231182212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease and epistaxis is the most common symptom. This can be treated conservatively but severe cases may require operative interventions. Endoscopic endonasal coblation of HHT lesions has been used successfully but postoperative pain management has not been well described. OBJECTIVES This study aimed to assess levels of postoperative pain and opioid use among patients with HHT who underwent coblation of sinonasal lesions. METHODS This is a longitudinal, prospective cohort study of adult patients undergoing endoscopic endonasal coblation for treatment of HHT lesions with or without bevacizumab injection between November 2019 and March 2020 at a single academic university hospital. Patients were given preoperative questionnaires and contacted via telephone 48 hours after surgery. If they reported using opioids for pain control, they were called every 2 days until they no longer used these medications. RESULTS Fourteen cases, including 13 unique patients, were included in this study. Opioids were ordered on discharge in 4 cases and the average morphine milligram equivalent prescribed on discharge was 41. The median pain score on postoperative day (POD) 2 was 4 of 10. Twelve patients reported using acetaminophen and 4 were using opioid pain medications. Of those using opioid pain medications, only 1 patient was using opioid pain medication by POD 4 and denied any use after POD 10. CONCLUSION This study is the first to analyze postoperative pain management and opioid prescribing patterns in HHT patients undergoing endonasal coblation of telangiectasias. Postoperative pain was mild to moderate and most patients stopped using opioid medications by POD 4, although the majority of patients solely used acetaminophen. Future studies with increased sample size will be useful to further identify predictors of need for analgesics postoperatively and other non-opioid adjuncts for pain control.
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Affiliation(s)
- Kristen Kraimer
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Brian Scott
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nyssa Farrell
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St Louis, MI, USA
| | - Mathew Geltzeiler
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Kara Detwiller
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR, USA
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Beaulieu-Jones BR, Marwaha JS, Kennedy CJ, Le D, Berrigan MT, Nathanson LA, Brat GA. Comparing Rationale for Opioid Prescribing Decisions after Surgery with Subsequent Patient Consumption: A Survey of the Highest Quartile of Prescribers. J Am Coll Surg 2023; 237:835-843. [PMID: 37702392 DOI: 10.1097/xcs.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Opioid prescribing patterns, including those after surgery, have been implicated as a significant contributor to the US opioid crisis. A plethora of interventions-from nudges to reminders-have been deployed to improve prescribing behavior, but reasons for persistent outlier behavior are often unknown. STUDY DESIGN Our institution employs multiple prescribing resources and a near real-time, feedback-based intervention to promote appropriate opioid prescribing. Since 2019, an automated system has emailed providers when a prescription exceeds the 75th percentile of typical opioid consumption for a given procedure-as defined by institutional data collection. Emails include population consumption metrics and an optional survey on rationale for prescribing. Responses were analyzed to understand why providers choose to prescribe atypically large discharge opioid prescriptions. We then compared provider prescriptions against patient consumption. RESULTS During the study period, 10,672 eligible postsurgical patients were discharged; 2,013 prescriptions (29.4% of opioid prescriptions) exceeded our institutional guideline. Surveys were completed by outlier prescribers for 414 (20.6%) encounters. Among patients where both consumption data and prescribing rationale surveys were available, 35.2% did not consume any opioids after discharge and 21.5% consumed <50% of their prescription. Only 93 (39.9%) patients receiving outlier prescriptions were outlier consumers. Most common reasons for prescribing outlier amounts were attending preference (34%) and prescriber analysis of patient characteristics (34%). CONCLUSIONS The top quartile of opioid prescriptions did not align with, and often far exceeded, patient postdischarge opioid consumption. Providers cite assessment of patient characteristics as a common driver of decision-making, but this did not align with patient usage for approximately 50% of patients.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Jayson S Marwaha
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Chris J Kennedy
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
| | - Danny Le
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA (Le)
| | - Margaret T Berrigan
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
| | - Larry A Nathanson
- Emergency Medicine (Nathanson), Beth Israel Deaconess Medical Center, Boston, MA
| | - Gabriel A Brat
- From the Departments of Surgery (Beaulieu-Jones, Marwaha, Kennedy, Berrigan, Brat), Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA (Beaulieu-Jones, Marwaha, Kennedy, Brat)
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Meade MH, Schultz MJ, Radack T, Michael M, Hilibrand AS, Kurd MF, Hsu V, Kaye ID, Schroeder GD, Kepler C, Vaccaro AR, Woods BI. The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion. Clin Spine Surg 2023; 36:E410-E415. [PMID: 37363819 DOI: 10.1097/bsd.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/17/2023] [Indexed: 06/28/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF). BACKGROUND Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery. PATIENTS AND METHODS Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index. RESULTS Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58). CONCLUSIONS While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Matthew H Meade
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, NJ
| | | | - Tyler Radack
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mark Michael
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, NJ
| | - Alan S Hilibrand
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mark F Kurd
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Victor Hsu
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Ian David Kaye
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Christopher Kepler
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Barrett I Woods
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Benlolo S, Nensi A, Shishkina A, Robertson D, Kives S. The Tailored Opioid Reduction Strategy (TORS): A Quality Improvement Initiative to Reduce Opioid Prescription Following Hysterectomy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102214. [PMID: 37709142 DOI: 10.1016/j.jogc.2023.102214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To evaluate a tailored opioid reduction strategy (TORS) in minimizing opioid prescriptions for patients undergoing hysterectomy. METHODS This quality improvement initiative was developed by multiple stakeholders at an academic hospital in a Canadian urban centre. The intervention consisted of a three-pronged approach: (1) patient and provider education, (2) perioperative multimodal analgesia, and (3) a targeted opioid reduction strategy. All eligible patients were asked to fill pre- and postoperative questionnaires. Analysis of outcomes pre- and post-TORS implementation as well as intervention compliance was performed. RESULTS From September 2020 to April 2021, 133 patients who underwent hysterectomy were included in the study, 69 in the pre-intervention group and 64 in the post-intervention group. Of 133 hysterectomies, 78 (58.6%) were performed laparoscopically, 16 (12%) open, 14 (10.5%) vaginally, and 25 (18.8%) robotically. The rate of discharge opioid prescriptions was significantly reduced in the post-intervention group compared with the pre-intervention group (37/64, 58% versus 62/69, 90%, respectively, P < 0.001), as well as the amount of opioid prescribed in oral morphine equivalents (OME) (mean 47 mg pre-intervention, 28 mg post-intervention, P < 0.001). There was no significant difference in patient satisfaction or postoperative pain scores between groups. Overall, compliance with 2 or more components of TORS intervention was seen in 64/64 (100%) cases. CONCLUSION TORS implementation was successful in reducing the rate of discharge opioid prescriptions and the total amount of opiates prescribed in patients undergoing hysterectomy with no decrease in patient satisfaction or change in postoperative pain scores. We believe it can be applied more broadly across different surgical patient populations to prevent opioid abuse.
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Affiliation(s)
| | - Alysha Nensi
- Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anna Shishkina
- Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Deborah Robertson
- Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sari Kives
- Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Meldon A, Davey MG, Joyce WP. Evaluating opioid prescribing patterns following discharge from elective surgical procedures: a worrying trend during the 'opioid crisis' - an audit of elective surgical procedures. Ir J Med Sci 2023; 192:2993-2999. [PMID: 37081287 DOI: 10.1007/s11845-023-03363-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 04/03/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The 'opioid crisis' has reached epidemic proportions globally. Importantly, 30% of opioid dependency stem from opioids obtained on hospital discharge prescriptions. AIM The aim of this study is to evaluate opioid prescription patterns on discharge of post-operative patients in an Irish Hospital. METHODS A retrospective cohort study was undertaken in a single institution during the 5 year eligibility period (January 2017-October 2021). Comparisons in opioid prescription patterns following minor (inguinal hernia repair (IHR), intermediate (laparoscopic cholecystectomy (LC)) and major (colonic resection (CR)) were made. Descriptive statistics were performed using SPSS version 26.0 RESULTS: In total, 300 patients were included in this study with mean age 59.6 years (range: 20-92). Of these, 112 patients underwent IHR (37.3%), 116 patients underwent LC (38.7%), and 72 patients underwent CR (24.0%). The mean age at diagnosis was 61 years, 53 years and 58 years for IHR, LC and CR, respectively (P < 0.001). Patients undergoing CR were more likely to have greater comorbidity burden (3.1 vs. 1.2 (IHR) vs. 1.8 (LC) respectively (P = 0.030). On discharge, 27.8% of CR patients received opioids (20/72) compared to 24.1% of IHR (28/116) and 15.9% of LC (18/113) patients, respectively (P = 0.126). CONCLUSION We observed considerable variability in opioid prescribing patterns following minor, intermediate and major operations in our centre. Care is required when prescribing opioids in the post-operative setting, and opioid prescription guidelines are required to both tackle and prevent an escalation of this 'opioid crisis'.
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Affiliation(s)
- Aengus Meldon
- Department of Surgery, Galway Clinic, Doughiska, Co. Galway , H91 HHT0, Republic of Ireland.
| | - Matthew G Davey
- Department of Surgery, Galway Clinic, Doughiska, Co. Galway , H91 HHT0, Republic of Ireland
| | - William P Joyce
- Department of Surgery, Galway Clinic, Doughiska, Co. Galway , H91 HHT0, Republic of Ireland
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Beaton AC, Solanki D, Salazar H, Folkerth S, Singla N, Minkowitz HS, Leiman D, Vaughn B, Skuban N, Niebler G. A randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of a bupivacaine hydrochloride implant in patients undergoing abdominoplasty. Reg Anesth Pain Med 2023; 48:601-607. [PMID: 37076252 PMCID: PMC10646917 DOI: 10.1136/rapm-2022-104110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Surgical site infiltration with bupivacaine hydrochloride (HCl) is a standard element of postoperative analgesia for soft tissue surgeries, but results in short-lived analgesia. A novel bupivacaine implant, XARACOLL (bupivacaine HCl), is Food and Drug Administration approved for treatment of acute postsurgical pain following adult inguinal herniorrhaphy. This study examined the efficacy and safety of the bupivacaine implant (300 mg) compared with placebo for postsurgical pain after abdominoplasty. METHODS In this double-blind, placebo-controlled study, patients undergoing abdominoplasty were randomized to three 100 mg bupivacaine implants or three placebo collagen implants, in a 1:1 ratio, implanted intraoperatively. No other analgesics were administered into the surgical site. Patients were allowed opioids and acetaminophen for postoperative pain. Patients were followed for up to 30 days after treatment. PRIMARY OUTCOME the analgesic effect of the bupivacaine implants through 24 hours postsurgery, measured by the sum of time-weighted pain intensity (SPI24). Prespecified key secondary outcomes included SPI48 and SPI72, percentage of opioid-free patients through 24, 48, and 72 hours, and adverse events, which were tested sequentially to control for multiplicity (ie, if the first variable failed to reach significance, no subsequent variables were declared statistically significant). RESULTS The bupivacaine implant patients (n=181) reported statistically significant lower SPI24 (mean (SD) SPI24=102 (43), 95% CI 95 to 109) compared with placebo patients (n=184; SPI24=117 (45), 95% CI 111 to 123, p=0.002). SPI48 was 190 (88, 95% CI 177 to 204) for INL-001 and 206 (96, 95% CI 192 to 219) for placebo, and not significantly different between groups. The subsequent secondary variables were therefore declared not statistically significant. SPI72 was 265 (131, 95% CI 244 to 285) for INL-001 and 281 (146, 95% CI 261 to 301) for placebo. The opioid-free percentage of patients at 24, 48, and 72 hours was 19%, 17%, and 17% for INL-001 and 6.5% for placebo patients (at all timepoints). The only adverse event occurring in ≥5% of patients and for which proportion INL-001 >placebo was back pain (7.7% vs 7.6%). CONCLUSION The study design was limited by not containing an active comparator. Compared with placebo, INL-001 provides postoperative analgesia that is temporally aligned with the period of maximal postsurgical pain in abdominoplasty and offers a favorable safety profile. TRIAL REGISTRATION NUMBER NCT04785625.
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Affiliation(s)
| | | | | | | | - Neil Singla
- Lotus Clinical Research, LLC, Pasadena, California, USA
| | | | - David Leiman
- HD Research/First Surgical Hospital, Bellaire, Texas, USA
| | | | - Nina Skuban
- Innocoll Pharmaceuticals Limited, Innocoll Biotherapeutics, Princeton, New Jersey, USA
| | - Gwendolyn Niebler
- Innocoll Pharmaceuticals Limited, Innocoll Biotherapeutics, Princeton, New Jersey, USA
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Villarreal E, Wolf SE, Golovko G, Bagby S, Wermine K, Gotewal S, Obi A, Corona K, Huang L, Keys P, Song J, El Ayadi A. Opioid prescription and opioid disorders in burns: A large database analysis from 1990 to 2019. Burns 2023; 49:1845-1853. [PMID: 37872016 DOI: 10.1016/j.burns.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 06/28/2023] [Accepted: 09/20/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Opioids remain crucial in the management of burn pain. A comprehensive analysis of opioid use in burns and their complications has not been investigated. METHODS Data were collected from TriNetX, a large multicenter database with de-identified patient information. The population included patients prescribed opioids on or following burn injury from January 1st, 1990, to December 31st, 2019. Opioid prescription use was analyzed after cohort stratification by decades: 1990-1999, 2000-2009, and 2010-2019. Outcomes for opioid-related disorders, opioid dependence, opioid abuse, intentional self-harm, and mental and behavioral disorders from psychoactive substance use were investigated. RESULTS Hydrocodone was the most frequently prescribed opioid in 1990-1999 and 2000-2009, with oxycodone taking the lead in 2010-2019 (p < 0.0001). During 1990-1999, patients had a decreased risk of recorded opioid-related disorders (RR=0.52), opioid dependence (RR=0.46), opioid abuse (RR=0.55), mental and behavioral disorders (RR=0.88), and intentional self-harm (RR=0.37) when compared to 2000-2009. A comparison of the 2000-2009-2010-2019 cohorts showed an increased risk of recorded opioid-related disorders (RR= 1.91), opioid dependence (RR=1.56), opioid abuse (RR=1.67), mental and behavioral disorders (RR =1.73), and intentional self-harm (RR=2.02). CONCLUSIONS The risk of opioid-related disorders has nearly doubled since the year 2000 warranting precautions when prescribing pain medications to burn patients.
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Affiliation(s)
- Elvia Villarreal
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - George Golovko
- Department of Pharmacology, University of Texas Medical Branch, Galveston, TX, USA
| | - Shelby Bagby
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Kendall Wermine
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Sunny Gotewal
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ann Obi
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Kassandra Corona
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Lyndon Huang
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Phillip Keys
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Juquan Song
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Amina El Ayadi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA.
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Admiraal M, Hermanides J, Meinsma SL, Wartenberg HCH, Rutten MVH, Heine Y, Kallewaard JW, Hollmann MW, Hermanns H. The effectiveness of a transitional pain service in patients undergoing surgery with an increased risk of developing chronic postsurgical pain (TRUSt study). A randomized clinical trial. J Clin Anesth 2023; 91:111262. [PMID: 37722149 DOI: 10.1016/j.jclinane.2023.111262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023]
Abstract
STUDY OBJECTIVE Poorly controlled acute postsurgical pain is associated with delayed recovery, chronic postsurgical pain (CPSP), chronic opioid use and impaired functioning in daily activities. The aim was to determine the effectiveness of a transitional pain service (TPS) to improve quality of recovery for patients at risk of CPSP. We hypothesized that a TPS improves the quality of recovery in patients at risk of CPSP. DESIGN Single-center, pragmatic, randomized, superiority trial. SETTING Tertiary hospital in the Netherlands. PATIENTS Assessed for eligibility if ≥18 years of age, undergoing elective surgery, and had an increased risk of developing CPSP. After being stratified for sex, 176 patients were included. INTERVENTION Patients were randomized to receive TPS or standard of care (SOC). TPS was a multidisciplinary intervention providing a patient-tailored perioperative pain management plan, throughout all phases of surgery. MEASUREMENTS The primary outcome was the difference in quality of recovery on the third postoperative day, measured by the Quality of Recovery (QoR)-15 questionnaire. Secondary outcomes include the between group differences in opioid consumption. MAIN RESULTS The primary outcome was available in 169 (96.0%) patients. No difference between groups was found in QoR-15 on the third postoperative day (mean difference 2.0, 95% CI -5.5 to 9.4, p = 0.607). A decrease in opioid usage (compared to baseline) was observed in chronic opioid users, the median [IQR] reduction in total daily oral morphine milligram equivalents (MME) for TPS was -30 [-60, 0] at three and - 29.3 [-65.6, 0] at six months, whereas SOC had a median reduction of 0 [-56, 0] at three, and 0 [-60, 7.5] at six months. CONCLUSIONS TPS did not significantly affect short-term quality of recovery but might improve long-term outcomes, such as the incidence of chronic pain, opioid consumption, and functioning in daily life. However, sample size in the present study was too small to provide solid evidence for this positive signal.
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Affiliation(s)
- Manouk Admiraal
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Soe L Meinsma
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hans C H Wartenberg
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Martin V H Rutten
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Yvonne Heine
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Willem Kallewaard
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Anaesthesiology, Rijnstate Hospital, Velp, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Coffman CR, Leng JC, Ye Y, Hunter OO, Walters TL, Wang R, Wong JK, Mudumbai SC, Mariano ER. More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health. Semin Cardiothorac Vasc Anesth 2023; 27:273-282. [PMID: 37679298 DOI: 10.1177/10892532231200620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.
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Affiliation(s)
- Clarity R Coffman
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jody C Leng
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ying Ye
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Oluwatobi O Hunter
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Tessa L Walters
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rachel Wang
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jimmy K Wong
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Seshadri C Mudumbai
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Zoma L, Paxton RA, Dehoorne M, Giuliano C. Comparing Post-operative Opioid Consumption before and after a Patient-Controlled Analgesia Shortage: A Re-evaluation of Safety and Effectiveness. J Pain Palliat Care Pharmacother 2023; 37:272-277. [PMID: 37669436 DOI: 10.1080/15360288.2023.2250334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 09/07/2023]
Abstract
This retrospective cohort study aimed to compare post-surgical opioid consumption before and after a PCA (patient-controlled analgesia) shortage. The study evaluated patients who received PCA vs. nurse-administered opioid analgesia (non-PCA). Two hundred and twenty-four patients ≥18 years who were initiated on analgesia within 24 h of surgery were included. The primary outcome was opioid consumption in average daily oral morphine milliequivalents (MME). The results showed that patients in the PCA group had increased MME consumption (162 ± 100.4 vs. 70.7 ± 52.8, p < 0.01), increased length of hospital stay (4.2 vs. 3.2 days, p < 0.01), and increased frequency of nausea (33 vs. 17.9%, p < 0.01). After controlling for confounding factors, the PCA group utilized significantly more opioids (84.6 MME/day, p < 0.01) than the non-PCA group. There was no difference in pain AUC/T (0.19 ± 0.07 vs. 0.21 ± 0.08, p = 0.07) and average opioid prescribing upon discharge (150 [77.5-360] vs. 90 [77.5-400], p = 0.64) between the PCA group and non-PCA group, respectively. These results question the routine use of PCA in post-operative patients due to the increased risk of opioid consumption, longer length of hospital stay, and higher incidence of nausea.
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Affiliation(s)
- Lena Zoma
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | | | - Michelle Dehoorne
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Science, Wayne State University, Ascension St. John Hospital, Detroit, MI, USA
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Darville-Beneby R, Lomanowska AM, Yu HC, Jobin P, Rosenbloom BN, Gabriel G, Daudt H, Negraeff M, Di Renna T, Hudspith M, Clarke H. The Impact of Preoperative Patient Education on Postoperative Pain, Opioid Use, and Psychological Outcomes: A Narrative Review. Can J Pain 2023; 7:2266751. [PMID: 38126044 PMCID: PMC10732618 DOI: 10.1080/24740527.2023.2266751] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/30/2023] [Indexed: 12/23/2023]
Abstract
Background Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use. Objectives The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes. Method The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded. Results From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety. Conclusion Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.
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Affiliation(s)
- Rasheeda Darville-Beneby
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anna M. Lomanowska
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
| | - Hai Chuan Yu
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Parker Jobin
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Brittany N. Rosenbloom
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gretchen Gabriel
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
| | - Helena Daudt
- Pain BC/Pain Canada, Vancouver, British Columbia, Canada
| | - Michael Negraeff
- Pain BC/Pain Canada, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Tania Di Renna
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Academic Pain Medicine Institute, Toronto, Ontario, Canada
| | - Maria Hudspith
- Pain BC/Pain Canada, Vancouver, British Columbia, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, Ontario, Canada
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Hite MA, McCutcheon T, Feng MP, Ford MM, Geiger TM, Hopkins MB, Muldoon RL, Irlmeier R, Fa A, Ye F, Hawkins AT. Opioid Utilization in Outpatient Anorectal Surgery: An Opportunity for Improvement. J Surg Res 2023; 291:105-115. [PMID: 37354704 DOI: 10.1016/j.jss.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/19/2023] [Accepted: 05/16/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION The opioid epidemic has resulted in close examination of postsurgical prescribing patterns. Little is known about postoperative opioid use in outpatient anorectal procedures. This study evaluated patient opioid use and created prescribing recommendations for these procedures. METHODS One hundred and four patients undergoing outpatient anorectal procedures from January to May 2018 were surveyed on opioid consumption, surgical experience, and pain satisfaction. Patients were grouped into three tiers based on opioid usage. Multivariable models were used to determine factors associated with poor pain control. RESULTS Patient satisfaction with pain control was 85.6%. Twenty five percent of patients reported leftover medication and 9.6% of patients requested opioid refills. Opioid prescribing recommendations were generated for each tier using 50th percentile with interquartile ranges. On multivariable modeling, the high-tier group was associated with poorer pain control. CONCLUSIONS We created opioid quantity prescribing guidelines for common outpatient anorectal procedures. A multimodal approach to pain control utilizing nonopioids may reduce healthcare utilization.
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Affiliation(s)
- Melissa A Hite
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tonna McCutcheon
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael P Feng
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Molly M Ford
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - M Benjamin Hopkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roberta L Muldoon
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Irlmeier
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrea Fa
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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Campbell LJ, Mummaneni PV, Letchuman V, Langnas E, Agarwal N, Guan LS, Croci R, Vargas E, Reisner L, Bickler P, Chou D, Chang E, Guan Z. Mismatched opioid prescription in patients discharged after neurological surgeries: a retrospective cohort study. Pain 2023; 164:2615-2621. [PMID: 37326642 DOI: 10.1097/j.pain.0000000000002966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/22/2023] [Indexed: 06/17/2023]
Abstract
ABSTRACT Although postsurgical overprescription has been well-studied, postsurgical opioid underprescription remains largely overlooked. This retrospective cohort study was to investigate the extent of discharge opioid overprescription and underprescription in patients after neurological surgeries. Six thousand nine hundred forty-nine adult opioid-naive patients who underwent inpatient neurosurgical procedures at the University of California San Francisco were included. The primary outcome was the discrepancy between individual patient's prescribed daily oral morphine milligram equivalent (MME) at discharge and patient's own inpatient daily MME consumed within 24 hours of discharge. Analyses include Wilcoxon, Mann-Whitney, Kruskal-Wallis, and χ 2 tests, and linear or multivariable logistic regression. 64.3% and 19.5% of patients were opioid overprescribed and underprescribed, respectively, with median prescribed daily MME 360% and 55.2% of median inpatient daily MME in opioid overprescribed and underprescribed patients, respectively. 54.6% of patients with no inpatient opioid the day before discharge were opioid overprescribed. Opioid underprescription dose-dependently increased the rate of opioid refill 1 to 30 days after discharge. From 2016 to 2019, the percentage of patients with opioid overprescription decreased by 24.8%, but the percentage of patients with opioid underprescription increased by 51.2%. Thus, the mismatched discharge opioid prescription in patients after neurological surgeries presented as both opioid overprescription and underprescription, with a dose-dependent increased rate of opioid refill 1 to 30 days after discharge in opioid underprescription. Although we are fighting against opioid overprescription to postsurgical patients, we should not ignore postsurgical opioid underprescription.
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Affiliation(s)
- Liam J Campbell
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Lucy S Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Rhiannon Croci
- UCSF Health Informatics, University of California San Francisco, San Francisco, CA, United States
| | - Enrique Vargas
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Lori Reisner
- Department of Clinical Pharmacology, University of California San Francisco, San Francisco, CA, United States
| | - Phil Bickler
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, Columbia University, New York, NY, United States
| | - Edward Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
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Chang JS, Lee DH, Kang MW, Kim JW, Kim CH. Effectiveness of Intravenous Non-Opioid Analgesics for Postoperative Pain Management of in Patients Undergoing Hip Surgery: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1904. [PMID: 38003953 PMCID: PMC10673097 DOI: 10.3390/medicina59111904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Intravenous (IV) non-opioid analgesics (NOAs) have been extensively investigated as a multimodal analgesic strategy for the management of acute pain after hip surgery. This pair-wise meta-analysis examined IV NOA effects following hip surgery. Materials and Methods: A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies investigating the effect of IV NOA for postoperative pain management following hip surgery up to 7 June 2023. We compared in-admission opioid use, postoperative VAS (visual analogue scale) score, hospital stay duration, and opioid-related adverse events between IV NOA and control groups. Results: Seven studies were included with a total of 953 patients who underwent hip surgery. Of these, 478 underwent IV NOA treatment, and 475 did not. The IV NOA groups had lower opioid use within 24-h following hip surgery (SMD, -0.48; 95% CI, -0.66 to -0.30; p < 0.01), lower VAS score (SMD, -0.47; 95% CI, -0.79 to -0.16; p < 0.01), shorter hospital stay (SMD, -0.28; 95% CI, -0.44 to -0.12; p < 0.01), and lower incidence of nausea and vomiting (OR, 0.32; 95% CI, 0.15 to 0.67; p < 0.01) compared with the control groups. Conclusions: This meta-analysis demonstrated that IV NOA administration following hip surgery may have more favorable postoperative outcomes than those in control groups.
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Affiliation(s)
- Jae Suk Chang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Dong Hwan Lee
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Min Wook Kang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
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Georgiadis E, Johnson MI. Incorporating personal narratives in positive psychology interventions to manage chronic pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1253310. [PMID: 37869366 PMCID: PMC10588179 DOI: 10.3389/fpain.2023.1253310] [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: 07/05/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
In this perspective paper, we argue for incorporating personal narratives in positive psychology interventions for chronic pain. Narratives refer to the telling and retelling of events. Narratives detail accounts of events and provide rich, in-depth information on human interactions, relationships, and perspectives. As such, narratives have been used to understand people's experiences with pain and pain coping mechanisms-as well as to facilitate therapeutic outcomes. Furthermore, narrative research has shown that narration can help restore and promote relief, calm, hope, self-awareness, and self-understanding in chronic pain sufferers. Positive psychology interventions have been successful in improving the lives of people living with chronic pain, but these psychology interventions do not typically incorporate personal narratives. Still, narrative, and positive psychology scholarship foci overlap, as both aim to enhance people's quality of life, happiness, and well-being, and to promote the understanding of psychosocial strengths and resources. In this article, we provide a rationale for incorporating personal narratives as an agentic form of positive psychology intervention. To that aim, we outline areas of convergence between positive psychology and narrative research and show how combining positive psychology exercises and narration can have additive benefits for pain sufferers. We also show how integrating narration in positive psychology intervention research can have advantages for healthcare research and policy.
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Affiliation(s)
- Emmanouil Georgiadis
- School of Social Sciences and Humanities, University of Suffolk, Ipswich, United Kingdom
| | - Mark I. Johnson
- Centre for Pain Research, School of Health, Leeds Beckett University, Leeds, United Kingdom
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Lambrechts MJ, Toci GR, Fried TB, Issa TZ, Karamian BA, Carter MV, Breyer GM, Curran JG, Hassan W, Jeyamohan H, Minetos PD, Stolzenberg D, Mehnert M, Canseco JA, Woods BI, Kaye ID, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Preoperative Opioid Prescribers and Lumbar Fusion: Their Effect on Clinical Outcomes and Postoperative Opioid Usage. Clin Spine Surg 2023; 36:E375-E382. [PMID: 37296494 DOI: 10.1097/bsd.0000000000001465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine the impact of multiple preoperative opioid prescribers on postoperative patient opioid usage and patient-reported outcome measures after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA Prior literature has identified opioid prescriptions from multiple postoperative providers increase opioid usage rates. However, there is limited evidence on how multiple preoperative opioid prescribers affect postoperative opioid usage or clinical outcomes after a single-level lumbar fusion. PATIENTS AND METHODS A retrospective review of single-level transforaminal lumbar interbody fusion or posterolateral lumbar fusions between September 2017 and February 2020 at a single academic institution was performed. Patients were excluded if they were not identifiable in our state's prescription drug-monitoring program. Univariate comparisons and regression analyses identified factors associated with postoperative clinical outcomes and opioid usage. RESULTS Of 239 patients, 160 (66.9%) had one or fewer preoperative prescribers and 79 (33.1%) had >1 prescribers. On regression analysis, the presence of multiple preoperative prescribers was an independent predictor of increased improvement in Visual Analog Scale (∆VAS) Back (β=-1.61, P =0.012) and the involvement of a nonoperative spine provider was an independent predictor of increased improvement in ∆VAS Leg (β = -1.53, P = 0.034). Multiple preoperative opioid prescribers correlated with an increase in opioid prescriptions postoperatively (β = 0.26, P = 0.014), but it did not significantly affect the amount of morphine milligram equivalents prescribed (β = -48.79, P = 0.146). A greater number of preoperative opioid prescriptions predicted worse improvements in VAS Back, VAS Leg, and Oswestry Disability Index and predicted increased postoperative opioid prescriptions, prescribers, and morphine milligram equivalents. CONCLUSIONS Multiple preoperative opioid prescribers predicted increased improvement in postoperative back pain, whereas preoperative involvement of a nonoperative spine provider predicted improvements in leg pain after surgery. The number of preoperative opioid prescriptions was a better metric for predicting poor postoperative outcomes and increased opioid consumption compared with the number of preoperative opioid prescribers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - David Stolzenberg
- Department of Physical Medicine and Rehabilitation, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Michael Mehnert
- Department of Physical Medicine and Rehabilitation, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Kharasch ED, Brunt LM, Blood J, Komen H. Intraoperative Methadone in Next-day Discharge Outpatient Surgery: A Randomized, Double-blinded, Dose-finding Pilot Study. Anesthesiology 2023; 139:405-419. [PMID: 37350677 PMCID: PMC10527477 DOI: 10.1097/aln.0000000000004663] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Contemporary perioperative practice seeks to use less intraoperative opioid, diminish postoperative pain and opioid use, and enable less postdischarge opioid prescribing. For inpatient surgery, anesthesia with intraoperative methadone, compared with short-duration opioids, results in less pain, less postoperative opioid use, and greater patient satisfaction. This pilot investigation aimed to determine single-dose intraoperative methadone feasibility for next-day discharge outpatient surgery, determine an optimally analgesic and well-tolerated dose, and explore whether methadone would result in less postoperative opioid use compared with conventional short-duration opioids. METHODS This double-blind, randomized, dose-escalation feasibility and pilot study in next-day discharge surgery compared intraoperative single-dose IV methadone (0.1 then 0.2, 0.25 and 0.3 mg/kg ideal body weight) versus as-needed short-duration opioid (fentanyl, hydromorphone) controls. Perioperative opioid use, pain, and side effects were assessed before discharge. Patients recorded pain, opioid use, and side effects for 30 days postoperatively using take-home diaries. Primary clinical outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30-day opioid consumption, pain, opioid side effects, and leftover opioid counts. RESULTS Median (interquartile range) intraoperative methadone doses were 6 (5 to 7), 11 (10 to 12), 14 (13 to 16), and 18 (15 to 19) mg in 0.1, 0.2, 0.25, and 0.3 mg/kg ideal body weight groups, respectively. Anesthesia with single-dose methadone and propofol or volatile anesthetic was effective. Total in-hospital opioid use (IV milligram morphine equivalents [MME]) was 25 (20 to 37), 20 (13 to 30), 27 (18 to 32), and 25 (20 to 36) mg, respectively, in patients receiving 0.1, 0.2, 0.25 and 0.3 mg/kg methadone, compared to 46 (33 to 59) mg in short-duration opioid controls. Opioid-related side effects were not numerically different. Home pain and opioid use were numerically lower in patients receiving methadone. CONCLUSIONS The most effective and well-tolerated single intraoperative induction dose of methadone for next-day discharge surgery was 0.25 mg/kg ideal body weight (median, 14 mg). Single-dose intraoperative methadone was analgesic and opioid-sparing in next-day discharge outpatient surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
| | - L. Michael Brunt
- Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Jane Blood
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO
| | - Helga Komen
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO
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Bullock WM, Kumar AH, Manning E, Jones J. Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction. Orthop Clin North Am 2023; 54:495-506. [PMID: 37718088 DOI: 10.1016/j.ocl.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.
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Affiliation(s)
- William Michael Bullock
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5672C HAFS, Durham, NC 27710, USA. https://twitter.com/wmbullockMDPhD
| | - Amanda H Kumar
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5672C HAFS, Durham, NC 27710, USA. https://twitter.com/amandakumarMD
| | - Erin Manning
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5672C HAFS, Durham, NC 27710, USA. https://twitter.com/ukmdphd2006
| | - Jerry Jones
- East Memphis Anesthesia Services, 5545 Murray Avenue, Suite 130, Memphis, TN 38119, USA; Department of Anesthesiology, University of Tennessee Health Science Center, 877 Jefferson Avenue, Chandler Building, Suite 600, Memphis, TN, USA.
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Nazzal EM, Reddy RP, Haley RM, Wilson JM, Lamplot JD, Musahl V, Xerogeanes JW. Standardized Opioid Counseling Is Underperformed Before and After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100782. [PMID: 37554768 PMCID: PMC10404863 DOI: 10.1016/j.asmr.2023.100782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/25/2023] [Indexed: 08/10/2023] Open
Abstract
PURPOSE To characterize contemporary pain management strategies after anterior cruciate ligament reconstruction (ACLR) within the US and international orthopaedic community. METHODS This was a cross-sectional survey-based study disseminated to a consortium of expert orthopaedic surgeons in the management of anterior cruciate ligament injuries. The survey was a 27-question, multiple choice-style questionnaire with question topics ranging from demographic characteristics and practice characteristics to surgeon-specific pain management strategies in the postoperative period after ACLR. Specific topics of interest included the use of preoperative opioid education and/or counseling sessions, implementation of standardized pain management regimens, use of pain tracking systems, and use of any adjunct non-narcotic analgesic modalities. RESULTS A total of 34 completed surveys were collected, representing a 73.9% response rate. Over 85% of respondents reported prescribing opioids as a standardized postoperative regimen after ACLR. Surgeons reported prescribing 5- to 10-mg doses, with the tablet count ranging anywhere from fewer than 10 tablets to more than 20 tablets, often instructing their patients to stop opioid use 2 to 4 days postoperatively. Prescribed dosages remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents reported using standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. CONCLUSIONS Over 85% of respondents prescribe opioids as a standardized postoperative regimen after ACLR, with only 15% providing non-narcotic pain regimens. However, prescribed dosages have remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents use standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. CLINICAL RELEVANCE The ongoing opioid epidemic has created an urgent need to identify the most effective pain management strategies after orthopaedic procedures, especially ACLR. This study provides important information about current pain management practices for patients who have undergone ACLR.
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Affiliation(s)
- Ehab M. Nazzal
- University of Pittsburgh Medical Center Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, U.S.A
| | - Rajiv P. Reddy
- University of Pittsburgh Medical Center Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, U.S.A
| | - Rebecca M. Haley
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Jacob M. Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Joseph D. Lamplot
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Volker Musahl
- University of Pittsburgh Medical Center Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, U.S.A
| | - John W. Xerogeanes
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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van der Veen A, Ramaekers M, Marsman M, Brenkman HJF, Seesing MFJ, Luyer MDP, Nieuwenhuijzen GAP, Stoot JHMB, Tegels JJW, Wijnhoven BPL, de Steur WO, Kouwenhoven EA, Wassenaar EB, Draaisma WA, Gisbertz SS, van der Peet DL, May AM, Ruurda JP, van Hillegersberg R. Pain and Opioid Consumption After Laparoscopic Versus Open Gastrectomy for Gastric Cancer: A Secondary Analysis of a Multicenter Randomized Clinical Trial (LOGICA-Trial). J Gastrointest Surg 2023; 27:2057-2067. [PMID: 37464143 PMCID: PMC10579125 DOI: 10.1007/s11605-023-05728-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/01/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Laparoscopic gastrectomy could reduce pain and opioid consumption, compared to open gastrectomy. However, it is difficult to judge the clinical relevance of this reduction, since these outcomes are reported in few randomized trials and in limited detail. METHODS This secondary analysis of a multicenter randomized trial compared laparoscopic versus open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). Postoperative pain was analyzed by opioid consumption in oral morphine equivalents (OME, mg/day) at postoperative day (POD) 1-5, WHO analgesic steps, and Numeric Rating Scales (NRS, 0-10) at POD 1-10 and discharge. Regression and mixed model analyses were performed, with and without correction for epidural analgesia. RESULTS Between 2015 and 2018, 115 patients in the laparoscopic group and 110 in the open group underwent surgery. Some 16 patients (14%) in the laparoscopic group and 73 patients (66%) in the open group received epidural analgesia. At POD 1-3, mean opioid consumption was 131, 118, and 53 mg OME lower in the laparoscopic group, compared to the open group, respectively (all p < 0.001). After correcting for epidural analgesia, these differences remained significant at POD 1-2 (47 mg OME, p = 0.002 and 69 mg OME, p < 0.001, respectively). At discharge, 27% of patients in the laparoscopic group and 43% patients in the open group used oral opioids (p = 0.006). Mean highest daily pain scores were between 2 and 4 at all PODs, < 2 at discharge, and did not relevantly differ between treatment arms. CONCLUSION In this multicenter randomized trial, postoperative pain was comparable between laparoscopic and open gastrectomy. After laparoscopic gastrectomy, this was generally achieved without epidural analgesia and with fewer opioids. TRIAL REGISTRATION NCT02248519.
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Affiliation(s)
- Arjen van der Veen
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100 G04.228, 3508 GA, Utrecht, Netherlands.
| | - Mark Ramaekers
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Marije Marsman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Hylke J F Brenkman
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100 G04.228, 3508 GA, Utrecht, Netherlands
| | - Maarten F J Seesing
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100 G04.228, 3508 GA, Utrecht, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | | | - Jan H M B Stoot
- Department of Surgery, Zuyderland Medical Center, Heerlen and Sittard-Geleen, Netherlands
| | - Juul J W Tegels
- Department of Surgery, Zuyderland Medical Center, Heerlen and Sittard-Geleen, Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wobbe O de Steur
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Werner A Draaisma
- Department of Surgery, Meander Medical Center, Amersfoort, Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Location VUmc, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Anne M May
- University Medical Center Utrecht, Utrecht University, Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100 G04.228, 3508 GA, Utrecht, Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100 G04.228, 3508 GA, Utrecht, Netherlands.
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Dahlin LB, Perez R, Nyman E, Zimmerman M, Merlo J. Overuse of the psychoactive analgesics' opioids and gabapentinoid drugs in patients having surgery for nerve entrapment disorders. Sci Rep 2023; 13:16248. [PMID: 37758760 PMCID: PMC10533484 DOI: 10.1038/s41598-023-43253-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023] Open
Abstract
Knowledge about risks for overuse of psychoactive analgesics in patients having primary surgery for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, is limited. We investigated if patients with those nerve entrapment disorders have a higher risk of overuse of psychoactive analgesics (i.e., opioids and gabapentinoid drugs) before, after, and both before and after surgery than observed in the general population after accounting for demographical and socioeconomic factors. Using a large record linkage database, we analysed 5,966,444 individuals (25-80 years), residing in Sweden December 31st, 2010-2014, of which 31,380 underwent surgery 2011-2013 for CTS, UNE, or both, applying logistic regression to estimate relative risk (RR) and 95% confidence interval (CI). Overall, overuse of the psychoactive analgesics was low in the general population. Compared to those individuals, unadjusted RR (95% CI) of overuse ranged in patients between 2.77 (2.57-3.00) with CTS after surgery and 6.21 (4.27-9.02) with both UNE and CTS after surgery. These risks were only slightly reduced after adjustment for demographical and socioeconomic factors. Patients undergoing surgery for CTS, UNE, or both, have a high risk of overuse of psychoactive analgesics before, after, and both before and after surgery.
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Affiliation(s)
- Lars B Dahlin
- Department of Translational Medicine - Hand Surgery, Skåne University Hospital, Lund University, Jan Waldenströms g 5, 20502, Malmö, Sweden.
- Department of Hand Surgery, Skåne University Hospital, 20502, Malmö, Sweden.
- Department of Biomedical and Clinical Sciences, Linköping University, 58183, Linköping, Sweden.
| | - Raquel Perez
- Department of Translational Medicine - Hand Surgery, Skåne University Hospital, Lund University, Jan Waldenströms g 5, 20502, Malmö, Sweden
- Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, 20502, Malmö, Sweden
| | - Erika Nyman
- Department of Biomedical and Clinical Sciences, Linköping University, 58183, Linköping, Sweden
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, 58183, Linköping, Sweden
| | - Malin Zimmerman
- Department of Translational Medicine - Hand Surgery, Skåne University Hospital, Lund University, Jan Waldenströms g 5, 20502, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, 20502, Malmö, Sweden
- Department of Orthopedics, Helsingborg Hospital, Helsingborg, Sweden
| | - Juan Merlo
- Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, 20502, Malmö, Sweden
- Center for Primary Health Research, Region Skåne, 20502, Malmö, Sweden
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Mainprize M, Yilbas A, Spencer Netto FAC, Svendrovski A, Katz J. Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital. Langenbecks Arch Surg 2023; 408:366. [PMID: 37726600 DOI: 10.1007/s00423-023-03111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/14/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital. METHODS After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary. RESULTS A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005. CONCLUSION Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.
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Affiliation(s)
| | - Ayse Yilbas
- Department of Surgery, Shouldice Hospital, ON, Canada
| | | | | | - Joel Katz
- Department of Psychology, York University, ON, Canada
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