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Mathew J, Gum JL, Carreon LY, Sampedro BC, Harpe-Bates J, Hines BP, Brown ME, Daniels CL, Mkorombindo T, Glassman SD. Opioid Sparing Anesthesia for Adult Spinal Deformity Surgery Reduces Postoperative Pain, Length of Stay, Opioid Consumption, and Opioid-Related Complications: A Propensity-Matched Analysis. Spine (Phila Pa 1976) 2025; 50:804-808. [PMID: 39262217 DOI: 10.1097/brs.0000000000005159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/29/2024] [Indexed: 09/13/2024]
Abstract
STUDY DESIGN This study was a retrospective propensity-matched study of patients receiving opioid-sparing anesthesia (OSA) and those who did not receive an opioid-sparing anesthesia regimen. OBJECTIVES To determine whether patients undergoing spine fusion for deformity fared better with an OSA regimen than those not having an OSA regimen. SUMMARY OF BACKGROUND DATA There has been a tremendous focus on opioid overuse. Accordingly, OSA regimens are being introduced to reduce narcotic use. However, OSA has not been studied in the adult spine deformity population. METHODS Forty-three patients undergoing fusion of at least five levels in the thoracolumbar spine received OSA. They were matched to 43 patients who did receive an OSA regimen. We analyzed several metrics including blood loss, anesthesia time, postanesthesia care unit (PACU) pain scores, postoperative pain scores, complications, length of stay, and readmissions. RESULTS The OSA group had significantly lower pain scores both before transfer to (4.6 vs . 7.6, P =0.000) and after transfer from (4.2 vs . 6.2 P =0.002) the PACU. Opioid use was significantly lower in the OSA group (454 vs . 241 MMEs by POD4, P =0.022). Fewer patients required blood transfusion in the OSA (1 vs . 28, P =0.000) group. Fewer patients in the OSA group had constipation and urinary retention (1 vs . 9, P =0.015). There was no difference in discharge home or to a facility. The lengths of hospital (4.33 vs . 6.19, P =0.009) and ICU (0.12 vs . 0.70 d, P =0.009) stays were significantly shorter in the OSA group. CONCLUSIONS OSA regimens have numerous benefits in patients undergoing spinal deformity surgery, including less opioid use, fewer postoperative complications, and a reduced length of stay.
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Carter M, Narayanan R, Toci G, Lee Y, Opara O, Hassan WA, Tewell N, Toth A, Sabitsky M, Fras S, Bowen G, Von Suskil M, Kurd M, Kaye ID, Canseco J, Hilibrand A, Vaccaro A, Kepler C, Schroeder G. The Effect of Nonsteroidal Anti-Inflammatory Drug Contraindications on Opioid Use, Length of Stay, and Patient-Reported Outcomes After Lumbar Fusion. J Am Acad Orthop Surg 2025:00124635-990000000-01322. [PMID: 40344653 DOI: 10.5435/jaaos-d-24-00450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 09/23/2024] [Indexed: 05/11/2025] Open
Abstract
OBJECTIVE To assess opioid use, length of stay (LOS), and patient-reported outcome measures (PROMs) among patients undergoing lumbar fusion with contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs) compared to those without any contraindications. SUMMARY OF BACKGROUND DATA Nonsurgical patients with NSAID contraindications have an increased association with opioid use disorder. There is a lack of research examining long-term pain medication trends among surgical patients with NSAID contraindications, specifically before and after lumbar fusion. METHODS Patients aged 18 years or older who underwent lumbar fusion from 2018 to 2019 were analyzed and compared based on NSAID contraindication. Opioid utilization (total number of prescriptions and morphine milligram equivalents [MMEs]) and benzodiazepine, muscle relaxant, and pregabalin/gapentin usage were tracked from 1 year preoperatively to 2 years postsurgery, through Pennsylvania Prescription Drug Monitoring Program. RESULTS Two hundred sixteen patients had ≥1 NSAID contraindication, whereas 639 did not have any contraindications. LOS was markedly longer by approximately 1 day (P = 0.004) for NSAID contraindication patients. On bivariate analysis, more patients with NSAID contraindications consumed opioids within 1 year before surgery (P = 0.008), and these patients consumed a higher MME at 30 to 60 days (P < 0.001) and 0 to 30 days (P = 0.034) preoperatively. Postoperatively, patients with NSAID contraindications also consumed higher MMEs from 30 to 90 days (P = 0.034), 90 to 365 days (P = 0.003), and 1 to 2 years (P = 0.001). Patients with NSAID contraindications had higher gabapentin/pregabalin usage. No differences existed regarding ΔPROMs between the cohorts. On multivariate analysis, specific NSAID contraindications (allergy and history of gastric surgery) independently predicted a longer LOS (P = 0.018 and 0.027, respectively) and greater postoperative opioid prescriptions (P < 0.001). CONCLUSION Patients with contraindications to NSAIDs remained in the hospital longer and consumed higher quantities of opioids. Despite this, patients with NSAID contraindications reported comparable PROMs to patients without contraindications. Providers should strongly consider alternative pain management strategies in this population, and future research should investigate the effect of specific NSAID contraindications in their ability to prolong LOS and increase postoperative opioid use. STUDY DESIGN A retrospective cohort study.
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Affiliation(s)
- Michael Carter
- From the Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Tingen J, D'Amico A, Kanter M, Riesenburger RI, Kryzanski J. Assessing a dose-response relationship: Preoperative opioid daily MME and duration on lumbar spine surgery patient-reported outcomes. Clin Neurol Neurosurg 2025; 252:108865. [PMID: 40157141 DOI: 10.1016/j.clineuro.2025.108865] [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: 02/17/2025] [Revised: 03/17/2025] [Accepted: 03/22/2025] [Indexed: 04/01/2025]
Abstract
OBJECTIVE It has been posited that preoperative opioid use can be a detrimental factor in prognosis, although its association with patient-reported outcomes (PROs) remains unclear. We aimed to examine complication rates, satisfaction, return to work, and improvement in back/leg pain with Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) considering preoperative opioid use utilizing a national, prospective registry. METHODS From 40,321 lumbar spine surgery patients, chronicity of preoperative use was defined as opioid-naive (no use), new (<6 wk), short-term (6 wk-3 mo), intermediate (3-6 mo), long-term (6 mo-1 yr), and chronic use (>1 yr). Daily use was defined according to an established morphine milliequivalent (MME) threshold. Multivariate regression models were constructed. RESULTS Long-term use was associated with lower improvement in VAS for back pain at 3- (p < .005) and 12-months (p = 0.026), as well as for leg pain at 12-months (p = 0.012). There were lower odds of achieving VAS back pain (p = .021) and ODI (p = .032) MCID at 3-months for those with high daily MME, though 12-month outcomes were comparable. All preoperative opioid use durations and MME levels were associated with higher postoperative use (p < .005), yet return to work rates and satisfaction were comparable. CONCLUSIONS Chronic preoperative opioid use is associated with worse PROs yet satisfaction, complication rates, and return to work were largely unaffected. Daily opioid burden in MME showed little impact on long-term outcomes. Most patients with preoperative opioid use benefit from lumbar spine surgery, yet preoperative opioid counseling remains necessary.
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Affiliation(s)
- Joseph Tingen
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
| | - Andrew D'Amico
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
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Rancu AL, Gouzoulis MJ, Winter AD, Katsnelson BM, Ansah-Twum JK, Grauer JN. Opioid Prescribing Trends Following Lumbar Discectomy. J Am Acad Orthop Surg 2024:00124635-990000000-01198. [PMID: 39706160 DOI: 10.5435/jaaos-d-24-00908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Accepted: 11/18/2024] [Indexed: 12/23/2024] Open
Abstract
BACKGROUND Lumbar diskectomy is a common procedure, following which a brief course of narcotics is often prescribed. Nonetheless, increasing attention has been given to such prescribing patterns to limit adverse effects and the potential for abuse. This study investigated prescribing patterns of opioid within 90 days following lumbar diskectomy. METHODS Patients undergoing single-level lumbar laminotomy/diskectomy from 2011 to 2021 were identified in the PearlDiver Mariner161 database. Exclusion criteria included the following: additional same-day spine procedures, age less than 18 years, same-day diagnosis of neoplasm, trauma, or infection, prior diagnosis of chronic pain, records active for less than 90 days following surgery, and filled opioid prescription between 7 and 30 days before the surgery. Predictors associated with receiving opioid prescriptions and excess prescribed morphine milligram equivalents (MMEs) were assessed with multivariable regression analyses. Prescribing patterns over the years were then analyzed with simple linear regression and compared for 2011 and 2021. RESULTS A total of 271,631 patients met the inclusion criteria. Opioids were prescribed for 195,835 (72.1%) and were independently associated with lower age, female sex, higher Elixhauser Comorbidity Index, and geographic region (P < 0.0001 for each). Greater MMEs were independently prescribed to those who were younger, had higher Elixhauser Comorbidity Index, and lived in specific geographic regions (P < 0.0001 for each). The proportion of patients receiving opioid prescriptions slightly increased over time (69.0% in 2011 to 71.0% in 2021), whereas a decrease was observed in median MMEs prescribed (428.9 in 2011 to 225.0 in 2021, P < 0.0001) and mean number of prescriptions filled (3.3 in 2011 and 2.3 in 2021, P < 0.0001). CONCLUSION Following lumbar diskectomy, this study found clinical and nonclinical factors to be associated with prescribing opioids and prescribed MME. The decreased MME prescribed over the years was encouraging and the decreased number of prescriptions filled suggests that patients are not needing to return for more prescriptions than prior.
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Affiliation(s)
- Albert L Rancu
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Rhon DI, Greenlee TA, Lawson BK, McCafferty RR, Gill NW. Assessment of Surgical Complications Strengthen the Relationship Between Spine Surgery Procedure Intensity and Chronic Opioid Use After Surgery. Spine (Phila Pa 1976) 2024; 49:1607-1613. [PMID: 38881243 DOI: 10.1097/brs.0000000000005069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024]
Abstract
STUDY DESIGN Prospective cohort using routinely collected health data. OBJECTIVE To compare opioid use based on surgery intensity (low or high). SUMMARY OF BACKGROUND DATA Many factors influence an individual's experience of pain. The extent to which postsurgical opioid use is influenced by the severity of spine surgery is unknown. METHODS The participants were individuals undergoing spine surgery in a large military hospital. Procedures were categorized as low intensity (eg, microdiscectomy and laminectomy) and high intensity (eg, fusion and arthroplasty). The Surgical Scheduling System and Military Health System Data Repository were queried for healthcare utilization the 1 year before and after surgery. We compared opioid use after surgery between groups, adjusting for prior opioid use and surgical complications. RESULTS A total of 342 individuals met the inclusion criteria, with mean age 45.4 years (SD 10.9), and 33.0% were women. Of these, 221 (64.6%) underwent a low-intensity procedure and 121 (35.4%) underwent a high-intensity procedure. Mean postoperative opioid prescription fills were greater in the high- versus low-intensity group (9.0 vs. 5.7; P <0.001), as were the mean total days' supply (158.9 vs. 81.8; P <0.001). Median morphine milligram equivalents (MMEs) were not significantly different (40.2 vs. 42.7; P =0.287). Of the cohort, 26.3% were chronic opioid users after surgery. Adjusted rates of long-term opioid use were not different between groups when only accounting for prior opioid use but significantly higher for the high-intensity group when adjusting for surgical complications (OR=2.08; 95% CI 1.09-3.97). Of the entire cohort, 52.5% was still filling opioid prescriptions after 6 months. CONCLUSIONS Higher-intensity procedures were associated with greater postoperative opioid use than lower-intensity procedures. Chronic opioid use was not significantly different between surgical intensity groups when considering only prior opioid use. Chronic opioid use was significantly higher among higher intensity procedures when accounting for surgical complications. The presence of surgical complications is a stronger predictor of postsurgical long-term opioid use in high-intensity surgeries than history of opioid use alone. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Bryan K Lawson
- Orthopaedic Surgery Services, Brooke Army Medical Center, San Antonio, TX
| | | | - Norman W Gill
- Army-Baylor Doctoral Program in Physical Therapy, Medical Department Center of Excellence, Fort Sam Houston, TX
- Department of Human Function and Rehabilitation Sciences, The George Washington University, Washington, DC
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Meade MH, Radack T, Riebesell S, Schultz MJ, Buchan L, Hilibrand AS, Kurd MF, Hsu V, Kaye ID, Schroeder GD, Kepler C, Vaccaro AR, Woods BI. The Effect of Patient Resilience on Postoperative Scores After One- and Two-Level Anterior Cervical Discectomy and Fusion. World Neurosurg 2024; 189:e953-e958. [PMID: 39004180 DOI: 10.1016/j.wneu.2024.07.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To investigate the association between resilience and outcomes of pain and neck-related disability after single- and double-level anterior cervical discectomy and fusion (ACDF). METHODS Patients who underwent single- or double-level ACDF were sent a survey between 6 months and 2 years after surgery. The survey included the Brief Resilience Scale (BRS), visual analogue scale (VAS) for pain, Neck Disability Index (NDI), and Pain Self-Efficacy Questionnaire (PSEQ-2). Patients completed the VAS and NDI twice, once describing preoperative pain and disability and once describing current pain and disability. Respondents were classified as high resilience (HR), medium resilience (MR), or low resilience (LR). Demographics, PSEQ-2 scores, pre- and postoperative VAS and NDI scores, and change in VAS (ΔVAS) and NDI (ΔNDI) scores were compared between groups. RESULTS Thirty-three patients comprised the HR group, 273 patients comprised the MR group, and 47 patients comprised the LR group. All groups demonstrated postoperative improvement in VAS and NDI scores that exceeded previously established MCID values. The HR group demonstrated greater improvement in pain compared with the LR group (ΔVAS: -5.8 for HR vs. -4.4 for LR, P = 0.05). Compared with the MR group, the LR group demonstrated greater postoperative pain (VAS: 3.2 for LR vs. 2.5 for MR, P = 0.02) and disability (NDI: 11.9 for LR vs. 8.6 for MR, P = 0.02). CONCLUSIONS Patients demonstrated improvement in pain and neck-related disability after single- and double-level ACDF, regardless of resilience score. Patients with greater resilience may be expected to demonstrate more improvement in pain after ACDF.
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Affiliation(s)
- Matthew H Meade
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, New Jersey, USA.
| | - Tyler Radack
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samantha Riebesell
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew J Schultz
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, New Jersey, USA
| | - Levi Buchan
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, New Jersey, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark F Kurd
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Victor Hsu
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher Kepler
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Homeier DD, Kang D, Molinari R, Mesfin A. The top-cited military relevant spine articles. J Orthop 2024; 54:38-45. [PMID: 38524362 PMCID: PMC10957343 DOI: 10.1016/j.jor.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Historically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine. Methods In April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict. Results 1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts. Conclusion The 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.
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Affiliation(s)
- Daniel D. Homeier
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Daniel Kang
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA
| | - Robert Molinari
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, MedStar Health, Columbia, MD, USA
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Chelly JE, Goel SK, Kearns J, Kopac O, Sadhasivam S. Nanotechnology for Pain Management. J Clin Med 2024; 13:2611. [PMID: 38731140 PMCID: PMC11084313 DOI: 10.3390/jcm13092611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.
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Affiliation(s)
- Jacques E. Chelly
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA
| | - Shiv K. Goel
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Jeremy Kearns
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Orkun Kopac
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA; (S.K.G.); (J.K.); (O.K.); (S.S.)
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Kapadi R, Elander J, Bateman AH. Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia. Subst Use Misuse 2024; 59:1047-1058. [PMID: 38485654 DOI: 10.1080/10826084.2024.2320373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (β = 0.249, p = <0.002) and PCS subscale rumination (β = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction β = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.
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Affiliation(s)
| | - James Elander
- School of Psychology, University of Derby, Derby, UK
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Pettitt-Schieber B, Lesko RP, Wang F, Shah J, Ricci JA. Opioid prescribing patterns for distal radius fractures in the ambulatory setting: A 10-year retrospective study. J Opioid Manag 2024; 20:109-117. [PMID: 38700392 DOI: 10.5055/jom.0862] [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
OBJECTIVE Distal radius fractures (DRFs) are one of the most common orthopedic injuries, with most managed in the nonoperative ambulatory setting. The objectives of this study are to examine National Health Center Statistics (NHCS) data for DRF treated in the nonoperative ambulatory setting to identify opioid and nonopioid analgesic prescribing patterns and to determine demographic risk factors for prescription of these medications. Design, setting, patients, and measures: This study is a retrospective analysis of data collected by the NHCS from 2007 to 2016. Utilizing International Classification of Diseases codes, all visits to emergency departments and doctors' offices for DRFs were identified. Variables of interest included demographic data, expected payment source, and prescription of opioid or nonopioid analgesics. RESULTS During the study timeframe, 15,572,531 total visits for DRFs were recorded. DRF visits requiring opioid and nonopioid analgesic prescriptions increased over time. Patients aged 45-64 years were significantly more likely to receive an opioid prescription than any other age group (p < 0.05). Opioid prescription was positively correlated with the use of workers' compensation and negatively correlated with patients receiving services under charity care (p < 0.05). CONCLUSIONS Prescriptions of both opioid and nonopioid analgesic medications for DRF have been steadily increasing over time in the nonoperative ambulatory setting, with middle-aged adults most likely to receive an opioid prescription. Opioid prescription rates differ significantly between patients utilizing workers' compensation and patients receiving services under charity care, suggesting that socioeconomic factors play a role in prescribing patterns.
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Affiliation(s)
- Brian Pettitt-Schieber
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Robert P Lesko
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fei Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Jinesh Shah
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. ORCID: https://orcid.org/0000-0002-5791-4378
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11
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Gerlach EB, Plantz MA, Swiatek PR, Wu SA, Arpey N, Fei-Zhang D, Divi SN, Hsu WK, Patel AA. The Drivers of Persistent Opioid Use and Its Impact on Healthcare Utilization After Elective Spine Surgery. Global Spine J 2024; 14:370-379. [PMID: 35603925 PMCID: PMC10802539 DOI: 10.1177/21925682221104731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine the incidence of and risk factors for persistent opioid use after elective cervical and lumbar spine procedures and to quantify postoperative healthcare utilization in this patient population. METHODS Patients were retrospectively identified who underwent elective spine surgery for either cervical or lumbar degenerative pathology between November 1, 2013, and September 30, 2018, at a single academic center. Patients were split into 2 cohorts, including patients with and without opioid use at 180-days postoperatively. Baseline patient demographics, underlying comorbidities, surgical variables, and preoperative/postoperative opioid use were assessed. Health resource utilization metrics within 1 year postoperatively (ie, imaging studies, emergency and urgent care visits, hospital readmissions, opioid prescriptions, etc.) were compared between these 2 groups. RESULTS 583 patients met inclusion criteria, of which 16.6% had opioid persistence after surgery. Opioid persistence was associated with ASA score ≥3 (P = .004), diabetes (P = .019), class I obesity (P = .012), and an opioid prescription in the 60 days prior to surgery (P = .006). Independent risk factors for opioid persistence assessed via multivariate regression included multi-level lumbar fusion (RR = 2.957), cervical central stenosis (RR = 2.761), and pre-operative opioid use (RR = 2.668). Opioid persistence was associated with higher rates of health care utilization, including more radiographs (P < .001), computed tomography (CT) scans (.007), magnetic resonance imaging (MRI) studies (P = .014), emergency department (ED) visits (.009), pain medicine referrals (P < .001), and spinal injections (P = .003). CONCLUSIONS Opioid persistence is associated with higher rates of health care utilization within 1 year after elective spine surgery.
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Affiliation(s)
- Erik B. Gerlach
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Mark A. Plantz
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Peter R. Swiatek
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Scott A. Wu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Nicholas Arpey
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - David Fei-Zhang
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Srikanth N. Divi
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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12
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Ahmad AH, Carreon LY, Glassman SD, Harpe-Bates J, Sampedro BC, Brown ME, Daniels CL, Schmidt GO, Hines B, Gum JL. Opioid-sparing Anesthesia Decreases In-hospital and 1-year Postoperative Opioid Consumption Compared With Traditional Anesthesia: A Propensity-matched Cohort Study. Spine (Phila Pa 1976) 2024; 49:58-63. [PMID: 37612894 DOI: 10.1097/brs.0000000000004806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
STUDY DESIGN Propensity-matched cohort. OBJECTIVE The aim of this study was to determine if opioid-sparing anesthesia (OSA) reduces in-hospital and 1-year postoperative opioid consumption. SUMMARY OF BACKGROUND DATA The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OSA protocol for lumbar spinal fusion surgery to mitigate opioid exposure. MATERIALS AND METHODS Patients undergoing lumbar fusion for degenerative conditions over one to four levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, body mass index, American Society of Anesthesiologists grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption, and opioid prescriptions 1 year after surgery were compared. RESULTS Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69 yr; non-OSA: 67 males, mean age=58.94 yr). OSA patients had lower blood loss (326 mL vs. 399 mL, P =0.014), surgical time (201 vs. 233 min, P <0.001) emergence to extubation time (9.1 vs. 14.2 min, P< 0.001), and recovery room time (119 vs. 140 min, P =0.0.012) compared with non-OSA patients. Fewer OSA patients required nonhome discharge (18 vs. 41, P =0.001) compared with the non-OSA cohort, but no difference in length of stay (90.3 vs. 98.5 h, P =0.204). Daily opioid consumption was lower in the OSA versus the non-OSA cohort from postoperative day 2 (223 vs. 185 morphine milligram equivalents, P =0.017) and maintained each day with lower total consumption (293 vs. 225 morphine milligram equivalents, P =0.003) throughout postoperative day 4. The number of patients with active opioid prescriptions at 1, 3, 6, and 12 months postoperative was statistically fewer in the OSA compared with the non-OSA patients. CONCLUSIONS OSA for lumbar spinal fusion surgery decreases in-hospital and 1-year postoperative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays, and fewer discharges to nonhome facilities.
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Affiliation(s)
- Amer H Ahmad
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY
- Norton Leatherman Spine Center, Louisville, KY
| | | | - Steven D Glassman
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY
- Norton Leatherman Spine Center, Louisville, KY
| | | | | | | | | | | | - Bren Hines
- Norton Leatherman Spine Center, Louisville, KY
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY
- Norton Leatherman Spine Center, Louisville, KY
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13
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Dufour S, Banaag A, Schoenfeld AJ, Adams RS, Koehlmoos TP, Gray JC. Diagnostic profiles associated with long-term opioid therapy in active duty servicemembers. PM R 2024; 16:14-24. [PMID: 37162022 PMCID: PMC10786620 DOI: 10.1002/pmrj.12994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/20/2023] [Accepted: 04/26/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Over-prescription of opioids has diminished in recent years; however, certain populations remain at high risk. There is a dearth of research evaluating prescription rates using specific multimorbidity patterns. OBJECTIVE To identify distinct clinical profiles associated with opioid prescription and evaluate their relative odds of receiving long-term opioid therapy. DESIGN Retrospective analysis of the complete military electronic health record. We assessed demographics and 26 physiological, psychological, and pain conditions present during initial opioid prescription. Latent class analysis (LCA) identified unique clinical profiles using diagnostic data. Logistic regression measured the odds of these classes receiving long-term opioid therapy. SETTING All electronic health data under the TRICARE network. PARTICIPANTS All servicemembers on active duty during fiscal years 2016 through 2019 who filled at least one opioid prescription. MAIN OUTCOME MEASURES Number and qualitative characteristics of LCA classes; odds ratios (ORs) from logistic regression. We hypothesized that LCA classes characterized by high-risk contraindications would have significantly higher odds of long-term opioid therapy. RESULTS A total of N = 714,446 active duty servicemembers were prescribed an opioid during the study window, with 12,940 (1.8%) receiving long-term opioid therapy. LCA identified five classes: Relatively Healthy (82%); Musculoskeletal Acute Pain and Substance Use Disorders (6%); High Pain, Low Mental Health Burden (9%); Low Pain, High Mental Health Burden (2%), and Multisystem Multimorbid (1%). Logistic regression found that, compared to the Relatively Healthy reference, the Multisystem Multimorbid class, characterized by multiple opioid contraindications, had the highest odds of receiving long-term opioid therapy (OR = 9.24; p < .001; 95% confidence interval [CI]: 8.56, 9.98). CONCLUSION Analyses demonstrated that classes with greater multimorbidity at the time of prescription, particularly co-occurring psychiatric and pain disorders, had higher likelihood of long-term opioid therapy. Overall, this study helps identify patients most at risk for long-term opioid therapy and has implications for health care policy and patient care.
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Affiliation(s)
- Steven Dufour
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
- Naval Medical Center Portsmouth, Portsmouth, VA
| | - Amanda Banaag
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rachel Sayko Adams
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO
| | - Tracey Perez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joshua C. Gray
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
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14
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Watters JA, Banaag A, Massengill JC, Koehlmoos TP, Staat BC. Postpartum Opioid Use among Military Health System Beneficiaries. Am J Perinatol 2024; 41:60-66. [PMID: 34784618 DOI: 10.1055/s-0041-1740006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of the study is to evaluate the prevalence and factors associated with opioid prescriptions to postpartum patients among TRICARE beneficiaries receiving care in the civilian health care system versus a military health care facility. STUDY DESIGN We evaluated postpartum opioid prescriptions filled at discharge among patients insured by TRICARE Prime/Prime Plus using the Military Health System Data Repository between fiscal years 2010 to 2015. We included women aged 15 to 49 years old and excluded abortive pregnancy outcomes and incomplete datasets. The primary outcome investigated mode of delivery and demographics for those filling an opioid prescription. Secondary outcomes compared prevalence of filled opioid prescription at discharge for postpartum patients within civilian care and military care. RESULTS Of a total of 508,258 postpartum beneficiaries, those in civilian health care were more likely to fill a discharge opioid prescription compared with those in military health care (OR 3.9, 95% CI 3.8-3.99). Cesarean deliveries occurred less frequently in military care (26%) compared with civilian care (30%), and forceps deliveries occurred more frequently in military care (1.38%) compared with civilian care (0.75%). Women identified as Asian race were least likely to fill an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Women aged 15 to 19 years had a lower odds of filling an opioid prescription (OR 0.83, 95% CI 0.80-0.86). Women associated with a senior officer rank were less likely to fill an opioid prescription postpartum (OR 0.83, 95% CI 0.73-0.91), while those associated with warrant officer rank were more likely to fill an opioid prescription (OR 1.14, 95% CI 1.06-1.23). CONCLUSION Our data indicates that women who received care in civilian facilities were more likely to fill an opioid prescription at discharge when compared with military facilities. Factors such as race and age were associated with opioid prescription at discharge. This study highlights areas for improvement for potential further studies. KEY POINTS · Opioid prescription patterns for postpartum women may vary across the country.. · Our study indicates postpartum patients in civilian care are more likely to fill opioids postpartum.. · This study highlights a population which may have an improved opioid prescribing pattern..
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Affiliation(s)
- Julie A Watters
- Department of Obstetrics and Gynecology, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, California
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Amanda Banaag
- Center for Health Services Research, Henry M. Jackson Foundation, Bethesda, Maryland
| | - Jason C Massengill
- Department of Obstetrics and Gynecology, Wright-Patterson United States Air Force Medical Center, Dayton, Ohio
| | - Tracey P Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Barton C Staat
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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15
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Subramanian T, Shinn DJ, Korsun MK, Shahi P, Asada T, Amen TB, Maayan O, Singh S, Araghi K, Tuma OC, Singh N, Simon CZ, Zhang J, Sheha ED, Dowdell JE, Huang RC, Albert TJ, Qureshi SA, Iyer S. Recovery Kinetics After Cervical Spine Surgery. Spine (Phila Pa 1976) 2023; 48:1709-1716. [PMID: 37728119 DOI: 10.1097/brs.0000000000004830] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively maintained multisurgeon registry. OBJECTIVE To study recovery kinetics and associated factors after cervical spine surgery. SUMMARY OF BACKGROUND DATA Few studies have described return to activities cervical spine surgery. This is a big gap in the literature, as preoperative counseling and expectations before surgery are important. MATERIALS AND METHODS Patients who underwent either anterior cervical discectomy and fusion (ACDF) or cervical disk replacement (CDR) were included. Data collected included preoperative patient-reported outcome measures, return to driving, return to working, and discontinuation of opioids data. A multivariable regression was conducted to identify the factors associated with return to driving by 15 days, return to working by 15 days, and discontinuing opioids by 30 days. RESULTS Seventy ACDF patients and 70 CDR patients were included. Overall, 98.2% of ACDF patients and 98% of CDR patients returned to driving in 16 and 12 days, respectively; 85.7% of ACDF patients and 90.9% of CDR patients returned to work in 16 and 14 days; and 98.3% of ACDF patients and 98.3% of CDR patients discontinued opioids in a median of seven and six days. Though not significant, minimal (odds ratio (OR)=1.65) and moderate (OR=1.79) disability was associated with greater odds of returning to driving by 15 days. Sedentary work (OR=0.8) and preoperative narcotics (OR=0.86) were associated with decreased odds of returning to driving by 15 days. Medium (OR=0.81) and heavy (OR=0.78) intensity occupations were associated with decreased odds of returning to work by 15 days. High school education (OR=0.75), sedentary work (OR=0.79), and retired/not working (OR=0.69) were all associated with decreased odds of discontinuing opioids by 30 days. CONCLUSIONS Recovery kinetics for ACDF and CDR are comparable. Most patients return to all activities after ACDF and CDR within 16 days. These findings serve as an important compass for preoperative counseling.
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Affiliation(s)
- Tejas Subramanian
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Daniel J Shinn
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Maximilian K Korsun
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Pratyush Shahi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Tomoyuki Asada
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Troy B Amen
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Omri Maayan
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Sumedha Singh
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Olivia C Tuma
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Nishtha Singh
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Chad Z Simon
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Joshua Zhang
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Evan D Sheha
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - James E Dowdell
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Russel C Huang
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Todd J Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
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16
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Arciero E, Coury JR, Dionne A, Reyes J, Lombardi JM, Sardar ZM. Optimizing Preoperative Chronic Pain Management in Elective Spine Surgery Patients: A Narrative Review of Outcomes with Opioid and Adjuvant Pain Therapies. JBJS Rev 2023; 11:01874474-202312000-00006. [PMID: 38100612 DOI: 10.2106/jbjs.rvw.23.00156] [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: 12/17/2023]
Abstract
» Chronic preoperative opioid use negatively affects outcomes after spine surgery, with increased complications and reoperations, longer hospital stays, decreased return-to-work rates, worse patient-reported outcomes, and a higher risk of continued opioid use postoperatively.» The definition of chronic opioid use is not consistent across studies, and a more specific and consistent definition will aid in stratifying patients and understanding their risk of inferior outcomes.» Preoperative weaning periods and maximum dose thresholds are being established, which may increase the likelihood of achieving a meaningful improvement after surgery, although higher level evidence studies are needed.» Spinal cord stimulators and intrathecal drug delivery devices are increasingly used to manage chronic back pain and are equivalent or perhaps even superior to opioid treatment, although few studies exist examining how patients with these devices do after subsequent spine surgery.» Further investigation is needed to determine whether a true mechanistic explanation exists for spine-related analgesia related to spinal cord stimulators and intrathecal drug delivery devices.
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Affiliation(s)
- Emily Arciero
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
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17
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Meade MH, Schultz MJ, Radack T, Michael M, Hilibrand AS, Kurd MF, Hsu V, Kaye ID, Schroeder GD, Kepler C, Vaccaro AR, Woods BI. The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion. Clin Spine Surg 2023; 36:E410-E415. [PMID: 37363819 DOI: 10.1097/bsd.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/17/2023] [Indexed: 06/28/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF). BACKGROUND Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery. PATIENTS AND METHODS Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index. RESULTS Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58). CONCLUSIONS While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Matthew H Meade
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, NJ
| | | | - Tyler Radack
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mark Michael
- Division of Orthopedic Surgery, Jefferson Health-NJ, Stratford, NJ
| | - Alan S Hilibrand
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mark F Kurd
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Victor Hsu
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Ian David Kaye
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Christopher Kepler
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Barrett I Woods
- Department of Orthopaedic Spine Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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18
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Madsen C, Korona-Bailey J, Janvrin ML, Schoenfeld AJ, Koehlmoos TP. Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1133-1137. [PMID: 37280084 PMCID: PMC10546480 DOI: 10.1093/pm/pnad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. METHODS We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. RESULTS Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. CONCLUSIONS Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.
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Affiliation(s)
- Cathaleen Madsen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Jessica Korona-Bailey
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Miranda Lynn Janvrin
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Harvard Medical School, Brigham & Women’s Hospital, Boston, MA 02115, United States
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19
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Barrie U, Montgomery EY, Ogwumike E, Pernik MN, Luu IY, Adeyemo EA, Christian ZK, Edukugho D, Johnson ZD, Hoes K, El Tecle N, Hall K, Aoun SG, Bagley CA. Household Income as a Predictor for Surgical Outcomes and Opioid Use After Spine Surgery in the United States. Global Spine J 2023; 13:2124-2134. [PMID: 35007170 PMCID: PMC10538313 DOI: 10.1177/21925682211070823] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Cross-Sectional Study. OBJECTIVES Socioeconomic status (SES) is a fundamental root of health disparities, however, its effect on surgical outcomes is often difficult to capture in clinical research, especially in spine surgery. Here, we present a large single-center study assessing whether SES is associated with cause-specific surgical outcomes. METHODS Patients undergoing spine surgery between 2015 and 2019 were assigned income in accordance with the national distribution and divided into quartiles based on the ZIP code-level median household income. We performed univariate, chi-square, and Analysis of Variance (ANOVA) analysis assessing the independent association of SES, quantified by household income, to operative outcomes, and multiple metrics of opioid consumption. RESULTS 1199 patients were enrolled, and 1138 patients were included in the analysis. Low household income was associated with the greatest rates of 3-month opioid script renewal (OR:1.65, 95% CI:1.14-2.40). In addition, low-income was associated with higher rates of perioperative opioid consumption compared to higher income including increased mean total morphine milligram equivalent (MME) 252.25 (SD 901.32) vs 131.57 (SD 197.46) (P < .046), and inpatient IV patient-controlled analgesia (PCA) MME 121.11 (SD 142.14) vs 87.60 (SD 86.33) (P < .023). In addition, household income was independently associated with length of stay (LOS), and emergency room (ER) revisits with low-income patients demonstrating significantly longer postop LOS and increasing postoperative ER visits. CONCLUSIONS Considering the comparable surgical management provided by the single institution, the associated differences in postoperative outcomes as defined by increased morbidities and opioid consumption can potentially be attributed to health disparities caused by SES.
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Affiliation(s)
- Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Erica Ogwumike
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Ivan Y. Luu
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Emmanuel A. Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Zachary K. Christian
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Derrek Edukugho
- Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Zachary D. Johnson
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Kathryn Hoes
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Saint Louis University School of Medicine, St Louis, MI, USA
| | - Kristen Hall
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
- Department of Orthopedic Surgery Dallas, University of Texas Southwestern Medical School, Texas, USA
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20
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Zheng B, Guo C, Xu S, Li H, Wu Y, Liu H. Anesthesia methods for full-endoscopic lumbar discectomy: a review. Front Med (Lausanne) 2023; 10:1193311. [PMID: 37663652 PMCID: PMC10469954 DOI: 10.3389/fmed.2023.1193311] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Full-endoscopic lumbar discectomy under local anesthesia is major trends for the treatment of lumbar disc herniation in spine minimally invasive surgery. However, sometimes local anesthesia is not enough for analgesic in surgery especially in interlaminar approach. This study summarizes the current study of anesthesia methods in full-endoscopic lumbar discectomy. Local anesthesia is still the most common anesthesia method in full-endoscopic lumbar discectomy and the comparison group for other anesthesia methods due to high safety. Compared to local anesthesia, Epidural anesthesia is less applied in full-endoscopic lumbar discectomy but reports better intraoperative pain control and equivalent safety due to the motor preservation and pain block characteristic of ropivacaine. General anesthesia can achieve totally pain block during surgery but nerve injury can not be ignored, and intraoperative neuromonitoring can assist. Regional anesthesia application is rare but also reports better anesthesia effects during surgery and equivalent safety. Anesthesia methods for full-endoscopic lumbar discectomy should be based on patient factors, surgical factors, and anesthesiologist factors to achieve satisfactory anesthesia experience and successful surgery.
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Affiliation(s)
- Bin Zheng
- Spine Surgery, Peking University People's Hospital, Beijing, China
| | - Chen Guo
- Spine Surgery, Peking University People's Hospital, Beijing, China
| | - Shuai Xu
- Spine Surgery, Peking University People's Hospital, Beijing, China
| | - Haoyuan Li
- Spine Surgery, Peking University People's Hospital, Beijing, China
| | - Yonghao Wu
- Spine Surgery, Peking University People's Hospital, Beijing, China
| | - Haiying Liu
- Spine Surgery, Peking University People's Hospital, Beijing, China
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21
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Fritz JM, Rhon DI, Garland EL, Hanley AW, Greenlee T, Fino N, Martin B, Highland KB, Greene T. The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S115-S125. [PMID: 36069630 PMCID: PMC10403309 DOI: 10.1093/pm/pnac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP. DESIGN Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome. SUMMARY This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.
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Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Eric L Garland
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Adam W Hanley
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Tina Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Nora Fino
- Department of Population Health Sciences, The University of Utah, Salt Lake City, Utah
| | - Brook Martin
- Department of Orthopedics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Krista B Highland
- Department of Orthopedics, School of Medicine, The University of Utah, Salt Lake City, Utah
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, USA
| | - Tom Greene
- Department of Population Health Sciences, The University of Utah, Salt Lake City, Utah
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22
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Montgomery EY, Pernik MN, Johnson ZD, Dosselman LJ, Christian ZK, Deme PR, Adeyemo EA, Barrie U, Badejo O, Stewart NA, Uttarkar R, Adogwa O, Tecle NE, Aoun SG, Bagley CA. Perioperative Factors Associated With Chronic Opioid Use After Spine Surgery. Global Spine J 2023; 13:1450-1456. [PMID: 34414800 PMCID: PMC10448093 DOI: 10.1177/21925682211035723] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective case control. OBJECTIVES The purpose of the current study is to determine risk factors associated with chronic opioid use after spine surgery. METHODS In our single institution retrospective study, 1,299 patients undergoing elective spine surgery at a tertiary academic medical center between January 2010 and August 2017 were enrolled into a prospectively collected registry. Patients were dichotomized based on renewal of, or active opioid prescription at 3-mo and 12-mo postoperatively. The primary outcome measures were risk factors for opioid renewal 3-months and 12-months postoperatively. These primarily included demographic characteristics, operative variables, and in-hospital opioid consumption via morphine milligram equivalence (MME). At the 3-month and 12-month periods, we analyzed the aforementioned covariates with multivariate followed by bivariate regression analyses. RESULTS Multivariate and bivariate analyses revealed that script renewal at 3 months was associated with black race (P = 0.001), preoperative narcotic (P < 0.001) or anxiety/depression medication use (P = 0.002), and intraoperative long lumbar (P < 0.001) or thoracic spine surgery (P < 0.001). Lower patient income was also a risk factor for script renewal (P = 0.01). Script renewal at 12 months was associated with younger age (P = 0.006), preoperative narcotics use (P = 0.001), and ≥4 levels of lumbar fusion (P < 0.001). Renewals at 3-mo and 12-mo had no association with MME given during the hospital stay or with the usage of PCA (P > 0.05). CONCLUSION The current study describes multiple patient-level factors associated with chronic opioid use. Notably, no metric of perioperative opioid utilization was directly associated with chronic opioid use after multivariate analysis.
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Affiliation(s)
- Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Zachary D. Johnson
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Luke J. Dosselman
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Zachary K. Christian
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Palvasha R. Deme
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Emmanuel A. Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Olatunde Badejo
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Nick A. Stewart
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Ruta Uttarkar
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Owoicho Adogwa
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Saint Louis University School of Medicine, MO, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
- Department of Orthopedic Surgery, University of Texas Southwestern Medical School, TX, USA
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23
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Kowalski C, Ridenour R, McNutt S, Ba D, Liu G, Bible J, Aynardi M, Garner M, Leslie D, Dhawan A. Risk Factors For Prolonged Opioid Use After Spine Surgery. Global Spine J 2023; 13:683-688. [PMID: 33853404 DOI: 10.1177/21925682211003854] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Our purpose was to evaluate factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. METHODS The MarketScan commercial claims and encounters database includes approximately 39 million patients per year. Patients undergoing cervical and lumbar spine surgery between the years 2005-2014 were identified using CPT codes. Pre-operative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications, and diabetes were queried and documented. Patients who utilized opioids from 1-3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed pre- and post-operative narcotic medications up to 1 month prior to surgery. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. RESULTS 553,509 patients who underwent spine surgery during the 10-year period were identified. 34.9% of patients utilized opioids 1-3 months pre-operatively. 25% patients were still utilizing opioids at 6 weeks, 17.3% at 3 months, 12.7% at 6 months, and 9.0% at 1 year after surgery. Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks (OR 5.45, 95% CI 5.37-5.53), 3-6 months (OR 6.48, 95% CI 6.37-6.59), 6-12 months (OR 6.97, 95% CI 6.84-7.11), and >12 months (OR 7.12, 95% CI 6.96-7.29). Mental health diagnosis, tobacco usage, diagnosis of chronic pain or CRPS, and non-narcotic neuromodulatory medications yielded increased likelihood of prolonged post-op opioid usage. CONCLUSIONS Pre-operative narcotic use and several patient comorbidities diagnoses are associated with prolonged post-operative opioid usage following spine surgery. Chronic opioid use, diagnosis of chronic pain, or use of non-narcotic neuromodulatory medications have the highest risk of prolonged post-operative opioid consumption. Patients using opiates pre-operatively did have an increased 30 and 90-day readmission risk, in addition to a number of serious post-operative complications. This data provides spine surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers, and payers with information on complications associated with pre-operative opioid utilization.
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Affiliation(s)
- Christopher Kowalski
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Ryan Ridenour
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Sarah McNutt
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Djibril Ba
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Guodong Liu
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Jesse Bible
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Michael Aynardi
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Matthew Garner
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Douglas Leslie
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
| | - Aman Dhawan
- Department of Orthopaedics & Rehabilitation, 12311Penn State Milton S. Hershey Medical Center, Hope Drive, Hershey, PA, USA
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24
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Pester BD, Yoon J, Yamin JB, Papianou L, Edwards RR, Meints SM. Let’s Get Physical! A Comprehensive Review of Pre- and Post-Surgical Interventions Targeting Physical Activity to Improve Pain and Functional Outcomes in Spine Surgery Patients. J Clin Med 2023; 12:jcm12072608. [PMID: 37048691 PMCID: PMC10095133 DOI: 10.3390/jcm12072608] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
The goal of this comprehensive review was to synthesize the recent literature on the efficacy of perioperative interventions targeting physical activity to improve pain and functional outcomes in spine surgery patients. Overall, research in this area does not yet permit definitive conclusions. Some evidence suggests that post-surgical interventions may yield more robust long-term outcomes than preoperative interventions, including large effect sizes for disability reduction, although there are no studies directly comparing these surgical approaches. Integrated treatment approaches that include psychosocial intervention components may supplement exercise programs by addressing fear avoidance behaviors that interfere with engagement in activity, thereby maximizing the short- and long-term benefits of exercise. Efforts should be made to test brief, efficient programs that maximize accessibility for surgical patients. Future work in this area should include both subjective and objective indices of physical activity as well as investigating both acute postoperative outcomes and long-term outcomes.
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Affiliation(s)
- Bethany D. Pester
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-973-464-6386
| | - Jihee Yoon
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Jolin B. Yamin
- Harvard Medical School, Boston, MA 02115, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Lauren Papianou
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Samantha M. Meints
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
- Harvard Medical School, Boston, MA 02115, USA
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25
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Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy. Surgery 2023; 173:864-869. [PMID: 36336504 DOI: 10.1016/j.surg.2022.07.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/03/2022] [Accepted: 07/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Surgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy. METHODS In a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts. RESULTS There were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001). CONCLUSION Performing a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.
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26
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Lim S, Yeh HH, Macki M, Haider S, Hamilton T, Mansour TR, Telemi E, Schultz L, Nerenz DR, Schwalb JM, Abdulhak M, Park P, Aleem I, Easton R, Khalil JG, Perez-Cruet M, Chang V. Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study. J Neurosurg Spine 2023; 38:242-248. [PMID: 36208431 DOI: 10.3171/2022.8.spine22571] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. METHODS Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. RESULTS Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). CONCLUSIONS The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.
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Affiliation(s)
| | | | | | | | | | | | | | - Lonni Schultz
- Departments of1Neurological Surgery
- 2Public Health Services, and
| | - David R Nerenz
- Departments of1Neurological Surgery
- 3Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | | | | | - Ilyas Aleem
- 5Orthopedics, University of Michigan, Ann Arbor, Michigan
| | - Richard Easton
- 6Department of Orthopedics, William Beaumont Hospital, Troy, Michigan; and
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27
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Skibicki H, Saini S, Rogero R, Nicholson K, Shakked RJ, Fuchs D, Winters BS, Raikin SM, Pedowitz DI, Daniel JN. Opioid Consumption Patterns and Prolonged Opioid Use Among Opioid-Naïve Ankle Fracture Patients. Foot Ankle Spec 2023; 16:36-42. [PMID: 33576251 DOI: 10.1177/1938640021992922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Here, the investigators assess immediate postoperative opioid consumption patterns as well as the incidence of prolonged opioid use among opioid-naïve patients following ankle fracture surgery. METHODS Included patients underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture over a 1-year period. At patients' first postoperative visit, opioid pills were counted and standardized to the equivalent number of 5-mg oxycodone pills. Prolonged use was defined as filling a prescription for a controlled substance more than 90 days after the index procedure, tracked by the New Jersey Prescription Drug Monitoring Program up to 1 year postoperatively. RESULTS At the first postoperative visit, 173 patients consumed a median of 24 out of 40 pills prescribed. The initial utilization rate was 60%, and 2736 pills were left unused. In all, 32 (18.7%) patients required a narcotic prescription 90 days after the index procedure. Patients with a self-reported history of depression (P = .11) or diabetes (P = .07) demonstrated marginal correlation with prolonged narcotic use. CONCLUSION Our study demonstrated that, on average, patients utilize significantly fewer opioid pills than prescribed and that many patient demographics are not significant predictors of continued long-term use following outpatient ankle fracture surgery. Large variations in consumption rates make it difficult for physicians to accurately prescribe and predict prolonged narcotic use. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hope Skibicki
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | - Sundeep Saini
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | - Ryan Rogero
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.,Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | | | | | - Daniel Fuchs
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | | | | | | | - Joseph N Daniel
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey.,Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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28
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Abul K, Yilgor C, Yucekul A, Alanay NA, Yavuz Y, Zulemyan T, Boissiere L, Bourghli A, Obeid I, Pizones J, Kleinstueck F, Perez-Grueso FJS, Pellise F, Alanay A. Long-term opioid medication profile of European adult spinal deformity patients: minimum five years follow-up study. Spine J 2023; 23:209-218. [PMID: 36336253 DOI: 10.1016/j.spinee.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/03/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT There remains significant variability in the use of postoperative opioids. On one end, it is proven that appropriate pain control is a critical aspect of patient management; on the other end, past few decades have been associated with major increases in opioid-related overdoses and addiction treatment. We hypothesized that several pre- and postoperative risk factors affecting long-term opioid use could be identified. PURPOSE Evaluation of factors associated with minimum 5-year postoperative opioid use following adult spinal deformity surgery. STUDY DESIGN/SETTING Prospectively followed study group database. PATIENT SAMPLE Adult spinal deformity patients who underwent elective spine surgery between 2009 and 2016 were included. OUTCOME MEASURES Opioid usage or otherwise at minimum 5 years follow-up. Use of nonopioid analgesics, weak and strong opioids METHODS: Retrospective analysis of patients undergoing elective spinal deformity surgery. A total of 37 factors comprising patient characteristics, radiographic measurements, operative details, preoperative and early postoperative opioid use, and mechanical complications and revisions were analyzed. Details on identified factors were provided. RESULTS A total of 265 patients (215F, 50M) from five sites were included. The mean follow-up duration was 68.4±11.7 (60-102) months. On average, 10.6±3.5 levels were fused. Preoperatively, 64 (24.2%) patients were using opioids. The rate of opioid users increased to 33.6% at 6 weeks and decreased to 21.5% at 6 months. During follow-up, there were patients who discontinued opioids, while others have started and/or restarted using opioids. As a result, 59 (22.3%) patients were still on opioids at the latest follow-up. Multivariate analyses showed that factors independently affecting opioid use at an average of 68 months postoperatively, in order of significance, were opioid use at sixth weeks, preoperative opioid use and opioid use at sixth months with the odds ratios of 2.88, 2.51, and 2.38 respectively. At these time points, factors such as age, number of comorbidities, tobacco use, the time of the last prior spine surgery and postoperative sagittal plane alignment affected opioid usage rates. CONCLUSIONS Opioid usage at 6 weeks was found to be more predictive of long-term opioid use compared to preoperative use. Patients should be well informed to have realistic expectations regarding opioid use when considering adult spinal deformity surgery.
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Affiliation(s)
- Kadir Abul
- Clinic of Orthopedics and Traumatology, Basaksehir Pine and Sakura City Hospital, Olimpiyat Bulvarı Yolu, 34480 Basaksehir, Istanbul, Turkey
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey
| | - Altug Yucekul
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey
| | - Nezih Arin Alanay
- Lycée Français Notre Dame de Sion, Cumhuriyet Cad 127, 34373 Sisli, Istanbul, Turkey
| | - Yasemin Yavuz
- Department of Biostatistics, Ankara University School of Medicine, Adnan Saygun Cad., 06230 Altindag, Ankara, Turkey
| | - Tais Zulemyan
- Comprehensive Spine Center, Acibadem University Maslak Hospital, Buyukdere Cad 40, 34457 Sariyer, Istanbul, Turkey
| | - Louis Boissiere
- Clinique du Dos, Elsan Jean Villar Private Hospital, 2 Av. de Terrefort, 33520 Bruges, Bordeaux, France
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Al Mathar Ash Shamali, 11564 Riyadh, Saudi Arabia
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, 2 Av. de Terrefort, 33520 Bruges, Bordeaux, France
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | - Frank Kleinstueck
- Spine Center Division, Department of Orthopedics and Neurosurgery, Schulthess Klinik, Lengghalde 2, 8008 Zurich, Switzerland
| | | | - Ferran Pellise
- Spine Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem University School of Medicine, Kayisdagi Cad 32, 34752 Icerenkoy, Atasehir, Istanbul, Turkey.
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Hamilton GM, Ladha K, Wheeler K, Nguyen F, McCartney CJL, McIsaac DI. Incidence of persistent postoperative opioid use in patients undergoing ambulatory surgery: a retrospective cohort study. Anaesthesia 2023; 78:170-179. [PMID: 36314355 DOI: 10.1111/anae.15900] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 01/11/2023]
Abstract
The opioid crisis remains a major public health concern. In ambulatory surgery, persistent postoperative opioid use is poorly described and temporal trends are unknown. A population-based retrospective cohort study was undertaken in Ontario, Canada using routinely collected administrative data for adults undergoing ambulatory surgery between 1 January 2013 and 31 December 2017. The primary outcome was persistent postoperative opioid use, defined using best-practice methods. Multivariable generalised linear models were used to estimate the association of persistent postoperative opioid use with prognostic factors. Temporal trends in opioid use were examined using monthly time series, adjusting for patient-, surgical- and hospital-level variables. Of 340,013 patients, 44,224 (13.0%, 95%CI 12.9-13.1%) developed persistent postoperative opioid use after surgery. Following multivariable adjustment, the strongest predictors of persistent postoperative opioid use were pre-operative: utilisation of opioids (OR 9.51, 95%CI 8.69-10.39); opioid tolerance (OR 88.22, 95%CI 77.21-100.79); and utilisation of benzodiazepines (OR 13.75, 95%CI 12.89-14.86). The time series model demonstrated a small but significant trend towards decreasing persistent postoperative opioid use over time (adjusted percentage change per year -0.51%, 95%CI -0.83 to -0.19%, p = 0.003). More than 10% of patients who underwent ambulatory surgery experienced persistent postoperative opioid use; however, there was a temporal trend towards a reduction in persistent opioid use after surgery. Future studies are needed that focus on interventions which reduce persistent postoperative opioid use.
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Affiliation(s)
- G M Hamilton
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, ON, Canada
| | - K Ladha
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto and Institute of Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
| | - K Wheeler
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - F Nguyen
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, ON, Canada
| | - D I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, ON, Canada
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Opioid Dose, Pain, and Recovery following Abdominal Surgery: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11247320. [PMID: 36555937 PMCID: PMC9781588 DOI: 10.3390/jcm11247320] [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] [Received: 09/20/2022] [Revised: 12/04/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The optimal dosage for opioids given to patients after surgery for pain management remains controversial. We examined the association of higher post-surgical opioid use with pain relief and recovery. Methods: We retrospectively enrolled adult patients who underwent elective abdominal surgery at our hospital between August 2021 and April 2022. Patients were divided into the “high-intensity” or “low-intensity” groups based on their post-surgical opioid use. Generalized estimating equation models were used to assess the associations between pain scores at rest and during movement on days 1, 2, 3, and 5 after surgery as primary outcomes. The self-reported recovery and incidence of adverse events were analyzed as secondary outcomes. Results: Among the 1170 patients in the final analysis, 293 were in the high-intensity group. Patients in the high-intensity group received nearly double the amount of oral morphine equivalents per day compared to those in the low-intensity group (84.52 vs. 43.80), with a mean difference of 40.72 (95% confidence interval (CI0 38.96−42.48, p < 0.001) oral morphine equivalents per day. At all timepoints, the high-intensity group reported significantly higher pain scores at rest (difference in means 0.45; 95% CI, 0.32 to 0.58; p < 0.001) and during movement (difference in means 0.56; 95% CI, 0.41 to 0.71; p < 0.001) as well as significantly lower recovery scores (mean difference (MD) −8.65; 95% CI, −10.55 to −6.67; p < 0.001). A post hoc analysis found that patients with moderate to severe pain during movement were more likely to receive postoperative high-intensity opioid use. Furthermore, patients in the non-high-intensity group got out of bed sooner (MD 4.31 h; p = 0.001), required urine catheters for shorter periods of time (MD 12.26 h; p < 0.001), and were hospitalized for shorter periods (MD 1.17 days; p < 0.001). The high-intensity group was at a higher risk of chronic postsurgical pain (odds ratio 1.54; 95% CI, 1.14 to 2.08, p = 0.005). Conclusions: High-intensity opioid use after elective abdominal surgery may not be sufficient for improving pain management or the quality of recovery compared to non-high-intensity use. Our results strengthen the argument for a multimodal approach that does not rely so heavily on opioids.
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Perioperative transcutaneous electrical acupoint stimulation (pTEAS) in pain management in major spinal surgery patients. BMC Anesthesiol 2022; 22:342. [PMID: 36348477 PMCID: PMC9641754 DOI: 10.1186/s12871-022-01875-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lumbar disc herniation is seen in 5–15% of patients with lumbar back pain and is the most common spine disorder demanding surgical correction. Spinal surgery is one of the most effective management for these patients. However, current surgical techniques still present complications such as chronic pain in 10–40% of all patients who underwent lumbar surgery, which has a significant impact on patients’ quality of life. Research studies have shown that transcutaneous electrical acupoint stimulation (TEAS) may reduce the cumulative dosage of intraoperative anesthetics as well as postoperative pain medications in these patients. Objective To investigate the effect of pTEAS on pain management and clinical outcome in major spinal surgery patients. Methods We conducted a prospective, randomized, double-blind study to verify the effect of pTEAS in improving pain management and clinical outcome after major spinal surgery. Patients (n = 90) who underwent posterior lumbar fusion surgery were randomized into two groups: pTEAS, (n = 45) and Control (n = 45). The pTEAS group received stimulation on acupoints Zusanli (ST.36), Sanyinjiao (SP.6), Taichong (LR.3), and Neiguan (PC.6). The Control group received the same electrode placement but with no electrical output. Postoperative pain scores, intraoperative outcome, perioperative hemodynamics, postoperative nausea and vomiting (PONV), and dizziness were recorded. Results Intraoperative outcomes of pTEAS group compared with Control: consumption of remifentanil was significantly lower (P < 0.05); heart rate was significantly lower at the end of the operation and after tracheal extubation (P < 0.05); and there was lesser blood loss (P < 0.05). Postoperative outcomes: lower pain visual analogue scale (VAS) score during the first two days after surgery (P < 0.05); and a significantly lower rate of PONV (on postoperative Day-5) and dizziness (on postoperative Day-1 and Day-5) (P < 0.05). Conclusion pTEAS could manage pain effectively and improve clinical outcomes. It could be used as a complementary technique for short-term pain management, especially in patients undergoing major surgeries. Trial registration ChiCTR1800014634, retrospectively registered on 25/01/2018. http://medresman.org/uc/projectsh/projectedit.aspx?proj=183 Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01875-3
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Neufeld EV, Ng T, Schaffler BC, Iturriaga C, Katz A, Job A, Petersen C, Perfetti D, Verma R. Liposomal bupivacaine does not decrease postoperative opioid use or length of hospital stay in patients undergoing anterior cervical discectomy and fusion. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:314-322. [PMID: 36285100 PMCID: PMC9547693 DOI: 10.21037/jss-22-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/27/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Despite its widespread use, definitive data demonstrating the efficacy of liposomal bupivacaine (LB) is limited especially in patients undergoing anterior cervical discectomy and fusion (ACDF). Therefore, this investigation examined whether ACDF patients who received intra-operative LB (LB cohort) exhibited decreased post-operative opioid use and lengths of hospital stay (LOS) compared to ACDF patients who did not receive intra-operative LB (controls). METHODS Eighty-two patients who underwent primary ACDF by a single surgeon from 2016 to 2019 were identified from an institutional database. Fifty-nine patients received intra-operative LB while twenty-three did not. Patient characteristics, medical comorbidities, complications, post-operative opioid consumption, and LOS data were collected. RESULTS The LB cohort did not require fewer opioids on post-operative day (POD) 0, POD1, POD2, or throughout the hospital course after normalizing by LOS (total per LOS). The number of cervical vertebrae involved in surgery, but not LB use, predicted opioid consumption on POD0, POD1, and total per LOS. For every vertebral level involved, 242 additional morphine milligram equivalents (MME) were consumed on POD0, 266 additional MME were utilized on POD1, and 130 additional MME were consumed in total per LOS. CONCLUSIONS ACDF patients who received intra-operative LB did not require fewer post-operative opioids or exhibit a decreased LOS compared to controls. Patients whose procedures involved a greater number of cervical vertebrae were associated with greater opioid consumption on POD0, POD1, and total per LOS. ACDF patients, especially those who had a high number of vertebrae involved, may require alternative analgesia to LB.
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Affiliation(s)
- Eric V. Neufeld
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Terence Ng
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Benjamin C. Schaffler
- Department of Orthopaedic Surgery, New York University Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Cesar Iturriaga
- Department of Orthopaedic Surgery, Northwell Health Plainview Hospital, Zucker School of Medicine at Hofstra/Northwell, Plainview, NY, USA
| | - Austen Katz
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Alan Job
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Christopher Petersen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Dean Perfetti
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Rohit Verma
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
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Tilhou AS, Glass JE, Hetzel SJ, Shana OE, Borza T, Baltes A, Deyo BMF, Agarwal S, O'Rourke A, Brown RT. Association between spine injury and opioid misuse in a prospective cohort of Level I trauma patients. OTA Int 2022; 5:e205.1-6. [PMID: 36275837 PMCID: PMC9575565 DOI: 10.1097/oi9.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/20/2022] [Indexed: 11/25/2022]
Abstract
Objective To explore patient and treatment factors explaining the association between spine injury and opioid misuse. Design Prospective cohort study. Setting Level I trauma center in a Midwestern city. Participants English speaking patients aged 18 to 75 on Trauma and Orthopedic Surgical Services receiving opioids during hospitalization and prescribed at discharge. Exposure Spine injury on the Abbreviated Injury Scale. Main outcome measures Opioid misuse was defined by using opioids: in a larger dose, more often, or longer than prescribed; via a non-prescribed route; from someone other than a prescriber; and/or use of heroin or opium. Exploratory factor groups included demographic, psychiatric, pain, and treatment factors. Multivariable logistic regression estimated the association between spine injury and opioid misuse when adjusting for each factor group. Results Two hundred eighty-five eligible participants consented of which 258 had baseline injury location data and 224 had follow up opioid misuse data. Most participants were male (67.8%), white (85.3%) and on average 43.1 years old. One-quarter had a spine injury (25.2%). Of those completing follow-up measures, 14 (6.3%) developed misuse. Treatment factors (injury severity, intubation, and hospital length of stay) were significantly associated with spine injury. Spine injury significantly predicted opioid misuse [odds ratio [OR] 3.20, 95% confidence interval [CI] (1.05, 9.78)]. In multivariable models, adjusting for treatment factors attenuated the association between spine injury and opioid misuse, primarily explained by length of stay. Conclusion Spine injury exhibits a complex association with opioid misuse that predominantly operates through treatment factors. Spine injury patients may represent a subpopulation requiring early intervention to prevent opioid misuse.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Boston University/Boston Medical Center, Boston, MA
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Group, Seattle, WA
| | - Scott J Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health
| | | | - Tudor Borza
- Departments of Urology and Surgery, University of Wisconsin School of Medicine and Public Health
| | - Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bri M F Deyo
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Ann O'Rourke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Li YS, Chang KY, Lin SP, Chang MC, Chang WK. Group-based trajectory analysis of acute pain after spine surgery and risk factors for rebound pain. Front Med (Lausanne) 2022; 9:907126. [PMID: 36072941 PMCID: PMC9441669 DOI: 10.3389/fmed.2022.907126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background This retrospective study was designed to explore the types of postoperative pain trajectories and their associated factors after spine surgery. Materials and methods This study was conducted in a single medical center, and patients undergoing spine surgery with intravenous patient-controlled analgesia (IVPCA) for postoperative pain control between 2016 and 2018 were included in the analysis. Maximal pain scores were recorded daily in the first postoperative week, and group-based trajectory analysis was used to classify the variations in pain intensity over time and investigate predictors of rebound pain after the end of IVPCA. The relationships between the postoperative pain trajectories and the amount of morphine consumption or length of hospital stay (LOS) after surgery were also evaluated. Results A total of 3761 pain scores among 547 patients were included in the analyses and two major patterns of postoperative pain trajectories were identified: Group 1 with mild pain trajectory (87.39%) and Group 2 with rebound pain trajectory (12.61%). The identified risk factors of the rebound pain trajectory were age less than 65 years (odds ratio [OR]: 1.89; 95% CI: 1.12–3.20), female sex (OR: 2.28; 95% CI: 1.24–4.19), and moderate to severe pain noted immediately after surgery (OR: 3.44; 95% CI: 1.65–7.15). Group 2 also tended to have more morphine consumption (p < 0.001) and a longer length of hospital stay (p < 0.001) than Group 1. Conclusion The group-based trajectory analysis of postoperative pain provides insight into the patterns of pain resolution and helps to identify unusual courses. More aggressive pain management should be considered in patients with a higher risk for rebound pain after the end of IVPCA for spine surgery.
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Affiliation(s)
- Yi-Shiuan Li
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuang-Yi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Chau Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Orthopedics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Wen-Kuei Chang,
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Kikuchi JY, Banaag A, Koehlmoos TP. Antibiotic Prescribing Patterns and Guideline Concordance for Uncomplicated Urinary Tract Infections Among Adult Women in the US Military Health System. JAMA Netw Open 2022; 5:e2225730. [PMID: 35925603 PMCID: PMC9353594 DOI: 10.1001/jamanetworkopen.2022.25730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Urinary tract infections (UTIs) are one of the most commonly diagnosed infections, and prior studies have reported discordance in antibiotic treatment with the Infectious Diseases Society of America (IDSA) guidelines. OBJECTIVE To assess IDSA guideline concordance rates for women with uncomplicated UTIs treated with antibiotics, and compare concordance rates between different specialty field. DESIGN, SETTING, AND PARTICIPANTS Retrospective cross-sectional study of health care claims data from the US Military Health System Data Repository, which contains comprehensive health care encounter and claims data for all military beneficiaries. Participants were adult women between the ages of 18 to 50 years with uncomplicated UTIs from October 1, 2017, to September 30, 2019. Data extraction and analysis were performed in 2022. Patients with diagnosis of UTI in the preceding 6 months, current pregnancy, history of pyelonephritis, history of diabetes, history of organ transplant, history of human immunodeficiency virus, immunosuppression, renal insufficiency, urinary tract abnormalities, or history of urologic procedures were excluded. EXPOSURES Antibiotic treatment for uncomplicated UTIs. Only antibiotics received within 1 day after the diagnosis were analyzed. The IDSA recommends the following antibiotics as first-line therapy: nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, pivmecillinam. MAIN OUTCOMES AND MEASURES The IDSA guideline concordance rates were calculated as the number of patients receiving first-line antibiotic therapy divided by the total number of cases for uncomplicated UTIs. RESULTS A total of 46 793 adult women (67.3% [31 475 of 46 793] aged 18-34 years; 38.2% [31 475 of 46 793] of White race) were diagnosed with uncomplicated UTIs with 91.0% receiving guideline-concordant antibiotic treatment. In comparison with obstetrics and gynecology, IDSA guideline-concordant treatment was more likely in internal medicine (adjusted odds ratio [aOR], 2.87; 95% CI, 2.73-3.03), family medicine (aOR, 1.81; 95% CI, 1.76-1.87), surgery (aOR, 1.51; 95% CI, 1.36-1.67), and emergency medicine (aOR, 1.36; 95% CI, 1.32-1.39) and less likely in urology (aOR, 0.40; 95% CI, 0.38-0.43). Compared with direct military care, private sector care had lower concordance rates (aOR, 0.63; 95% CI, 0.62-0.64). CONCLUSIONS AND RELEVANCE In this cross-sectional study of antibiotic treatments for uncomplicated UTIs in a universally insured population, the IDSA guideline-concordance rate was high at 91.0% with higher rates in direct military care compared with private sector care. There were higher rates in general medical specialties, surgery, and emergency medicine and lower rates in urology and obstetrics and gynecology. These results further enhance the literature on current antibiotic prescribing practices for uncomplicated UTIs in adult women.
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Affiliation(s)
- Jacqueline Y. Kikuchi
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amanda Banaag
- Department of Preventative Medicine and Biostatistics, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Tracey P. Koehlmoos
- Department of Preventative Medicine and Biostatistics, Uniformed Services University, Bethesda, Maryland
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Freda PJ, Kranzler HR, Moore JH. Novel digital approaches to the assessment of problematic opioid use. BioData Min 2022; 15:14. [PMID: 35840990 PMCID: PMC9284824 DOI: 10.1186/s13040-022-00301-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 06/30/2022] [Indexed: 11/16/2022] Open
Abstract
The opioid epidemic continues to contribute to loss of life through overdose and significant social and economic burdens. Many individuals who develop problematic opioid use (POU) do so after being exposed to prescribed opioid analgesics. Therefore, it is important to accurately identify and classify risk factors for POU. In this review, we discuss the etiology of POU and highlight novel approaches to identifying its risk factors. These approaches include the application of polygenic risk scores (PRS) and diverse machine learning (ML) algorithms used in tandem with data from electronic health records (EHR), clinical notes, patient demographics, and digital footprints. The implementation and synergy of these types of data and approaches can greatly assist in reducing the incidence of POU and opioid-related mortality by increasing the knowledge base of patient-related risk factors, which can help to improve prescribing practices for opioid analgesics.
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Affiliation(s)
- Philip J Freda
- Cedars-Sinai Medical Center, Department of Computational Biomedicine, 700 N. San Vicente Blvd., Pacific Design Center Suite G540, West Hollywood, CA, 90069, USA.
| | - Henry R Kranzler
- University of Pennsylvania, Center for Studies of Addiction, 3535 Market St., Suite 500 and Crescenz VAMC, 3800 Woodland Ave., Philadelphia, PA, 19104, USA
| | - Jason H Moore
- Cedars-Sinai Medical Center, Department of Computational Biomedicine, 700 N. San Vicente Blvd., Pacific Design Center Suite G540, West Hollywood, CA, 90069, USA
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Witt RG, Newhook TE, Prakash LR, Bruno ML, Arvide EM, Dewhurst WL, Ikoma N, Maxwell JE, Kim MP, Lee JE, Katz MHG, Tzeng CWD. Association of Patient Controlled Analgesia and Total Inpatient Opioid Use After Pancreatectomy. J Surg Res 2022; 275:244-251. [PMID: 35306260 PMCID: PMC9052944 DOI: 10.1016/j.jss.2022.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The initial settings on an intravenous patient-controlled analgesia (IV-PCA) pump can represent a significant source of postoperative opioid exposure. The primary aim of this study was to evaluate the impact of first day IV-PCA use on total inpatient opioid use after open pancreatectomy, before and after standardization of initial dosing. METHODS Inpatient oral morphine equivalents (OMEs) were reviewed for pancreatectomy patients treated with IV-PCA at a single institution before and after (3/2016-8/2017 versus 3/2019-11/2020) implementation of a standardized initial IV-PCA dosing regimen (initial limit 0.1 mg hydromorphone, or 1 mg OME, every 10 min as needed). IV-PCA OME in the first 24 h and the total inpatient OME were compared between cohorts. RESULTS Of 220 total patients, 132 were in the prestandardization (PRE) historical cohort. A first-24-h IV-PCA use was different (PRE median 95 mg versus poststandardization [POST] 15 mg, P < 0.001). The median total inpatient OME was different (P < 0.001) between PRE (525 mg, interquartile range [IQR] 239-951 mg) and POST patients (129 mg, IQR 65-204 mg) with 77% (median 373 mg) of total inpatient OMEs contributed by IV-PCA in the PRE and 56% (median 64 mg) in the POST cohorts. There were similar patient-reported pain scores between groups. CONCLUSIONS Standardizing initial IV-PCA settings was associated with a reduced first-24-h opioid exposure, proportional and absolute total IV-PCA use, and total inpatient OMEs. Because of the contribution of an IV-PCA to the total inpatient opioid exposure, purposeful reduction or omission of an IV-PCA is critical to perioperative opioid reduction strategies.
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Affiliation(s)
- Russell G Witt
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Timothy E Newhook
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Laura R Prakash
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Morgan L Bruno
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Elsa M Arvide
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Whitney L Dewhurst
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Jessica E Maxwell
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas.
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Inclan P, CreveCoeur TS, Bess S, Gum JL, Line BG, Lenke LG, Kelly MP. SRS-22r question 11 is a valid opioid screen and stratifies opioid consumption. Spine Deform 2022; 10:913-917. [PMID: 35088385 DOI: 10.1007/s43390-022-00473-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/08/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To validate the Scoliosis Research Society-22r (SRS-22r) question 11 (Q11) response as a measure to assess and quantify opioid consumption. METHODS A post hoc analysis of a prospective study regarding opioid use during ASD surgery was performed. Data were collected at enrollment and 2-year follow-up including the SRS-22r and a standardized data collection form (CRF) for self-reported opioid consumption. Responses to Q11 of the SS-22r were compared with responses to the opioid consumption CRF (as measured by morphine equivalent dose (MED)). Inter-rater agreement was calculated. Sensitivity and specificity for the Q11 (+) responses were calculated using MED reports as the "true" value. RESULTS Cohen's kappa indicated almost perfect agreement between the MED CRF and Q11 (k = 0.878, p < 0.001). Mean daily MED consumption for patients reporting "Daily Narcotic" use was 62.0 (Median: 38.7, SD 87.5) mg; for patients reporting "Narcotics weekly or less", mean daily MED consumption was 21.6 (15.0, 29.0) mg. The positive Q11 responses were 96% sensitive and 92% specific for opioid users. CONCLUSION SRS-22r Q11 exhibits almost perfect agreement with an independent questionnaire designed to assess opioid consumption in this cohort. "Daily narcotic" users report nearly three times the mean daily MED of "Weekly or less" users (62.0 ± 87.5 mg vs 21.6 ± 29 mg, p = 0.037). Q11 exhibited excellent sensitivity and specificity for determining opioid users and non-users. Given the need for opioid research in ASD, Q11 may be useful to use existing registries and observational cohorts to design more definitive studies regarding opioid consumption. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Paul Inclan
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 Euclid Avenue, St. Louis, MO, 63110, USA
| | - Travis S CreveCoeur
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Breton G Line
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University College of Physicians and Surgeons, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Michael P Kelly
- Rady Children's Hospital, University of California, San Diego, San Diego, CA, USA.
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Liu Z, Karamesinis AD, Plummer M, Segal R, Bellomo R, Smith JA, Perry LA. Epidemiology of persistent postoperative opioid use after cardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2022; 129:366-377. [PMID: 35778278 DOI: 10.1016/j.bja.2022.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/01/2022] [Accepted: 05/19/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The epidemiology of persistent postoperative opioid use at least 3 months after cardiac surgery is poorly characterised despite its potential public health importance. METHODS We searched MEDLINE, Embase, and Google Scholar from inception to December 2021 and included studies reporting the rate and risk factors of persistent postoperative opioid use after cardiac surgery in opioid-naive and opioid-exposed patients. We recorded incidence rates and odds ratios (ORs) with 95% confidence intervals (CIs) for risk factors from individual studies and used random-effects inverse variance modelling to generate pooled estimates. RESULTS From 10 studies involving 112 298 patients, the pooled rate of persistent postoperative opioid use in opioid-naive patients was 5.7% (95% CI: 4.2-7.2%). Risk factors included female sex (OR 1.18; 95% CI: 1.09-1.29), smoking (OR 1.34; 95% CI: 1.06-1.69), alcohol use (OR 1.43; 95% CI: 1.17-1.76), congestive cardiac failure (OR 1.17; 95% CI: 1.08-1.27), diabetes mellitus (OR 1.21; 95% CI: 1.07-1.37), chronic lung disease (OR 1.42; 95% CI: 1.16-1.75), chronic kidney disease (OR 1.35; 95% CI: 1.08-1.68), and length of hospital stay (per day) (OR 1.03; 95% CI: 1.02-1.04). CONCLUSIONS Persistent postoperative opioid use after cardiac surgery affects at least one in 20 patients. The identification of risk factors, such as female sex, smoking, alcohol use, congestive cardiac failure, diabetes mellitus, chronic lung disease, chronic kidney disease, and length of hospital stay, should help target interventions aimed at decreasing its prevalence.
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Affiliation(s)
- Zhengyang Liu
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia.
| | | | - Mark Plummer
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Reny Segal
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Melbourne, VIC, Australia; Monash University School and Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Heidelberg, VIC, Australia
| | - Julian A Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia; Department of Cardiothoracic Surgery, Monash Health, Clayton, VIC, Australia
| | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
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Singleton M, Ghisi D, Memtsoudis S. Perioperative management in complex spine surgery: a narrative review. Minerva Anestesiol 2022; 88:396-406. [PMID: 35315618 DOI: 10.23736/s0375-9393.22.15933-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The last two decades have seen a significant increase in the number of spine surgical procedures performed worldwide. This type of surgery includes a wide variety of procedures, from mini-invasive discectomies to multi-level spinal arthrodesis and osteotomies. Moreover, different surgical approaches are described at different spine levels: the anesthesiologist should be aware of the potential benefits and risks for the patients and be prepared for their management. In this narrative review we seek to describe basic concepts of perioperative spine care and address evolving areas in which care is changing. We will discuss preoperative concerns, intraoperative management including airway management, choice of maintenance, intraoperative neuromonitoring and anesthetic effect, blood management and the dynamic topic of anesthetic and analgesic techniques. Finally, we will briefly address the issue of perioperative complications as they relate specifically to spine surgery.
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Affiliation(s)
- Michael Singleton
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Daniela Ghisi
- Anesthesia, Intensive Care and Pain Therapy, Istituto Ortopedico Rizzoli, Bologna, Italy -
| | - Stavros Memtsoudis
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.,Department of Public Health, Division of Epidemiology, Weill Cornell Medical College, New York, NY, USA
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Côté C, Bérubé M, Moore L, Lauzier F, Tremblay L, Belzile E, Martel MO, Pagé G, Beaulieu Y, Pinard AM, Perreault K, Sirois C, Grzelak S, Turgeon AF. Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review. BMC Musculoskelet Disord 2022; 23:238. [PMID: 35277150 PMCID: PMC8917706 DOI: 10.1186/s12891-022-05044-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area. METHODS This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines. RESULTS A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence. CONCLUSIONS This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.
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Affiliation(s)
- C. Côté
- Population Health and Optimal Health Practices Research Unit, Trauma – Emergency – Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), 1401 18e Rue, Québec City, Québec G1J 1Z4 Canada
- Faculty of Nursing, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - M. Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma – Emergency – Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), 1401 18e Rue, Québec City, Québec G1J 1Z4 Canada
- Faculty of Nursing, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - L. Moore
- Population Health and Optimal Health Practices Research Unit, Trauma – Emergency – Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), 1401 18e Rue, Québec City, Québec G1J 1Z4 Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - F. Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma – Emergency – Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), 1401 18e Rue, Québec City, Québec G1J 1Z4 Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - L. Tremblay
- Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, Ontario M4N 3M5 Canada
| | - E. Belzile
- Department of Orthopaedic Surgery, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - M-O Martel
- Faculty of Dentistry & Department of Anesthesia, McGill University, 1010 Rue Sherbrooke Ouest, Montreal, Québec H3A 2R7 Canada
| | - G. Pagé
- Research Center of the Centre hospitalier de l’Université de Montréal (CRCHUM), 850 rue St-Denis, Montreal, Québec H2X 0A9 Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montreal, Québec H3T 1J4 Canada
| | - Y. Beaulieu
- Department of Orthopaedic Surgery, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - A. M. Pinard
- Department of Anesthesiology and Critical Care Medicine, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - K. Perreault
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 525, boul. Wilfrid-Hamel, Québec City, Québec G1M 2S8 Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - C. Sirois
- Faculty of Pharmacy, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - S. Grzelak
- Population Health and Optimal Health Practices Research Unit, Trauma – Emergency – Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), 1401 18e Rue, Québec City, Québec G1J 1Z4 Canada
- Faculty of Nursing, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
| | - A. F. Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma – Emergency – Critical Care Medicine, Centre de Recherche du CHU de Québec – Université Laval (Hôpital de l’Enfant-Jésus), 1401 18e Rue, Québec City, Québec G1J 1Z4 Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, 1050 Avenue de la Médecine, Québec City, Québec G1V 0A6 Canada
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Ramos O, Speirs J, Morrison M, Danisa O. Effect of narcotic prescription limiting legislation on opioid utilization following pediatric spinal fusion for scoliosis. Spine Deform 2022; 10:335-341. [PMID: 34449074 DOI: 10.1007/s43390-021-00406-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND CONTEXT Since 2016, 35 of 50 US states have approved opioid-limiting and monitoring laws. The impact on postoperative opioid prescribing and secondary outcomes following pediatric scoliosis deformity correction surgery remains unknown. PURPOSE To evaluate the effect of CURES 2.0 opioid-limiting regulations on postoperative opioid prescriptions and unplanned readmissions following pediatric scoliosis deformity correction surgery. STUDY DESIGN Retrospective review of prospectively collected data. PATIENT SAMPLE Two patient cohorts (pre-CURES January 1, 2017-October 22, 2018 and post-CURES September 1, 2018-May 30, 2020) that included all patients undergoing pediatric scoliosis deformity surgery at a single institution. METHODS Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) prescribed was compared at 30-day postoperative intervals. Readmission rates were calculated. Categorical variables were evaluated with Chi squared analysis and continuous variables were evaluated with t test or Mann-Whitney U test as appropriate. Logistic regression was used to evaluate risk factors for increased postoperative opioid. RESULTS Of 108 identified patients, 94 (49 pre-CURES, 45 post-CURES) were included in the study. Post-CURES patients were older (p = 0.001). All other demographic, medical, and surgical factors were similar between pre-CURES and post-CURES patients (all p > 0.05). Post-CURES, patients received fewer pills in their first postoperative prescription (43.4 vs. 57.4 pills, p = 0.006), less opioids (MMEs) during the first 0 to 30-day and 31 to 60-day postoperative intervals (261.8 MMEs vs. 337.6 MMEs, p = 0.028 and 17.8 MMEs vs. 59.7 MMEs, p = 0.016, respectively). Increased 120-day opioid utilization was associated with surgery in the pre-CURES period, age, BMI, and decreased number of levels fused (all p < 0.05). Postoperative readmission within 90 days was associated with age, BMI, number of levels fused, and length of stay. CONCLUSIONS Implementation of CURES 2.0 has resulted in a reduction in the opioid prescription following pediatric scoliosis deformity surgery without an increase in readmissions. Further studies are needed to evaluate how legislations of this kind affect patient reported outcomes, satisfaction, and quality of life.
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Affiliation(s)
- Omar Ramos
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA.
| | - Joshua Speirs
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA
| | - Martin Morrison
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA
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Lovecchio F, Premkumar A, Steinhaus M, Alexander K, Mejia D, Yoo JS, Lafage V, Iyer S, Huang R, Lebl D, Qureshi S, Kim HJ, Singh K, Albert T. Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery. Clin Spine Surg 2022; 35:E121-E126. [PMID: 33783369 DOI: 10.1097/bsd.0000000000001176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a prospective observational study. OBJECTIVE The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions. METHODS Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed. RESULTS Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006). CONCLUSION Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.
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Affiliation(s)
| | | | | | | | | | - Joon S Yoo
- Midwest Orthopaedics at Rush, Chicago, IL
| | | | | | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | - Kern Singh
- Midwest Orthopaedics at Rush, Chicago, IL
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Punchak MA, Agarwal AK, Joshi D, Xiong R, Malhotra NR, Marcotte PJ, Ozturk A, Petrov D, Schuster J, Welch W, Delgado MK, Ali Z. Understanding the Natural History of Postoperative Pain and Patient-Reported Opioid Consumption After Elective Spine and Nerve Surgeries With an Automated Text Messaging System. Neurosurgery 2022; 90:329-339. [DOI: 10.1227/neu.0000000000001822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
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The association between opioid misuse or abuse and hospital-based, acute care after spinal surgery. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mohan S, Lynch CP, Cha EDK, Jacob KC, Patel MR, Geoghegan CE, Prabhu MC, Vanjani NN, Pawlowski H, Singh K. Baseline Risk Factors for Prolonged Opioid Use Following Spine Surgery: Systematic Review and Meta-Analysis. World Neurosurg 2021; 159:179-188.e2. [PMID: 34971835 DOI: 10.1016/j.wneu.2021.12.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To conduct a comprehensive systematic review and meta-analysis of current retrospective cohort studies to identify significant preoperative risk factors for prolonged postoperative opioid use following spine surgery. METHODS Studies were identified according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) through a search of the PubMed, Google Scholar, Scopus, Cochrane databases. Unique articles were screened by two independent reviewers. Primary research articles reporting odds ratios (OR) of risk factors for prolonged opioid use as following spine surgery were included. Prolonged opioid use was defined as continued use ≥ 3 months following surgery, and study quality was evaluated using the Newcastle-Ottawa Scale (NOS). Random effects meta-analysis was performed to calculate pooled OR and confidence intervals. RESULTS 648 studies were returned upon initial search. Following duplicate removal, 492 titles and abstracts were screened. After full-text review of 68 studies, 19 final studies including 168,961 patients were eligible for meta-analysis. NOS scores ranged from 6-9. Seventeen risk factors for long-term opioid use were assessed by meta-analysis. Preoperative opioid use, depression, depression and/or anxiety, drug abuse or dependency, female gender, fibromyalgia, lower back pain, tobacco use, and chronic pulmonary disease were found to be statistically significant risk factors for prolonged opioid use. CONCLUSION These results suggest that several patient-level factors may play a role in the tendency to persistently utilize opioids following spine surgery. By preoperatively identifying these characteristics, clinicians may be better able to identify patients that are at-risk and employ methods to mitigate potential long-term opioid use.
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Affiliation(s)
- Shruthi Mohan
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Conor P Lynch
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Kevin C Jacob
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Madhav R Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Michael C Prabhu
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Nisheka N Vanjani
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Hanna Pawlowski
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612.
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Ziino C, Karhade AV, Schoenfeld AJ, Harris MB, Schwab JH. Characteristics of postoperative opioid prescription use following lumbar discectomy. J Neurosurg Spine 2021; 35:710-714. [PMID: 34450580 DOI: 10.3171/2021.2.spine202041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of spine surgeons in precipitating and mediating sustained prescription opioid use remains controversial at this time. The purpose of this study was to identify prescription opioid use following lumbar discectomy and characterize the source of opioid prescriptions by clinician specialty (surgeon vs nonsurgeon). METHODS Using a retrospective review, the authors identified adult patients undergoing lumbar discectomy for a primary diagnosis of disc herniation between 2010 and 2017. The primary outcome was sustained prescription opioid use, defined as issue of an opioid prescription at a time point 90 days or longer after the surgical procedure. The primary predictor variable was prescriber specialty (surgeon vs nonsurgeon). The independent effect of provider specialty on the number of opioid prescriptions issued to patients was assessed using multivariable Poisson regression that accounted for confounding from all other clinical and sociodemographic variables. RESULTS This study included 622 patients who underwent a lumbar discectomy. A total of 610 opioid prescriptions were dispensed for this population after surgery. In total, 126 patients (20.3%) had at least one opioid prescription in the period beyond 90 days following their surgery. The majority of opioid prescriptions, 494 of 610 (81%), were non-inpatient prescriptions. Among these, only a minority (26%) of outpatient opioid prescriptions were written by surgical providers. Following multivariable Poisson regression analysis, surgical providers were found to have a lower likelihood of issuing an opioid prescription compared to nonsurgical clinicians (incidence rate ratio [IRR] 0.78; 95% CI 0.68-0.89; p = 0.001). CONCLUSIONS A minority of lumbar discectomy patients continue to receive opioid prescriptions up to 15 months after surgery. Many of these prescriptions are written by nonsurgical providers unaffiliated with the operative team.
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Affiliation(s)
- Chason Ziino
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and
- 2Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aditya V Karhade
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and
- 2Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- 2Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B Harris
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and
| | - Joseph H Schwab
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and
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Vraa ML, Myers CA, Young JL, Rhon DI. More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Opioids Long-term After Spinal Fusion: A Systematic Review. Clin J Pain 2021; 38:222-230. [PMID: 34856579 DOI: 10.1097/ajp.0000000000001006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/02/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A common expectation for patients after elective spine surgery is that the procedure will result in pain reduction and minimize the need for pain medication. Most studies report changes in pain and function after spine surgery, but few report the extent of opioid use after surgery. This systematic review aims to identify the rates of opioid use after lumbar spine fusion. MATERIALS AND METHODS PubMed, CINAHL, Cochrane Central Register of Controlled Trials, and Ovid Medline were searched to identify studies published between January 1, 2005 and June 30, 2020 that assessed the effectiveness of lumbar fusion for the management of low back pain. RESULTS Of 6872 abstracts initially identified, 329 studies met the final inclusion criteria, and only 32 (9.7%) reported any postoperative opioid use. Long-term opioid use after surgery persists for more than 1 in 3 patients with usage ranging from 6 to 85.9% and a pooled mean of 35.0% based on data from 21 studies (6.4% of all lumbar fusion studies). DISCUSSION Overall, opioid use is not reported in the majority of lumbar fusion trials. Patients may expect a reduced need for opioid-based pain management after surgery, but the limited data available suggests long-term use is common. Lack of consistent reporting of these outcomes limits definitive conclusions regarding the efficacy of spinal fusion for reducing long-term opioid. Patient decisions about undergoing surgery may be altered if they had realistic expectations about rates of postsurgical opioid use. Spine surgery trials should track opioid utilization out to a minimum of 6 months after surgery as a core outcome.
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Affiliation(s)
- Matthew L Vraa
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Physical Therapy Program, Northwest University, Kirkland, WA
| | - Christina A Myers
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Department of Physical Therapy, South College, Knoxville, TN
| | - Jodi L Young
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
| | - Daniel I Rhon
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, MD
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Rhon DI, Greenlee TA, Dickens JF, Wright AA. Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review. Orthop J Sports Med 2021; 9:23259671211053034. [PMID: 34805422 PMCID: PMC8600561 DOI: 10.1177/23259671211053034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Female servicemembers sustain higher rates of lower extremity injuries as
compared with their male counterparts. This can include intra-articular
pathology in the hip. Female patients are considered to have worse outcomes
after hip arthroscopy for femoroacetabular impingement and for hip labral
repair. Purpose: To (1) compare published rates of hip arthroscopy between male and female
military servicemembers and (2) determine if there are any sex-based
differences in outcomes after hip arthroscopy in the military. Study Design: Systematic review; Level of evidence, 3. Methods: We reviewed the literature published from January 1, 2000, through December
31, 2020, to identify studies in which hip arthroscopy was performed in
military personnel. Clinical trials and cohort studies were included. The
proportion of women within each cohort was identified, and results of any
between-sex analyses were reported. Results: Identified were 11 studies that met established criteria. Studies included
2481 patients, 970 (39.1%) of whom were women. Surgery occurred between
January 1998 and March 2018. Despite women accounting for approximately 15%
of the active-duty military force, they represented 39.1% (range,
25.7%-57.6%) of patients undergoing hip arthroscopy. In most cases, there
were no differences in self-reported outcomes (pain, disability, and
physical function), return to duty, or medical disability status based on
sex. Conclusion: Women account for approximately 15% of the military, but they made up 40% of
patients undergoing hip arthroscopy. Outcomes were not different between the
sexes; however, definitive conclusions were limited by the heterogeneity of
outcomes, missing data, lack of sex-specific subgroup analyses, and zero
studies with sex differences as the primary outcome. A proper understanding
of sex-specific outcomes after hip arthroscopy will require a paradigm shift
in the design and reporting of trials in the military health system.
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
| | - Jonathan F Dickens
- Uniformed Services University of Health Sciences, Bethesda, Maryland, USA.,Department of Sports Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,John A. Feagin Jr Sports Medicine Fellowship, Keller Army Community Hospital, West Point, New York, USA
| | - Alexis A Wright
- School of Medicine, Tufts University, Boston, Massachusetts, USA
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Smeland AH, Twycross A, Lundeberg S, Småstuen MC, Rustøen T. Educational Intervention to Strengthen Pediatric Postoperative Pain Management: A Cluster Randomized Trial. Pain Manag Nurs 2021; 23:430-442. [PMID: 34836822 DOI: 10.1016/j.pmn.2021.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/24/2021] [Accepted: 09/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric postoperative pain is still undertreated. AIMS To assess whether educational intervention increases nurses' knowledge and improves pediatric postoperative pain management. DESIGN Cluster randomized controlled trial with three measurement points (baseline T1, 1 month after intervention T2, and 6 months after intervention T3). PARTICIPANTS/SUBJECTS The study was conducted in postanesthesia care units at six hospitals in Norway. Nurses working with children in the included units and children who were undergoing surgery were invited to participate in this study. METHODS Nurses were cluster randomized by units to an intervention (n = 129) or a control group (n = 129). This allocation was blinded for participants at baseline. Data were collected using "The Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain: Norwegian Version" (primary outcome), observations of nurses' clinical practice, and interviews with children. The intervention included an educational day, clinical supervision, and reminders. RESULTS At baseline 193 nurses completed the survey (75% response rate), 143 responded at T2, and 107 at T3. Observations of nurses' (n = 138) clinical practice included 588 children, and 38 children were interviewed. The knowledge level increased from T1 to T3 in both groups, but there was no statistically significant difference between the groups. In the intervention group, there was an improvement between T1 and T2 in the total PNKAS-N score (70% vs. 83%), observed increase use of pain assessment tools (17% vs. 39%), and children experienced less moderate-to-severe pain. CONCLUSIONS No significant difference was observed between the groups after intervention, but a positive change in knowledge and practice was revealed in both groups. Additional studies are needed to explore the most potent variables to strengthen pediatric postoperative pain management.
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Affiliation(s)
- Anja H Smeland
- Children's Surgical Department, Division of Head, Neck and Reconstructive Surgery, Oslo University Hospital, Norway; Institute of Health and Society, University of Oslo, Norway.
| | - Alison Twycross
- Children and Young People's Nursing School of Health, The Open University, UK
| | - Stefan Lundeberg
- Pain Treatment Service, Astrid Lindgren Children's Hospital, Sweden
| | - Milada C Småstuen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway; Department of Health, Nutrition and Management, Faculty of Health Sciences, OsloMet, Oslo Metropolitan University, Norway
| | - Tone Rustøen
- Institute of Health and Society, University of Oslo, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway
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