Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders

"My life is under control with these medications": an interpretative phenomenological analysis of managing chronic pain with opioids

Background

The use of opioids to relieve chronic pain has increased during the last decades, but experiences of chronic opioid therapy (COT) (> 90 days) point at risks and loss of beneficial effects. Still, some patients report benefits from opioid medication, such as being able to stay at work. Guidelines for opioid use in chronic pain do not consider the individual experience of COT, including benefits and risks, making the first person perspective an important scientific component to explore. The aim of this study was to investigate the lived experience of managing chronic pain with opioids in a sample who have severe chronic pain but are able to manage their pain sufficiently to remain at work.

Methods

We used a qualitative research design: interpretative phenomenological analysis. Ten individuals with chronic pain and opioid therapy were purposively sampled in Swedish tertiary care.

Results

Three super-ordinate themes emerged from the analyses: Without opioids, the pain becomes the boss; Opioids as a salvation and a curse, and Acknowledgement of the pain and acceptance of opioid therapy enables transition to a novel self. The participants used opioids to regain control over their pain, thus reclaiming their wanted life and self, and sense of control over one’s life-world. Using opioids to manage pain was not unproblematic and some of the participants had experienced a downward spiral of escalating pain and uncontrollable opioid use, and stigmatisation.

Conclusions

All participants emphasised the importance of control, regarding both pain and opioid use. To accomplish this, trust between participants and health care providers was essential for satisfactory treatment. Regardless of the potential sociocultural benefits of staying at work, participants had experiences of balancing positive and negative effects of opioid therapy, similar to what previous qualitative research has found.

Measurable improvement of function and quality of life, may justify the long-term use of opioids in some cases. However, monitoring of adverse events should be mandatory. This requires close cooperation and a trusting relationship between the patients and their health care provider.

Elbow contracture following operative fixation of fractures about the elbow

BACKGROUND

The rates of elbow contracture and contracture release after surgically treated elbow trauma are poorly defined. The purpose of this study was to define the incidence of elbow contracture diagnosis and release after surgical treatment for elbow trauma.

METHODS

The Humana insurance database was queried using the PearlDiver Patient Records Database between 2007 and 2017. Subjects were identified using International Classification of Diseases (ICD) codes in combination with Current Procedural Terminology codes and were included if they had a minimum of 1-year follow-up. Qualifying operative elbow trauma patients were queried for development of postoperative elbow contracture. Patient demographic characteristics, risk factors for elbow stiffness, and use of postoperative anticoagulation were recorded. Fracture severity was classified based on ICD-9 and ICD-10 codes. Logistic multivariate analysis was performed to determine independent risk factors for postoperative elbow contracture.

RESULTS

The study population included 10,672 patients who were surgically treated for elbow trauma. In total, 902 patients (8.4%) were diagnosed with a contracture following fracture. Of patients with a diagnosis of elbow contracture, 65 patients (7.2%) underwent contracture release. On average, time to contracture diagnosis was 3.6 months (SD 7 months) and time to contracture release was 8.4 months (SD 3.6 months). The use of postoperative anticoagulation, burn or head injury at the time of fracture, male sex, obesity, opioid use, and moderate or severe fracture severity were significantly associated with progression to elbow contracture.

CONCLUSION

The development of elbow contracture after surgical treatment of elbow trauma has a relatively high incidence of 8.4%.

Detailing postoperative pain and opioid utilization after periacetabular osteotomy with automated mobile messaging

In the setting of periacetabular osteotomy (PAO), this investigation sought to (i) describe patient-reported pain scores and opioid utilization in the first 6 weeks following surgery and (ii) evaluate the effectiveness of postoperative communication using a robotic mobile messaging platform. Subjects indicated for PAO were enrolled from a young adult hip clinic. For the first 2 weeks after surgery, subjects received daily mobile messages inquiring about pain level on a 0–10 scale and the number of opioid pain medication tablets they consumed in the previous 24 h. Messaging frequency decreased to 3 per week in Weeks 3–6. Pain scores, opioid utilization and response rates with our mobile messaging platform were quantified for the 6-week postoperative period. Twenty-nine subjects underwent PAO. Twenty-one had concurrent hip arthroscopy. Average daily pain scores decreased over the first four postoperative days. Average pain scores reported were 5.9 ± 1.9, 4.1 ± 3.3 and 3.0 ± 3.5 on Day 1, Day 14 and Week 6, respectively. Reported opioid tablet utilization was 5.0 ± 3.2, 2.2 ± 2.0 and 0.0 ± 0.0 on Days 1 and 14 and at 6 weeks. Response rate for participants completing the 6-week messaging protocol was 84.1%. Patient-reported pain scores decreased over the first two postoperative weeks following PAO before plateauing in weeks 3–6. Opioid pain medication utilization increased in the first postoperative week before gradually declining to no tabs consumed at 6 weeks after PAO. Automated mobile messaging is an effective method of perioperative communication for the collection of pain scores and opioid utilization in patients undergoing PAO.

A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes

BACKGROUND

Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA).

METHODS

A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts.

RESULTS

No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001).

CONCLUSION

The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty

BACKGROUND

Despite favorable clinical and functional results for reverse total shoulder arthroplasty (RSA), there remains a group of patients without postoperative complications who demonstrate poor improvement and overall outcome.

METHODS

Using a single surgeon shoulder arthroplasty registry, we identified patients who underwent RSA from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded. Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. Multivariate logistic regression modeling was used to determine preoperative characteristics (e.g., demographics, comorbidities, preoperative ASES score) associated with poor outcome.

RESULTS

A total of 137 patients met the inclusion and exclusion criteria. Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement.

CONCLUSIONS

Prior ipsilateral shoulder surgery was strongly associated with poor clinical improvement and outcome after RSA. No other factors correlated with both poor improvement and outcome. This association is important to decision making for any shoulder surgery, given the long-term implications.

Prevalence and Expenses of Outpatient Opioid Prescriptions, With Associated Sociodemographic, Economic, and Work Characteristics

Information on opioids obtained by workers is important for both health and safety. We examined the prevalence and total expenses of obtaining outpatient opioid prescriptions, along with associated sociodemographic, economic, and work characteristics, in national samples of U.S. workers. We used Medical Expenditure Panel Survey data (2007–2016) along with descriptive and multiple logistic regression. During the study period, an estimated 21 million workers (12.6%) aged 16 years or older obtained one or more outpatient opioid prescriptions, at an expense of $2.81 billion per year. Private health insurance covered half of the total opioid expenses for workers. The prevalence of obtaining opioid prescriptions was higher for women than for men, but men had higher opioid expenses. In addition, the prevalence of obtaining opioid prescriptions was higher for workers who were older; non-Hispanic white; divorced, separated, or widowed; and non-college-educated. There is an inverse relationship between family income and the likelihood of obtaining opioids. Compared to workers with private insurance, workers with public health insurance had higher expenses for opioid prescriptions. Finally, workers in occupations at higher risk for injury and illness – including construction and extraction; farming; service; and production, transportation, and material moving occupations – were more likely to obtain opioid prescriptions.

Opioid Use Disorders and the Risk of Postoperative Pulmonary Complications

BACKGROUND

As the rate of opioid use disorders continues to rise, perioperative physicians are increasingly faced with the challenge of providing analgesia to these patients after surgery. Due to the likelihood of opioid dose escalation in the perioperative period, we hypothesized that opioid-dependent patients would be at increased risk for postoperative pulmonary complications.

METHODS

A retrospective cross-sectional analysis of patients undergoing 6 representative elective surgical procedures was performed using the Nationwide Inpatient Sample from 2002 to 2011. The primary outcome was a composite including prolonged mechanical ventilation, reintubation, and acute respiratory failure. Secondary outcomes were length of stay, in-hospital mortality, and total hospital costs. Both multivariable logistic regression and propensity score matching were used to determine the impact of opioid use disorder on outcomes.

RESULTS

The total sample-weighted cohort consisted of 7,533,050 patients. Patients with opioid use disorders were more likely to suffer pulmonary complications, with a frequency of 4.2% compared to 1.6% in the nonopioid-dependent group (P < .001), and had a 1.62 times higher odds (95% confidence interval [CI], 1.16-2.27) in multivariable regression analysis. In a secondary subgroup analysis, only patients undergoing a colectomy had a greater odds of suffering pulmonary complications (odds ratio, 2.64; 95% CI, 1.42-4.91; P = .0021). Additionally, patients with an opioid use disorder had a longer length of stay (0.84 days [95% CI, 0.52-1.16; P < .001]) and greater costs ($1816 [95% CI, 935-2698; P < .001]).

CONCLUSIONS

This study demonstrates that patients with opioid use disorders are at increased risk for postoperative pulmonary complications, and have prolonged length of stay and resource utilization. Further research is needed regarding interventions to reduce the risk of complications in this subset of patients.

Assessing treatment and monitoring of musculoskeletal conditions using opioid versus nonopioid therapy: A cross-sectional study

The purpose of this study is to examine the treatment of noncancer musculoskeletal pain in different clinical settings by assessing patient demographics, pain diagnoses, opioid analgesic monitoring, and alternative treatments.Data was collected in a retrospective chart review involving 300 randomly selected charts with an active musculoskeletal diagnosis based on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes. The population consisted of primary care outpatient clinic and emergency department encounters during the timeframe of January 1, 2016 to March 31, 2016 in a predominantly rural community in Michigan. Variables included prescription medications, musculoskeletal conditions, and prescription drug monitoring modalities. Statistical analysis was accomplished using means, standard deviations, proportions, 2-sample proportional tests, multivariable logistic regression, and multinomial regression models.Opioid prescribing was observed in 64% of outpatient and 68.9% of emergency department encounters. Back pain was the most common problem with 61.9% patients prescribed opioids having at least 1 diagnosis of back pain. Patients on opioids were older (mean age 58) than patients taking nonopioids (mean age 50). For every year of increasing age, there is a 3.1% increase in the odds of an opioid being prescribed (odds ratio 1.03, confidence interval 1.012-1.049, P = .001). Documentation was extremely low with only 15.2%, 1.5%, and 1.5% of patient charts prescribed opioids demonstrating documentation of urine drug screens, pain agreements, and review of a state prescription drug monitoring program, respectively.Despite drug monitoring recommendations, low rates of monitoring were observed. Back pain was the largest contributing pain location and had higher opioid use compared to other sites. Many patients had additional pain medications being concurrently prescribed with opioids suggesting that musculoskeletal pain is not often controlled by a single medication type. Reported alcohol abuse, active tobacco use, and illicit substance use can serve as predictors when assessing patients for pain management options. The use of alternative measures and integrative treatment modalities (which saw low utilization in this study) should be implemented as either primary or supplementary therapy as a way to reduce the pharmacologic burden on the patient.

Elective Shoulder Surgery in the Opioid Naïve: Rates of and Risk Factors for Long-term Postoperative Opioid Use

BACKGROUND

Little is known regarding the rates and risk factors for long-term postoperative opioid use among opioid-naïve patients undergoing elective shoulder surgery.

PURPOSE

To identify (1) the proportion of opioid-naïve patients undergoing elective shoulder surgery, (2) the rates of postoperative opioid use among these patients, and (3) the risk factors associated with long-term postoperative opioid use.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of a private administrative claims database was performed to identify those individuals who underwent elective shoulder surgery between 2007 and 2015. "Opioid-naïve" patients were identified as those patients who had not filled an opioid prescription in the 180 days before the index surgery. Within this subgroup, we tracked postoperative opioid prescription refill rates and used a logistic regression to identify patient variables that were predictive for long-term opioid use, which we defined as continued opioid refills beyond 180 days after surgery. Results were reported as odds ratios (ORs).

RESULTS

Over the study period, 79,287 patients were identified who underwent elective shoulder surgery, of whom 79.5% were opioid naïve. Among opioid-naïve patients, the rate of postoperative opioid use declined over time, and 14.6% of patients were still using opioids beyond 180 days. The greatest proportion of opioid-naïve patients still filling opioid prescriptions beyond 180 days postoperatively was seen after open rotator cuff repair (20.9%), whereas arthroscopic labral repair had the lowest proportion (9.8%). Overall, a history of alcohol abuse (OR 1.56), a history of depression (OR 1.46), a history of anxiety (OR, 1.31), female sex (OR, 1.11), and higher Charlson Comorbidity Index (OR 1.02) had the most significant influence on the risk for long-term opioid use among opioid naïve patients.

CONCLUSIONS

Most patients were opioid naïve before elective shoulder surgery; however, among opioid-naïve patients, 1 in 7 patients were still using opioids beyond 180 days after surgery. Among all variables, a history of mental illness most significantly increased the risk of long-term opioid use after elective shoulder surgery.

Disability Benefits and Change in Prescription Opioid Dose

Among chronic low back pain (CLBP) patients, workers' compensation is associated with longer term prescription opioid analgesic use (OAU). The aim was to study the association between receiving Social Security Disability Insurance (SSDI) benefits and course of OAU. This prospective cohort study utilized data from primary care patients diagnosed with non-cancer CLBP. The outcomes were morphine equivalent dose (MED) - categorized as no OAU, 1-50mg MED, or >50mg MED - and change in MED over time using mixed multinomial logistic regression models. Covariates included sociodemographics, pain severity, pain management characteristics, continuity of care with their physician, health-related quality of life, number of comorbid health conditions, obesity, depression, and anxiety. In adjusted analysis, SSDI vs. non-SSDI patients were more likely to be receiving >50mg MED vs. no OAU at baseline (OR = 10.19; 95% CI:1.51-68.83). Differences in OAU trajectory between SSDI groups were nonsignificant (P = 0.204). Collection of SSDI benefits was an independent predictor of higher MED at baseline and persistently higher MED during 2 years of follow-up. Providers should consider the risk of persistent, high-dose opioid use in patients receiving SSDI benefits.

Prescription opioid use by injured workers in Tennessee: a descriptive study using linked statewide databases

PURPOSE

This is the first study in Tennessee to measure opioid use in injured workers and among the first nationally to use a prescription drug monitoring program to do so. We conducted a retrospective cohort study to evaluate the prevalence of opioid use after injury and associated characteristics among workers reporting one injury to Tennessee Workers' Compensation.

METHODS

Injured workers identified in Workers' Compensation records 2013-2015 were linked to their prescription history in Tennessee's prescription drug monitoring database.

RESULTS

Among 172,256 injured workers, the prevalence of receiving an opioid after injury was 22.8% in 1 week, 29.7% in 1 month, and 33.3% in 6 months. Receiving an opioid was associated with having a fracture (odds ratio, 4.9; 95% confidence interval, 4.64-5.11 vs. other injuries). Hydrocodone short-acting was the most commonly received opioid (69.5% of injured workers), and the mean of each worker's maximum dose was 42.8 morphine milligram equivalents (SD 39.26). Ten percent of injured workers who received opioids also received a benzodiazepine.

CONCLUSIONS

Injured workers have a high prevalence of opioid use after injury, but prescribing patterns generally tend to follow Tennessee prescribing guidelines.

Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review

Objective

To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.

Methods

Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.

Results

No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.

Conclusions

There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.

Mechanisms that drive bone pain across the lifespan

Disorders of the skeleton are frequently accompanied by bone pain and a decline in the functional status of the patient. Bone pain occurs following a variety of injuries and diseases including bone fracture, osteoarthritis, low back pain, orthopedic surgery, fibrous dysplasia, rare bone diseases, sickle cell disease and bone cancer. In the past 2 decades, significant progress has been made in understanding the unique population of sensory and sympathetic nerves that innervate bone and the mechanisms that drive bone pain. Following physical injury of bone, mechanotranducers expressed by sensory nerve fibres that innervate bone are activated and sensitized so that even normally non-noxious loading or movement of bone is now being perceived as noxious. Injury of the bone also causes release of factors that; directly excite and sensitize sensory nerve fibres, upregulate proalgesic neurotransmitters, receptors and ion channels expressed by sensory neurons, induce ectopic sprouting of sensory and sympathetic nerve fibres resulting in a hyper-innervation of bone, and central sensitization in the brain that amplifies pain. Many of these mechanisms appear to be involved in driving both nonmalignant and malignant bone pain. Results from human clinical trials suggest that mechanism-based therapies that attenuate one type of bone pain are often effective in attenuating pain in other seemingly unrelated bone diseases. Understanding the specific mechanisms that drive bone pain in different diseases and developing mechanism-based therapies to control this pain has the potential to fundamentally change the quality of life and functional status of patients suffering from bone pain.

Anti-nerve growth factor does not change physical activity in normal young or aging mice but does increase activity in mice with skeletal pain

Anti-nerve growth factor (anti-NGF) therapy has shown significant promise in attenuating several types of skeletal pain. However, whether anti-NGF therapy changes the level of physical activity in individuals with or without skeletal pain is largely unknown. Here, automated day/night activity boxes monitored the effects of anti-NGF treatment on physical activity in normal young (3 months old) and aging (18-23 months old) mice and mice with bone fracture pain. Although aging mice were clearly less active and showed loss of bone mass compared with young mice, anti-NGF treatment had no effect on any measure of day/night activity in either the young or aging mice. By contrast, in mice with femoral fracture pain, anti-NGF treatment produced a clear increase (10%-27%) in horizontal activity, vertical rearing, and velocity of travel compared with the Fracture + Vehicle group. These results suggest, just as in humans, mice titrate their level of physical activity to their level of skeletal pain. The level of skeletal pain may in part be determined by the level of free NGF that seems to rise after injury but not normal aging of the skeleton. In terms of bone healing, animals that received anti-NGF showed an increase in the size of calcified callus but no increase in the number of displaced fractures or time to cortical union. As physical activity is the best nondrug treatment for many patients with skeletal pain, anti-NGF may be useful in reducing pain and promoting activity in these patients.

New Insights in Understanding and Treating Bone Fracture Pain

PURPOSE OF REVIEW

This paper describes recent advances in understanding the mechanisms that drive fracture pain and how these findings are helping develop new therapies to treat fracture pain.

RECENT FINDINGS

Immediately following fracture, mechanosensitive nerve fibers that innervate bone are mechanically distorted. This results in these nerve fibers rapidly discharging and signaling the initial sharp fracture pain to the brain. Within minutes to hours, a host of neurotransmitters, cytokines, and nerve growth factor are released by cells at the fracture site. These factors stimulate, sensitize, and induce ectopic nerve sprouting of the sensory and sympathetic nerve fibers which drive the sharp pain upon movement and the dull aching pain at rest. If rapid and effective healing of the fracture occurs, these factors return to baseline and the pain subsides, but if not, these factors can drive chronic bone pain. New mechanism-based therapies have the potential to fundamentally change the way acute and chronic fracture pain is managed.

Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain

BACKGROUND

The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders.

METHODS

A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables.

RESULTS

The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70).

CONCLUSION

Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

The impact of opioid analgesic prescription uptake on the costs of recovery from injury: Evidence from compensable orthopaedic road trauma patients

Long-term opioid prescribing after compensable orthopaedic injury may contribute to the 'long right tail' in the cost of recovery. The aim of this study was to estimate the effect of prescription opioid uptake on injury compensation cost, using orthopaedic road traffic injury claims data from Victoria, Australia. We used a maximum likelihood estimation that accounts for potential endogeneity associated with opioid uptake, utilizing information on the doctor's differential propensity to prescribe opioids when treating other compensable injury patients. Our results suggest that opioid recipients incurred significantly greater hospital costs, income compensation payments, and medical and paramedical expenses. Overall, income compensation was the primary driver of the claim cost difference between opioid recipients and non-recipients. The findings imply that there is scope to impose restrictions on long-term opioid usage, and to encourage the use of alternative pain relief medicines.

Characterizing the Interrelationships of Prescription Opioid and Benzodiazepine Drugs With Worker Health and Workplace Hazards

OBJECTIVE

Prescription opioid and benzodiazepine drug use, which has risen significantly, can affect worker health. Exploration of the scientific literature assessed (1) interrelationships of such drug use, occupational risk factors, and illness and injury, and (2) occupational and personal risk factor combinations that can affect their use.

METHODS

The scientific literature from 2000 to 2015 was searched to determine any interrelationships.

RESULTS

Evidence for eight conceptual models emerged based on the search yield of 133 articles. These models summarize interrelationships among prescription opioid and benzodiazepine use with occupational injury and illness. Factors associated with the use of these drugs included fatigue, impaired cognition, falls, motor vehicle crashes, and the use of multiple providers.

CONCLUSION

Prescription opioid and benzodiazepine drugs may be both a personal risk factor for work-related injury and a consequence of workplace exposures.

Complexities of Perioperative Pain Management in Orthopedic Trauma

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The impact of preoperative opioid use on outcomes after arthroscopic rotator cuff repair

Background

Preoperative opioid use has been correlated to suboptimal outcomes in orthopedic surgery. This study evaluated the effect of preoperative opioid use on outcomes after arthroscopic rotator cuff repair (RCR).

Methods

A retrospective review was performed of 79 patients who underwent arthroscopic RCR; of these, 31 with a history of preoperative opioid use were compared with a control group of 48 patients without a history of preoperative opioid use. Preoperative and postoperative patient-reported outcomes and functional scores were compared.

Results

Both cohorts significantly improved on all patient-reported shoulder scores; however, the nonopioid group demonstrated significantly better postoperative patient-reported outcome scores (P = .015) and external rotation measurement (P = .008). Functional outcomes also significantly improved from preoperatively to postoperatively for forward flexion, but no differences were seen between groups.

Conclusions

Patients with a history of preoperative opioid use can still achieve significant improvements in outcomes after arthroscopic RCR, although not to the same extent as opioid-naïve patients. Therefore, orthopedic surgeons must consider a patient's preoperative opioid use and temper expectations with regard to outcomes so that they are able to set realistic postoperative goals for patients undergoing RCR.

Work Enabling Opioid Management

OBJECTIVE

This study describes the relationship between opioid prescribing and ability to work.

METHODS

The opioid prescription patterns of 4994 claimants were studied. Three groups were constructed: 1) at least 3 consecutive months prescribed (chronic opioid therapy; COT); 2) less than 3 consecutive months prescribed (acute opioid therapy; AOT); and 3) no opioids prescribed. Variables included sex, age, daily morphine equivalent dose (MED), days opioids were prescribed, temporary total days (TTDs), and medical/indemnity/total costs.

RESULTS

The COT versus AOT claimants had higher opioid costs ($8618 vs $94), longer TTD (636.2 vs 182.3), and average MED (66.8 vs 34.9). Only 2% of the COT cohort were not released to work. Fifty-seven percent of patients in the COT category (64 of 112) were released to work while still receiving opioids.

CONCLUSION

COT does not preclude ability to work when prescribing within established guidelines.

Effect of pre-injection opioid use on post-injection patient-reported outcomes following epidural steroid injections for radicular pain

BACKGROUND CONTEXT

Chronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain.

PURPOSE

We evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection.

STUDY DESIGN

This study is a retrospective analysis of a prospective longitudinal registry database.

PATIENT SAMPLE

A total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study.

OUTCOME MEASURES

Patient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection.

METHODS

Multivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases.

RESULTS

A total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg-19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold.

CONCLUSION

Increased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence.

Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers' Compensation Patients After Lumbar Diskectomy

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

The aim of this study was to determine the impact of preoperative opioid use in workers' compensation (WC) patients undergoing lumbar diskectomy (LD).

SUMMARY OF BACKGROUND DATA

The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain.

METHODS

Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW).

RESULTS

Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups.

CONCLUSION

Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden.

LEVEL OF EVIDENCE

3.

Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program

OBJECTIVE

This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up.

METHODS

Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up.

RESULTS

Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up.

DISCUSSION

This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.

Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures

BACKGROUND

Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. Understanding prescribing habits and patient utilization of these medications following a surgical procedure is critical to establishing appropriate prescribing protocols that effectively control pain while minimizing unused opioid distribution. We evaluated prescribing habits and patient utilization following elective orthopaedic surgical procedures to identify ways of improving postoperative opioid-prescribing practices.

METHODS

We performed a review of prescribing data of 1,199 procedures and gathered telephone survey results from 557 patients to determine the number of opioid pills prescribed postoperatively and the number of unused pills. The data were collected from adult patients who underwent 1 of the 5 most common elective orthopaedic procedures at our institution in fiscal year 2015: total hip arthroplasty, total knee arthroplasty, endoscopic carpal tunnel release, arthroscopic rotator cuff repair, or lumbar decompression. We converted all dosages to opioid equivalents of oxycodone 5 mg and performed analyses of prescribing patterns, patient utilization, and patient disposal of unused opioids.

RESULTS

Prescribing patterns following the 5 orthopaedic procedures showed wide variation. The median numbers of oxycodone 5-mg equivalent opioid pills prescribed upon discharge were 90 pills (range, 20 to 330 pills) for total hip arthroplasty, 90 pills (range, 10 to 200 pills) for total knee arthroplasty, 20 pills (range, 0 to 168 pills) for endoscopic carpal tunnel release, 80 pills (range, 18 to 100 pills) for arthroscopic rotator cuff repair, and 80 pills (range, 10 to 270 pills) for lumbar decompression. Thirty-seven percent of patients overall requested and received at least 1 refill. The mean number of total pills prescribed (and standard deviation) including refills was 113.6 ± 75.7 for total hip arthroplasty, 176.4 ± 108.0 for total knee arthroplasty, 24.3 ± 29.0 for carpal tunnel release, 98.2 ± 59.6 for rotator cuff repair, and 107.4 ± 64.4 for lumbar decompression. Participants reported unused opioid medication in 61% of cases. During the study year, >43,000 unused opioid pills were prescribed. Forty-one percent of patients reported appropriate disposal of unused opioid pills.

CONCLUSIONS

Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.

Factors Affecting Long-Term Postoperative Narcotic Use in Discectomy Patients

BACKGROUND

Long-term narcotic use has risks and potentially life-threatening opioid-related side effects. Extended narcotic use in patients undergoing discectomy raises concerns of other underlying causes of pain or overprescription and/or abuse. The goal of this study was to determine which factors have an effect on active narcotic prescription >3 months after discectomy.

METHODS

The PearlDiver Database was used in this study. Patients 30-55 years old undergoing discectomy without fusions were queried for active narcotic drug prescription occurring >30 days and >3 months after original surgery. Medical co-diagnoses were independently analyzed for effects on long-term active narcotic prescriptions. Prior narcotic use was defined by use within 4 months before surgery.

RESULTS

Of 1321 patients undergoing discectomy, 621 had actively prescribed narcotics >3 months after surgery. Preoperative narcotic use had the largest effect on odds of postoperative prescription (odds ratio [OR] = 3.4). Medical comorbidities increasing odds of long-term narcotic prescriptions included migraines (OR = 1.4), diabetes mellitus (OR = 1.4), depression (OR = 1.6), and smoking (OR = 1.9).

CONCLUSIONS

Narcotic abuse is a serious problem rooted in overprescription of these drugs, which has ultimately led to much more caution in prescribing among physicians. Because pain management and drug prescription must be balanced, identifying patients who may be susceptible to narcotic overprescription is important. Patients with co-diagnoses increasing odds of long-term narcotic prescriptions would benefit from early and continual postsurgical follow-up to ensure accurate pain management and to determine if narcotic prescriptions are justly warranted in the later postoperative period.

Psychosocial factors predict opioid analgesia through endogenous opioid function

Use of opioid analgesics for management of chronic nonmalignant pain has become common, yet there are presently no well-validated predictors of optimal opioid analgesic efficacy. We examined whether psychosocial factors (eg, depressive symptoms) predicted changes in spontaneous low back pain after administration of opioid analgesics, and whether endogenous opioid (EO) function mediated these relationships. Participants with chronic low back pain but who were not chronic opioid users (N = 89) underwent assessment of low back pain intensity pre- and post-drug in 3 (counterbalanced) conditions: (1) placebo, (2) intravenous naloxone, and (3) intravenous morphine. Comparison of placebo condition changes in back pain intensity to those under naloxone and morphine provided indexes of EO function and opioid analgesic responses, respectively. Results showed that (1) most psychosocial variables were related significantly and positively to morphine analgesic responses for low back pain, (2) depressive symptoms, trait anxiety, pain catastrophizing, and pain disability were related negatively to EO function, and (3) EO function was related negatively to morphine analgesic responses for low back pain. Bootstrapped mediation analyses showed that links between morphine analgesic responses and depressive symptoms, trait anxiety, pain catastrophizing, and perceived disability were partially mediated by EO function. Results suggest that psychosocial factors predict elevated analgesic responses to opioid-based medications, and may serve as markers to identify individuals who benefit most from opioid therapy. Results also suggest that people with greater depressive symptoms, trait anxiety, pain catastrophizing, and perceived disability may have deficits in EO function, which may predict enhanced response to opioid analgesics.

The perioperative effects of chronic preoperative opioid use on shoulder arthroplasty outcomes

HYPOTHESIS AND BACKGROUND

Chronic opioid therapy is an increasingly used modality for the treatment of osteoarthritis-associated pain. We hypothesized that chronic opioid use would be associated with adverse outcomes in shoulder arthroplasty.

METHODS

A retrospective analysis of patients undergoing elective anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) at a single institution from 2012-2015 was performed. Patients were stratified by preoperative opioid use (nonusers, short-acting opioid users, and long-acting opioid users), and their postoperative clinical outcomes were assessed.

RESULTS

We identified 262 patients (170 rTSA and 92 anatomic TSA), of whom 138 were using opioids preoperatively (82% short acting and 18% long acting). When non-opioid users, short-acting opioid users, and long-acting opioid users were compared, mean total milligrams of morphine equivalents administered during postoperative hospitalization was significantly higher for those with preoperative opioid use (66.9 mg, 111.4 mg, and 208.3 mg, respectively; P < .001). In addition, postoperative visual analog scale pain scores were higher on postoperative day 0 (2.6, 3.2, and 3.9, respectively; P = .007), day 1 (4.0, 4.9, and 6.0, respectively; P < .001), and day 2 (3.0, 3.9, and 5.1, respectively; P < .001). Opioid use was not associated with a significantly increased hospital length of stay, complications, or readmission rates. For patients who completed 2-year follow-up, both the opioid user and non-opioid user groups demonstrated similarly improved postoperative American Shoulder and Elbow Surgeons shoulder scores.

CONCLUSION

A preoperative history of opioid use before shoulder arthroplasty was associated with significantly higher perioperative opioid consumption and visual analog scale scores. However, unlike in patients undergoing total knee or hip arthroplasty, preoperative opioid use was not associated with increased hospital length of stay, perioperative complications, or 90-day readmission rates for shoulder arthroplasty.

Narcotic Consumption Following Anterior and Lateral Lumbar Interbody Fusion Procedures

STUDY DESIGN/SETTING

This is a retrospective analysis of a prospectively maintained surgical registry.

OBJECTIVE

To characterize postoperative narcotic consumption in patients undergoing either an anterior lumbar interbody fusion (ALIF) or a lateral lumbar interbody fusion (LLIF).

BACKGROUND CONTEXT

There is substantial interest in evaluating the safety, efficacy, and outcomes following minimally invasive techniques for lumbar fusion procedures. However, few studies have characterized postoperative narcotic consumption in patients undergoing ALIF or LLIF procedures.

METHODS

Consecutive patients who underwent either an ALIF or LLIF during 2007-2014 were identified. Inpatient narcotic consumption was recorded in oral morphine equivalents and dichotomized as greater or less than the 75th percentile total consumption (elevated or normal inpatient consumption). Demographic, comorbidity, and perioperative characteristics were tested for independent association with inpatient narcotic consumption and with continued narcotic usage during the months following surgery.

RESULTS

A total of 169 patients met inclusion criteria. Of these, 118 (69.8%) underwent ALIF and 51 (30.2%) underwent LLIF procedures. The risk for elevated inpatient narcotic consumption was greater in patients whose body mass index was≥30 kg/m [relative risk (RR), 2.8; 95% confidence interval (CI), 1.6-4.8; P<0.001). The risk for continued narcotic usage at the first postoperative visit was elevated in patients with worker's compensation payment status (RR, 2.0; 95% CI, 1.5-2.7; P<0.001). The risk for continued narcotic usage at the second postoperative visit was elevated in patients with worker's compensation payment status (RR, 2.6; 95% CI, 1.7-4.1; P<0.001) and in patients with preoperative narcotic utilization (RR, 2.2; 95% CI, 1.4-3.5; P<0.001).

CONCLUSIONS

The present study suggests that while patients with greater body mass index have increased narcotic consumption as inpatients, preoperative narcotic consumption and worker's compensation payment status are the best predictors of continued narcotics usage during the months following surgery. Worker's compensation patients and patients who utilize narcotics preoperatively should be the targets of efforts to reduce continued postoperative narcotic usage.

Opioid Demand Before and After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Surgeons and health care systems have received a call to action in an effort to curtail the current opioid epidemic.

PURPOSE

To (1) define the natural history of opioid demand after anterior cruciate ligament reconstruction (ACLR), (2) consider how filling preoperative opioid prescriptions affects opioid demand after ACLR, and (3) evaluate the effect of additional procedures during ACLR and patient age on postoperative opioid demand.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

ACLRs performed in the Humana database between 2007 and 2014 were identified using Current Procedural Terminology code 29888. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Patients were defined as "chronic" opioid users if they had filled a prescription preoperatively at 1 to 3 months from surgery. Further categorization was performed by identifying patients who only underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with meniscectomy, and those who underwent ACLR with microfracture. Categorization by age was also performed. The relative risk (RR) of postoperative opioid use was calculated, and 95% CIs were determined.

RESULTS

Over the course of the study period, 4946 ACLRs were performed. At 3 months after their procedure, 7.24% of patients were still filling opioid prescriptions. At 9 and 12 months postoperatively, 4.97% and 4.71% of patients, respectively, were still filling opioid prescriptions. Nearly 35% of patients (1716/4946) were filling opioid pain prescriptions in the 3 months before ACLR. Those filling preoperative opioid prescriptions were 5.35 (95% CI, 4.15-6.90) times more likely to be filling opioid prescriptions at 3 months after ACLR than nonusers (15.38% vs 2.88%, respectively). Those filling opioid prescriptions chronically before surgery were at a 10.50 (95% CI, 7.53-14.64) times increased risk of filling postoperative opioid prescriptions at 5 months. At 5 months postoperatively, patients undergoing ACLR with microfracture had a 1.96 (95% CI, 1.34-2.87) increased risk of filling opioid prescriptions compared with ACLR alone, 2.38 (95% CI, 1.48-3.82) increased risk compared with ACLR with meniscus repair, and 1.51 (95% CI, 1.04-2.19) increased risk compared with ACLR with meniscectomy. Patients younger than 25 years of age had an increased risk of filling opioid prescriptions after ACLR at all time points of the study.

CONCLUSION

Opioid demand after ACLR dropped significantly in the vast majority of patients by the third postoperative month. Surprisingly, 35% of patients undergoing ACLR were observed to be using opioid medication preoperatively, and this study found preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5- to 7-fold increased risk in this patient population. Patients who were filling opioid prescriptions 1 to 3 months from their surgical date were at the highest risk for postoperative opioid utilization. Patients undergoing ACLR with microfracture were at an increased risk of filling opioid prescriptions. Patients less than 25 years of age were at an elevated risk of filling opioid prescriptions at all time points postoperatively.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue where opioids are routinely used for pain management. There are concerns that the use of high doses of opioids for chronic non-cancer pain lacks evidence of effectiveness and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and Overviews regarding the efficacy and safety of high-dose opioids (here defined as 200 mg morphine equivalent or more per day) for chronic non-cancer pain.

METHODS

We identified Cochrane Reviews and Overviews through a search of the Cochrane Database of Systematic Reviews (The Cochrane Library). The date of the last search was 18 April 2017. Two review authors independently assessed the search results. We planned to analyse data on any opioid agent used at high dose for two weeks or more for the treatment of chronic non-cancer pain in adults.

MAIN RESULTS

We did not identify any reviews or overviews meeting the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses where all doses were analysed as a single group; no data for high dose only could be extracted.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence regarding how well high-dose opioids work for the management of chronic non-cancer pain in adults, and regarding the presence and severity of adverse events. No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Trials typically used doses below our cut-off; we need to know the efficacy and harm of higher doses, which are often used in clinical practice.

Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is common and can be challenging to manage. Despite increased utilisation of opioids, the safety and efficacy of long-term use of these compounds for chronic non-cancer pain (CNCP) remains controversial. This overview of Cochrane Reviews complements the overview entitled 'High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews'.

OBJECTIVES

To provide an overview of the occurrence and nature of adverse events associated with any opioid agent (any dose, frequency, or route of administration) used on a medium- or long-term basis for the treatment of CNCP in adults.

METHODS

We searched the Cochrane Database of Systematic Reviews (the Cochrane Library) Issue 3, 2017 on 8 March 2017 to identify all Cochrane Reviews of studies of medium- or long-term opioid use (2 weeks or more) for CNCP in adults aged 18 and over. We assessed the quality of the reviews using the AMSTAR criteria (Assessing the Methodological Quality of Systematic Reviews) as adapted for Cochrane Overviews. We assessed the quality of the evidence for the outcomes using the GRADE framework.

MAIN RESULTS

We included a total of 16 reviews in our overview, of which 14 presented unique quantitative data. These 14 Cochrane Reviews investigated 14 different opioid agents that were administered for time periods of two weeks or longer. The longest study was 13 months in duration, with most in the 6- to 16-week range. The quality of the included reviews was high using AMSTAR criteria, with 11 reviews meeting all 10 criteria, and 5 of the reviews meeting 9 out of 10, not scoring a point for either duplicate study selection and data extraction, or searching for articles irrespective of language and publication type. The quality of the evidence for the generic adverse event outcomes according to GRADE ranged from very low to moderate, with risk of bias and imprecision being identified for the following generic adverse event outcomes: any adverse event, any serious adverse event, and withdrawals due to adverse events. A GRADE assessment of the quality of the evidence for specific adverse events led to a downgrading to very low- to moderate-quality evidence due to risk of bias, indirectness, and imprecision.We calculated the equivalent milligrams of morphine per 24 hours for each opioid studied (buprenorphine, codeine, dextropropoxyphene, dihydrocodeine, fentanyl, hydromorphone, levorphanol, methadone, morphine, oxycodone, oxymorphone, tapentadol, tilidine, and tramadol). In the 14 Cochrane Reviews providing unique quantitative data, there were 61 studies with a total of 18,679 randomised participants; 12 of these studies had a cross-over design with two to four arms and a total of 796 participants. Based on the 14 selected Cochrane Reviews, there was a significantly increased risk of experiencing any adverse event with opioids compared to placebo (risk ratio (RR) 1.42, 95% confidence interval (CI) 1.22 to 1.66) as well as with opioids compared to a non-opioid active pharmacological comparator, with a similar risk ratio (RR 1.21, 95% CI 1.10 to 1.33). There was also a significantly increased risk of experiencing a serious adverse event with opioids compared to placebo (RR 2.75, 95% CI 2.06 to 3.67). Furthermore, we found significantly increased risk ratios with opioids compared to placebo for a number of specific adverse events: constipation, dizziness, drowsiness, fatigue, hot flushes, increased sweating, nausea, pruritus, and vomiting.There was no data on any of the following prespecified adverse events of interest in any of the included reviews in this overview of Cochrane Reviews: addiction, cognitive dysfunction, depressive symptoms or mood disturbances, hypogonadism or other endocrine dysfunction, respiratory depression, sexual dysfunction, and sleep apnoea or sleep-disordered breathing. We found no data for adverse events analysed by sex or ethnicity.

AUTHORS' CONCLUSIONS

A number of adverse events, including serious adverse events, are associated with the medium- and long-term use of opioids for CNCP. The absolute event rate for any adverse event with opioids in trials using a placebo as comparison was 78%, with an absolute event rate of 7.5% for any serious adverse event. Based on the adverse events identified, clinically relevant benefit would need to be clearly demonstrated before long-term use could be considered in people with CNCP in clinical practice. A number of adverse events that we would have expected to occur with opioid use were not reported in the included Cochrane Reviews. Going forward, we recommend more rigorous identification and reporting of all adverse events in randomised controlled trials and systematic reviews on opioid therapy. The absence of data for many adverse events represents a serious limitation of the evidence on opioids. We also recommend extending study follow-up, as a latency of onset may exist for some adverse events.

Comparing Pain and Depressive Symptoms of Chronic Opioid Therapy Patients Receiving Dose Reduction and Risk Mitigation Initiatives With Usual Care

Dose reduction and risk mitigation initiatives have been recommended to reduce opioid-related risks among patients receiving chronic opioid therapy (COT), but questions remain over whether these initiatives worsen pain control and quality of life. In 2014 to 2015, we interviewed 1,588 adult COT patients within a health care system in Washington State and compared those who received dose reduction and risk mitigation initiatives in primary care clinics (intervention) with patients in comparable health care settings without initiatives (control). The primary outcomes were pain assessed using the pain, enjoyment, and general activity (PEG) scale, a 3-item scale to assess global pain intensity and interference, with secondary measures including depression (Patient Health Questionnaire-8 scale). Generalized estimating equations for linear regression models were used to estimate differences in mean scores between intervention and control sites. Estimated differences, adjusted for patient characteristics and weighted for nonresponse, between patients at intervention and control clinics were not clinically significant for the PEG (-.03, 95% confidence interval = -.25 to .19) or Patient Health Questionnaire-8 (-.64, 95% confidence interval = -1.19 to -.08). We found no evidence that COT patients in clinics with dose reduction and risk mitigation initiatives had clinically meaningful differences in pain intensity, interference with activities and enjoyment of life, or depressive symptoms compared with control health care settings.

PERSPECTIVE

This article evaluates the effect of dose reduction and risk mitigation initiatives, such as those recently recommended by the Centers for Disease Control and Prevention, to reduce risks associated with COT on global pain and interference, depressive symptoms, and perceived pain relief and bothersomeness of side effects.

Opioid Consumption After Rotator Cuff Repair

PURPOSE

Rising perioperative opioid use in the United States is of increasing concern. The purposes of this study were (1) to define opioid consumption after rotator cuff repair (RCR) in the United States and (2) to evaluate patient factors that may be associated with prolonged opioid use after arthroscopic RCR.

METHODS

All arthroscopic RCRs performed between 2007 and 2014 were identified by use of Current Procedural Terminology code (29,827). Patients who filled opioid prescriptions preoperatively were divided into those who filled prescriptions at 1 to 3 months preceding RCR and those who filled opioid prescriptions only in the 1 month preceding RCR. Risk ratios (RRs) were calculated by dividing the cumulative incidence of opioid prescriptions in patients with each patient factor by the cumulative incidence in those without each patient factor.

RESULTS

During the study period, 35,155 arthroscopic RCRs were performed. Of the patients, approximately 43% had filled an opioid prescription in the 3 months before RCR. At 3 months after RCR, patients who filled opioid prescriptions at 1 to 3 months before RCR were 7.45 (95% confidence interval [CI], 6.95-7.98) times more likely to be filling opioid medication prescriptions than those who had not been prescribed opioid medications before surgery; patients who filled opioid prescriptions in the month before RCR were 3.04 (95% CI, 2.8-3.29) times more likely to be filling opioid prescriptions at 3 months after RCR. Patients with psychiatric diagnoses (RR, 1.94; 95% CI, 1.85-2.04), myalgia (RR, 1.67; 95% CI, 1.6-1.75), and low-back pain (RR, 2.09; 95% CI, 2-2.2) were also found to be at risk of filling opioid prescriptions at 3 months postoperatively.

CONCLUSIONS

We found approximately 43% of patients undergoing RCR received opioid medications before RCR. Patients who are prescribed narcotics before RCR are at increased risk of postoperative opioid demand. Patients with psychiatric diagnoses, myalgia, and low-back pain may be at increased risk of prolonged opioid use after surgery.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Is There a Preoperative Morphine Equianalgesic Dose that Predicts Ability to Achieve a Clinically Meaningful Improvement Following Spine Surgery?

BACKGROUND

Preoperative opioid use is widespread and associated with worse patient-reported outcomes following spine surgery.

OBJECTIVE

To calculate a threshold preoperative morphine equianalgesic (MEA) dose beyond which patients are less likely to achieve the minimum clinically important difference (MCID) following elective surgery for degenerative spine disease.

METHODS

The study included 543 cervical and 1293 lumbar patients. Neck Disability Index and Oswestry Disability Index scores were collected at baseline and 12 mo postoperatively. Preoperative MEA doses were calculated retrospectively. Multivariate logistic regression was then performed to determine the relationship between MEA dose and the odds of achieving MCID. As a part of this regression, Bayesian inference and Markov Chain Monte Carlo methods were used to estimate the values of inflection points (or “thresholds”) in MEA.

RESULTS

Overall, 1020 (55.5%) patients used preoperative opioids. A total of 50.3% of cervical and 61.9% of lumbar patients achieved MCID. The final logistic regression model demonstrated that MCID achievement decreased significantly when mean preoperative MEA dose exceeded 47.8 mg/d, with a 95% credible interval of 29.0 to 60.0 mg/d.

CONCLUSION

Minimum and maximum MEA doses exist, between which increasing opioid dose is associated with decreased ability to achieve clinically meaningful improvement following spine surgery. Patients with preoperative MEA dose exceeding 29 mg/d, the lower limit of the 95% credible interval for the mean MEA dose above which patients exhibit significantly decreased achievement of MCID, may be considered for preoperative opioid weaning.

Patterns of Opioid Prescribing for an Orthopaedic Trauma Population

OBJECTIVES

To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center.

DESIGN

A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Adult patients with OT admitted over a 30-day period (n = 110).

INTERVENTION

All discharge and follow-up opioid prescriptions were recorded.

MAIN OUTCOME MEASUREMENTS

Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed.

RESULTS

One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%).

CONCLUSIONS

Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Endogenous Opioid Function and Responses to Morphine: The Moderating Effects of Anger Expressiveness

Long-term use of opioid analgesics may be ineffective or associated with significant negative side effects for some people. At present, there is no sound method of identifying optimal opioid candidates. Individuals with chronic low back pain (n = 89) and healthy control individuals (n = 102) underwent ischemic pain induction with placebo, opioid blockade (naloxone), and morphine in counterbalanced order. They completed the Spielberger Anger-Out subscale. Endogenous opioid function × Anger-out × Pain status (chronic pain, healthy control) interactions were tested for morphine responses to ischemic threshold, tolerance, and pain intensity (McGill Sensory and Affective subscales) and side effects. For individuals with chronic pain and healthy control participants, those with low endogenous opioid function and low anger-out scores exhibited the largest morphine analgesic responses, whereas those with high anger-out and low endogenous opioid function showed relatively weaker morphine analgesic responses. Further, individuals with chronic pain with low endogenous opioid function and low anger-out scores also reported the fewest negative effects to morphine, whereas those with low endogenous opioid function and high anger-out reported the most. Findings point toward individuals with chronic pain who may strike a favorable balance of good analgesia with few side effects, as well as those who have an unfavorable balance of poor analgesia and many side effects.

PERSPECTIVE

We sought to identify optimal candidates for opioid pain management. Low back pain patients who express anger and also have deficient endogenous opioid function may be poor candidates for opioid therapy. In contrast, low back patients who tend not to express anger and who also have deficient endogenous opioid function may make optimal candidates for opioid therapy.

Characteristics of new depression diagnoses in patients with and without prior chronic opioid use

Chronic use (>90 Days) of opioid analgesics significantly increases the risk of development of new depression episodes (NDE). It is unclear whether depression that develops in this manner is similar to or different from NDE in persons not exposed to opioid analgesic use (OAU).

METHODS

VA patients were classified into two groups, those who did not receive an opioid and developed depression (non-OAU+NDE, n=4314) and those that had >90 days OAU and developed NDE (OAU+NDE, n=444). OAU+NDE patients were compared to non-OAU+NDE in terms of depression severity (PHQ-9 scores), incidence of PTSD, other anxiety disorders and substance use disorders after NDE, receipt of acute phase antidepressant treatment, dual antidepressant treatment, mood stabilizers and atypical antipsychotics. Prior to computing bivariate analysis, the prevalence of pain conditions and average maximum pain scores were equalized between the two groups using propensity scores and inverse probability of treatment weighting.

RESULTS

Controlling for pain, OAU+NDE patients had more depression symptoms (p=.012), more incident PTSD (p=.04) and opioid abuse/dependence and were more likely to receive 12 weeks of antidepressant treatment (p<.0001). Last, non-OAU+NDE were more likely to have incident diagnoses for any other anxiety disorder (p=.014).

CONCLUSIONS

Within the limitations of electronic medical record data, results indicate OAU+NDE patients have more depression symptoms, greater treatment adherence and different comorbid psychiatric conditions compared to non-OAU+NDE, independent of pain. Overall OAU related depression is as severe as non-OAU related depression and repeated depression screening in chronic opioid therapy may be warranted for pain patients, regardless of pain severity.

Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal Fusion

BACKGROUND

The coexistence of degenerative hip disease and spinal pathology is not uncommon with the number of surgical treatments performed for each condition increasing annually. The limited research available suggests spinal pathology portends less pain relief and worse outcomes after total hip arthroplasty (THA). We hypothesize that primary THA patients with preexisting lumbar spinal fusions (LSF) experience worse early postoperative outcomes.

METHODS

This study is a retrospective matched cohort study. Primary THA patients at 1 institution who had undergone prior LSF (spine arthrodesis-hip arthroplasty [SAHA]) were identified and matched to controls of primary THA without LSF. Early outcomes (<90 days) were compared.

RESULTS

From 2012 to 2014, 35 SAHA patients were compared to 70 matched controls. Patients were similar in age, sex, American Society of Anesthesiologist score, body mass index, and Charlson Comorbidity Index. SAHA patients had higher rates of complications (31.4% vs 8.6%, P = .008), reoperation (14.3% vs 2.9%, P = .040), and general anesthesia (54.3% vs 5.7%, P = .0001). Bivariate analysis demonstrated SAHA to predict reoperation (odds ratio, 5.67; P = .045) and complications (odds ratio, 4.89; P = .005). With the numbers available, dislocations (0% vs 2.8%), infections (0% vs 8.6%), readmissions, postoperative walking distance, and disposition only trended to favor controls (P > .05). Comparing controls to SAHA patients with <3 or ≥3 levels fused, longer fusions had increased cumulative postoperative narcotic consumption (mean morphine equivalents, 44.3 vs 46.9 vs 169.4; P = .001).

CONCLUSION

Patients with preexisting LSF experience worse early outcomes after primary THA including higher rates of complications and reoperation. Lower rates of neuraxial anesthesia and increased narcotic usage represent potential contributors. The complex interplay between the lumbar spine and hip warrants attention and further investigation.

The dark side of opioids in pain management: basic science explains clinical observation

Although there is no doubt about opioids' ability to relieve pain in the short term, it is not always clear why longer-term analgesic efficacy seems to be impaired. Tolerance and hyperalgesia have been suggested as mechanisms for opioid analgesic deterioration. But could there also be an effect of opioids on pain itself?

Introduction:

In the past 2 decades, opioids have been used increasingly for the treatment of persistent pain, and doses have tended to creep up. As basic science elucidates mechanisms of pain and analgesia, the cross talk between central pain and opioid actions becomes clearer.

Objectives:

We aimed to examine the published literature on basic science explaining pronociceptive opioid actions, and apply this knowledge to clinical observation.

Methods:

We reviewed the existing literature on the pronociceptive actions of opioids, both preclinical and clinical studies.

Results:

Basic science provides a rationale for the clinical observation that opioids sometimes increase rather than decrease pain. Central sensitization (hyperalgesia) underlies pain chronification, but can also be produced by high dose and high potency opioids. Many of the same mechanisms account for both central pain and opioid hyperalgesia.

Conclusion:

Newly revealed basic mechanisms suggest possible avenues for drug development and new drug therapies that could alter pain sensitization through endogenous and exogenous opioid mechanisms. Recent changes in practice such as the introduction of titration-to-effect for opioids have resulted in higher doses used in the clinic setting than ever seen previously. New basic science knowledge hints that these newer dosing practices may need to be reexamined. When pain worsens in a patient taking opioids, can we be assured that this is not because of the opioids, and can we alter this negative effect of opioids through different dosing strategies or new drug intervention?

Long-Acting Opioid Use Independently Predicts Perioperative Complication in Total Joint Arthroplasty

BACKGROUND

Opioid therapy is an increasingly used modality for treatment of musculoskeletal pain despite multiple associated risks. The purpose of this study was to evaluate how preoperative opioid use affects early outcomes after total joint arthroplasty.

METHODS

A total of 174 patients undergoing total joint arthroplasty were matched by age, gender, and procedure into 3 groups stratified by preoperative opioid use (nonuser, short acting [eg, Vicodin], long acting [eg, Oxycontin]).

RESULTS

Compared to nonusers, preoperative long-acting use was associated with increased postoperative mean opioid consumption (46 mg vs 366 mg mean morphine equivalents, P < .001) and independently predicted complications within 90 days (odds ratio: 6.15, confidence interval: [1.46, 25.95], P = .013).

CONCLUSION

Preoperative opioid use should be disclosed as a risk factor for complication to patients and taken into consideration by physicians before initiating opioid management.

Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty

BACKGROUND

The purpose of this study was to assess whether weaning of opioid use in the preoperative period improved total joint arthroplasty (TJA) outcomes.

METHODS

Forty-one patients who regularly used opioids and successfully weaned (defined as a 50% reduction in morphine-equivalent dose) before a primary total knee or hip arthroplasty were matched with a group of TJA patients who did not wean and a matched control group of TJA patients who did not use opioids preoperatively. The difference between preoperative and postoperative (at 6-12 months follow-up) patient-reported outcomes were assessed using the change in University of California, Los Angeles (UCLA) activity score, SF12v2, and The Western Ontario and McMaster Universities Arthritis Index (WOMAC). Paired t tests and 1-way repeated measures analysis of variance were performed to assess differences in TJA outcomes between groups.

RESULTS

Patients using opioids who successfully weaned had greater improvements in both disease-specific and generic measures of health outcomes than patients who did not wean (WOMAC 43.7 vs 17.8, P < .001; SF12v2 Physical Component Score 10.5 vs 1.85, P = .003; UCLA activity score 1.49 vs 0, P < .001). There was no statistical difference between the 2 groups on SF12v2 Mental Component Score 2.48 vs 4.21, P = .409. Patients who successfully weaned from opioids had similar outcomes to control patients who did not use opioids: WOMAC 39.0 vs 43.7, P = .31; SF12v2 Physical Component Score 12.5 vs 10.5, P = .35; SF12v2 Mental Component Score 3.08 vs 2.48, P = .82; UCLA activity 1.90 vs 1.49, P = .23.

CONCLUSION

Patients with a history of chronic opioid use who successfully decreased their use of opioids before surgery had substantially improved clinical outcomes that were comparable to patients who did not use opioids at all.