Pain Duration and Resolution following Surgery: An Inception Cohort Study

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

"My Surgical Success": Feasibility and Impact of a Single-Session Digital Behavioral Pain Medicine Intervention on Pain Intensity, Pain Catastrophizing, and Time to Opioid Cessation After Orthopedic Trauma Surgery-A Randomized Trial

BACKGROUND:

Behavioral pain treatments may improve postsurgical analgesia and recovery; however, effective and scalable options are not widely available. This study tested a digital perioperative behavioral medicine intervention in orthopedic trauma surgery patients for feasibility and efficacy for reducing pain intensity, pain catastrophizing, and opioid cessation up to 3 months after surgery.

METHODS:

A randomized controlled clinical trial was conducted at an orthopedic trauma surgery unit at a major academic hospital to compare a digital behavioral pain management intervention (“My Surgical Success” [MSS]) to a digital general health education (HE) intervention (HE; no pain management skills). The enrolled sample included 133 patients; 84 patients were randomized (MSS, n = 37; HE, n = 47) and completed study procedures. Most patients received their assigned intervention within 3 days of surgery (85%). The sample was predominantly male (61.5%), White (61.9%), and partnered (65.5%), with at least a bachelor’s degree (69.0%). Outcomes were collected at 1–3 months after intervention through self-report e-surveys and electronic medical record review; an intention-to-treat analytic framework was applied. Feasibility was dually determined by the proportion of patients engaging in their assigned treatment and an application of an 80% threshold for patient-reported acceptability. We hypothesized that MSS would result in greater reductions in pain intensity and pain catastrophizing after surgery and earlier opioid cessation compared to the digital HE control group.

RESULTS:

The engagement rate with assigned interventions was 63% and exceeded commonly reported rates for fully automated Internet-based e-health interventions. Feasibility was demonstrated for the MSS engagers, with >80% reporting treatment acceptability. Overall, both groups improved in the postsurgical months across all study variables. A significant interaction effect was found for treatment group over time on pain intensity, such that the MSS group evidenced greater absolute reductions in pain intensity after surgery and up to 3 months later (treatment × time fixed effects; F[215] = 5.23; P = .024). No statistically significant between-group differences were observed for time to opioid cessation or for reductions in pain catastrophizing (F[215] = 0.20; P = .653), although the study sample notably had subclinical baseline pain catastrophizing scores (M = 14.10; 95% confidence interval, 11.70–16.49).

CONCLUSIONS:

Study findings revealed that a fully automated behavioral pain management skills intervention (MSS) may be useful for motivated orthopedic trauma surgery patients and reduce postsurgical pain up to 3 months. MSS was not associated with reduced time to opioid cessation compared to the HE control intervention.

Intramuscular stimulation as a new modality to control postthoracotomy pain: A randomized clinical trial

OBJECTIVE

Postoperative pain after thoracic surgery primarily hinders patients' mobility, decreasing the quality of life. To date, various modalities have been suggested to improve postoperative pain. However, pain alleviation still remains a challenge, resulting in continued reliance on opioids. To tackle this problem, this study introduces a needle electrical twitch obtaining intramuscular stimulation (NETOIMS) as a new effective treatment modality for postoperative pain after thoracoscopic surgery.

METHODS

This randomized clinical trial analyzed patients receiving video-assisted thoracoscopic surgery pulmonary resection between March 2018 and June 2020 at a single institution. A total of 77 patients (NETOIMS, 36; intravenous patient-controlled analgesia, 41) were included. NETOIMS was conducted on the retracted intercostal muscle immediately following the main procedure, just before skin closure. Postoperative pain (numeric rating scale) and oral opioid morphine milligram equivalent were assessed daily until postoperative day 5.

RESULTS

The NETOIMS group had a significantly lower numeric rating scale score on postoperative day (POD) 0 (P < .01), POD2 (P < .001), POD4 (P < .001), and POD5 (P = .01). The predicted time to complete pain resolution was 6.15 days in the NETOIMS group and 20.7 days in the intravenous patient-controlled analgesia group. The oral opioid morphine milligram equivalent was significantly lower in the NETOIMS group on POD0 (P < .001) and POD1 (P < .001).

CONCLUSIONS

NETOIMS appears to be an effective modality in alleviating postoperative pain after thoracoscopic surgery, thereby reducing the reliance on opioid use.

Ultrasound-guided erector spinae plane catheter versus video-assisted paravertebral catheter placement in minimally invasive thoracic surgery: comparing continuous infusion analgesic techniques on early quality of recovery, respiratory function and chronic persistent surgical pain: study protocol for a double-blinded randomised controlled trial

Background

Compared to conventional thoracotomy, minimally invasive thoracic surgery (MITS) can reduce postoperative pain, reduce tissue trauma and contribute to better recovery. However, it still causes significant acute postoperative pain. Truncal regional anaesthesia techniques such as paravertebral and erector spinae blocks have shown to contribute to postoperative analgesia after MITS. Satisfactory placement of an ultrasound-guided thoracic paravertebral catheter can be technically challenging compared to an ultrasound-guided erector spinae catheter. However, in MITS, an opportunity arises for directly visualised placement of a paravertebral catheter by the surgeon under thoracoscopic guidance. Alongside with thoracic epidural, a paravertebral block is considered the “gold standard” of thoracic regional analgesic techniques. To the best of our knowledge, there are no randomised controlled trials comparing surgeon-administered paravertebral catheter and anaesthesiologist-assisted erector spinae catheter for MITS in terms of patient-centred outcomes such as quality of recovery.

Methods

This trial will be a prospective, double-blinded randomised controlled trial. A total of 80 eligible patients will be randomly assigned to receive either an anaesthesiologist-assisted ultrasound-guided erector spinae catheter or a surgeon-assisted video-assisted paravertebral catheter, in a 1:1 ratio following induction of general anaesthesia for minimally assisted thoracic surgery. Both groups will receive the same standardised analgesia protocol for both intra- and postoperative periods. The primary outcome is defined as Quality of Recovery (QoR-15) score between the two groups at 24 h postoperative. Secondary outcomes include assessment of chronic persistent surgical pain (CPSP) at 3 months postoperative using the Brief Pain Inventory (BPI) Short Form and Short Form McGill (SF-15) questionnaires, assessment of postoperative pulmonary function, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 at 48 h, and postoperative complications and morbidity as measured by the Comprehensive Complication Index.

Discussion

Despite surgical advancements in thoracic surgery, severe acute postoperative pain following MITS is still prevailing. This study will provide recommendations about the efficacy of an anaesthesia-administered ultrasound-guided erector spinae catheter or surgeon-administered, video-assisted paravertebral catheter techniques for early quality of recovery following MITS.

Trial registration

ClinicalTrials.govNCT04729712. Registered on 28 January 2021. All items from the World Health Organization Trial Registration Data Set have been included.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Monopolar electrocautery tip vs plasma ablation in tonsillotomy: A randomized case-control study comparing outcomes in pediatric population

BACKGROUND

The objective of this study was to compare the low-priced monopolar electrocautery to the high-priced, worldwide used, plasma ablation in tonsillotomy among children aged between three and twelve years, suffering from obstructive breathing disorders (OBD), with respect to post-operative pain, bleeding and related morbidities.

METHODS

A randomized case-control study was conducted in the Eye and Ear Hospital International- Lebanon. 103 children aged between three and twelve years suffering from OBD secondary to tonsillar hypertrophy were randomly assigned into two groups. Post-operative pain was evaluated using age-adequate validated scales: "FLACC-R" (Face, Legs, Activity, Cry, Consolability-Revised) for children aged less than five years, and "Wong Baker faces" for older children. Additional post-operative outcomes were evaluated using Pain-PROM (Patient reported Pain-Related Outcome Measures) and TAHSI (Tonsil and Adenoid Health Status Instrument) scales.

RESULTS

Significantly, higher rates of patients who underwent tonsillotomy via plasma ablation technique used analgesics and had severe pain compared to the monopolar electrocautery group. A longer operative duration was significantly associated with higher pain scores, and the plasma ablation technique yielded significantly higher operative mean durations. 10 days post-operatively, a significantly higher percentage of children reported an overall high pain severity and more than expected overall pain when using the plasma ablation technique compared to the monopolar electrocautery one. Overall bleeding rates were similar. No difference was reported one month post-operatively.

CONCLUSION

When compared to plasma ablation, monopolar electrocautery, can provide the same efficiency in relieving OBD in healthy children, with equal overall bleeding rates, but significantly lower cost, operating time, pain scores and need for analgesics.

Relationship Between Blood Cytokine Levels, Psychological Comorbidity, and Widespreadness of Pain in Chronic Pelvic Pain

Background: Low-grade inflammation has been implicated in the etiology of depression, long-term fatigue and chronic pain. TNFα and IL-6 are perhaps the most studied pro-inflammatory cytokines in the field of psychoneuroimmunology. The purpose of our study was to further investigate these relationships in patients with chronic pelvic pain specifically. Using plasma samples from a large, well-described cohort of patients with pelvic pain and healthy controls via the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network, we examined the relationship between TNFα and IL-6 and comorbid psychological symptoms. We also investigated the relationship between IL-8 and GM-CSF, and widespreadness of pain. Methods: We included baseline blood samples in the analyses, 261 patients (148 women) and 110 healthy controls (74 women). Fourteen pro- and anti-inflammatory or regulatory cytokines were analyzed in a Luminex^® xMAP^® high-sensitivity assay. We used regression models that accounted for known factors associated with the outcome variables to determine the relationship between cytokine levels and clinical measures. Results: There were no statistical differences in cytokine levels between patients and healthy controls when controlling for age. In patients, TNFα was significantly associated with levels of fatigue (p = 0.026), but not with pain intensity or depression. IL-6 was not significantly related to any of the outcome variables. Women with pelvic pain showed a negative relationship between IL-8 and widespreadness of pain, while men did not (p = 0.003). For both sexes, GM-CSF was positively related to widespreadness of pain (p = 0.039). Conclusion: Our results do not suggest low-grade systemic inflammation in chronic pelvic pain. Higher TNFα blood levels were related to higher fatigue ratings, while higher systemic GM-CSF levels predicted more widespread pain. Our study further suggests a potentially protective role of IL-8 with regard to with regard to the widepreadness of pain in the body, at least for women.

Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial

Background

Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use.

Methods

In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18–75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively.

Results

Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87–1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68–0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40–0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39–0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80–0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89–1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06–1.77; P=0.016).

Conclusion

Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.

"My Surgical Success": Effect of a Digital Behavioral Pain Medicine Intervention on Time to Opioid Cessation After Breast Cancer Surgery-A Pilot Randomized Controlled Clinical Trial

Objective

This study aims to assess the feasibility of digital perioperative behavioral pain medicine intervention in breast cancer surgery and evaluate its impact on pain catastrophizing, pain, and opioid cessation after surgery.

Design and Setting

A randomized controlled clinical trial was conducted at Stanford University (Palo Alto, CA, USA) comparing a digital behavioral pain medicine intervention (“My Surgical Success” [MSS]) with digital general health education (HE).

Participants

A convenience sample of 127 participants were randomized to treatment group. The analytic sample was 68 patients (N = 36 MSS, N = 32 HE).

Main Outcomes

The primary outcome was feasibility and acceptability of a digital behavioral pain medicine intervention (80% threshold for acceptability items). Secondary outcomes were pain catastrophizing, past seven-day average pain intensity, and time to opioid cessation after surgery for patients who initiated opioid use.

Results

The attrition rate for MSS intervention (44%) was notably higher than for HE controls (18%), but it was lower than typical attrition rates for e-health interventions (60–80%). Despite greater attrition for MSS, feasibility was demonstrated for the 56% of MSS engagers, and the 80% threshold for acceptability was met. We observed a floor effect for baseline pain catastrophizing, and no significant group differences were found for postsurgical pain catastrophizing or pain intensity. MSS was associated with 86% increased odds of opioid cessation within the 12-week study period relative to HE controls (hazard ratio = 1.86, 95% confidence interval = 1.12–3.10, P = 0.016).

Conclusions

Fifty-six percent of patients assigned to MSS engaged with the online platform and reported high satisfaction. MSS was associated with significantly accelerated opioid cessation after surgery (five-day difference) with no difference in pain report relative to controls. Perioperative digital behavioral pain medicine may be a low-cost, accessible adjunct that could promote opioid cessation after breast cancer surgery.

Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment

Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.

Preexisting Opioid Use Disorder and Outcomes After Lower Extremity Arthroplasty: A Multistate Analysis, 2007–2014

Objective

The aim of this study was to examine the association of preexisting opioid use disorder and postoperative outcomes in patients undergoing total hip or knee arthroplasty (THA and TKA, respectively) in the overall population and in the Medicare-only population.

Methods

This retrospective cohort study examined data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007–2014 from California, Florida, New York, Maryland, and Kentucky. We compared patients with and without opioid use disorders on unadjusted rates and calculated adjusted odds ratios (aORs) of in-hospital mortality, postoperative complications, length of stay, and 30-day and 90-day readmission status; analyses were repeated in a subgroup of Medicare insurance patients only.

Subjects

After applying our exclusion criteria, our study included 1,422,210 adult patients undergoing lower extremity arthroplasties, including 818,931 Medicare insurance patients. In our study, 0.4% of THA patients and 0.3% of TKA patients had present-on-admission opioid use disorder.

Results

Opioid use disorder patients were at higher risk for in-hospital mortality (aOR = 3.10), 30- and 90-day readmissions (aORs = 1.81, 1.81), and pulmonary and infectious complications (aORs = 1.25, 1.96).

Conclusions

Present-on-admission opioid use disorder was a risk factor for worse postoperative outcomes and increased health care utilization in the lower extremity arthroplasty population. Opioid use disorder is a potentially modifiable risk factor for mortality, postoperative complications, and health care utilization, especially in the at-risk Medicare population.

American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives

Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.

Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial

Importance

Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice.

Objective

To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation.

Design, Setting, and Participants

A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings.

Interventions

Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.

Main Outcomes and Measures

Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.

Results

Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).

Conclusions and Relevance

Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research.

Trial Registration

clinicaltrials.gov Identifier: NCT01067144.

Neuroimaging-based pain biomarkers: definitions, clinical and research applications, and evaluation frameworks to achieve personalized pain medicine

One of the key ambitions of neuroimaging-based pain biomarker research is to augment patient and clinician reporting of clinically relevant phenomena with neural measures for prediction, prognosis, and detection of pain. Despite years of productive research on the neuroimaging of pain, such applications have seen little advancement. However, recent developments in identifying brain-based biomarkers of pain through advances in technology and multivariate pattern analysis provide some optimism. Here, we (1) define and review the different types of potential neuroimaging-based biomarkers, their clinical and research applications, and their limitations and (2) describe frameworks for evaluation of pain biomarkers used in other fields (eg, genetics, cancer, cardiovascular disease, immune system disorders, and rare diseases) to achieve broad clinical and research utility and minimize the risks of misapplication of this emerging technology. To conclude, we discuss future directions for neuroimaging-based biomarker research to achieve the goal of personalized pain medicine.

Development and Validation of a Bedside Risk Assessment for Sustained Prescription Opioid Use After Surgery

IMPORTANCE

The increased use of prescription opioid medications has contributed to an epidemic of sustained opioid use, misuse, and addiction. Adults of working age are thought to be at greatest risk for prescription opioid dependence.

OBJECTIVE

To develop a risk score (the Stopping Opioids After Surgery score) for sustained prescription opioid use after surgery in a working-age population using readily available clinical information.

DESIGN, SETTING, AND PARTICIPANTS

In this case-control study, claims from TRICARE (the insurance program of the US Department of Defense) for working-age adult (age 18-64 years) patients undergoing 1 of 10 common surgical procedures from October 1, 2005, to September 30, 2014, were queried. A logistic regression model was used to identify variables associated with sustained prescription opioid use. The point estimate for each variable in the risk score was determined by its β coefficient in the model. The risk score for each patient represented the summed point totals, ranging from 0 to 100, with a lower score indicating lower risk of sustained prescription opioid use. Data were analyzed from September 25, 2018, to February 5, 2019.

EXPOSURES

Exposures were age; race; sex; marital status; socioeconomic status; discharge disposition; procedure intensity; length of stay; intensive care unit admission; comorbid diabetes, liver disease, renal disease, malignancy, depression, or anxiety; and prior opioid use status.

MAIN OUTCOMES AND MEASURES

The primary outcome was sustained prescription opioid use, defined as uninterrupted use for 6 months following surgery. A risk score for each patient was calculated and then used as a predictor of sustained opioid use after surgical intervention. The area under the curve and the Brier score were used to determine the accuracy of the scoring system and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate model calibration.

RESULTS

Of 86 356 patients in the analysis (48 827 [56.5%] male; mean [SD] age, 46.5 [14.5] years), 6365 (7.4%) met criteria for sustained prescription opioid use. The sample used for model generation consisted of 64 767 patients, while the validation sample had 21 589 patients. Prior opioid exposure was the factor most strongly associated with sustained opioid use (odds ratio, 13.00; 95% CI, 11.87-14.23). The group with the lowest scores (<31) had a mean (SD) 4.1% (2.5%) risk of sustained opioid use; those with intermediate scores (31-50) had a mean (SD) risk of 14.9% (6.3%); and those with the highest scores (>50) had a mean (SD) risk of 35.8% (3.6%).

CONCLUSIONS AND RELEVANCE

This study developed an intuitive and accessible opioid risk assessment applicable to the care of working-age patients following surgery. This tool is scalable to clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time.

Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design

INTRODUCTION

Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies.

METHODS AND ANALYSIS

The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site.

ETHICS AND DISSEMINATION

The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).

Post-Discharge Opioid Prescribing Patterns and Risk Factors in Patients Undergoing Elective Colon and Rectal Surgery Without Complications

BACKGROUND

Few studies have examined opioid usage in the post-discharge period. The primary aim of this study was to evaluate the need for post-discharge opioids in a unique set of patients: those undergoing colorectal operations and experiencing no surgical complications. The secondary aim was to examine the accuracy of the Opioid Risk Tool (ORT) to predict the need for additional opioid prescriptions. Our hypotheses were that few patients would require post-discharge opioids and that the ORT would predict patients requiring post-discharge opioids.

METHODS

All patients undergoing elective colorectal surgery between January 2012 and December 2014 that did not experience NSQIP complications within 30 days or receive an opioid prescription in the 2 weeks prior to operation were reviewed. ORT score was calculated for all patients. Patients requiring post-discharge opioids within 1 year were compared to those not receiving additional opioids after discharge.

RESULTS

There were 367 patients that met inclusion criteria and 56 (15%) received post-discharge opioids. Opioid use in the year prior to surgery was the only significant risk factor to receive post-discharge opioids. Opioids were prescribed for three distinct reasons by three groups of prescribers. The ORT did not accurately predict need for post-discharge opioids.

CONCLUSIONS

Even among patients without complications, 15% received post-discharge opioid prescriptions. Previous opioid use within the year prior to surgery was a major risk factor for additional prescriptions. The timing and prescriber's specialty are impacted by the indication for post-discharge opioids. The ORT did not predict which patients would receive post-discharge opioids.

Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery: Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable.

OBJECTIVE

To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018.

INTERVENTIONS

Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours.

MAIN OUTCOMES AND MEASURES

A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery.

RESULTS

Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P < .001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P < .001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P = .89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P = .008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P < .001), a history of alcohol or drug abuse treatment (ARR, 1.90; 95% CI, 1.42-2.53; P < .001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P = .03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P < .001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P < .001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P < .001).

CONCLUSIONS AND RELEVANCE

This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01067144.

Complexities of Perioperative Pain Management in Orthopedic Trauma

PURPOSE OF REVIEW

This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period.

RECENT FINDINGS

Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.

An Innovative Perioperative Pain Program for Chronic Opioid Users: An Academic Medical Center’s Response to the Opioid Crisis

Increased utilization of prescription opioids for pain management has led to a nationwide public health crisis with alarming rates of addiction and opioid-related deaths. In the surgical setting, opioid prescriptions have been implicated as a contributing factor to the opioid epidemic. The authors developed an innovative model to address aspects of pain management and opioid utilization during preoperative evaluation, acute surgical hospitalization, and postoperative follow-up for chronic opioid users. This program involves multidisciplinary teams that include acute and chronic pain specialists, psychiatrists, integrative medicine specialists, and physical medicine and rehabilitation services. It also features a novel infrastructure for triage and pain management education and treatment. Individualized patient plans are devised that can include preoperative opioid weaning, regional anesthesia that minimizes opioid use, and multimodal techniques for surgical pain treatment. Multidisciplinary programs such as this have the potential to both improve perioperative pain control and prevent escalation of opioid use among chronic opioid users.

Prevalence and Predictors of Persistent Post-Surgical Opioid Use: A Prospective Observational Cohort Study

Post-surgical opioid prescribing intended for the short-term management of acute pain may lead to long-term opioid use. This study was undertaken to determine the prevalence of persistent post-surgical opioid use and patient-related factors associated with post-surgical opioid use. One thousand and thirteen opioid-naïve patients awaiting elective surgery in a tertiary private hospital in Sydney were enrolled. Preoperatively, patients completed a questionnaire comprising potential predictors of persistent post-surgical opioid use. Patients underwent surgery with routine perioperative care, and were followed up at 90 to 120 days after surgery to determine opioid use. Factors associated with opioid use were assessed with logistic regression. We had an overall response rate of 95.8% (n=970) of patients, of whom 10.5% (n=102) continued to use opioids at >90 days after surgery. On surgical subtype analysis, the prevalence of persistent opioid use was 23.6% after spinal surgery, and 13.7% after orthopaedic surgery. Four factors were independently associated with persistent post-surgical opioid use in a multivariate model: having orthopaedic (odds ratio [OR] 4.6, 95% confidence interval [CI] 2.0 to 10.8, P <0.001) or spinal surgery (OR 4.0, 95% CI 1.7 to 9.2, P <0.001), anxiety (OR 2.1, 95% CI 1.1 to 4.1, P=0.03), attending pre-admission clinic (OR 3.7, 95% CI 1.6 to 8.6, P=0.002), and higher self-reported pain score at >90 days after surgery (P <0.001). More than 10% of opioid-naïve patients undergoing elective surgery experience persistent post-surgical opioid use. Identification of factors associated with persistent post-surgical opioid use may allow development of a risk stratification tool to predict those at highest risk.

A retrospective cohort study of adverse events in patients undergoing orthopaedic surgery

Background

This study’s objective was to identify adverse events following common orthopaedic procedures, and to estimate the incidence rates and risks of these events and their associations with age, sex, and comorbidities.

Methods

This retrospective cohort study manually reviewed and extracted electronic medical data on the incidence and predictors of adverse events that occurred within 90 days of the 50 most frequent orthopaedic surgeries at an academic hospital in 2010. We also extracted demographic data, baseline comorbidities, and duration of follow-up (≤90 days). Patients were scored on the Charlson Comorbidity Index (CCI) and the Functional Comorbidity Index (FCI). We estimated incidence rates and risks for all events and associations using regression methods. Prolonged pain 42-days post-surgery was treated as a separate outcome.

Results

We included 1,552 patients; average age was 53.4 years, and 51.7% were female. A total of 1,148 adverse events were identified in 729 patients. The incidence rate of all adverse events was 10 events per 1,000 person-days at risk; 47% of all patients experienced at least one adverse event within 90 days. The most frequent events were prolonged pain (31% of all adverse events) and persistent swelling (7%). We found positive associations between both comorbidity scores and the incidence rate and 90-day risk of all adverse events, excluding pain, adjusting for age and sex (neither of which was associated with adverse events); the association was stronger for the FCI than for the CCI. For total hip arthroplasty (THA) and total knee arthroplasty (TKA), the incidence rate of all adverse events, excluding pain, was positively associated with both comorbidity scores and age; the 90-day risk was positively associate with the FCI score and male sex. The prevalence of prolonged pain at 42 days was greater in patients with higher FCI scores; for THA and TKA only, pain prevalence was greater in those with higher FCI scores and in men.

Conclusions

Adverse events are frequent following common orthopaedic procedures. The incidence is greatest for patients with more functional comorbidities. For THA and TKA procedures, being male and being older are also associated with a greater incidence of adverse events.