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Kim HS, Courtney DM, McCarthy DM, Cella D. Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers. Acad Emerg Med 2020; 27:403-418. [PMID: 31945245 DOI: 10.1111/acem.13918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 01/07/2023]
Abstract
Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.
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Affiliation(s)
- Howard S. Kim
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - D. Mark Courtney
- Department of Emergency Medicine University of Texas Southwestern Medical School Dallas TX
| | - Danielle M. McCarthy
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - David Cella
- Department of Medical Social Sciences Northwestern University Feinberg School of Medicine Chicago IL
- Center for Patient‐Centered Outcomes Northwestern University Feinberg School of Medicine Chicago IL
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Gessner DM, Horn JL, Lowenberg DW. Pain management in the orthopaedic trauma patient: Non-opioid solutions. Injury 2020; 51 Suppl 2:S28-S36. [PMID: 31079833 DOI: 10.1016/j.injury.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/18/2019] [Indexed: 02/02/2023]
Abstract
When treating pain in the orthopaedic trauma patient opioids have classically represented the mainstay of treatment. They are relatively inexpensive and modestly effective for basic pain management. However, they are fraught with considerable side effects as well as the very high risk of addiction. Their use in pain management has been implicated in the opioid epidemic. For this reason, as well as their only moderate efficacy, alternative modes of treatment have been sought for both the patient with isolated limb trauma and the patient with poly trauma. We review alternative treatment methods in pain management for those with isolated limb trauma and poly trauma. These methods include topical agents, as well as non steroidal anti-inflammatory medications, acetaminophen, gabapetoids, intravenous agents, varying degrees of local anesthetic infiltration and peripheral nerve blocks, and the newer modality of fascial plane blocks. Often, it is a combination of these analgesic modalities that gives the most optimum treatment for the trauma patient. This also, more frequently than not, must be individually tailored to the patient, as no two patients act the same in this regard. It is therefore of importance that the physician managing such patients's pain be experienced and well-versed in all these treatment modalities. We also provide a basic stepwise algorithm we have found useful in treating those with single extremity or single site trauma versus those patients with poly trauma and resultant multiple sources as pain generators. It is hoped that this breakdown of the different modalities along with a better understanding of each modality's potential benefits and indications will aid the surgeon in providing better care to patients following orthopedic trauma.
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Affiliation(s)
- Daniel M Gessner
- Department of Anesthesiology, Stanford University School of Medicine, USA
| | - Jean-Louis Horn
- Department of Anesthesiology, Stanford University School of Medicine, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Mailcode 6342, Redwood City, CA, 94063, USA.
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103
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Current Concepts in Rehabilitation Protocols to Optimize Patient Function Following Musculoskeletal Trauma. Injury 2020; 51 Suppl 2:S5-S9. [PMID: 32418645 DOI: 10.1016/j.injury.2020.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/29/2020] [Indexed: 02/02/2023]
Abstract
Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.
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Friedman BW, Ochoa LA, Naeem F, Perez HR, Starrels JL, Irizarry E, Chertoff A, Bijur PE, Gallagher EJ. Opioid Use During the Six Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study. Ann Emerg Med 2020; 75:578-586. [PMID: 31685253 PMCID: PMC7188578 DOI: 10.1016/j.annemergmed.2019.08.446] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/16/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE Despite the frequent use of opioids to treat acute pain, the long-term risks and analgesic benefits of an opioid prescription for an individual emergency department (ED) patient with acute pain are still poorly understood and inadequately quantified. Our objective was to determine the frequency of recurrent or persistent opioid use during the 6 months after the ED visit METHODS: This was a prospective, observational cohort study of opioid-naive patients presenting to 2 EDs for acute pain who were prescribed an opioid at discharge. Patients were followed by telephone 6 months after the ED visit. Additionally, we reviewed the statewide prescription monitoring program database. Outcomes included frequency of recurrent and persistent opioid use and frequency of persistent moderate or severe pain 6 months after the ED visit. Persistent opioid use was defined as filling greater than or equal to 6 prescriptions during the 6-month study period. RESULTS During 9 months beginning in November 2017, 733 patients were approached for participation. Four hundred eighty-four met inclusion criteria and consented to participate. Four hundred ten patients (85%) provided 6-month telephone data. The prescription monitoring database was reviewed for all 484 patients (100%). Most patients (317/484, 66%; 95% confidence interval 61% to 70%) filled only the initial prescription they received in the ED. One in 5 patients (102/484, 21%; 95% confidence interval 18% to 25%) filled at least 2 prescriptions within the 6-month period. Five patients (1%; 95% confidence interval 0% to 2%) met criteria for persistent opioid use. Of these 5 patients, all but 1 reported moderate or severe pain in the affected body part 6 months later. CONCLUSION Although 1 in 5 opioid-naive ED patients who received an opioid prescription for acute pain on ED discharge filled at least 2 opioid prescriptions in 6 months, only 1% had persistent opioid use. These patients with persistent opioid use were likely to report moderate or severe pain 6 months after the ED visit.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.
| | - Lorena Abril Ochoa
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Farnia Naeem
- Medical College, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Hector R Perez
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Andrew Chertoff
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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105
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Miano TA, Shashaty MGS, Yang W, Brown JR, Zuppa A, Hennessy S. Effect of Renin-Angiotensin System Inhibitors on the Comparative Nephrotoxicity of NSAIDs and Opioids during Hospitalization. ACTA ACUST UNITED AC 2020; 1:604-613. [PMID: 33163971 DOI: 10.34067/kid.0001432020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDS) are increasingly important alternatives to opioids for analgesia during hospitalization as health systems implement opioid-minimization initiatives. Increasing NSAID use may increase AKI rates, particularly in patients with predisposing risk factors. Inconclusive data in outpatient populations suggests that NSAID nephrotoxicity is magnified by renin-angiotensin system inhibitors (RAS-I). No studies have tested this in hospitalized patients. Methods Retrospective, active-comparator cohort study of patients admitted to four hospitals in Philadelphia, Pennsylvania. To minimize confounding by indication, NSAIDs were compared to oxycodone, and RAS-I were compared to amlodipine. We tested synergistic NSAID+RAS-I nephrotoxicity by comparing the difference in AKI rate between NSAID versus oxycodone in patients treated with RAS-I to the difference in AKI rate between NSAID versus oxycodone in patients treated with amlodipine. In a secondary analysis, we restricted the cohort to patients with baseline diuretic treatment. AKI rates were adjusted for 71 baseline characteristics with inverse probability of treatment-weighted Poisson regression. Results The analysis included 25,571 patients who received a median of 2.4 days of analgesia. The overall AKI rate was 23.6 per 1000 days. The rate difference (RD) for NSAID versus oxycodone in patients treated with amlodipine was 4.1 per 1000 days (95% CI, -2.8 to 11.1), and the rate difference for NSAID versus oxycodone in patients treated with RAS-I was 5.9 per 1000 days (95% CI, 1.9 to 10.1), resulting in a nonsignificant interaction estimate: 1.85 excess AKI events per 1000 days (95% CI, -6.23 to 9.92). Analysis in patients treated with diuretics produced a higher, albeit nonsignificant, interaction estimate: 9.89 excess AKI events per 1000 days (95% CI, -5.04 to 24.83). Conclusions Synergistic nephrotoxicity was not observed with short-term NSAID+RAS-I treatment in the absence of concomitant diuretics, suggesting that RAS-I treatment may not be a reason to choose opioids in lieu of NSAIDs in this population. Synergistic nephrotoxicity cannot be ruled out in patients treated with diuretics.
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Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.,Department of Epidemiology, Geisel School of Medicine, Hanover, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine, Hanover, New Hampshire
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Niu B, Yin Z, Qiu N, Yu Y, Huang Q, Zhu Q, Zhuang X, Chen Y. Effective management of acute postoperative pain using intravenous emulsions of novel ketorolac prodrugs: in vitro and in vivo evaluations. Eur J Pharm Sci 2020; 149:105344. [PMID: 32311454 DOI: 10.1016/j.ejps.2020.105344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 11/17/2022]
Abstract
The aim was to prepare intravenous fat emulsions (IFEs) of ketorolac (KTL) ester prodrugs and to investigate the pharmacokinetics and pharmacodynamics of these formulations. Three prodrugs of KTL (KTL-IS, KTL-AX and KTL-BT) were synthesized as a means to increase the lipid solubility of KTL. All KTL prodrugs with higher Log P values presented increased tendency to partition into a blank IFE using extemporaneous addition method - the encapsulation efficiency of KTL-IS IFE and KTL-BT IFE was more than 97%. The particle sizes and zeta potentials of these two formulations were comparable to that of the blank IFE. PK studies in rabbits showed significant larger AUC0-8h (646.969 ± 154.326 mg/L•h-1 for KTL-IS IFE and 559.426 ± 103.057 mg/L•h-1 for KTL-BT IFE) than that of ketorolac tromethamine (KTL-T) injectable (286.968 ± 63.045 mg/L•h-1) and approximately 2-fold increases in the elimination t1/2 over KTL-T. In a rat postoperative pain model, the paw withdrawal thresholds and the paw withdrawal latency after I.V. KTL prodrug IFEs were significantly higher than that after I.V. KTL-T at 3~4 h. Effective controlling of acute postoperative pain in a longer duration can be achieved by using non-addictive ketorolac derivatives intraveneous emulsions.
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Affiliation(s)
- Bixi Niu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, West China School of Pharmacy, Sichuan University, 17 Section 3, Renmin South Road, Chengdu, Sichuan Province, 610041, China; Laboratory for Drug Delivery & Translational Medicine, School of Pharmacy, Nantong University, 19 Qixiu Road, Nantong, Jiangsu Province, 226001, China
| | - Zongning Yin
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, West China School of Pharmacy, Sichuan University, 17 Section 3, Renmin South Road, Chengdu, Sichuan Province, 610041, China
| | - Nanqing Qiu
- Laboratory for Drug Delivery & Translational Medicine, School of Pharmacy, Nantong University, 19 Qixiu Road, Nantong, Jiangsu Province, 226001, China
| | - Yuting Yu
- Laboratory for Drug Delivery & Translational Medicine, School of Pharmacy, Nantong University, 19 Qixiu Road, Nantong, Jiangsu Province, 226001, China
| | - Qian Huang
- Laboratory for Drug Delivery & Translational Medicine, School of Pharmacy, Nantong University, 19 Qixiu Road, Nantong, Jiangsu Province, 226001, China
| | - Qing Zhu
- Laboratory for Drug Delivery & Translational Medicine, School of Pharmacy, Nantong University, 19 Qixiu Road, Nantong, Jiangsu Province, 226001, China
| | - Xiaoxiao Zhuang
- Formulation Division, Suzhou Salupurus Pharmaceutical Technology, 1 Zhaoyan Road, Suzhou, Jiangsu Province, 215421, China
| | - Yong Chen
- Laboratory for Drug Delivery & Translational Medicine, School of Pharmacy, Nantong University, 19 Qixiu Road, Nantong, Jiangsu Province, 226001, China.
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107
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Montoy JCC, Coralic Z, Herring AA, Clattenburg EJ, Raven MC. Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study. JAMA Intern Med 2020; 180:487-493. [PMID: 31961377 PMCID: PMC6990860 DOI: 10.1001/jamainternmed.2019.6544] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics. OBJECTIVE To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTS This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018. INTERVENTIONS Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction. MAIN OUTCOMES AND MEASURES The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting. RESULTS A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons. CONCLUSIONS AND RELEVANCE These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04155229.
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Affiliation(s)
| | - Zlatan Coralic
- Department of Emergency Medicine, University of California, San Francisco
| | - Andrew A Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California
| | - Eben J Clattenburg
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California.,Tuba City Regional Health Care Corporation, Tuba City, Arizona
| | - Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco
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Schaffer AL, Cairns R, Brown JA, Gisev N, Buckley NA, Pearson S. Changes in sales of analgesics to pharmacies after codeine was rescheduled as a prescription only medicine. Med J Aust 2020; 212:321-327. [DOI: 10.5694/mja2.50552] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/18/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Andrea L Schaffer
- Centre for Big Data Research in HealthUniversity of New South Wales Sydney NSW
| | - Rose Cairns
- University of Sydney Sydney NSW
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
| | - Jared A Brown
- Centre for Big Data Research in HealthUniversity of New South Wales Sydney NSW
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
| | - Natasa Gisev
- National Drug and Alcohol Research CentreUniversity of New South Wales Sydney NSW
| | | | - Sallie‐Anne Pearson
- Centre for Big Data Research in HealthUniversity of New South Wales Sydney NSW
- Menzies Centre for Health PolicyUniversity of Sydney Sydney NSW
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Kettler E, Brennan J, Coyne CJ. The effects of a morphine shortage on emergency department pain control. Am J Emerg Med 2020; 43:229-234. [PMID: 32192896 DOI: 10.1016/j.ajem.2020.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE In 2018, due to a national morphine shortage, our two study emergency departments (EDs) were unable to administer intravenous (IV) morphine for over six months. We evaluated the effects of this shortage on analgesia and patient disposition. METHODS This was a retrospective study in two academic EDs. Our control period (with morphine) was 4/1/17-6/30/17 and our study period (without morphine) was 4/1/18-6/30/18. We included all adult patients with a chief complaint of pain, initial pain score ≥4, and ≥2 recorded pain scores. The primary outcome was delta pain score. Secondary outcomes included final pain score, proportion of ED visits with opioids vs. non-opioids administered, and ED disposition. RESULTS We identified 6296 patients during our control period and 5816 during our study period. There was no significant difference in mean final pain score (study 4.45, control 4.44, p = 0.802), delta pain score (study -3.30, control -3.32, p = 0.556), nor admission rates (study 18.8%, control 17.8%, p = 0.131). We saw a decrease in opioid use (study 47.4%, control 60.0%, p < 0.01) and an increased use of non-opioid analgesics (study 27.3%, control 18.44%, p < 0.01). CONCLUSIONS Removing IV morphine in the ED, without a compensatory rise in alternative opioids, does not appear to significantly impact analgesia or disposition. These data favor a more limited opioid use strategy in the ED.
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Affiliation(s)
- Ellen Kettler
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Jesse Brennan
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
| | - Christopher J Coyne
- University of California, San Diego School of Medicine, La Jolla, CA, USA; Department of Emergency Medicine, 200 W. Arbor Dr. #8676 San Diego, CA 92103, USA.
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Godwin SA, Cherkas DS, Panagos PD, Shih RD, Byyny R, Wolf SJ. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Ann Emerg Med 2020; 74:e41-e74. [PMID: 31543134 DOI: 10.1016/j.annemergmed.2019.07.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This clinical policy from the American College of Emergency Physicians addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? Evidence was graded and recommendations were made based on the strength of the available data.
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111
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Nelson LS, Mazer-Amirshahi M, Perrone J. Opioid Deprescribing in Emergency Medicine-A Tool in an Expanding Toolkit. JAMA Netw Open 2020; 3:e201129. [PMID: 32211866 DOI: 10.1001/jamanetworkopen.2020.1129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark
- Division of Medical Toxicology, Rutgers New Jersey Medical School, Newark
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Center for Addiction Medicine and Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Smith BC, Vigotsky AD, Apkarian AV, Schnitzer TJ. Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department. JAMA Netw Open 2020; 3:e200802. [PMID: 32211867 PMCID: PMC7097712 DOI: 10.1001/jamanetworkopen.2020.0802] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown. OBJECTIVE To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included. MAIN OUTCOMES AND MEASURES The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber. RESULTS Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808 (95% CI, 0.802-0.814) compared with the prior year. In patients with musculoskeletal pain (back, joint, limb, and neck pain), opioid prescribing decreased by 71.1% (from 36.7 to 10.6 opioids per 100 encounters between 2013 and 2018; aOR, 0.758; 95% CI, 0.744-0.773). In patients with musculoskeletal trauma (fracture, sprain, contusion, and injury), opioid prescribing decreased by 58.0% (from 34.2 to 14.8 opioids per 100 encounters; aOR, 0.811; 95% CI, 0.797-0.824). In patients with nonmusculoskeletal pain (abdominal pain, kidney stone, respiratory distress, and pharyngitis) opioid prescribing decreased by 53.7% (from 20.1 to 9.3 opioids per 100 encounters; aOR, 0.850; 95% CI, 0.834-0.868). Between 2009 and 2018, patients who were black (aOR, 0.760; 95% CI, 0.741-0.779) and those who were Asian (aOR, 0.714; 95% CI, 0.665-0.764) had the lowest odds of receiving an opioid compared with other racial/ethnic groups. CONCLUSIONS AND RELEVANCE There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones.
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Affiliation(s)
- Ben C. Smith
- Medical Student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew D. Vigotsky
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
- Department of Statistics, Northwestern University, Evanston, Illinois
| | - A. Vania Apkarian
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Thomas J. Schnitzer
- Anesthesiology and Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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King C, Curran J, Devanagondi S, Balach T, Conti Mica M. Targeted Intervention to Increase Awareness of Opioid Overprescribing Significantly Reduces Narcotic Prescribing Within an Academic Orthopaedic Practice. JOURNAL OF SURGICAL EDUCATION 2020; 77:413-421. [PMID: 31587957 DOI: 10.1016/j.jsurg.2019.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 06/07/2019] [Accepted: 09/11/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the impact of a targeted intervention focused on increasing awareness of opioid overprescribing within an academic orthopaedic practice. DESIGN Retrospective prescribing data was collected through an electronic chart review. A single time point, a departmental grand rounds titled "Opioid Use, Misuse, & Abuse in Orthopaedics," was conducted on February 8, 2017. Opioid prescribing data was analyzed for the year preceding and year immediately following this targeted intervention. Narcotics were standardized using milligram morphine equivalents (MME) for comparison, and patients were categorized as opioid naive or non-naive based on whether an opioid prescription was written within 90 days prior to surgery. A segmented time series regression model was utilized to determine statistical significance of the educational intervention. SETTING Academic Medical Center. PARTICIPANTS All patients undergoing orthopaedic procedures at our institution between January 2016 and March 2018. RESULTS A total of 5882 patients underwent orthopaedic procedures at our institution during the study period. Of these, 2887 were in the year preceding and 2995 were in the year immediately following the targeted intervention to increase awareness of opioid overprescribing. The interve.ntion was associated with an acute decrease of 167 mean MME from 780 to 613 in opioid naive (p = 0.028) and 154 mean MME from 1,015 to 861 in opioid non-naive patients (p = 0.010). The intervention was also associated with a favorable change in the overall mean MME prescribing trend over time in both naive (p = 0.011) and non-naive (p = 0.064) patients. CONCLUSIONS This study demonstrates decreased opioid prescribing within an academic orthopaedic department after a targeted intervention focused on raising the awareness of opioid overprescribing. Ongoing provider education and awareness are critical parts of any plan to continue curtail opioid overprescribing among surgeons.
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Affiliation(s)
- Connor King
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois.
| | - John Curran
- University of Chicago Pritzker, School of Medicine, Chicago, Illinois
| | - Shwetha Devanagondi
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois
| | - Tessa Balach
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois
| | - Megan Conti Mica
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois
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Haslam A, Livingston C, Prasad V. Medical Reversals in Family Practice: A Review. CURRENT THERAPEUTIC RESEARCH 2020; 92:100579. [PMID: 32180846 PMCID: PMC7063107 DOI: 10.1016/j.curtheres.2020.100579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/14/2020] [Indexed: 11/25/2022]
Abstract
Background Primary care physicians are challenged by the need to stay abreast of current research on a wide variety of topics in an environment of time constraints, evolving literature, and misinformation on health topics that are sometimes promulgated to the public. Objective We sought to identify and discuss common clinical situations encountered in primary care for which medical reversals have occurred. Methods We recently identified almost 400 medical practices that were used in clinical care before they were tested in well-done randomized controlled trials and subsequently were found to be ineffective or harmful. Results We review several of these practices commonly used in family medicine, which include arthroscopy for osteoarthritis of the knee, opioids for common causes of pain, and aspirin and continuous positive airway pressure for the prevention of cardiovascular disease. Conclusions Although these practices were implemented because of sound biologic plausibility or encouraging observational data, well done randomized controlled trials have failed to show evidence of effectiveness. These examples raise caution in introducing new clinical interventions into widespread clinical practice without sufficient high-quality evidence demonstrating efficacy.
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Affiliation(s)
- Alyson Haslam
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Vinay Prasad
- Division of Hematology Oncology, Knight Cancer Institute, and Center for Health Care Ethics, Oregon Health & Science University, Portland, Oregon
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115
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Schwarz ES, Moy HP. In acute pain in prehospital settings, opioid and nonopioid analgesics do not differ for pain at 15 or 60 min. Ann Intern Med 2020; 172:JC20. [PMID: 32066153 DOI: 10.7326/acpj202002180-020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Hawnwan P. Moy
- Washington University School of MedicineSt. Louis, Missouri, USADisclosures: The commentators have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3039
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116
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Optimizing Opioid Pain Medication Use After Vasectomy—A Prospective Study. Urology 2020; 136:41-45. [DOI: 10.1016/j.urology.2019.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/04/2019] [Accepted: 11/15/2019] [Indexed: 11/23/2022]
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117
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Hastings JS, Howison M, Inman SE. Predicting high-risk opioid prescriptions before they are given. Proc Natl Acad Sci U S A 2020; 117:1917-1923. [PMID: 31937665 PMCID: PMC6994994 DOI: 10.1073/pnas.1905355117] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Misuse of prescription opioids is a leading cause of premature death in the United States. We use state government administrative data and machine learning methods to examine whether the risk of future opioid dependence, abuse, or poisoning can be predicted in advance of an initial opioid prescription. Our models accurately predict these outcomes and identify particular prior nonopioid prescriptions, medical history, incarceration, and demographics as strong predictors. Using our estimates, we simulate a hypothetical policy which restricts new opioid prescriptions to only those with low predicted risk. The policy's potential benefits likely outweigh costs across demographic subgroups, even for lenient definitions of "high risk." Our findings suggest new avenues for prevention using state administrative data, which could aid providers in making better, data-informed decisions when weighing the medical benefits of opioid therapy against the risks.
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Affiliation(s)
- Justine S Hastings
- Research Improving People's Lives, Providence, RI 02903;
- Watson Institute for International and Public Affairs, Brown University, Providence, RI 02912
- Department of Economics, Brown University, Providence, RI 02912
- National Bureau of Economic Research, Cambridge, MA 02138
| | - Mark Howison
- Research Improving People's Lives, Providence, RI 02903
- Watson Institute for International and Public Affairs, Brown University, Providence, RI 02912
| | - Sarah E Inman
- Research Improving People's Lives, Providence, RI 02903
- School of International and Public Affairs, Columbia University, New York, NY 10027
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118
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The analgesic efficacy and safety of peri-articular injection versus intra-articular injection in one-stage bilateral total knee arthroplasty: a randomized controlled trial. BMC Anesthesiol 2020; 20:2. [PMID: 31901229 PMCID: PMC6942284 DOI: 10.1186/s12871-019-0922-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/23/2019] [Indexed: 12/19/2022] Open
Abstract
Background As an essential component of multimodal analgesia approaches after total knee arthroplasty (TKA), local infiltration analgesia (LIA) can be classified into peri-articular injection (PAI) and intra-articular injection (IAI) according to administration techniques. Currently, there is no definite answer to the optimal choice between the two techniques. Our study aims to investigate analgesic efficacy and safety of PAI versus IAI in patients receiving simultaneous bilateral TKA. Methods This randomized controlled trial was conducted from February 2017 and finished in July 2018. Sixty patients eligible for simultaneous bilateral total knee arthroplasty were randomly assigned to receive PAI on one side and IAI on another. Primary outcomes included numerical rating scale (NRS) pain score at rest or during activity at 3 h, 6 h, 12 h, 24 h, 48 h, and 72 h following surgery. Secondary outcomes contained active or passive range of motion (ROM) at 1, 2, and 3 days after surgery, time to perform straight leg raise, wound drainage, operation time, and wound complications. Results Patients experienced lower NRS pain scores of the knee receiving PAI compared with that with PAI during the first 48 h after surgery. The largest difference of NRS pain score at rest occurred at 48 h (PAI: 0.68, 95%CI[0.37, 0.98]; IAI: 2.63, 95%CI [2.16, 3.09]; P < 0.001); and the largest difference of NRS pain score during activity also took place at 48 h (PAI: 2.46, 95%CI [2.07, 2.85]; IAI: 3.90, 95%CI [3.27, 4.52]; P = 0.001). PAI group had better results of range of motion and time to perform straight leg raise when compared with IAI group. There were no differences in operation time, wound drainage, and wound complication. Conclusion PAI had the superior performance of pain relief and improvement of range of motion to IAI. Therefore, the administration technique of peri-articular injection is recommended when performing local infiltration analgesia after total knee arthroplasty. Trial registration The trial was retrospectively registered in the Chinese Clinical Trial Registry as ChiCTR1800020420 on 29th December, 2018. Level of evidence Therapeutic Level I.
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119
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Yip K, Oettinger J. Why are we still using opioids for osteoarthritis? Int J Clin Pract 2020; 74:e13416. [PMID: 31508873 DOI: 10.1111/ijcp.13416] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/11/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Osteoarthritis is a common debilitating condition affecting a substantial portion of the population and is an accepted consequence of ageing and overuse. Whilst surgical interventions are a definitive approach, most cases are managed medically with analgesia. Pharmacological therapies have included acetaminophen, non-steroidal anti-inflammatory drugs and opiates. Although significant controversies exist in the use of opioids for chronic musculoskeletal pain, many leading guidelines continue to recommend its use despite increasing evidence to suggest an increase in addiction, morbidity and mortality. With the opiate crisis growing, we re-examine the role opiates have in this chronic condition and current data, and briefly evaluate alternative therapies.
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Affiliation(s)
- Kevin Yip
- Department of Internal Medicine, New York University Langone Health, New York City, NY, USA
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120
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Odineal DD, Marois MT, Ward D, Schmid CH, Cabrera R, Sim I, Wang Y, Wilsey B, Duan N, Henry SG, Kravitz RL. Effect of Mobile Device-Assisted N-of-1 Trial Participation on Analgesic Prescribing for Chronic Pain: Randomized Controlled Trial. J Gen Intern Med 2020; 35:102-111. [PMID: 31463686 PMCID: PMC6957655 DOI: 10.1007/s11606-019-05303-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 07/03/2019] [Accepted: 08/06/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed for chronic musculoskeletal pain, despite limited evidence of effectiveness and well-documented adverse effects. We assessed the effects of participating in a structured, personalized self-experiment ("N-of-1 trial") on analgesic prescribing in patients with chronic musculoskeletal pain. METHODS We randomized 215 patients with chronic pain to participate in an N-of-1 trial facilitated by a mobile health app or to receive usual care. Medical records of participating patients were reviewed at enrollment and 6 months later to assess analgesic prescribing. We established thresholds of ≥ 50, ≥ 20, and > 0 morphine milligram equivalents (MMEs) per day to capture patients taking relatively high doses only, patients taking low-moderate as well as relatively high doses, and patients taking any dose of opioids, respectively. RESULTS There was no significant difference between the N-of-1 and control groups in the percentage of patients prescribed any opioids (relative odds ratio (ROR) = 1.05; 95% confidence interval [CI] = 0.61 to 1.80, p = 0.87). There was a clinically substantial but statistically not significant reduction of the percentage of patients receiving ≥ 20 MME (ROR = 0.58; 95% CI = 0.33 to 1.04, p = 0.07) and also in the percentage receiving ≥ 50 MME (ROR = 0.50; 95% CI = 0.19 to 1.34, p = 0.17). There was a significant reduction in the proportion of patients in the N-of-1 group prescribed NSAIDs compared with control (relative odds ratio = 0.53; 95% CI = 0.29 to 0.96, p = 0.04), with no concomitant increase in average pain intensity. There was no significant change in use of adjunctive medications (acetaminophen, gabapentenoids, or topicals). DISCUSSION These exploratory results suggest that participation in N-of-1 trials may reduce long-term use of NSAIDs; there is also a weak signal for an effect on use of opioids. Additional research is needed to confirm these results and elucidate possible mechanisms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02116621.
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Affiliation(s)
- David D Odineal
- Department of Medicine, Madigan Army Medical Center, Joint Base Lewis McChord, Tacoma, WA, USA
- School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Maria T Marois
- Center for Health Care Policy and Research, University of California Davis, Sacramento, CA, USA
| | - Deborah Ward
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, USA
| | - Christopher H Schmid
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Rima Cabrera
- Center for Health Care Policy and Research, University of California Davis, Sacramento, CA, USA
| | - Ida Sim
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
- Open mHealth, New York, NY, USA
| | - Youdan Wang
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Barth Wilsey
- Veterans Affairs Northern California Health Care System, Sacramento Medical Center, Mather, CA, USA
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Naihua Duan
- Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Stephen G Henry
- Department of Internal Medicine, Division of General Medicine, University of California Davis, Sacramento, CA, USA
| | - Richard L Kravitz
- Department of Internal Medicine, Division of General Medicine, University of California Davis, Sacramento, CA, USA.
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121
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Diaz-Abele J, Luc M, Dyachenko A, Aldekhayel S, Ciampi A, McCusker J. Lidocaine With Epinephrine Versus Bupivacaine With Epinephrine as Local Anesthetic Agents in Wide-Awake Hand Surgery: A Pilot Outcome Study of Patient’s Pain Perception. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:1-6. [PMID: 35415474 PMCID: PMC8991639 DOI: 10.1016/j.jhsg.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/06/2019] [Indexed: 11/16/2022] Open
Abstract
Purpose Wide-awake local anesthesia hand surgery has many advantages over other forms of anesthesia, including faster recovery, lower cost, and improved patient safety; however, few studies compare postoperative pain and analgesic consumption after long- and short-acting anesthetics. This is important because surgeons seek to minimize opioid consumption during the opioid epidemic. Methods This was a double-blinded, prospective, randomized, parallel design pilot study. We randomized 61 patients to receive carpal tunnel surgery with a short-lasting regional anesthetic (lidocaine, 29 patients) or a long-lasting one (bupivacaine, 32 patients). Primary outcomes were pain levels over the first and second 24 hours. Secondary outcomes were postoperative consumption of acetaminophen and opioids over the first and second 12 hours after surgery. Results Pain intensity and acetaminophen consumption were significantly less in the bupivacaine group over the first 24 and 12 hours after surgery, respectively. The bupivacaine group consumed less opioids in the first 12 hours and delayed consumption of the first medication after surgery, but these results were not statistically significant. There was no difference in pain intensity or analgesic consumption between 24 and 48 hours after surgery. Conclusions The use of a long-term anesthetic (bupivacaine) over a short-term one (lidocaine) in awake carpal tunnel release surgery decreases postoperative pain over the initial 12 hours after surgery and delays the initiation of analgesic consumption; however, this difference is small. The amount of opioid consumption was not significantly different between groups, but both groups consumed less than 10% of the prescribed opioids. It is important to reevaluate the need for opioids in minor hand surgery and favor the use of alternatives such as nonsteroidal anti-inflammatory drugs and acetaminophen. Type of study/level of evidence Therapeutic I.
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122
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Foster AA, Porter JJ, Bourgeois FT, Mannix R. The use of opioids in low acuity pediatric trauma patients. PLoS One 2019; 14:e0226433. [PMID: 31841556 PMCID: PMC6913969 DOI: 10.1371/journal.pone.0226433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/26/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To describe temporal trends and factors associated with opioid administration among children discharged from the emergency department (ED) after a trauma visit. METHODS This was a cross-sectional study of ED visits for children <19 years old who received a trauma-related diagnosis and were discharged from the ED. Data were obtained from the National Hospital Ambulatory Medical Care Survey 2006-2015. OUTCOME MEASURES Administration of an opioid medication either during the ED visit or as a discharge prescription. Survey-adjusted regression analyses were used to determine the probability of a patient receiving an opioid medication. RESULTS During the study period, there were 19,241 pediatric trauma visits discharged from the ED, of which 14% were associated with an opioid. Opioid administration decreased by nearly 30% during the study period (p<0.001 for trend). In multivariable analysis, patient factors associated with opioid administration were adolescent age, evening visit, region of the country, and severe pain score. The diagnosis associated with the most opioids was ankle sprain and the diagnosis with the highest rate of opioid administration was radius fracture. The most common opioid administered to children under 12 years of age was acetaminophen-codeine. CONCLUSIONS Opioid administration appears to be decreasing among pediatric patients presenting to the ED with trauma, but a high number of children continue to be exposed to opioids every year. Further education on opioid sparing pain management strategies may be warranted to decrease opioid exposure, including the inappropriate use of codeine, in this low risk trauma population.
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Affiliation(s)
- Ashley A. Foster
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - John J. Porter
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Florence T. Bourgeois
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Loh FE, Herzig SJ. Pain in the United States: Time for a Culture Shift in Expectations, Messaging, and Management. J Hosp Med 2019; 14:787-788. [PMID: 31339835 PMCID: PMC6897535 DOI: 10.12788/jhm.3277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Opioid prescribing has dramatically increased in the
United States (US) over the past two decades, fueling
the current crisis of opioid-related adverse
events and deaths.1 Understanding the potential
contributors to this increased prescribing is paramount to developing
effective strategies for preventing propagation. In this
issue of the Journal of Hospital Medicine, Burden et al. report
the results of a cross-sectional observational study investigating
the rates of opioid receipt, patient satisfaction with pain control,
and other perceptions of pain management in a sample of patients
from geographically diverse US hospitals compared with
patients hospitalized in seven other countries.2 Although cultural
influences on pain perceptions have been demonstrated by
others previously, this is the first study to measure opioid receipt
and patient satisfaction with pain control across an international
sample of hospitalized patients.
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Affiliation(s)
- F Ellen Loh
- Department of Social, Behavioral and Administrative Sciences, Touro College of Pharmacy, New York, New York
| | - Shoshana J Herzig
- Department of Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Corresponding Author: Shoshana J. Herzig, MD, MPH; E-mail: ; Telephone: 617-754-1413; Twitter:@ShaniHerzig
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Menchine M, Lam CN, Arora S. Prescription Opioid Use in General and Pediatric Emergency Departments. Pediatrics 2019; 144:peds.2019-0302. [PMID: 31619511 DOI: 10.1542/peds.2019-0302] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent evidence reveals that exposure to emergency department (ED) opioids is associated with a higher risk of misuse. Pediatric EDs are generally thought to provide the highest-quality care for young persons, but most children are treated in general EDs. We sought to determine if ED opioid administration and prescribing vary between pediatric and general EDs. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey (2006-2015), a representative survey of ED visits, by using multivariate logistic regressions. Outcomes of interest were the proportion of patients ≤25 years of age who (1) were administered an opioid in the ED, (2) were given a prescription for an opioid, or (3) were given a prescription for a nonopioid analgesic. The key predictor variable was ED type. A secondary analysis was conducted on the subpopulation of patients with a diagnosis of fracture or dislocation. RESULTS Of patients ≤25 years of age, 91.1% were treated in general EDs. The odds of being administered an opioid in the ED were similar in pediatric versus general EDs (adjusted odds ratio [OR] 0.88; 95% confidence interval [CI] 0.61-1.27; P = .49). Patients seen in pediatric EDs were less likely to receive an outpatient prescription for opioids (adjusted OR 0.38; 95% CI 0.27-0.52; P < .01) than similar patients in general EDs. This was true for the fracture subset as well (adjusted OR 0.27; 95% CI 0.13-0.54; P < .01). CONCLUSIONS Although children, adolescents, and young adults had similar odds of being administered opioids while in the ED, they were much less likely to receive an opioid prescription from a pediatric ED compared with a general ED.
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Affiliation(s)
- Michael Menchine
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
| | - Chun Nok Lam
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
| | - Sanjay Arora
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
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Anderson BJ, Hannam JA. A target concentration strategy to determine ibuprofen dosing in children. Paediatr Anaesth 2019; 29:1107-1113. [PMID: 31472084 DOI: 10.1111/pan.13731] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/14/2019] [Accepted: 08/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Ibuprofen is widely used for ductus arteriosus closure in premature neonates and for analgesia in children and adults. There are no maturation descriptors of clearance. This lack of maturation understanding limits dosing recommendations from premature neonates to adulthood. METHODS Published clearance estimates from different aged patients determined after administration from time-concentration profiles were used to construct a maturation model based on size and age. Curve fitting was performed using nonlinear mixed-effects models. A target concentration strategy was used to estimate maintenance dose at different ages. RESULTS There were three publications reporting an estimate of individual clearance estimates in premature neonates, three reporting population clearances in infants, 11 in children 2-15 years (1 with individual and 9 with population clearances), and 13 adult studies (1 with individual and 12 with population clearances). Clearance maturation, standardized to a 70 kg person was described using the Hill equation. Mature clearance was 3.81 (CV 15.5%, 95%CI 3.72, 3.92) L/h/70 kg. The maturation half-time was 36.8 (CV 9.2%, 95%CI 34.7, 40.9) weeks postmenstrual age and the Hill coefficient 11.5 (95%CI 8.1, 15). A target effect of four units (visual analogue scale 0-10) correlated with an effect site concentration of 6.3 mg/L: a concentration achieved at trough after 400 mg 8 hourly in adults. CONCLUSION Previously published pharmacokinetic parameters can be used to develop maturation models that address gaps in current knowledge regarding the influence of age on a drug's disposition. Maturation of ibuprofen clearance was rapid and was 90% of adult values by the first month of life in term neonates (ie, 44 weeks postmenstrual age) and 98% of standardized adult estimates by 3 months of age (53 weeks postmenstrual age). Clearance informed dosing predictions in all ages (premature neonate to adult) and matched those doses in common use in children older than 3 months.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.,Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
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Florine BL. Is it Time to Relegate Routine Opioid Prescriptions to the Oral Surgery Archives? J Oral Maxillofac Surg 2019; 78:5-6. [PMID: 31626743 DOI: 10.1016/j.joms.2019.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 10/26/2022]
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127
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Moe S, Kirkwood J, Allan GM. Incidence of iatrogenic opioid use disorder. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:724. [PMID: 31604741 PMCID: PMC6788669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Samantha Moe
- Clinical Evidence Expert for the College of Family Physicians of Canada in Mississauga, Ont
| | - Jessica Kirkwood
- Family physician at the Boyle McCauley Health Centre in Edmonton, Alta
| | - G Michael Allan
- Director of Programs and Practice Support for the College of Family Physicians of Canada and Professor in the Department of Family Medicine at the University of Alberta in Edmonton
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Gong J, Colligan M, Kirkpatrick C, Jones P. Oral Paracetamol Versus Combination Oral Analgesics for Acute Musculoskeletal Injuries. Ann Emerg Med 2019; 74:521-529. [DOI: 10.1016/j.annemergmed.2019.05.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/15/2019] [Accepted: 05/21/2019] [Indexed: 11/28/2022]
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129
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Moe S, Kirkwood J, Allan GM. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e431-e432. [PMID: 31604753 PMCID: PMC6788670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Samantha Moe
- Données probantes cliniques au Collège des médecins de famille du Canada à Mississauga (Ontario)
| | - Jessica Kirkwood
- Médecin de famille au Centre médical Boyle McCauley à Edmonton (Alberta)
| | - G Michael Allan
- Directeur de Programmes et soutien à la pratique du Collège des médecins de famille du Canada, et professeur au Département de médecine familiale de l'Université de l'Alberta à Edmonton
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Viglino D, Termoz Masson N, Verdetti A, Champel F, Falcon C, Mouthon A, Mabiala Makele P, Collomb Muret R, Maindet Dominici C, Maignan M. Multimodal oral analgesia for non-severe trauma patients: evaluation of a triage-nurse directed protocol combining methoxyflurane, paracetamol and oxycodone. Intern Emerg Med 2019; 14:1139-1145. [PMID: 31290084 DOI: 10.1007/s11739-019-02147-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/03/2019] [Indexed: 01/03/2023]
Abstract
Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled methoxyflurane) initiated by triage nurse. We performed a prospective, observational study in an emergency department (Grenoble Alpes University Hospital, France) between December 2017 and April 2018. Adult non-severe trauma patients with a numerical pain rating scale (NRS) score ≥ 4 were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤ 3 at 15 min. Pain intensity was measured for 60 min and during radiography. Data on adverse events and satisfaction were recorded. A total of 200 adult patients were included (median [interquartile range (IQR)] age: 32 [23-49] years; 126 men (63%)). Sixty-six patients (33%) reported an NRS score ≤ 3 at 15 min. The time required to achieve a decrease of at least 2 points in the NRS score was 10 (5-20) min. The median [IQR] pain intensity was 4 [2-5] before radiography and 4 [2-6] during radiography. Adverse events were frequent (n = 128, 64%). No serious adverse events were reported. The patients and caregivers reported good levels of satisfaction. The administration of a nurse-driven multimodal analgesia protocol (combining paracetamol, oxycodone, and methoxyflurane) was feasible on admission to the emergency department. It rapidly produced long-lasting analgesia in adult trauma patients.Trial registration: NCT03380247.
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Affiliation(s)
- Damien Viglino
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Nicolas Termoz Masson
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Agnès Verdetti
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Flore Champel
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Cédric Falcon
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Alexis Mouthon
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Prudence Mabiala Makele
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France
| | | | - Maxime Maignan
- Emergency Department, Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble Cedex 9, France.
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A Quality Improvement Initiative Featuring Peer-Comparison Prescribing Feedback Reduces Emergency Department Opioid Prescribing. Jt Comm J Qual Patient Saf 2019; 45:669-679. [PMID: 31488343 DOI: 10.1016/j.jcjq.2019.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/22/2019] [Accepted: 07/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Opioid prescribing in the United States nearly tripled from 1999 to 2015, and opioid overdose deaths doubled in the same time frame. Emergency departments (EDs) may play a pivotal role in the opioid epidemic as a source of first-time opioid exposure; however, many prescribers are generally unaware of their prescribing behaviors relative to their peers. METHODS All 117 ED prescribers at an urban academic medical center were provided with regular feedback on individual rates of opioid prescribing relative to their de-identified peers. To evaluate the effect of this intervention on the departmental rate of opioid prescribing, a statistical process control (SPC) chart was created to identify special cause variation, and an interrupted time series analysis was conducted to evaluate the immediate effect of the intervention and any change in the postintervention trend due to the intervention. RESULTS The aggregate opioid prescribing rate in the preintervention period was 8.6% (95% confidence interval [CI]: 8.3%-8.9%), while the aggregate postintervention prescribing rate was 5.8% (95% CI: 5.5%-6.1%). The SPC chart revealed special cause variation in both the pre- and postintervention periods, with an overall downtrend of opioid prescribing rates across the evaluation period and flattening of rates in the final four blocks. Interrupted time series analysis demonstrated a significant immediate downward effect of the intervention and a nonsignificant additional decrease in postintervention trend. CONCLUSION Implementation of peer-comparison opioid prescribing feedback was associated with a significant immediate reduction in the rate of ED discharge opioid prescribing.
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Häske D, Böttiger BW, Bouillon B, Fischer M, Gaier G, Gliwitzky B, Helm M, Hilbert-Carius P, Hossfeld B, Schempf B, Wafaisade A, Bernhard M. Analgesie bei Traumapatienten in der Notfallmedizin. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-00629-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
The management of acute pain in older adults (age 65 or greater) requires special attention due to various physiologic, cognitive, functional, and social issues that may change with aging. Especially in the postoperative setting, there are significant complications that can occur if pain is not treated adequately for elderly patients. In this article, the authors describe these changes in detail and discuss how pain should be assessed appropriately in older patients. In addition, the authors detail the unique risks and benefits of several mainstream analgesic medications as well as interventional treatments for elderly patients. The authors' goal is to provide recommendations for health care providers on appropriately recognizing and treating pain in a safe, effective manner for aging patients.
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Affiliation(s)
- Jay Rajan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Avenue, S-455, San Francisco, CA 94143, USA
| | - Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Avenue, S-455, San Francisco, CA 94143, USA.
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Abstract
EBN Perspectives brings together key issues from the commentaries in one of our nursing topic themes.
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Affiliation(s)
- Lisa Kidd
- Nursing and Healthcare, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Alison Twycross
- School of Health and Social Care, London South Bank University, London, UK
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Daniels SE, Playne R, Stanescu I, Zhang J, Gottlieb IJ, Atkinson HC. Efficacy and Safety of an Intravenous Acetaminophen/Ibuprofen Fixed-dose Combination After Bunionectomy: a Randomized, Double-blind, Factorial, Placebo-controlled Trial. Clin Ther 2019; 41:1982-1995.e8. [PMID: 31447129 DOI: 10.1016/j.clinthera.2019.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/29/2019] [Accepted: 07/09/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Multimodal analgesia with acetaminophen and/or nonsteroidal anti-inflammatory drugs is recommended for the treatment of postoperative pain. Although oral fixed-dose combinations (FDCs) are available, parenteral administration may be clinically justified. The goal of this study was to investigate the clinical efficacy and safety of an intravenous FDC of ibuprofen and acetaminophen after bunionectomy. METHODS This study was a prospective, randomized, double-blind, multicenter, placebo-controlled factorial clinical trial conducted at 2 clinical research centers in the United States between November 2016 and June 2017. Eligible patients (male and female subjects, aged 18-65 years, reporting pain intensity levels ≥40 mm on a 100-mm visual analog scale (VAS) after distal, first metatarsal bunionectomy) were randomized (3:3:3:2) to receive the FDC (ibuprofen 300 mg + acetaminophen 1000 mg), ibuprofen 300 mg, acetaminophen 1000 mg, or placebo (vehicle), administered as 15-minute intravenous infusions every 6 hours for 48 hours. The primary efficacy end point was the time-adjusted sum of pain intensity differences from baseline over 48 hours (SPID48). In addition to VAS pain intensity scores, pain relief scores, time to perceptible and meaningful pain relief, the use of rescue medication, and participant's global evaluations of the study drug were recorded. Adverse events occurring during the 48-hour treatment period were included in the safety analysis. FINDINGS A total of 276 participants were enrolled; most were female (82%), the mean age was 42.4 years, and the median baseline VAS was 67 mm, indicating moderate to severe pain. SPID48 was significantly higher for the FDC (23.4 [2.5] mm) than for ibuprofen (9.5 [2.5] mm), acetaminophen (10.4 [2.5] mm), and placebo (-1.3 [3.1] mm; all, P < 0.001). The superior analgesic effect of the FDC was supported by a range of secondary end points, including reduced opioid usage rates (75% for FDC, 92% for ibuprofen, 93% for acetaminophen, and 96% for placebo; all, P < 0.005). The safety profile of the FDC was comparable to that of intravenous ibuprofen or acetaminophen alone. Three participants withdrew from the study due to adverse events: 2 in the ibuprofen group and 1 in the acetaminophen group. IMPLICATIONS The study found that repeated administration of an intravenous FDC of ibuprofen and acetaminophen provided statistically significant improvement in SPID48 over comparable doses of either monotherapy without an increase in adverse events. ClinicalTrials.gov identifier: NCT02689063.
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Collinsworth KM, Goss DL. Battlefield Acupuncture and Physical Therapy Versus Physical Therapy Alone After Shoulder Surgery. Med Acupunct 2019; 31:228-238. [PMID: 31456869 DOI: 10.1089/acu.2019.1372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: Opioid pain medications are commonly prescribed postsurgically for pain. Few studies have investigated the effects of Battlefield Acupuncture (BFA) on postsurgical pain and pain-medication use. To date, no studies have investigated BFA's effectiveness for reducing postoperative shoulder pain and pain-medication use post surgery. The objective of this study was to determine if adding BFA to a rehabilitation protocol was effective for reducing pain and use of prescribed pain medications, compared to that protocol alone after shoulder surgery. Materials and Methods: Forty Department of Defense beneficiaries (ages 17-55) were randomized to either a standard-of-care group or a standard-of-care + BFA group prior to shoulder surgery. The standard BFA protocol was administered with semipermanent acupuncture needles emplaced on the subjects' ears for 3-5 days within 24 hours after shoulder surgery in an outpatient physical therapy setting. BFA was reapplied, as needed, up to 6 weeks postsurgically for pain management in the intervention group. The primary outcomes were visual analogue scale (VAS) pain rating and daily pain medication use by each subject. Secondary outcome measures were the Global Rating of Change and Patient Specific Functional scale. Outcome measures were obtained at 24 hours, 72 hours, 1 week, 2 weeks, and 6 weeks post surgery. Results: Significant differences in average and worst VAS pain change scores were noted between baseline and 7 days (P < 0.05). The main effect for time was significant (average and worst VAS pain) at all timepoints (P < 0.05), without time-group interactions seen. No significant differences between the groups in pain-medication use were observed (P > 0.05) Conclusions: BFA reduced postsurgical shoulder pain significantly between the groups' average and worst pain change scores between baseline and 7 days despite similar opioid and nonsteroidal anti-inflammatory drug use between the groups.
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Affiliation(s)
- Keith M Collinsworth
- Keller Army Community Hospital, West Point, NY.,Baylor-KACH Division 1 Sport Physical Therapy, Waco, TX
| | - Donald L Goss
- Keller Army Community Hospital, West Point, NY.,Baylor-KACH Division 1 Sport Physical Therapy, Waco, TX
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Barnett ML, Zhao X, Fine MJ, Thorpe CT, Sileanu FE, Cashy JP, Mor MK, Radomski TR, Hausmann LRM, Good CB, Gellad WF. Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis. J Gen Intern Med 2019; 34:1522-1529. [PMID: 31144281 PMCID: PMC6667564 DOI: 10.1007/s11606-019-05023-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/05/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.
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Affiliation(s)
- Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for High Value Health Care, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA.
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Truchot J, Mezaïb K, Ricard-Hibon A, Vicaut E, Claessens YE, Soulat L, Milon JY, Serrie A, Plaisance P. Assessment of procedural pain in French emergency departments: a multi-site, non-interventional, transverse study in patients with minor trauma injury. Hosp Pract (1995) 2019; 47:143-148. [PMID: 31343374 DOI: 10.1080/21548331.2019.1646074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To determine the mean number of procedural painful episodes per patient, and to retrieve information regarding diagnosis, therapeutic procedures and analgesic management, in patients visiting Emergency Departments (EDs) for minor trauma. Methods: This observational, non-interventional, multicenter study in adult patients was performed in 35 French EDs. All patients entering the EDs for minor trauma on a specified day between noon and 10 pm were registered; consenting patients were included in the study. Pain intensity was assessed using a verbal Numerical Rating Scale from 0 (no pain) to 10 (worst possible pain). An episode was described as painful if the difference in pain intensity between pain just before the procedure and maximal pain during the procedure was ≥2. Two independent nurses recorded data on 1 day in each center. Results: Overall, 909 patients were registered, 422 were included in the study, and complete data for 409 patients (1899 procedures) were available for analysis. The mean number of painful episodes per patient was 1.0 ± 1.3. Fifty-one percent of patients reported at least one painful procedure episode. Twenty-one percent of procedures were considered painful. Clinical examination was the procedure most often reported as painful. No preventive or curative analgesic treatment was reported in 95.1% of procedures. Conclusions: There is a need for improvement in routine pain assessment and, therefore, procedural pain management for ED patients. Specific protocols should be developed for procedural pain management, and teams should be trained especially for procedures usually not considered painful.
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Affiliation(s)
- Jennifer Truchot
- Department of Emergency Medicine, Lariboisière University Hospital, AP-HP, Paris Diderot University , Paris , France
| | - Karima Mezaïb
- Department of Pain Medicine, Institut Gustave Roussy , Villejuif , France
| | | | - Eric Vicaut
- Clinical Research Unit, Fernand Widal University Hospital , Paris , France
| | | | - Louis Soulat
- Department of Emergency Medicine, Rennes University Hospital , Rennes , France
| | | | - Alain Serrie
- Department of Pain and Palliative Medicine, Lariboisière University Hospital , Paris , France
| | - Patrick Plaisance
- Department of Emergency Medicine, Lariboisière University Hospital, AP-HP, Paris Diderot University , Paris , France
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Sim V, Hawkins S, Gave AA, Bulanov A, Elabbasy F, Khoury L, Panzo M, Sim E, Cohn S. How low can you go: Achieving postoperative outpatient pain control without opioids. J Trauma Acute Care Surg 2019; 87:100-103. [PMID: 31259870 DOI: 10.1097/ta.0000000000002295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative outpatient narcotic overprescription plays a significant role in the opioid epidemic. Outpatient opioid prescription ranges from 150 to 350 oral morphine equivalent (OME) for a laparoscopic cholecystectomy or appendectomy, with 75 OME (10 pills of 5 mg of oxycodone) being the lowest recommendation (National Institute on Drug Abuse, 2018). We hypothesized that the addition of nonopioid medications to the outpatient pain control regimen would decrease the need for narcotics. METHODS In this prospective, observational pilot study, we prescribed a 3-day regimen of ibuprofen and acetaminophen to patients after uncomplicated laparoscopic cholecystectomies and appendectomies. An additional opioid prescription for 5 pills of 5 mg of oxycodone (37.5 OME) was written for breakthrough pain. During their postoperative visit, we evaluated patients' adherence to the pain control regime, their postdischarge opioid use, and the adequacy of their pain control. RESULTS Sixty-five patients were included in the study (52% male). The majority (80%) of surgeries were performed urgently or emergently. The visual analog scale pain score at home was significantly better than upon discharge (3.7 vs. 5.5, p = 0.001). The average number of oxycodone pills taken postdischarge was 1.8 pills. Half (51%) of the patients did not take any opioids. All but four patients reported that their pain was adequately controlled. No patient required additional opioid prescriptions or visited the emergency department. CONCLUSION This study demonstrated that opioids can be eliminated in at least half of the patients and that five pills of 5 mg of oxycodone (37.5 OME) is sufficient for outpatient pain control when a 3-day course of ibuprofen and acetaminophen is prescribed. LEVEL OF EVIDENCE Therapeutic study, level V.
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Affiliation(s)
- Vasiliy Sim
- Staten Island University Hospital (V.S., S.H., A.A.G.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Staten Island University Hospital (A.B., F.E., L.K., M.P., E.S.); and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell (S.C.), Staten Island, New York
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Hersch C, Denis C, Sugár D. Frequency, nature and management of patient-reported severe acute pain episodes in the over-the-counter setting: results of an online survey. Pain Manag 2019; 9:379-387. [PMID: 30938229 DOI: 10.2217/pmt-2018-0092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Aim: Understand the frequency, nature and over-the-counter (OTC) self-management of patient-reported severe acute pain occasions. Patients & methods: A consumer-based survey of adults experiencing acute pain in Australia, Russia and the UK. Participants recorded pain type, frequency and intensity plus action taken to address pain. Results: A total of 2994 participants completed the survey; 1366 provided ≥1 diary entry (total 6527 pain occasions). Of these, 744 (11%) were reported as severe, and 72% were treated with OTC medication. Participants were somewhat satisfied/very satisfied with the action taken for 87% of pain occasions overall, and for 83% of severe pain episodes; however, participants with severe pain were somewhat/very dissatisfied with treatment in 9% of cases. Conclusion: Acute pain episodes described as 'severe' are not uncommon in the self-management setting; most can be managed successfully with self-medication. Individuals seeking strong OTC pain relief should be supported to consider self-management strategies first, before considering prescription medication.
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Affiliation(s)
- Connie Hersch
- Reckitt Benckiser Healthcare International Ltd, 103-105 Bath Road, Slough, Berkshire, SL1 3UH, UK
| | - Camille Denis
- Reckitt Benckiser Healthcare International Ltd, 103-105 Bath Road, Slough, Berkshire, SL1 3UH, UK
| | - Dalma Sugár
- Reckitt Benckiser Healthcare International Ltd, 103-105 Bath Road, Slough, Berkshire, SL1 3UH, UK
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Berthelot JM, Nizard J, Maugars Y. The negative Hawthorne effect: Explaining pain overexpression. Joint Bone Spine 2019; 86:445-449. [DOI: 10.1016/j.jbspin.2018.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
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Ferreira GE, Machado GC, Abdel Shaheed C, Lin CWC, Needs C, Edwards J, Facer R, Rogan E, Richards B, Maher CG. Management of low back pain in Australian emergency departments. BMJ Qual Saf 2019; 28:826-834. [DOI: 10.1136/bmjqs-2019-009383] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 01/08/2023]
Abstract
BackgroundTo describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by ambulance, received imaging, opioids and were admitted to hospital; and to explore factors associated with these four outcomes.MethodsIn this retrospective study, we analysed electronic medical records for all adults presenting with LBP at three Australian EDs from January 2016 to June 2018. Outcomes included discharge diagnoses and key aspects of care (ambulance transport, lumbar spine imaging, provision of opioids, admission). We explored factors associated with these care outcomes using multilevel mixed-effects logistic regression models and reported data as ORs.ResultsThere were 14 024 presentations with a ‘visit reason’ for low back pain, of which 6393 (45.6%) had a diagnosis of a lumbar spine condition. Of these, 31.4% arrived by ambulance, 23.6% received lumbar imaging, 69.6% received opioids and 17.6% were admitted to hospital. Older patients (OR 1.79, 95% CI 1.56 to 2.04) were more likely to be imaged. Opioids were less used during working hours (OR 0.81, 95% CI 0.67 to 0.98) and in patients with non-serious LBP compared with patients with serious spinal pathology (OR 1.65, 95% CI 1.07 to 2.55). Hospital admission was more likely to occur during working hours (OR 1.74, 95% CI 1.48 to 2.05) and for those who arrived by ambulance (OR 2.98, 95% CI 2.53 to 3.51).ConclusionMany ED presentations of LBP were not due to a lumbar spine condition. Of those that were, we noted relatively high rates of lumbar imaging, opioid use and hospital admission.
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Baker B, Kessler K, Kaiser B, Waller R, Ingle M, Brambilla S, Viscardi E, Richards K, O'Sullivan P, Goucke R, Smith A, Yao F, Lin I. Non-traumatic musculoskeletal pain in Western Australian hospital emergency departments: A clinical audit of the prevalence, management practices and evidence-to-practice gaps. Emerg Med Australas 2019; 31:1037-1044. [PMID: 31090200 DOI: 10.1111/1742-6723.13305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Musculoskeletal pain (MSP) conditions are a leading cause of morbidity worldwide and a common reason for ED presentation. Little is currently known about non-traumatic MSP (NTMSP) presenting to EDs. The present study described the prevalence and management practices of NTMSP in EDs. METHODS The design was a retrospective clinical audit in two hospital EDs in Western Australia covering 3 months beginning 1 January 2016. We defined NTMSP as pain of musculoskeletal origin occurring in the absence of external force or excessive physical loading. The outcomes measured included: patient, condition and hospital-episode characteristics, as well as management practices. Management practices were compared to recommended care derived from guideline recommendations. These included: assessment for red flags and psychosocial risk factors, appropriate use of diagnostic imaging, provision of patient education, administration and prescription of analgesic medication, and assessment of risk factors for opioid-related harm. RESULTS Eight hundred and eighty-eight patients were included in the present study. NTMSP accounted for 3.0% of all ED presentations. According to clinician documentation, red flag and psychosocial assessments were recorded in 73.3 and 10.5% of patients. Forty-one percent of patients were referred for imaging, of which 39.7% were inconsistent with guideline recommendations. Education was recorded 52.0% of the time. At least one opioid medication was administered to 55.3% of patients and there was no documented assessment of risk factors for opioid-related harm. CONCLUSIONS NTMSP is a relatively common reason for ED presentation. Documented management practices are discordant with guideline recommendations. Strategies to improve the concordance between management and guideline recommendations are needed.
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Affiliation(s)
- Briarley Baker
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Kenny Kessler
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,St John of God Midland Hospital, Perth, Western Australia, Australia
| | - Bronwyn Kaiser
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Robert Waller
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Michael Ingle
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Simone Brambilla
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Elena Viscardi
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Karen Richards
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,St John of God Midland Hospital, Perth, Western Australia, Australia
| | - Peter O'Sullivan
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Roger Goucke
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anne Smith
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Felix Yao
- St John of God Midland Hospital, Perth, Western Australia, Australia
| | - Ivan Lin
- Western Australian Centre for Rural Health, The University of Western Australia, Geraldton, Western Australia, Australia
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144
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Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet 2019; 393:1547-1557. [PMID: 30983590 PMCID: PMC6556783 DOI: 10.1016/s0140-6736(19)30428-3] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022]
Abstract
Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian T Bateman
- Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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145
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Canan C, Alexander GC, Moore R, Murimi I, Chander G, Lau B. Medicaid trends in prescription opioid and non-opioid use by HIV status. Drug Alcohol Depend 2019; 197:141-148. [PMID: 30825794 PMCID: PMC6530465 DOI: 10.1016/j.drugalcdep.2018.11.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/24/2018] [Accepted: 11/27/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pain is more common among people living with HIV (PLWH) than their counterparts; however, it is unclear whether analgesic use differs by HIV status. METHODS We analyzed Medicaid pharmacy claims from adults in 14 US states from 2001 to 2009 to identify opioid and non-opioid analgesic prescriptions and compared prescribing trends by HIV status. We accounted for clinical and demographic differences by using inverse probability weights and by restricting the sample to a subgroup with a common comorbidity, diabetes, chosen for its high prevalence and association with lifestyle and chronic pain. We estimated the incidence of chronic opioid therapy (COT) (≥90 consecutive days with an opioid prescription) among opioid-naïve individuals. RESULTS Rates of opioid and non-opioid use increased approximately two-fold from 2001 to 2009. PLWH received approximately twice as many prescriptions as those without HIV. In an unadjusted Cox regression, PLWH were three times more likely to receive COT compared to those without HIV (hazard ratio (HR) = 3.06, 95% CI 2.76-3.39). When restricting to patients with diabetes and adjusting for age, sex, state, comorbidity score, depression, bipolar disorder, and schizophrenia, the HR decreased to 1.26 (95% CI 0.97-1.63). CONCLUSIONS Higher opioid use among PLWH was largely a function of patients' demographic characteristics and health status. The high incidence of COT among PLWH underscores the importance of practice guidelines that minimize adverse events associated with opioid use.
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Affiliation(s)
- Chelsea Canan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA; Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Baltimore, MD, 21205, USA; Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Richard Moore
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Baltimore, MD, 21205, USA
| | - Irene Murimi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument Street, Baltimore, MD, 21205, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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146
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Osmundson SS, Min JY, Grijalva CG. Opioid prescribing after childbirth: overprescribing and chronic use. Curr Opin Obstet Gynecol 2019; 31:83-89. [PMID: 30789842 PMCID: PMC7195695 DOI: 10.1097/gco.0000000000000527] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Overprescribing opioids contributes to the epidemic of drug overdoses and deaths in the United States. Opioids are commonly prescribed after childbirth especially after caesarean, the most common major surgery. This review summarizes recent literature on patterns of opioid overprescribing and consumption after childbirth, the relationship between opioid prescribing and chronic opioid use, and interventions that can help reduce overprescribing. RECENT FINDINGS It is estimated that more than 80% of women fill opioid prescriptions after caesarean birth and about 54% of women after vaginal birth, although these figures vary greatly by geographical location and setting. After opioid prescriptions are filled, the median number of tablets used after caesarean is roughly 10 tablets and the majority of opioids dispensed (median 30 tablets) go unused. The quantity of opioid prescribed influences the quantity of opioid used. The risk of chronic opioid use related to opioid prescribing after birth may seem not high (annual risk: 0.12-0.65%), but the absolute number of women who are exposed to opioids after childbirth and become chronic opioid users every year is very large. Tobacco use, public insurance and depression are associated with chronic opioid use after childbirth. The risk of chronic opioid use among women who underwent caesarean and received opioids after birth is not different from the risk of women who received opioids after vaginal delivery. SUMMARY Women are commonly exposed to opioids after birth. This exposure leads to an increased risk of chronic opioid use. Physician and providers should judiciously reduce the amount of opioids prescribed after childbirth, although more research is needed to identify the optimal method to reduce opioid exposure without adversely affecting pain management.
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Affiliation(s)
| | - Jea Young Min
- Department of Health Policy, Vanderbilt University Medical Center
- Veterans Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center
- Veterans Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
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147
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Nikles J, Khan S, Leou J, Keijzers G, Ng J, Bond C, Nakamura G, Le R, Sterling M. Retrospective descriptive observational study of patients who presented to an Australian hospital emergency department with neck soft tissue injury. Emerg Med Australas 2019; 31:805-812. [PMID: 30895739 DOI: 10.1111/1742-6723.13253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe clinical presentation and management of neck soft tissue injury in an Australian ED. METHODS This is a retrospective cohort study conducted in a tertiary hospital ED in Queensland, Australia. This study included all patients aged 18-65 years presenting with neck sprain/strain in 2016. Main outcome measures are patient demographics, comorbidities, presentation, acute management and follow up. RESULTS Of 339 patients, 176 (52%) had cervical computed tomography (CT) scans and 3% plain radiographs. Two had fractures (CT yield of 2/176; 1.1%) and three were admitted with neurological symptoms, leaving 334 patients. Of 264 patients receiving medications in the ED, simple analgesia + oral opioid (146, 55.3%) was most frequently used, followed by simple analgesia (89, 33.7%) and opioid + benzodiazepine +/- simple analgesia (16, 6%). Opioids were prescribed for 169 (64%) (including i.v. opioids for 34 [12.9%] and for 85/97 (88%) with pain scores ≤4), and benzodiazepines for 22 (8.3%). Ten (3%) were referred for physiotherapy management in ED and eight (2.4%) for outpatient physiotherapy follow up. Of 113/334 (33.8%) receiving discharge prescription, 60 (53.1%) were prescribed oral opioid + simple analgesia, 37 (32.7%) oral opioids and seven (6.2%) opioids + benzodiazepines; 205 (61%) were discharged without a recorded follow-up plan. CONCLUSIONS There is large practice variation in management of neck soft tissue injury in ED. Over half of the patients received CT scans with modest yield. Opioids were commonly used both in ED and on discharge. There is need for a standard management plan to be developed for patients presenting with acute neck soft tissue injury.
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Affiliation(s)
- Jane Nikles
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
| | - Subaat Khan
- NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
| | - John Leou
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Joanna Ng
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Catherine Bond
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Gota Nakamura
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Rhonda Le
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Brisbane, Queensland, Australia
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148
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Abstract
Critically ill patients commonly experience pain, and the provision of analgesia is an essential component of intensive care unit (ICU) care. Opioids are the mainstay of pain management in the ICU but are limited by their adverse effects, risk of addiction and abuse, and recent drug shortages of injectable formulations. A multimodal analgesia approach, utilizing nonopioid analgesics as adjuncts to opioid therapy, is recommended since they may modulate the pain response and reduce opioid requirements by acting on multiple pain mediators. Nonopioid analgesics discussed in detail in this article are acetaminophen, α-2 receptor agonists, gabapentinoids, ketamine, lidocaine, and nonsteroidal anti-inflammatory drugs. This literature review describes the clinical pharmacology, supportive ICU and relevant non-ICU data, and practical considerations associated with the administration of nonopioid analgesics in critically ill adult patients.
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Affiliation(s)
| | - Kathryn E Smith
- 1 Department of Pharmacy, Maine Medical Center, Portland, ME, USA
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149
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Ueland W, Plymale MA, Davenport DL, Roth JS. Perioperative factors associated with pain following open ventral hernia repair. Surg Endosc 2019; 33:4102-4108. [PMID: 30805787 DOI: 10.1007/s00464-019-06713-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Effective pain control following open ventral and incisional hernia repair (VHR) impacts all aspects of patient recovery. To reduce opioid use and enhance pain management, multimodal therapy is thought to be beneficial. The purpose of this study was to identify patient characteristics associated with perioperative patient-reported pain scores. METHODS With IRB approval, surgical databases were searched for cases of open VHR performed over 3 years. Based on a retrospective chart review, modes of pain management and visual analog scale (VAS) pain scores were recorded in 12-h intervals to hospital discharge or to 8 days post-operation. Forward stepwise multivariable regression assessed the independent contribution of the perioperative factors to VAS pain scores. RESULTS Included in the analyses were 175 patients that underwent VHR. Average age was 55 years (+/- 12.8), and half were female (50.9%). Factors independently associated with increased preoperative VAS pain scores included preoperative opioid use, preoperative open wound, CDC Wound Class II, and prior hernia repair(s). Patients with epidural for postoperative pain had significantly decreased VAS pain scores across the time continuum. Operative factors significantly associated with increased preoperative VAS pain score included median hernia defect size, concomitantly performed procedure(s), duration of operation, and estimated blood loss. Greater preoperative VAS pain score predicted increased pain at each postoperative time point (all p < .05). CONCLUSIONS Preoperative pain and opioid use are associated with increased pain postoperatively. Epidural analgesia effectively results in decreased patient-reported pain. Increased operative complexity is associated with increased preoperative pain scores.
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Affiliation(s)
- Walker Ueland
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, C 225, 800 Rose Street, Lexington, KY, 40536, USA.
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, C 225, 800 Rose Street, Lexington, KY, 40536, USA
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150
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Aitken P, Stanescu I, Playne R, Zhang J, Frampton CMA, Atkinson HC. An integrated safety analysis of combined acetaminophen and ibuprofen (Maxigesic ® /Combogesic ®) in adults. J Pain Res 2019; 12:621-634. [PMID: 30804681 PMCID: PMC6371943 DOI: 10.2147/jpr.s189605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Acetaminophen (APAP) and ibuprofen (IBP) are two analgesic compounds with a long history of use. Both are considered safe at recommended over-the-counter daily doses. Chronic use, high doses, or concomitant medication can produce safety risks for both drugs. APAP is associated with increased risk of hepatic injury, while IBP can produce gastric bleeding and thromboembolic events. Using a combination of APAP and IBP provides superior analgesia without transgressing daily dose limits of each individual drug. METHODS The present study aimed to determine if treatment with a fixed-dose combination (FDC) containing APAP and IBP results in any unexpected adverse events (AEs) and/or changes in the safety profiles of its two ingredients compared to monotherapy. The analysis will examine clinical safety data obtained from either single dose trials, multiple dose trials, a long-term exposure trial, and post-marketing surveillance data of APAP/IBP FDC tablets (Maxigesic®/Combogesic®, AFT Pharmaceuticals Ltd). The largest dataset was obtained by pooling the four randomized-controlled, multiple-dose clinical studies with either APAP 325 mg + IBP 97.5 mg (FDC 325/97.5, three tablets per dose) or APAP 500 mg + IBP 150 mg (FDC 500/150, two tablets per dose). At maximum doses, the two FDCs are bioequivalent, permitting the pooling of data for the analysis of safety. RESULTS A safety population of 922 patients who received full doses of either FDC, APAP alone, IBP alone, or placebo was compiled from the four studies. A total of 521 AEs were experienced with the incidence of FDC AEs similar to or below either monotherapy group or placebo. The FDC did not alter the incidence and percentage of the most common AEs, including gastrointestinal events and postoperative bleeding. CONCLUSION Overall, the FDC is well tolerated and has a strong safety profile at single and multiple doses with improved efficacy over monotherapy.
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Affiliation(s)
- Phillip Aitken
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
| | - Ioana Stanescu
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
| | - Rebecca Playne
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
| | - Jennifer Zhang
- Drug Development, AFT Pharmaceuticals Ltd, Auckland, New Zealand,
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