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Js Medeiros H, Gee E, Pak A, Hu V, Crawford L, Razavi S, Anderson TA, Sabouri AS. The Analgesic Effects of the Thoracic Paravertebral Block on Post-percutaneous Nephrolithotripsy: A Retrospective Study. Cureus 2024; 16:e60272. [PMID: 38872686 PMCID: PMC11170241 DOI: 10.7759/cureus.60272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Percutaneous nephrolithotripsy (PCNL) is a minimally invasive procedure for treating large and complex kidney stones, often resulting in significant post-operative pain and increased opioid use. This study aims to compare pain scores between patients undergoing PCNL who did and did not receive a preoperative single-shot thoracic paravertebral block (PVB) at the post-anesthesia care unit (PACU) as the primary outcome. Secondary outcomes were patient-controlled analgesia (PCA) usage on post-operative day 1 (POD 1), total opioid consumption on PACU and POD 1, and post-operative nausea and vomiting (PONV). METHODS A retrospective cohort study was conducted on the medical records of 341 patients who underwent PCNL from July 2014 to April 2016 in a single major academic center. PVB was administered at thoracic levels T7-9 using a volume of 20 cc of bupivacaine, ranging from 0.25% to 0.5%, to achieve the desired analgesic effect. RESULTS After excluding 34 patients, the study included 123 in the no block (NB) group and 149 in the regional anesthesia (RA) group. There were no differences in demographics, including age, sex, weight and height, BMI, and indication for PCNL. The results revealed that the RA group experienced a statistically significant reduction in PCA usage in both crude and adjusted models (adjusted logistic regression analysis: OR = 0.19, 95% CI = 0.05-0.60; p = 0.008). However, there were no significant changes in total opioid consumption, pain scores, or incidents of PONV. CONCLUSION The retrospective analysis did not reveal any discernible advantage in pain management associated with the use of PVB for post-PCNL analgesia, except for reducing the percentage of PCA narcotics used. Future investigations with larger sample sizes and meticulous control for surgical indications and complexity are imperative to accurately assess the efficacy of this block in the context of post-PCNL surgery.
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Affiliation(s)
- Heitor Js Medeiros
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Erica Gee
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Aimee Pak
- Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Vivian Hu
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Lane Crawford
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Sarah Razavi
- Urology, Massachusetts General Hospital, Boston, USA
| | | | - A Sassan Sabouri
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
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Davis MP, McPherson ML, Reddy A, Case AA. Conversion ratios: Why is it so challenging to construct opioid conversion tables? J Opioid Manag 2024; 20:169-179. [PMID: 38700396 DOI: 10.5055/jom.0853] [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: 05/05/2024]
Abstract
Standardizing opioid management is challenging due to the absence of a ceiling dose, the unknown ideal therapeutic plasma level, and the lack of an clear relationship between dose and therapeutic response. Opioid rotation or conversion, which is switching from one opioid, route of administration, or both, to another, to improve therapeutic response and reduce toxicities, occurs in 20-40 percent of patients treated with opioids. Opioid conversion is often needed when there are adverse effects, toxicities, or inability to tolerate a certain opioid formulation. A majority of patients benefit from opioid conversion, leading to improved analgesia and less adverse effects. There are different published ways of converting opioids in the literature. This review of 20 years of literature is centered on opioid conversions and aims to discuss the complexity of converting opioids. We discuss study designs, outcomes and measures, pain phenotypes, patient characteristics, comparisons of equivalent doses between opioids, reconciling conversion ratios between opioids, routes, directional differences, half-lives and metabolites, interindividual variability, and comparison to package insert information. Palliative care specialists have not yet come to a consensus on the ideal opioid equianalgesic table; however, we discuss a recently updated table, based on retrospective evidence, that may serve as a gold standard for practical use in the palliative care population. More robust, well-designed studies are needed to validate and guide future opioid conversion data.
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Affiliation(s)
- Mellar P Davis
- Geisinger Medical Center, Danville, Pennsylvania. ORCID: https://orcid.org/0000-0002-7903-3993
| | - Mary Lynn McPherson
- University of Maryland School of Pharmacy, Baltimore, Maryland. ORCID: https://orcid.org/0000-0001-6098-2112
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas. ORCID: https://orcid.org/0000-0002-7628-8675
| | - Amy A Case
- Department of Palliative and Supportive Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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Wong AK, Klepstad P, Rubio JP, Somogyi AA, Vogrin S, Le B, Philip J. Opioid Switch Dosing in Chronic Cancer Pain: A Prospective Longitudinal Study. J Palliat Med 2024; 27:388-393. [PMID: 37955655 DOI: 10.1089/jpm.2023.0541] [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: 11/14/2023] Open
Abstract
Background: Opioid switching is common, however, conversion tables have limitations. Guidelines suggest postswitch dose reduction, yet, observations show opioid doses may increase postswitch. Objectives: To document the opioid conversion factor postswitch in cancer, and whether pain and adverse effect outcomes differ between switched opioid groups. Design/Setting: This multicenter prospective longitudinal study included people with advanced cancer in Australia. Clinical data (demographics, opioids) and validated instruments (pain, adverse effects) were collected twice, seven days apart. Results: Opioid switch resulted in dose increase (median oral morphine equivalent daily dose 90 mg [interquartile range {IQR} 45-184] to 150 mg [IQR 79-270]), reduced average pain (5.1 [standard deviation {SD} 1.7] to 3.8 [SD 1.6]), and reduced adverse effects. Hydromorphone dose increased 2.5 times (IQR 1.0-3.6) above the original conversion factor used. Conclusions: Opioid switching resulted in overall dose increase, particularly when switching to hydromorphone. Higher preswitch dosing may require higher dose conversion ratios. Dose reduction postswitch risks undertreatment and may not be always appropriate.
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Affiliation(s)
- Aaron K Wong
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
| | - Pal Klepstad
- Department Intensive Care Medicine, St. Olavs University Hospital, Trondheim, Norway
| | - Justin P Rubio
- Florey Department of Neuroscience and Mental Health, Florey Institute of Neuroscience and Mental Health, Victoria, Australia
| | - Andrew A Somogyi
- Department of Clinical & Experimental Pharmacology, Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Victoria, Australia
| | - Brian Le
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jennifer Philip
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
- Department of Palliative Care, Palliative Care Service, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Mongelli F, Marengo M, Bertoni MV, Volontè F, Ledingham NS, Garofalo F. Laparoscopic-Assisted Transversus Abdominis Plane (TAP) Block Versus Port-Site Infiltration with Local Anesthetics in Bariatric Surgery: a Double-Blind Randomized Controlled Trial. Obes Surg 2023; 33:3383-3390. [PMID: 37740830 DOI: 10.1007/s11695-023-06825-7] [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: 04/06/2023] [Revised: 08/21/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The transversus abdominis plane (TAP) block has shown great potential usefulness in the management of postoperative pain; however, there is lacking evidence regarding its use in bariatric surgery. This randomized double-blind trial was aimed at comparing the effectiveness of the TAP block and port-site infiltration (PSI) in patients undergoing bariatric surgery. METHODS We included patients ≥ 18 years old undergoing bariatric surgery. From July 2020 to July 2021, all eligible patients were randomized to receive either laparoscopic-assisted TAP block or PSI. Demographic and clinical data were collected and analyzed. RESULTS During the study period, we included 113 patients. Fifty-one were allocated to the TAP block group and 62 to the PSI group. The mean age was 47.9 ± 11.2 years, 88 (77.9%) patients were female, and mean BMI was 40.5 ± 5.9 kg/m2. Operative time was 110 ± 42 min vs. 114 ± 41 min in the TAP block and PSI groups (p = 0.658). At 24 h after surgery, pain on the VAS was 2.5 ± 2.6 vs. 2.3 ± 2.1 (p = 0.661). No significant difference between the groups was noted at 3, 6, 12, and 18 h. Also, opioid and antiemetic consumption, the length of stay (3.4 ± 1.5 days vs. 3.2 ± 1.1 days, p = 0.392), and satisfaction score (154 ± 10 pts vs. 154 ± 16 pts, p = 0.828) were similar in the two groups. CONCLUSIONS Patients undergoing bariatric surgery and receiving either the TAP block or the PSI had similar postoperative pain, nausea, length of stay, and satisfaction. As PSI is technically easier and more reproducible, it might be the first choice for postoperative multimodal analgesia in bariatric surgery.
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Affiliation(s)
- Francesco Mongelli
- Department of Surgery, Bellinzona e Valli Regional Hospital, EOC, Via Gallino 12, 6500, Bellinzona, Switzerland.
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, 6500, Lugano, Switzerland.
| | - Michele Marengo
- Department of Surgery, Locarno Regional Hospital, EOC, 6600, Locarno, Switzerland
| | | | | | | | - Fabio Garofalo
- Department of Surgery, Lugano Regional Hospital, EOC, 6900, Lugano, Switzerland
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La Regina D, Popeskou SG, Saporito A, Gaffuri P, Tasciotti E, Dossi R, Christoforidis D, Mongelli F. Laparoscopic versus ultrasound-guided transversus abdominis plane block in colorectal surgery: a non-inferiority, multicentric randomized double-blinded clinical trial. Colorectal Dis 2023; 25:1921-1928. [PMID: 37525414 DOI: 10.1111/codi.16689] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/03/2023] [Accepted: 04/25/2023] [Indexed: 08/02/2023]
Abstract
AIM The aim of this study was to assess if laparoscopic-assisted transversus abdominis plane (TAP) block (L-TAPB) is as efficient as ultrasound-guided TAP block (U-TAPB) in postoperative pain control. METHOD In all, 112 patients scheduled for elective laparoscopic colon resection from February 2018 to December 2021 at two Swiss hospitals were included and randomized in a 1:1 ratio before surgery with either L-TAPB or U-TAPB. The primary end-point was the non-inferiority of the L-TAPB compared to U-TAPB with regard to the total opioid consumption within the first 24 h after surgery. Data regarding patients' characteristics, opioid consumption, pain on the visual analogue scale, operative and anaesthesia induction time, complications and length of stay were collected and analysed. RESULTS Fifty-five patients were allocated to the L-TAPB and fifty-seven to the U-TAPB. No significant difference was found in the overall dose of opioids within 24 h, and the non-inferiority of the L-TAPB was confirmed. There were almost twice as many patients in the L-TAPB group requesting opioid reserves compared to the U-TAPB group (54.5% vs. 29.8%, P = 0.008). The anaesthesia induction time was significantly longer in the U-TAPB group (17 ± 11 min vs. 23 ± 12 min, P = 0.014). For all other variables (pain on the visual analogue scale, opioid consumption, need of epidural analgesia, operating time, postoperative complications and hospital stay) no statistically significant difference between the L-TAPB and the U-TAPB groups was noted. CONCLUSION Our results showed the non-inferiority of the laparoscopic delivery compared to ultrasound-guided administration of the TAP block, with the advantage of not affecting anaesthesia times. STUDY REGISTRATION NUMBER 2017-02017 CE 3294, ClinicalTrials.gov identifier NCT04575233.
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Affiliation(s)
- Davide La Regina
- Department of Surgery, Bellinzona e Valli Regional Hospital, EOC, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Sotirios Georgios Popeskou
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Surgery, Lugano Regional Hospital, EOC, Lugano, Switzerland
| | - Andrea Saporito
- Department of Anesthesia, Bellinzona e Valli Regional Hospital, EOC, Bellinzona, Switzerland
| | - Paolo Gaffuri
- Department of Surgery, Bellinzona e Valli Regional Hospital, EOC, Bellinzona, Switzerland
| | - Edoardo Tasciotti
- Department of Anesthesia, Bellinzona e Valli Regional Hospital, EOC, Bellinzona, Switzerland
| | - Roberto Dossi
- Department of Anesthesia, Bellinzona e Valli Regional Hospital, EOC, Bellinzona, Switzerland
| | - Dimitri Christoforidis
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Surgery, Lugano Regional Hospital, EOC, Lugano, Switzerland
- Centre Hospitalier Universitaire Vaudois CHUV, Lausanne, Switzerland
| | - Francesco Mongelli
- Department of Surgery, Bellinzona e Valli Regional Hospital, EOC, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Reddy A, Sinclair C, Crawford GB, McPherson ML, Mercadante S, Hui D, Haider A, Arthur J, Tanco K, Dalal S, Dev R, Amaram-Davila J, Adile C, Liu D, Schuler U, Jammi S, Shelal Z, Del Fabbro E, Davis M, Bruera E. Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey. J Palliat Med 2022; 25:1557-1562. [PMID: 35930252 PMCID: PMC9836667 DOI: 10.1089/jpm.2022.0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Sinclair
- Division of Palliative Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gregory B. Crawford
- Northern Adelaide Local Health Network, Adelaide, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Amaram-Davila
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ulrich Schuler
- Universitätsklinikum Carl Gustav Carus, PalliativCentrum & Medizinische Klinik, Dresden, Germany
| | - Sheetal Jammi
- Candidate for Bachelor of Science in Biology and Bachelor of Science in Psychology, University of Houston, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Egidio Del Fabbro
- Department of Internal Medicine, Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Lundberg M, Johansson MS, Søndergaard J, Thorlund JB. Opioid use among Danish patients with severe knee osteoarthritis: a drug utilization study. Eur J Clin Pharmacol 2022; 78:1481-1486. [PMID: 35695903 DOI: 10.1007/s00228-022-03350-x] [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: 01/31/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Knee osteoarthritis (OA) is one of the most common musculoskeletal diseases. Opioids have been increasingly used in the treatment of severe knee OA-related pain, particularly in the USA. Less is known about the patterns of use of opioids among Danish patients with severe knee OA. We investigated opioid use among Danish patients with severe knee OA in the 5 years preceding knee replacement surgery (KR). METHODS We identified adults who had undergone KR from January 1st, 2005, to December 31st, 2018, using the Danish National Patient Register. These patients were considered to have severe knee OA in the 5-year period leading up to KR. Individual-level data on prescribed opioids were retrieved from the Danish National Prescription Registry. RESULTS We identified 77,168 severe knee OA patients (mean age 66 years). The prevalence of opioid users increased from 21% 5 years before KR to 40% 1 year before. Total use of opioids increased each year and doubled from 3254 mg oral morphine equivalents (OMEQ)/1000 individuals/day 5 years before to 6396 mg OMEQ/1000 individuals/day the year before KR corresponding to an increase of 3141 mg OMEQ (95% confidence interval 3010 to 3273). Tramadol was the most frequently used opioid. About 10% of the population accounted for 90% of the total opioid use. CONCLUSION Among patients with severe knee OA, the prevalence and total use of opioids doubled during the 5 years before KR. In addition, 10% of the study population was responsible for 90% of the opioids used.
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Affiliation(s)
- Matilde Lundberg
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - Melker Staffan Johansson
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jonas Bloch Thorlund
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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Non-Peptide Opioids Differ in Effects on Mu-Opioid (MOP) and Serotonin 1A (5-HT 1A) Receptors Heterodimerization and Cellular Effectors (Ca 2+, ERK1/2 and p38) Activation. Molecules 2022; 27:molecules27072350. [PMID: 35408749 PMCID: PMC9000251 DOI: 10.3390/molecules27072350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/24/2022] [Accepted: 04/02/2022] [Indexed: 11/17/2022] Open
Abstract
The importance of the dynamic interplay between the opioid and the serotonin neuromodulatory systems in chronic pain is well recognized. In this study, we investigated whether these two signalling pathways can be integrated at the single-cell level via direct interactions between the mu-opioid (MOP) and the serotonin 1A (5-HT1A) receptors. Using fluorescence cross-correlation spectroscopy (FCCS), a quantitative method with single-molecule sensitivity, we characterized in live cells MOP and 5-HT1A interactions and the effects of prolonged (18 h) exposure to selected non-peptide opioids: morphine, codeine, oxycodone and fentanyl, on the extent of these interactions. The results indicate that in the plasma membrane, MOP and 5-HT1A receptors form heterodimers that are characterized with an apparent dissociation constant Kdapp = (440 ± 70) nM). Prolonged exposure to all non-peptide opioids tested facilitated MOP and 5-HT1A heterodimerization and stabilized the heterodimer complexes, albeit to a different extent: Kd, Fentanylapp = (80 ± 70) nM), Kd,Morphineapp = (200 ± 70) nM, Kd, Codeineapp = (100 ± 70) nM and Kd, Oxycodoneapp = (200 ± 70) nM. The non-peptide opioids differed also in the extent to which they affected the mitogen-activated protein kinases (MAPKs) p38 and the extracellular signal-regulated kinase (Erk1/2), with morphine, codeine and fentanyl activating both pathways, whereas oxycodone activated p38 but not ERK1/2. Acute stimulation with different non-peptide opioids differently affected the intracellular Ca2+ levels and signalling dynamics. Hypothetically, targeting MOP−5-HT1A heterodimer formation could become a new strategy to counteract opioid induced hyperalgesia and help to preserve the analgesic effects of opioids in chronic pain.
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Bettinger JJ, Amarquaye W, Fudin J, Schatman ME. Misinterpretation of the “Overdose Crisis” Continues to Fuel Misunderstanding of the Role of Prescription Opioids. J Pain Res 2022; 15:949-958. [PMID: 35414752 PMCID: PMC8994995 DOI: 10.2147/jpr.s367753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
| | | | - Jeffrey Fudin
- President, Remitigate Therapeutics, Delmar, NY, USA
- Department of Pharmacy Practice, Albany College of Pharmacy & Health Sciences, Albany, NY, USA
- Department of Pharmacy Practice, Western New England University College of Pharmacy, Springfield, MA, USA
- Department of Pharmacy and Pain Management, Stratton VA Medical Center, Albany, NY, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
- School of Social Work, North Carolina State University, Raleigh, NC, USA
- Correspondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA, Tel +425-647-4880, Email
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10
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Torre A, Marengo M, Ledingham NS, Ajani C, Volontè F, Garofalo F, Mongelli F. Opioid-Free Anesthesia in Bariatric Surgery: a Propensity Score-Matched Analysis. Obes Surg 2022; 32:1673-1680. [PMID: 35294692 DOI: 10.1007/s11695-022-06012-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 12/16/2022]
Abstract
PURPOSE Patients undergoing bariatric surgery are at particular high risk of postoperative nausea and vomiting (PONV). Few studies have shown the superiority of opioid-free anesthesia (OFA) over general anesthesia with opioids in bariatric surgery. The aim was to investigate the potential advantages of the OFA in bariatric surgery. MATERIALS AND METHODS This is a retrospective study on a prospectively collected database that included bariatric patients over a 3-year period. All patients who underwent bariatric surgery at our institution were included and divided into opioid-free or standard anesthesia. The primary endpoint was the length of hospital stay. Data was collected and analyzed using a propensity score. RESULTS We included 344 patients, of these 209 (60.8%) received opioid-free and 135 (39.2%) received a standard anesthesia. Mean age was 46.2 ± 11.2 years, 265 (77.0%) patients were female, and 238 (69.2%) had at least one associated medical problem. The two groups were similar in terms of age, gender, BMI, associated medical problems, and type of operations. Postoperatively, we observed no significant difference in opioid requirement, while significantly less doses of antiemetics were administered in the OFA group at postoperative day 1 (0.4 ± 0.7 vs. 0.7 ± 1.0 doses, p = 0.006) and 2 (0.1 ± 0.4 vs. 0.2 ± 0.6 doses, p = 0.022). Length of stay was significantly shorter in the OFA group (2.8 ± 0.9 vs. 3.5 ± 2.0 days, p < 0.001) both in the overall and in the propensity score-matched analyses. CONCLUSION OFA is effective for patients undergoing bariatric surgery. Perioperative outcomes are similar, while OFA patients required less antiemetics and were discharged earlier from hospital.
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Affiliation(s)
- Alessandro Torre
- Department of Surgery, Lugano Regional Hospital, EOC, Via Tesserete, 6900, Lugano, Switzerland
| | - Michele Marengo
- Department of Surgery, Locarno Regional Hospital, EOC, Via Dell'Ospedale, 6600, Locarno, Switzerland
| | - Nicola S Ledingham
- Department of Anesthesia, Lugano Regional Hospital, EOC, Via Tesserete, 6900, Lugano, Switzerland
| | - Costanza Ajani
- Department of Anesthesia, Lugano Regional Hospital, EOC, Via Tesserete, 6900, Lugano, Switzerland
| | - Francesco Volontè
- Department of Surgery, Sant'Anna Clinic, Via Sant'Anna 1, 6924, Lugano, Switzerland
| | - Fabio Garofalo
- Department of Surgery, Lugano Regional Hospital, EOC, Via Tesserete, 6900, Lugano, Switzerland
| | - Francesco Mongelli
- Department of Surgery, Bellinzona e Valli Regional Hospital, EOC, via Ospedale 12, 6500, Bellinzona, Switzerland.
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Using Prescription Drug Monitoring Program Data to Assess Likelihood of Incident Long-Term Opioid Use: a Statewide Cohort Study. J Gen Intern Med 2021; 36:3672-3679. [PMID: 33742304 PMCID: PMC8642457 DOI: 10.1007/s11606-020-06555-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/22/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Limiting the incidence of opioid-naïve patients who transition to long-term opioid use (i.e., continual use for > 90 days) is a key strategy for reducing opioid-related harms. OBJECTIVE To identify variables constructed from data routinely collected by prescription drug monitoring programs that are associated with opioid-naïve patients' likelihood of transitioning to long-term use after an initial opioid prescription. DESIGN Statewide cohort study using prescription drug monitoring program data PARTICIPANTS: All opioid-naïve patients in California (no opioid prescriptions within the prior 2 years) age ≥ 12 years prescribed an initial oral opioid analgesic from 2010 to 2017. METHODS AND MAIN MEASURES Multiple logistic regression models using variables constructed from prescription drug monitoring program data through the day of each patient's initial opioid prescription, and, alternatively, data available up to 30 and 60 days after the initial prescription were constructed to identify probability of transition to long-term use. Model fit was determined by the area under the receiver operating characteristic curve (C-statistic). KEY RESULTS Among 30,569,125 episodes of patients receiving new opioid prescriptions, 1,809,750 (5.9%) resulted in long-term use. Variables with the highest adjusted odds ratios included concurrent benzodiazepine use, ≥ 2 unique prescribers, and receipt of non-pill, non-liquid formulations. C-statistics for the day 0, day 30, and day 60 models were 0.81, 0.88, and 0.94, respectively. Models assessing opioid dose using the number of pills prescribed had greater discriminative capacity than those using milligram morphine equivalents. CONCLUSIONS Data routinely collected by prescription drug monitoring programs can be used to identify patients who are likely to develop long-term use. Guidelines for new opioid prescriptions based on pill counts may be simpler and more clinically useful than guidelines based on days' supply or milligram morphine equivalents.
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Tuan WJ, Sehgal N, Zgierska AE. Using electronic health record's data to assess daily dose of opioids prescribed for outpatients with chronic non-cancer pain. Fam Med Community Health 2021; 9:fmch-2021-001277. [PMID: 34819321 PMCID: PMC8614133 DOI: 10.1136/fmch-2021-001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This research intended to examine electronic health record (EHR) based methods for automated estimation of morphine equivalent daily dose (MEDD) of prescribed opioids in primary care research and practice. The study leveraged the health system’s audit of adults treated with long-term opioids for chronic non-cancer pain to compare two EHR-based automated MEDD calculation methods: RxSignature (active prescriptions’ signature information) and RxQuantity (quantity dispensed for prescriptions issued within the past 90 days). Prescribed opioid EHR data were extracted from the target population at a large US academic health system in a 2-year assessment period. Forty-five ‘target patients’ were selected by the health system for a manual audit by an expert physician who then ‘manually’ calculated the actual MEDD over the past 90 days (RxAudit) for those with discrepancies in the MEDD calculated with RxSignature and RxQuantity. Paired samples t-test compared the MEDD generated by the RxSignature and RxQuantity methods by opioid type in the target population. The audit (n=45) revealed the RxSignature and RxQuantity methods yielded comparable MEDD results for 20 patients and discrepant results for 25 patients. The former group had opioid prescriptions issued at regular intervals for stable, scheduled doses of opioids; the latter group had opioid prescriptions issued irregularly or for changed daily dosing regimen, for as-needed use, or had changes in the dosing regimen or inactive prescriptions mislabeled as active. RxAudit of the EHR of those with discrepant MEDD results (n=25) produced consistent results with those yielded by the RxQuantity, but not the RxSignature, method. Significant differences in MEDD were found for most opioid types when the MEDD was calculated for the target population using the RxSignature and RxQuantity methods. In conclusion, different EHR-based methods for MEDD calculation can lead to vastly different estimates, with implications for research and clinical care outcomes. Standardising data extraction and MEDD calculation algorithms could overcome these challenges, enabling a more accurate and reproducible approach to the dose calculation for prescribed opioids, improving the quality of research and patient safety.
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Affiliation(s)
- Wen-Jan Tuan
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Nalini Sehgal
- Department of Orthopedics & Rehabilitation, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Aleksandra E Zgierska
- Department of Family and Community Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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13
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Celiac plexus neurolysis for abdominal cancers: going beyond pancreatic cancer pain. Pain Rep 2021; 6:e930. [PMID: 34712884 PMCID: PMC8546843 DOI: 10.1097/pr9.0000000000000930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/19/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023] Open
Abstract
Celiac plexus neurolysis is primarily used for pancreatic cancer pain, but other symptoms and other cancers may also benefit from this intervention. Introduction: Celiac plexus neurolysis (CPN) has been verified for mitigating pancreatic cancer pain. However, information regarding CPN's use beyond this remains limited. Objectives: Identify which cancers benefit from CPN, which symptoms improve, and when symptoms improve. Methods: Retrospective analysis was conducted on 173 patients who received CPN for pain caused by various malignancies. Mean symptom changes on the MD Anderson Symptom Inventory (MDASI) from baseline to 2 weeks, 1 month, and 2 months after CPN were analyzed overall and then by cancer type: pancreatic (all stages and stages III–IV), hepatobiliary, and nonpancreatic, nonhepatobiliary gastrointestinal (NPNH-gastrointestinal). Results: Eighty-two pancreatic, 43 NPNH-gastrointestinal, 14 hepatobiliary, and 34 patients with other cancers met inclusion criteria. Statistically significant changes included decrease in the pain score at 1 month by 1.01 points for all cancers, 1.65 points for all pancreatic cancers, and 1.88 points for late-stage pancreatic cancers. At 2 months, pain decreased by 1.50 points for all cancers, 1.68 points for all pancreatic cancers, 2.37 points for late-stage pancreatic cancers, and 1.50 points in NPNH-gastrointestinal cancers. At 2 months, quality of life improved by 1.07 points for all cancers and 1.53 points for all pancreatic cancers. Sleep improved at 2 months for all cancers by 0.73 points and 1.60 points in late-stage pancreatic cancers. At 2 months, pancreatic cancer patients improved in general activity by 0.93 points, walking by 1.00 points, and working by 1.12 points. Conclusion: Celiac plexus neurolysis can decrease cancer symptom burden beyond pain including quality of life and sleep for pancreatic and nonpancreatic cancers, as well as general activity for pancreatic cancers.
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14
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Persico AL, Bettinger JJ, Wegrzyn EL, Fudin J, Strassels SA. Opioid Taper Practices Among Clinicians. J Pain Res 2021; 14:3353-3358. [PMID: 34707403 PMCID: PMC8542568 DOI: 10.2147/jpr.s322299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/04/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Opioid dose tapers are used frequently when cross-titrating from one or more opioids to another or when discontinuing therapy. Currently, there is no universally accepted evidence-based standard of care for this procedure which can leave patients at risk for withdrawal symptoms, inadequate pain control, or elevated suicide risk. Objective The objective of this study was to examine practices and rationale among clinicians, to determine if there is a difference among respondents in their comfort level, method and rationale for tapering opioids at various morphine milligram equivalents (MME) and to assess the need for the development of a standard of care. Methods Data were derived from an electronic survey developed using SurveyMonkey®. The survey was disseminated via e-mail listservs, social media, and professional organizations. Data were collected regarding profession, confidence tapering opioids at varying total MME, method and rationale for tapering, and pharmacologic management of withdrawal symptoms. Pearson's Chi squared and Fisher's exact tests were used to assess statistical significance of results. Results A total of 149 clinicians completed the survey, physicians, NPs, pharmacists, and PAs accounted for 51%, 20%, 19%, and 10% of participants, respectively. Overall, 55% of the respondents self-identified as pain specialists. There were no statistically significant differences in reported comfort level among the different types of providers. Nearly 50% of participants indicated their rationale for tapering or discontinuing opioids was the 2016 CDC guidelines. Conclusion Despite that the majority of providers surveyed self-identified as pain specialists, over 50% were not comfortable tapering opioids at doses greater than 120 MME/day. This observation suggests a need for further education and establishment of consensus guidelines on method and rationale for opioid tapering. Provider motivation for tapering was largely influenced by CDC guidelines based on low quality evidence. This strengthens the argument for the creation of guidelines based on high quality evidence.
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Affiliation(s)
- Amelia L Persico
- Shields Health Solutions, Stoughton, MA, 02072, USA.,Remitigate Therapeutics, Delmar, NY, 12054, USA
| | - Jeffrey J Bettinger
- Remitigate Therapeutics, Delmar, NY, 12054, USA.,Saratoga Hospital Medical Group, Saratoga, NY, 12866, USA
| | - Erica L Wegrzyn
- Remitigate Therapeutics, Delmar, NY, 12054, USA.,Stratton VA Medical Center, Albany, NY, 12208, USA
| | - Jeffrey Fudin
- Remitigate Therapeutics, Delmar, NY, 12054, USA.,Stratton VA Medical Center, Albany, NY, 12208, USA
| | - Scott A Strassels
- The Ohio State University, Columbus, OH, 43004, USA.,Atrium Health, Charlotte, NC, US
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15
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Chebini A, Marzoughi S, Randhawa J, Guh D, Wiseman S, Fedoroff I, Ong M. The effects of a multiday (10-14 days) subanesthetic dose IV ketamine infusion in the treatment of refractory chronic pain. Pain Manag 2021; 12:337-346. [PMID: 34528840 DOI: 10.2217/pmt-2021-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Ketamine is an anesthetic agent that at lower doses can be a potent analgesic. There has been an interest in the use of low dose ketamine in treatment of chronic pain syndromes. Patients & methods: We report the results of a retrospective observational study for patients diagnosed with a chronic noncancer pain syndrome receiving a 2-week continuous subanesthetic IV ketamine infusion. Results & conclusion: We conclude that a 10-14 days of subanesthetic ketamine infusion in chronic patients results in clinically significant lowering of patients' numerical pain score. Further studies looking at subanesthetic ketamine infusion in a prospective trial of multi-day IV ketamine infusion in chronic refractory chronic neuropathic pain are needed to further assess the efficacy of ketamine.
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Affiliation(s)
- Amokrane Chebini
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sina Marzoughi
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jason Randhawa
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daphne Guh
- Centre for Health Evaluation & Outcome Sciences, Vancouver, BC, Canada
| | - Stephen Wiseman
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Ingrid Fedoroff
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - May Ong
- Division of Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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16
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Daubresse M, Alexander GC, Crews DC, Segev DL, Lentine KL, McAdams-DeMarco MA. High-dose opioid utilization and mortality among individuals initiating hemodialysis. BMC Nephrol 2021; 22:65. [PMID: 33622271 PMCID: PMC7901089 DOI: 10.1186/s12882-021-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals undergoing hemodialysis in the United States frequently report pain and receive three-fold more opioid prescriptions than the general population. While opioid use is appropriate for select patients, high-dose utilization may contribute to an increased risk of death due to possible accumulation of opioid metabolites. METHODS We studied high-dose opioid utilization (≥120 morphine milligram equivalents [MME] per day) among adults initiating hemodialysis in the United States between 2007 and 2014 using national registry data. We calculated the cumulative incidence (%) of high-dose utilization and depicted trends in the average percentage of days individuals were exposed to opioids. We used adjusted Cox proportional hazards models to identify which opioid doses were associated with mortality. RESULTS Among 327,344 adults undergoing hemodialysis, the cumulative incidence of high-dose utilization was 14.9% at 2 years after initiating hemodialysis. Among patients with ≥1 opioid prescription during follow-up, the average percentage of days exposed to high-dose utilization increased from 13.9% in 2007 to 26.1% in 2014. Compared to 0MME per day, doses < 60MME were not associated with an increased risk of mortality, but high-dose utilization was associated with a 1.63-fold (95% CI, 1.57, 1.69) increased risk of mortality. The risk of mortality associated with opioid dose was highest in the first year after hemodialysis initiation. CONCLUSIONS The risk of mortality associated with opioid utilization among individuals on hemodialysis increases as doses exceed 60MME per day and is greatest during periods of high-dose utilization. Patients and clinicians should carefully weigh the risks and benefits of opioid doses exceeding 60MME per day.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista L Lentine
- Division of Nephrology, Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mara A McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA.
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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17
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Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015. BJGP Open 2020; 5:bjgpopen20X101122. [PMID: 33172848 PMCID: PMC7960521 DOI: 10.3399/bjgpopen20x101122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice. Aim To use an estimated oral morphine equivalent (OMEQe) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status. Design & setting A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank. Method An OMEQe measure was developed and used to describe trends in opioid burden over the study period. OMEQe burden was stratified by eight drug groups, which was based on usage and deprivation. Results An estimated 643 436 843 milligrams (mg) OMEQe was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQe per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQe prescribed than the least deprived over the study period. Conclusion Over the study period, OMEQe burden nearly doubled, with disproportionate OMEQe prescribed in the most deprived communities. Using OMEQe provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.
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18
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Erlenwein J, Emons MI, Petzke F, Quintel M, Staboulidou I, Przemeck M. The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis. Anaesthesist 2020; 69:639-648. [PMID: 32617631 PMCID: PMC7458942 DOI: 10.1007/s00101-020-00806-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 05/11/2020] [Accepted: 05/27/2020] [Indexed: 11/17/2022]
Abstract
Background Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). Material and methods This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0–10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. Results Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st–3rd quartile: 6 (3.75–8) vs. 5 (3–7), p = 0.023; maximum pain intensity: 7 (5–9) vs. 5 (3–8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47–154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = −2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = −1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. Conclusion In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.
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Affiliation(s)
- J Erlenwein
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - M I Emons
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - F Petzke
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - M Quintel
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - I Staboulidou
- Fetal Medicine Center Hannover, Podbielskistraße 122, 30177, Hannover, Germany
| | - M Przemeck
- Department of Anesthesiology and Intensive Care, Annastift, Hannover, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
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19
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Nissen SK, Pottegård A, Ryg J. Trends of Opioid Utilisation in Denmark: A Nationwide Study. Drugs Real World Outcomes 2019; 6:155-164. [PMID: 31535353 PMCID: PMC6879688 DOI: 10.1007/s40801-019-00163-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Opioid use has more than doubled over recent decades, and Denmark occupies fifth place in the global ranking. These increases have been partly attributed to the ageing population. Objective Our objective was to assess the impact of age over time on utilisation of the most commonly used opioids in Denmark. Methods We retrieved nationwide sales data on opioid sales in Denmark from 1999 to 2017. We investigated utilisation trends in age groups for the four opioids with the highest use. We used three volume-based metrics (defined daily doses/1000/day, oral morphine equivalents/1000/day, and packages dispensed/year) and one person-based metric (users/1000/year). Results The four opioids selected according to users/1000/year were tramadol (46.1), codeine and combination products (12.4 for codeine, 3.7 for codeine and acetylsalicylic acid, and 4.2 for codeine and paracetamol), morphine (17.0), and oxycodone (12.1). Overall utilisation according to volume and person metrics increased for all except codeine and combination products. Tramadol doses or strength increased, albeit less with increasing age. Oxycodone doses or strength decreased for all age groups but were nearly unchanged for the age group ≥ 80 years. Conclusion Tramadol is the most utilised opioid in Denmark and was prescribed at increasing doses or strengths over the study period, particularly in the younger (< 80 years) age groups. Overall, oxycodone was prescribed at decreasing doses or strengths over time but remained unchanged for the age group ≥ 80 years. There is a need to address the pharmacological treatment of pain in terms of age, with tramadol and oxycodone being possible targets for regulatory efforts. Electronic supplementary material The online version of this article (10.1007/s40801-019-00163-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Søren Kabell Nissen
- Department of Geriatric Medicine, Odense University Hospital, J. B. Winsløwsvej 4, 5000, Odense C, Denmark.
| | - Anton Pottegård
- Department of Public Health, University of Southern Denmark, Clinical Pharmacology and Pharmacy, J. B. Winsløwsvej 19, 3, 5000, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, J. B. Winsløwsvej 4, 5000, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, J. B. Winsløwsvej 19, 3, 5000, Odense C, Denmark
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Medicate or Meditate? Greater Pain Acceptance is Related to Lower Pain Medication Use in Persons With Chronic Pain and Spinal Cord Injury. Clin J Pain 2019; 34:357-365. [PMID: 28877136 DOI: 10.1097/ajp.0000000000000550] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES There is little information about whether use of pain self-management skills that are common targets of psychosocial interventions for pain are associated with reduced reliance on pain medications. The aim of this study was to test whether higher chronic pain acceptance, which is a readily modified pain self-management approach, is related to lower use of pain medications (eg, opioid medications, and gabapentinoids) in a sample with chronic pain and spinal cord injury (SCI). MATERIALS AND METHODS This is a cross-sectional survey study of pain medication use, pain severity and distribution (Brief Pain Inventory [BPI]), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and chronic pain acceptance (Chronic Pain Acceptance Questionnaire [CPAQ]) administered to a sample of 120 adults with chronic pain and SCI. RESULTS Regression results indicated that, above and beyond the effects of pain intensity, pain distribution, and depressive symptoms, higher pain acceptance was related to lower use of all types of pain medications, and lower odds of using opioid medications or gabapentinoids. Pain intensity was not related to pain medication use, but greater pain distribution was related to using more pain medications in general and to greater odds of using gabapentinoids. DISCUSSION Findings from this study indicate that those with chronic pain and SCI who have a more accepting orientation to pain are less reliant on pain medications, and thereby experience lower risks associated with medication consumption. Longitudinal, daily process, and clinical trial studies are needed to better understand the association between pain acceptance and pain medication consumption.
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21
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Raff M, Belbachir A, El-Tallawy S, Ho KY, Nagtalon E, Salti A, Seo JH, Tantri AR, Wang H, Wang T, Buemio KC, Gutierrez C, Hadjiat Y. Intravenous Oxycodone Versus Other Intravenous Strong Opioids for Acute Postoperative Pain Control: A Systematic Review of Randomized Controlled Trials. Pain Ther 2019; 8:19-39. [PMID: 31004317 PMCID: PMC6514019 DOI: 10.1007/s40122-019-0122-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Optimal pain management is crucial to the postoperative recovery process. We aimed to evaluate the efficacy and safety of intravenous oxycodone with intravenous fentanyl, morphine, sufentanil, pethidine, and hydromorphone for acute postoperative pain. Methods A systematic literature search of PubMed, Cochrane Library, and EMBASE databases was performed for randomized controlled trials published from 2008 through 2017 (inclusive) that evaluated the acute postoperative analgesic efficacy of intravenous oxycodone against fentanyl, morphine, sufentanil, pethidine, and hydromorphone in adult patients (age ≥ 18 years). Outcomes examined included analgesic consumption, pain intensity levels, side effects, and patient satisfaction. Results Eleven studies were included in the review; six compared oxycodone with fentanyl, two compared oxycodone with morphine, and three compared oxycodone with sufentanil. There were no eligible studies comparing oxycodone with pethidine or hydromorphone. Overall, analgesic consumption was lower with oxycodone than with fentanyl or sufentanil. Oxycodone exhibited better analgesic efficacy than fentanyl and sufentanil, and comparable analgesic efficacy to morphine. In terms of safety, there was a tendency towards more side effects with oxycodone than with fentanyl, but the incidence of side effects with oxycodone was comparable to morphine and sufentanil. Where patient satisfaction was evaluated, higher satisfaction levels were observed with oxycodone than with sufentanil and comparable satisfaction was noted when comparing oxycodone with fentanyl. Patient satisfaction was not evaluated in the studies comparing oxycodone with morphine. Conclusions Our findings suggest that intravenous oxycodone provides better analgesic efficacy than fentanyl and sufentanil, and comparable efficacy to morphine with less adverse events such as sedation. No studies comparing intravenous oxycodone with pethidine or hydromorphone were identified in this review. Better alignment of study methodologies for future research in this area is recommended to provide the best evidence base for a meta-analysis. Funding Mundipharma Singapore Holding Pte Ltd, Singapore. Electronic supplementary material The online version of this article (10.1007/s40122-019-0122-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Milton Raff
- Pain Clinic, Christiaan Barnard Memorial Hospital, Cape Town, South Africa.
| | - Anissa Belbachir
- Faculté de médecine, Université Paris-Descartes, Pôle d'anesthésie-réanimation, Hôpital Cochin, Paris, France
| | - Salah El-Tallawy
- Department of Anesthesia and Pain Management, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Kok Yuen Ho
- The Pain Clinic, Mount Alvernia Medical Centre, Singapore, Singapore
| | - Eric Nagtalon
- Department of Anesthesia, University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines
| | - Amar Salti
- Anesthesiology Institute, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Aida Rosita Tantri
- Department of Anesthesiology and Intensive Care, Universitas Indonesia, Dr. Ciptomangunkusumo National General Hospital, Jakarta, Indonesia
| | - Hongwei Wang
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | | | | | - Yacine Hadjiat
- Mundipharma Singapore Holding Pte. Ltd., Singapore, Singapore
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22
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Tenney L, McKenzie LM, Matus B, Mueller K, Newman LS. Effect of an opioid management program for Colorado workers' compensation providers on adherence to treatment guidelines for chronic pain. Am J Ind Med 2019; 62:21-29. [PMID: 30499587 PMCID: PMC6558965 DOI: 10.1002/ajim.22920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to examine adherence of state guidelines for Colorado workers' compensation physicians/providers treating individuals as injured workers with chronic pain after initiation of an opioid management program and provider incentives. METHODS A retrospective cohort of chronic, non-cancer pain claims was constructed from the Colorado's workers' compensation database. Adherence to treatment guidelines and opioid prescribing practices were evaluated during implementation of a new billing code to incentivize adherence. RESULTS Overall, less than 33% of claims showed evidence of opioid management. Comprehensive opioid management was observed in only 4.4% of claims. In 2010, after implementing the new billing code, the ratio of long acting opioids to short acting opioids decreased from 0.2 to 0.13; returning to 0.2 in one year. Similarly, morphine equivalent doses declined for a short period. CONCLUSIONS Incentivizing physicians to adhere to chronic pain management guidelines only temporarily improves prescribing practices.
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Affiliation(s)
- Liliana Tenney
- Center for Health, Work & Environment, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lisa M. McKenzie
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Brenden Matus
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Kathryn Mueller
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lee S. Newman
- Center for Health, Work & Environment, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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23
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Horgas AL, Snigurska U, Farland MZ, Marsiske M. Analyzing Analgesic Medications in Community-Dwelling Older Adults. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:58-67. [PMID: 29408973 PMCID: PMC6329439 DOI: 10.1093/pm/pnx340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives Analyzing medication data for research purposes is complex, and methods are rarely described in the literature. Our objective was to describe methods of quantifying opioid and nonopioid analgesics and to compare the utility of five different analgesic coding methods when analyzing relationships between pain, analgesic use, and clinical outcomes. In this study, we used physical function as the outcome variable for its clinical relevance and its relationship to pain in older adults. Design Secondary analyses of baseline cross-sectional data from the Advanced Cognitive Training Interventions for Vital Elders (ACTIVE) study. Setting Community settings in six regions of the United States. Subjects A total of 2,802 community-residing adults older than age 65 years. Methods A medication audit was conducted. Analgesics were coded as any pain medication, counts (total analgesics, number of opioids and nonopioids), equianalgesics (oral morphine equivalents, oral acetaminophen equivalents), and dose categories. Adjuvant medications used to treat pain (e.g., tricyclic antidepressants and anticonvulsants) and low-dose aspirin typically used for cardiovascular conditions were excluded from these analyses. To examine the utility of these various approaches, a series of hierarchical regression models were conducted with pain and analgesics as predictors and physical functioning as the dependent variable. Results Eighty-one point nine percent of participants reported experiencing recent pain, but 26% reported analgesic use. Nonopioids were the most common drug class used. Models revealed that pain was significantly associated with worse physical function (β = -0.45, P = 0.001), after controlling for demographic and analgesic variables. Two basic drug coding methods (e.g., any pain medication, number of pain medications) were equivalent in their explanatory power (β = -0.12, P = 0.001) and were slightly stronger predictors of function than the more complex coding procedures. Conclusions Analgesic medications are important variables to consider in community-based studies of older adults. We illustrate several methods of quantifying analgesic medications for research purposes. In this community-based sample, we found no advantage of complex equianalgesic coding methods over simple counts in predicting physical functioning. The results may differ depending on the research question or clinical outcome studied. Thus, methods of analyzing analgesic drug data warrant further research.
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Affiliation(s)
| | | | | | - Michael Marsiske
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
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24
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Stone AB, Urman RD, Kaye AD, Grant MC. Labeling Morphine Milligram Equivalents on Opioid Packaging: a Potential Patient Safety Intervention. Curr Pain Headache Rep 2018; 22:46. [PMID: 29855852 DOI: 10.1007/s11916-018-0695-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE OF REVIEW Given that the primary cause of overdose death in the USA is related to prescribed opioids, one potential strategy to improve awareness and decrease morbidity and/or mortality could include improved labeling. Specific patient populations which significantly struggle with adverse outcomes related to opioid abuse are seen in palliative care, chronic pain, and acute pain treatment settings. RECENT FINDINGS An unexplored option for improving the healthcare quality and safety for patients currently prescribed opioids would be to require pharmaceutical companies to provide a morphine milligram equivalent (MME) on opioid packaging. Some limitations to MME conversions include equianalgesic conversions being estimates at best and may not account for variations in genetics and pharmacokinetics. Changing opioid labeling requirements is feasible as it falls under the purview of the US Food and Drug Administration (FDA), which has been mandated to provide mechanisms to reduce or to minimize overdoses related to opioid prescriptions. Labeling opioid packaging with MME per dose will promote clearer communication about opioid strength between patients and physicians. Labeling MME on packaging could help prevent prescriber errors.
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Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
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25
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Patient-Controlled Intravenous Analgesia for Advanced Cancer Patients with Pain: A Retrospective Series Study. Pain Res Manag 2018; 2018:7323581. [PMID: 29849846 PMCID: PMC5904766 DOI: 10.1155/2018/7323581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/15/2018] [Indexed: 11/23/2022]
Abstract
Objective To compare the efficacy and side effects of patient-controlled intravenous analgesia (PCIA) with hydromorphone, sufentanil, and oxycodone on the management of advanced cancer patients with pain. Methods Patients allocated to receive PCIA between January 2015 and December 2016 were chosen for this study. After reviewing medical records, we verified if hydromorphone, sufentanil, or oxycodone for PCIA could equally provide effective pain relief. A numeric rating scale (NRS) of cancer pain was applied before PCIA, at 4 hours after PCIA, and at the discontinuation of PCIA. Secondary, the incidence of clinical side effects attributed to PCIA was observed. Results A total of 85 medical records were reviewed. PCIA with hydromorphone (n=30), sufentanil (n=34), and oxycodone (n=21) was used for cancer pain management. PCIA successfully improved pain control in 97.6% of the patients. The most common side effects were constipation (11.8%), nausea (8.2%), and sedation (5.9%). Drug addiction, delirium, or respiratory depression associated with PCIA was not reported in this case series study. No significant intergroup difference was observed in NRS at any of the abovementioned time points. There was no significant difference of analgesic effect among the hydromorphone, sufentanil, or oxycodone. Conclusion PCIA provided timely, safe, and satisfactory analgesia for advanced cancer patients with pain and may be useful for titration of opioids, management of severe breakthrough pain, and conversion to oral analgesia. There was no significant difference of analgesic effect and side effect among the hydromorphone, sufentanil, and oxycodone.
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26
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Methadone as anticancer treatment: hype, hope, or hazard? Wien Med Wochenschr 2018; 168:159-167. [DOI: 10.1007/s10354-018-0623-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/25/2018] [Indexed: 01/23/2023]
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Namdari S, Nicholson T, Abboud J, Lazarus M, Steinberg D, Williams G. Randomized Controlled Trial of Interscalene Block Compared with Injectable Liposomal Bupivacaine in Shoulder Arthroplasty. J Bone Joint Surg Am 2017; 99:550-556. [PMID: 28375887 DOI: 10.2106/jbjs.16.00296] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shortcomings of interscalene brachial plexus blockade include technical failure and rebound pain. Bupivacaine liposome injectable suspension, a sustained release preparation, is used for surgical-site administration. The purpose of this study was to evaluate these 2 postoperative pain management strategies in patients undergoing shoulder arthroplasty. METHODS In a non-blinded, randomized controlled trial of participants undergoing primary shoulder arthroplasty, patients were randomized to interscalene brachial plexus blockade or intraoperative soft-tissue infiltration of bupivacaine liposome injectable suspension. The primary outcome variable was morphine equivalent units consumed over the first 24 hours postoperatively. Secondary outcomes included morphine equivalent units consumed intraoperatively and a visual analog scale (VAS) for pain at 0, 8, 16, and 24 hours. RESULTS Seventy-eight patients were randomized to interscalene brachial plexus blockade treatment (the blockade group) and 78 patients were randomized to bupivacaine liposome injectable suspension treatment (the suspension group). The mean total postoperative narcotic consumption (and standard deviation) over 24 hours after the surgical procedure was 14.8 ± 11.3 morphine equivalent units in the blockade group compared with 14.4 ± 16.8 morphine equivalent units in the suspension group (p = 0.849). Intraoperative narcotics were significantly lower (p < 0.001) in the blockade group (8.9 ± 4.1 morphine equivalent units) compared with the suspension group (16.2 ± 7.0 morphine equivalent units). The mean VAS pain score was significantly lower in the blockade group than in the suspension group at 0 hours postoperatively (0.8 ± 2.2 compared with 3.3 ± 2.7 points; p < 0.001) and at 8 hours postoperatively (1.4 ± 2.4 compared with 3.2 ± 2.2 points; p < 0.001), but it was not significantly different at 16 hours postoperatively (4.3 ± 2.8 compared with 3.8 ± 2.4 points; p = 0.348). The VAS pain scores were significantly higher (p = 0.021) in the blockade group (4.9 ± 2.7 points) compared with the suspension group (3.9 ± 2.3 points) at 24 hours postoperatively. CONCLUSIONS Patients treated with bupivacaine liposome injectable suspension required an equivalent amount of postoperative narcotics and greater intraoperative narcotics compared with patients treated with interscalene brachial plexus blockade. Although interscalene brachial plexus blockade provided improved pain scores for the first 8 hours after the surgical procedure, pain scores were worse at 24 hours. The optimal postoperative pain regimen for shoulder arthroplasty and the cost-effectiveness of analgesic techniques require further investigation. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Surena Namdari
- 1Department of Orthopaedic Surgery, Rothman Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania 2Department of Anesthesia, Sidney Kimmel Medical College at Thomas Jefferson University-Methodist Hospital Division, Philadelphia, Pennsylvania
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Fudin J, Pratt Cleary J, Schatman ME. The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development. J Pain Res 2016; 9:153-6. [PMID: 27042140 PMCID: PMC4809343 DOI: 10.2147/jpr.s107794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jeffrey Fudin
- Western New England University College of Pharmacy, Springfield, MA, USA
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29
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Brooks A, Kominek C, Pham TC, Fudin J. Exploring the Use of Chronic Opioid Therapy for Chronic Pain: When, How, and for Whom? Med Clin North Am 2016; 100:81-102. [PMID: 26614721 DOI: 10.1016/j.mcna.2015.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article provides a broad overview regarding intent to initiate and consider ongoing chronic opioid therapy (COT) for treatment of chronic noncancer pain (CNCP). COT should be an individualized decision based on a comprehensive evaluation, assessment, and monitoring. It is imperative that providers discuss various risks and benefits of COT initially and at follow-up visits, and continue appropriate monitoring and follow-up at regular intervals. The decision to initiate or continue opioid therapy is based on clinical judgment; however, it is understood that opioid and other medication therapy represent one piece of the complete treatment plan for patients with CNCP.
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Affiliation(s)
- Abigail Brooks
- Pain Management, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Courtney Kominek
- Pain Management, Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Thien C Pham
- Pain & Palliative Care, Stratton VA Medical Center, Albany, NY, USA
| | - Jeffrey Fudin
- Pain Management, PGY2 Pain & Palliative Care Pharmacy Residency, Stratton VA Medical Center, Albany, NY, USA; Western New England University College of Pharmacy, Springfield, MA, USA; Albany College of Pharmacy & Health Sciences, Albany, NY, USA; University of Connecticut School of Pharmacy, Storrs, CT, USA.
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