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Kaiser D, Hoch A, Dimitriou D, Groeber T, Bomberg H, Aguirre JA, Eichenberger U, Zingg PO. Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial. Am J Sports Med 2024; 52:1165-1172. [PMID: 38456291 PMCID: PMC10986151 DOI: 10.1177/03635465241232157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/20/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery. PURPOSE/HYPOTHESIS The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events. RESULTS The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly. CONCLUSION Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy. REGISTRATION NCT04610398 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Dominik Kaiser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tanja Groeber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Hagen Bomberg
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José A. Aguirre
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Urs Eichenberger
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick O. Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Poeran J, Memtsoudis SG. Non-steroidal anti-inflammatory drugs in multimodal strategies: a potential double-edged sword but still more research needed. Anaesthesia 2024. [PMID: 38502825 DOI: 10.1111/anae.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 03/21/2024]
Affiliation(s)
- J Poeran
- Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S G Memtsoudis
- Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
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Hussain N, Brull R, Gilron I, Weaver TE, Shahzad H, D'Souza RS, Abdel-Rasoul M, Clarke H, McCartney CJL, Abdallah FW. Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study. Anaesthesia 2024. [PMID: 38385772 DOI: 10.1111/anae.16259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/23/2024]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.
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Affiliation(s)
- N Hussain
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - R Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital and Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - I Gilron
- Departments of Anesthesia and Perioperative Medicine and Biomedical and Molecular Science, Centre for Neuroscience Studies, School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - T E Weaver
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - H Shahzad
- Department of Orthopedics, UC Davis Health, Sacramento, CA, USA
| | - R S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Abdel-Rasoul
- Department of Biomedical Informatics, College of Medicine, Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - H Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Larach DB, Kertai MD, Billings FT, Anderson SB, Polkowski GG, Shinar AA, Milne GL, Mishra P, Bruehl S. Preoperative Predictors of Prolonged Opioid Use in the 6 Months After Total Knee Arthroplasty. Clin J Pain 2023; 39:516-523. [PMID: 37440337 PMCID: PMC10529895 DOI: 10.1097/ajp.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES Prolonged postoperative opioid use increases the risk for new postsurgical opioid use disorder. We evaluated preoperative phenotypic factors predicting prolonged postoperative opioid use. METHODS We performed a secondary analysis of a prospective observational cohort (n=108) undergoing total knee arthroplasty (TKA) for osteoarthritis with 6-week and 6-month follow-up. Current opioid use and psychosocial, pain, and opioid-related characteristics were assessed at preoperative baseline. Primary outcomes were days/week of opioid use at follow-up. RESULTS At 6 weeks, preoperative opioid use and greater cumulative opioid exposure, depression, catastrophizing, anxiety, pain interference, sleep disturbance, and central sensitization were significantly associated with more days/week of opioid use after controlling for contemporaneous pain intensity. Prior euphoric response to opioids were also significant predictors at 6 months. All 6-week predictors except anxiety remained significant after controlling for preoperative opioid use; at 6 months, cumulative opioid exposure, catastrophizing, pain interference, and sleep disturbance remained significant after this adjustment ( P <0.05). In multivariable models, a psychosocial factor reflecting negative affect, sleep, and pain accurately predicted 6-week opioid use (area under the curve=0.84). A combined model incorporating psychosocial factor scores, opioid-related factor scores, and preoperative opioid use showed near-perfect predictive accuracy at 6 months (area under the curve=0.97). DISCUSSION Overall, preoperative psychosocial, pain-related, and opioid-related phenotypic characteristics predicted prolonged opioid use after total knee arthroplasty.
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Affiliation(s)
- Daniel B. Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara B. Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory G. Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew A. Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger L. Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Baamer RM, Humes DJ, Toh LS, Knaggs RD, Lobo DN. Predictors of persistent postoperative opioid use following colectomy: a population-based cohort study from England. Anaesthesia 2023; 78:1081-1092. [PMID: 37265223 PMCID: PMC10953341 DOI: 10.1111/anae.16055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/03/2023]
Abstract
This retrospective cohort study on adults undergoing colectomy from 2010 to 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data to determine the prevalence of persistent postoperative opioid use following colectomy, stratified by pre-admission opioid exposure, and identify associated predictors. Based on pre-admission opioid exposure, patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and previously exposed (opioid prescription within 7-12 months before admission). Persistent postoperative opioid use was defined as requiring an opioid prescription within 90 days of discharge, along with one or more opioid prescriptions 91-180 days after hospital discharge. Multivariable logistic regression analyses were conducted to obtain odds ratios for predictors of persistent postoperative opioid use. Among the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 6791 (45.0%) were opioid-naïve, 7528 (49.9%) were currently exposed and 762 (5.0%) were previously exposed. From the whole cohort, 7540 (8.1%) developed persistent postoperative opioid use. Patients with pre-operative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group; 305 (9.8%) from the previously exposed group; and 1918 (2.5%) from the opioid-naïve group. The odds of developing persistent opioid use were higher among individuals who used long-acting opioid formulations in the 180 days before colectomy than those who used short-acting formulations (odds ratio 3.41 (95%CI 3.07-3.77)). Predictors of persistent opioid use included: previous opioid exposure; high deprivation index; multiple comorbidities; use of long-acting opioids; white race; and open surgery. Minimally invasive surgical approaches were associated with lower odds of persistent opioid use and may represent a modifiable risk factor.
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Affiliation(s)
- R. M. Baamer
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
- Department of Pharmacy Practice, Faculty of PharmacyKing Abdulaziz UniversityJeddahSaudi Arabia
| | - D. J. Humes
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
| | - L. S. Toh
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
| | - R. D. Knaggs
- Division of Pharmacy Practice and Policy, School of PharmacyUniversity of NottinghamNottinghamUK
- Pain Centre Versus ArthritisUniversity of NottinghamNottinghamUK
| | - D. N. Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical CentreNottinghamUK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing ResearchSchool of Life SciencesUniversity of Nottingham, Queen's Medical CentreNottinghamUK
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Adams TJ, Aljohani DM, Forget P. Perioperative opioids: a narrative review contextualising new avenues to improve prescribing. Br J Anaesth 2023; 130:709-718. [PMID: 37059626 DOI: 10.1016/j.bja.2023.02.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 04/16/2023] Open
Abstract
Opioids have dominated the management of perioperative pain in recent decades with higher doses than ever before used in some circumstances. Through the expanding use of opioids, growing research has highlighted their associated side-effects and the intertwined phenomena of acute withdrawal syndrome, opioid tolerance, and opioid-induced hyperalgesia. With multiple clinical guidelines now endorsing multimodal analgesia, a diverse array of opioid-sparing agents emerges and has been studied to variable degrees, including techniques of opioid-free anaesthesia. It remains unclear to what extent such methods should be adopted, yet current evidence does suggest dependence on opioids as the primary perioperative analgesic might not meet the principles of 'rational prescribing' as described by Maxwell. In this narrative review we describe how, using current evidence, a patient-centred rational-prescribing approach can be applied to opioids in the perioperative period. To contextualise this approach, we discuss the historical adoption of opioids in anaesthesia, our growing understanding of associated side-effects and emerging strategies of opioid-sparing and opioid-free anaesthesia. We discuss avenues and challenges for improving opioid prescribing to limit persistent postoperative opioid use and how these may be incorporated into a rational-prescribing approach.
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Affiliation(s)
- Tobias J Adams
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK.
| | - Dalia Mohammed Aljohani
- Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK; Department of Anesthesia Technology, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
| | - Patrice Forget
- Department of Anaesthesia, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK; Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, Aberdeen, UK; Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
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7
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Lam T, Xia T, Biggs N, Treloar M, Cheng O, Kabu K, Stevens JA, Evans JD, da Gama ME, Lubman DI, Nielsen S. Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone. Anaesthesia 2023; 78:420-431. [PMID: 36535726 DOI: 10.1111/anae.15933] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use ('persistence'). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience ('opioid-naive' having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed-effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid-naive and 27.24% opioid-experienced patients met the criteria for persistence. For opioid-naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69-0.94) for opioid-naive patients and 0.81 (0.71-0.93) for opioid-experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.
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Affiliation(s)
- T Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - T Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - N Biggs
- NostraData, Kew, VIC, Australia
| | | | - O Cheng
- IQVIA, St Leonards, NSW, Australia
| | - K Kabu
- IQVIA, St Leonards, NSW, Australia
| | - J A Stevens
- St Vincent's Clinical School, UNSW Medicine, Darlinghurst, NSW, Australia
| | - J D Evans
- Slade Pharmacy, Mount Waverley, VIC, Australia
| | | | - D I Lubman
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Turning Point, Eastern Health Clinical School, Monash University, Frankston, Richmond, VIC, Australia
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8
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Bicket MC, Brummett CM, Mariano ER. Tapentadol and the opioid epidemic: a simple solution or short-lived sensation? Anaesthesia 2023; 78:416-419. [PMID: 36449368 DOI: 10.1111/anae.15932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 12/02/2022]
Affiliation(s)
- M C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - C M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Quinlan J, Levy N, Lobo DN, Macintyre PE. No place for routine use of modified-release opioids in postoperative pain management. Br J Anaesth 2022; 129:290-293. [PMID: 35843745 DOI: 10.1016/j.bja.2022.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022] Open
Abstract
Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. Recognition that modified-release opioids show lack of benefit and increased risk of harm compared with immediate-release opioids in the acute, postoperative setting has become clear. Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.
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Affiliation(s)
- Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
| | - Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia; Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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Levy N, McNally SA, Lobo DN. The need to improve opioid prescribing and data collection in patients undergoing orthopaedic surgery. Anaesthesia 2022; 77:854-857. [PMID: 35762197 DOI: 10.1111/anae.15784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - S A McNally
- Department of Trauma and Orthopaedics, East Sussex Healthcare NHS Trust, Eastbourne, Sussex, UK
- Honorary Clinical Professor, Brighton and Sussex Medical School, Brighton, UK
| | - D N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, Cox FJ, de Boer HD, Dowdy SC, Hattingh K, Knaggs RD, Mariano ER, Pelosi P, Scott MJ, Lobo DN, Macintyre PE. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76:520-536. [PMID: 33027841 DOI: 10.1111/anae.15262] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 01/01/2023]
Abstract
This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.
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Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - J Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - W J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - V Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - F J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - H D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K Hattingh
- Bendigo Health, Bendigo, Victoria, Australia
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - M J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - P E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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Stubbs DJ, Levy N. Role of dexamethasone in reducing postoperative pain. Comment on Br J Anaesth 2021; 126: 862-71. Br J Anaesth 2021; 126:e139-e140. [PMID: 33589229 DOI: 10.1016/j.bja.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Daniel J Stubbs
- University Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk HS Foundation Trust, Bury St Edmunds, UK.
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Hah JM, Hilmoe H, Schmidt P, McCue R, Trafton J, Clay D, Sharifzadeh Y, Ruchelli G, Hernandez Boussard T, Goodman S, Huddleston J, Maloney WJ, Dirbas FM, Shrager J, Costouros JG, Curtin C, Mackey SC, Carroll I. Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial. J Pain Res 2020; 13:2959-2970. [PMID: 33239904 PMCID: PMC7680674 DOI: 10.2147/jpr.s269370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. Methods In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18–75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Results Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87–1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68–0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40–0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39–0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80–0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89–1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06–1.77; P=0.016). Conclusion Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.
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Affiliation(s)
- Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Heather Hilmoe
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Peter Schmidt
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Rebecca McCue
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA.,VA Program Evaluation and Resource Center, VHA Office of Mental Health Operations, Palo Alto, CA, USA
| | - Debra Clay
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Yasamin Sharifzadeh
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Gabriela Ruchelli
- Stanford Systems Neuroscience and Pain Lab, Stanford University, Stanford, CA, USA
| | - Tina Hernandez Boussard
- Department of Medicine, Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Stuart Goodman
- Department of Orthopaedic Surgery and (by Courtesy) Bioengineering, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - James Huddleston
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | | | - Joseph Shrager
- Division of Thoracic Surgery, Stanford University, Stanford, CA, USA
| | - John G Costouros
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Catherine Curtin
- Division of Hand and Plastic Surgery, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Sean C Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Ian Carroll
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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Affiliation(s)
- J Quinlan
- Department of Anaesthesia and Pain Management, Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Human Physiology Unit, MRCVersus Arthritis Centre for Musculoskeletal Ageing, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
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